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34
Parish of St. George the Martyr, Southwark.
in the street. Most of the houses dealt with that particular milk vendor, so that
any specific infection from that source would have caused a more general outbreak
in the street.
(c) Water.—By a similar line of reasoning water may be excluded.
(d) Drainage.—The outbreak cannot be traced to defective drainage. Cornbury
Street is sewered by two independent systems. Nine cases occurred in houses
connected with the boundary sewer and five in those connected with the Old
Kent Road sewer. At the same time it is probable that bad drainage together
with dampness and other unwholesome surroundings has a considerable indirect
influence in predisposing to attacks of diphtheria. For my own part I do not
believe that the poison of diphtheria is likely to be conveyed by drains. Further
it is a well known fact that sewer gas in houses is a fruitiul cause of sore-throats.
It is equally well known that the diphtheria bacillus fastens on the lining membrane
of any inflamed or otherwise damaged throat. In this way it seems probable
that persons dwelling in an unwholesome environment like that of Cornbury
Street will be specially prone to an invasion of diphtheria if once brought into
this neighbourhood.
(e) Social Influences.—This street a blind alley, with its closely-packed
population forms a sort of colony where a good deal of social intimacy prevails.
During the earlier stages of the outbreak I learn that patients were visited freely
by neighbours, including children, and that funerals became the subject of special
gatherings in the houses of the mourners. It is hardly necessary to point out
how such conditions would favour the spread of infection.
General Conclusion as to Cause — By a process of exclusion 1 am led to believe
that the epidemic in Cornbury Street was due to direct infection from the original case
at number 41 which was in turn infected by some outside source. That being the case
it will be necessary to inquire as to the measures for staying the outbreak, and why,
in spite of those measures, the disease spread to thirteen individuals and lasted over
a course of several months.
The chief measures by which diphtheria is to be controlled from a Public Health
point of view are prompt isolation and thorough disinfection. Isolation, however,
cannot be effected until the disease is recognised; and the question of early diagnosis
becomes of first importance. Without attempting to deal exhaustively with these
three points a few words may be said upon each in turn.
Early Diagnosis.—It is well known to medical men that some cases of diphtheria
are extremely difficult to detect. The diagnosis can only be made after a period of
waiting. Moreover, it seems probable that a certain number of cases are never detected
at ail. As an illustration of this difficulty I have it from a Doctor that four of his
patients in Cornbury Street, although suffering from suspicious sore throats, remained
unnotified owing to the clinical evidence being too weak in his judgment to support
the theory of diphtheria, lience, it is of the utmost importance to be able to decide at
once whether a sore-throat is or is not of a diphtheritic nature. This can now be done
in a bacteriological laboratory. In Marylebone, for instance, every medical man is
provided with a small cardboard box containinig two sterilised test-tubes. One of
these tubes is for membrane, if it can be obtained, and the other is furnished with a
sterilised swab of wool wound round a wire. The medical attendant touches the throat
with the wool and sends it off to the Medical Officer of Health, who is able to send
back within twenty-four hours a definite report as to the existence of the disease. The
cost of the whole examination of each case amounts to two shillings and sevenpence.
It should be clearly understood however that the examinations are not for the purpose
of revising certificates, but for dividing the cases into those which might possibly be
treated at home with safety and those which require strict isolation in an infectious
hospital.