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with the institutions themselves. It is also clear, now, that fish of the same kind,
and presumably of like origin with that demonstrated (in 1900, 1903,1906, 1908,
1910 and 1911) to have caused typhoid in certain localities, was also operative at
the same times in a similar manner in respect of groups of cases in other parts of
London and Greater London.
Furthermore, casting back to still earlier years, there is seen now to be high
probability that such outbreaks as those of 1891 (attributed at the time to icecream)
and of 1894 and 1895 (attributed at the time to milk) were really due to fish.
At the time of the great prevalence in S.E. London in 1891, the Foundling Hospital
(in St. Pancras) was heavily involved, and there were two other less considerable
institution outbreaks at the same time; but it was the wide distribution of groups
of cases, with multiple attacks in households, in many parts of London, that here
make fish origin specially probable. The Lambeth prevalences, "milk" and
"water" outbreaks, of 1894 have already been referred to. The Woolwich "milk"
outbreak of 1895 was of a more unique character, but it is remarkable that a fish
vendor's establishment adjoined the suspected milk shop, and was thus centrally
situated as far as the prevalence was concerned. The "water outbreaks" of 1896
and 1897, the well-marked groups of 1898-9 and 1900, the city establishment outbreak
early in 1899, the institution outbreaks of these same years, the groups of
1901-03, as well as those of 1908, 1910 and 1911 can seemingly in the light of all the
facts have had no other origin. The wide-spread prevalences of 1906 and 1910 were
unquestionably due to food and those in the latter year were definitely traced to
fish. In 1906 cockles were appealed to in some of the affected localities, but detailed
particulars ascertained at the time with regard to distribution of a particular wholesaler's
fish supply seems to place fish origin of most of these 1906 prevalences beyond
all doubt. This wholesale dealer supplied, between 1899 and 1905, from 12-21 retail
fried-fish shops in Greater London; 8 of these were situated in one or other of the
35 localities previously referred to, and the remainder in areas which all suffered
exceptionally heavily from typhoid fever.
As was pointed out, moreover, in the Annual Report for 1911 (p. 89), "It
is noteworthy that difficulty has arisen in some outbreaks as between cockles and
fried fish, watercress and fried fish, mussels and fried fish, and ice-cream and fried
fish." The impression gained from study of all the outbreaks of the last 30 years
is that in the large majority of them it was fish that was actually at fault.
(d) Finally, certain deductions may be drawn from study of the seasonal fluctuations
in typhoid prevalence in London. The two or three suspected cockle outbreaks
occurred in June-July. In Belfast nearly all the great typhoid prevalences,
which were traced to cockles, in the five or six years following upon 1900, particularly
affected this time of the year. Moreover, Easter Monday and Whit Monday, the
two bank holidays, have in the past been the great occasions in London for widespread
consumption of cockles. (See, however, on this question of bank holiday
cockle outbreaks in London, the remarks of Dr. Bulstrode in his Report on "Shellfish
other than Oysters in relation to Disease" p. 105. Analysis of the notification
figures for 10 years, 1899-1908, yields but scant evidence of mischief caused on any
considerable scale by cockle infection during those years.) As regards mussels,
Dr. Niven in Manchester speaks of a "rush of mussel cases" from October onwards.
In London in the decade 1891-1900 the seasonal peak of typhoid fever occurred
in November, a few weeks later than, on the average, in subsequent years. Probably,
in the decade in question, an appreciable amount of mischief may have been produced
in London (as was apparently the case in several other large towns in this
country) by mussels; but on the whole, and particularly since 1900, there has been
little, if any, proof of mussel infection in London.
The London evidence in fact, at any rate since 1891, incriminates mainly
flat fish, generally plaice, almost always purchased as cooked (fried) fish and often
in an ungutted state. Careful enquiry into the history of many hundreds of patients