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given to the special reports on these outbreaks published from time to time as Appendices
to the Annual Report of the Medical Officer of Health, County of London).
In addition, there have been during the last 32 years a few outbreaks traced to shellfish
(1, perhaps 2, to oysters; 2 perhaps 3, to cockles; and there has been suspicion
entertained in a few instances with regard to mussels.)
For many years doubt was felt as to the relative importance of the parts played,
by fish and various kinds of shellfish, in determining prevalence of typhoid in London.
Recent study of outbreaks shown in the accompanying diagram and table has
thrown further light on this question. For example, a few instances may be quoted.
In 1900 an area in North St. Pancras (one of the 35 areas referred to above) suffered
coincidently with other areas in which typhoid prevalences were traced to fish
As the result of the enquiry in St. Pancras at the time, mussels, which originally
fell under suspicion, were clearly not the cause of the mischief, but the question of
fish origin at the time was not investigated. The St. Pancras area suffered, however,
in other years, at about the same season and coincidently with fish outbreaks in
other boroughs; it may be concluded that if mussels were not at fault and fish
probably was, in one of these prevalences, the same conclusion is likely to be correct
in the case of other outbreaks occurring at the same time of year in the same locality.
Again, an outbreak of typhoid occurred early in 1894, in Lambeth, which was
attributed at the time to milk. The evidence against the milk was by no means conclusive,
indeed the distribution of the disease did not tally very closely with the area
of milk distribution. Later in the year sporadic cases of typhoid occurred, still
affecting the area of the supposed milk outbreak. At the end of 1894, in the 49th,
50th and 51st weeks, there was an increase in the amount of typhoid fever in London
extending over a large area, but at the time of this widespread prevalence there
was again special incidence upon the area involved at the time of the supposed milk
outbreak. It may be suggested that a possible explanation of these phenomena
is that fish distributed from a coster market (which exists at the centre of the area
involved in the supposed milk outbreak) (i.) was at fault in the original outbreak,
(ii.) was also concerned in producing the succeeding sporadic cases, and, (iii.) was still,
more widely distributed over London in the wider prevalence of the 49th, 50th and
51st weeks, the original " milk outbreak " area being also specially involved at
this time. A third instance is that of two outbreaks in 1899 (due to causes then unrecognised)
in "Area II." and "Area VII." of the 1903 Report. Area II. suffered from a
fish outbreak in 1900, and Area VII. is that in north St. Pancras referred to above,
which it is also presumed presented a fish outbreak in 1900. It is highly probable
that the causes at work in 1899 were identical with those of 1900.
During the years 1896-1903 the grouping of cases, combined with occurrences
of multiple cases and the manifestation of a peculiar age-incidence of attacks, began
to compel attention. It was not until 1900, however, that the occurrence of a large
but localised prevalence in St. George the Martyr, Southwark, synchronising with
somewhat similar though smaller prevalences in Lambeth and Chelsea (detached),
directed enquiry to fried fish; and it was not until 1903, when experience of
such smaller outbreaks in widely separated parts of London was repeated on a more
extended scale, that it became realised that infected fish, distributed perhaps on
successive occasions by particular retailers, might produce sporadic cases of typhoid
fever spread broadcast over the county. Looking back, it seems now possible that
in 1896 (or even earlier) areas, which later were found to be associated with fish
infection, were already involved, one in Lambeth, also two in St. Pancras, (Areas II.,
VII. and XII. in the diagram of the 1903 Report, all again implicated in 1898, 1899
and 1900), and one in Shoreditch (again implicated in 1908). It is further apparent
too, that institution outbreaks such as those involving the St. Mary's Workhouse
Schools in 1897-1900, and certain prisons, asylums and hospitals in the same or in later
years, were probably due to a like cause. In the schools first named and in some of
the hospital groups the areas surrounding the institutions suffered coincidently