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106
Annual Report of the London County Council, 1910.
It may here be noted that further cases occurred in association with these supplies. Thus six
patients sickened in the last few days of October. Two in Hackney were customers of P; two others
also in Hackney, were costomers of O; the remaining two were boys living in Tottenham, who had
obtained fried fish from the shop customers of which had, at an earlier period, suffered coincidently
with customers of O and P.
It should be added that members of a household attacked in November had consumed fried fish
obtained from O. The circumstances of these cases were very fully investigated by Drs. Goodall,
Gordon, Warry and myself. In brief, of 11 members of the family eight developed typhoid fever between
11th November and 20th November; these eight had eaten fried fish obtained from O—the three
members of the family escaping had not done so. Later, however (8th December), one of the latter
developed the disease.
Other groups of cases notified late in 1910 include three groups of multiple cases in houses in St.
Pancras, Shoreditch and Finsbury, all the sufferers being fried fish eaters; groups of cases in Camberwell
and Southwark, in the former borough there was some suspicion, and in the latter there was strong
suspicion of fish infection; and a group of eight cases (four in one house) all fried fish eaters in Edmonton.
The same source of fish supply was in question in the last instance as in the earlier group of Edmonton
cases, and it is noteworthy that the later Edmonton group occurred at the time when the family group
of eight cases occurred in Hackney among customers of the vendor O; thus both groups of Edmonton
cases were affected coincidently with the customers of O. (See p. 105.)
On the Extent to which Fish Infection has occurred in London in Recent Years.
The circumstances of the present outbreak of typhoid fever raise question with regard to London
typhoid fever generally. In Bethnal Green the occurrence of 50 cases in a limited area has enabled
a close analysis of the facts in relation to possible causes to be made, with the result that a fried fish
hypothesis emerges as the only obtainable explanation. In nine other boroughs of London, and in
Tottenham and Edmonton, there were contemporaneous excessive prevalences of typhoid fever, and
these prevalences also admit of explanation on a fish hypothesis. It is thus possible to proceed from
an established case to other cases in which the proffered explanation must be felt to be a probable one.
But coincidently with the excessive prevalence in the 12 named sanitary areas, there was the observed
"normal" incidence in the rest of London. If analysis be made of the cases which make up this
normal incidence it will be found that in addition to scattered or "sporadic" cases there were a few
instances of grouping. Thus, three cases were notified from one house in Battersea. Dr. Lennane,
the medical officer of health, made them the subject of full investigation, but no cause could be traced.
The patients, he noted, were eaters of fried fish. A group of cases at Rushey Green was investigated
by Dr. Wellesley Harris, the medical officer of health of Lewisham, with a like result. Bermondsey
showed some excess of typhoid fever, though less than that exhibited in the 10 boroughs already named.
Dr. Brown, the medical officer of health, could find no explanation of this incidence; but there was
some suggestion of grouping, and it may be that fish sold by a coster from a barrow, and fish from a
particular shop, one or other of which had been consumed by the sufferers, had infected a number
of the patients. In Wandsworth a curious group of cases occurred, again at the particular time in
question, but here there was an earlier case in the neighbourhood, and there is room, therefore, for
more than one explanation of the prevalence. Lastly, just outside the County boundary in Acton,
eight cases occurred in one house, all the patients sickening within a few days of one another. The
eight sufferers had eaten fried plaice, and the one inmate of the house not attacked had not done so.
Three cases simultaneously occurring in the near neighbourhood of this house were in all probability
fish infected also. Curiously enough coincidently with these typhoid fever cases, three instances of
"fish-poisoning," one of them involving a large number of persons, were reported from within or near
London.
Question necessarily arises as to whether or no some of these widely scattered groups, and
further as to whether some of the sporadic cases occurring at this time, may not also be attributable
to fish infection. In the Appendix to the Annual Report of the Medical Officer of Health of the County
of London for 1903, a similar question was discussed at some length. It will, therefore, be sufficient
here to refer to certain facts bearing upon the subject which have come to light since the occurrence
of the prevalences of fish-borne typhoid of 1900 and 1903.
The typhoid prevalence of 1906.—In 1906, between 1st and 20th June, 100 cases of typhoid fever
occurred in seven areas in London and West Ham. The suddenness of the outbreak made it possible
to exclude contact infection, rendering it practically certain that water, milk or other food was at fault.
The evidence from all seven areas was to the effect that milk could be excluded and the areas were so
scattered and so definitely localised that infection by water was rendered highly improbable. As
regards other foods, 53 per cent. of the sufferers had eaten cockles during the month prior to attack.
All save three of the London sufferers (92 per cent.) had eaten fried fish during the four weeks preceding
attack. Despite the large number of cockle eaters, a cockle hypothesis was inadequate, for it left 40-50
cases unexplained. On the other hand a fried fish hypothesis received support from the following
facts :—
1. The age-distribution of the sufferers was practically that which obtained in the
Southwark outbreak of 1900.
2. In three of the seven areas most of the sufferers were supplied with fried fish from
shops owned by the same man.