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39
made by the patients or their relatives or friends—statements elicited either in the
hospitals to which the patients had been removed, and (or) at the patients' homes—
that fish was consumed by practically all the sufferers whose illness proved to be
typhoid fever. The following further points are worthy of notice :—
(i.) The locus in quo of the outbreak.—This was an area of the kind which
had been involved in the large majority of the London outbreaks of typhoid
from the nineties up to the year 1911; indeed, much the same, though not
identically the same, ground was covered in 1924 as in two fish prevalences
in Bethnal Green specially reported upon in 1908 and 1910. In 1908 a fried
fish shop situated within, though not at, the centre of the area involved in
1924 was at fault. The evidence in 1910 led to the conclusion that the prevalences
of that particular year, which affected no fewer than 33 localities in and
immediately around London, were due to ungutted plaice or dabs, conveyed
from Billingsgate, partly by carriers, and partly by costers, and in the main
sold from fried fish shops, but in part sold as wet fish and cooked at home.
In 1910, as in 1908, not only was the ground actually covered, so far as Bethnal
Green was concerned, almost the same as in 1924, but the social circumstances
of the sufferers were practically identical with those encountered in the recent
outbreak; the fish coming under suspicion in 1924 was, moreover, as before
in 1908 and 1910, in numerous instances referred to as "plaice or dabs." In
1924, as in 1910, but not in 1908, the fish at fault was apparently purchased
not only as fried fish but partly also as wet fish destined to be cooked at home.
(ii.) The time relationships of the 1924 prevalence.—The date of original
infection in 1924 must have been in the first 12 days of September, and
probably within a day a two of Saturday, the 6th September. It was noted
from study of available records that, on September 4th and 5th, small plaice
and dabs were sold at exceptionally low prices at Billingsgate, and one of the
Bethnal Green inspectors, quite independently of this observation, reported
that "about the period covered by late August and early September last
there was a quantity of steamer small plaice (i.e., fish weighing from 4 to 8
ounces) on the market, and this was being sold in an ungutted state. When
the gutting process was performed at the fried fish premises the fish was in a
condition known in the trade as 'gassy,' viz., emitting a peculiar chemical
smell."
Examination
of the time
relations of
the outbreak
in comparison
with those of
certainearlier
London
outbreaks.
In the first fish outbreak, that of 1900, three different parts of London were
almost simultaneously involved, though two of them (Lambeth and Kensal Town)
were infected about a week earlier than the third area (Southwark). In each
instance cases continued to be notified for eight or ten weeks,* and question arose
at the time as to whether the infected fish was distributed on more than one occasion,
or whether the later occurring cases must be ascribed to secondary, i.e., "case to
case," infection. At the time of the report of 1900 the latter alternative was
accepted. In 1908, however, in Shoreditch, an outbreak was encountered which
lasted several months, and in which the evidence pointed to repeated distribution,
in the same group of courts and streets, by a coster, of plaice or dabs on at least
four or five different dates; though here the question arose whether incubation
periods of as long as four or even five weeks may not have occurred in some
instances. Again, reiterated distributions in one and the same area of infected
fish were encountered in 1910, and also on other occasions (see Annual Report,
1922, pp. 18-32).
* In several of the large outbreaks of typhoid in this country, e.g., Maidstone and Lincoln,
a similar period of eight weeks (or thereabouts), of continuance of fresh cases of the disease, had
been noted, and this phenomenon had been the subject of careful study by medical inspectors
of the Local Government Board, inasmuch as there was difficulty in reconciling so extended a
period with the assumed time when infection was possible and with the generally accepted length
of incubation period.