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among children attending the Board and National schools. The circumstances certainly suggest that
the keeping away from school of so large a number of children was one of the factors at work in serving
to check the spread of diphtheria, and the early closing of the affected classes would, I believe, have more
speedily brought about this result.
At the date of the commencement of my inquiry but comparatively few children were attending
school, and I could not learn that in any family which had been recently attacked the first sufferer had
been a school attendant, and it may be stated that a medical examination of the throats of the children
attending the Board school which was made on October 19th, on behalf of the sanitary authority,
showed that in no instance did the throat of a child present any suspicious appearance. With two
exceptions, that of a child attending the infants' department of the National school who sickened on
October 24th, and that of a boy attending the boys' department of the Board school who sickened on
October 20th, this freedom from attack of children attending the Board and National schools has
continued to the present time. On October 17th the Board school buildings were disinfected by the
officers of the sanitary authority, and on October 23rd the National schools were disinfected.
As regards the mortality caused by the outbreak, Dr. Jolly, the medical officer of health for the
district, has ascertained that 28 deaths had occurred up to the end of October (two in August, seven in
September, and 19 in October). It may be noted that patients who began to be ill during the latter
part of September suffered, generally speaking, from a more severe form of disease than did those
attacked either shortly before or immediately subsequent to that period. In other words, when the
outbreak was at its height the case mortality also attained its maximum. The ages of the patients
affected at the different periods no doubt had influence in this connection, but this consideration does
not appear to fully explain the fact that nearly 50 per cent. of the attacks which began between
September 17th and September 30th were fatal, while the mortality for the rest of the attacks
commencing between September 4th and October 20th was only about 13 per cent.
The facts observed during the recent outbreak in Lewisham in regard to the spread of diphtheria
in particular classes, emphasize the need for immediate inquiry into the details of school attendance in
connection with notified cases of infectious disease. If information of this kind be available it is possible
to decide whether or no the exclusion of particular classes from school attendance is necessary. Such
exclusion, if decided upon, might of course be accompanied by the exclusion from school of all children
belonging to a family of which a pupil in one of the excluded classes was a member and who are in
other classes of the school. Early action of the kind indicated may have an important influence upon
the spread of disease and may obviate the need for the larger interference with school work which
closure of an entire school entails.
Certain further lessons in connection with sanitary administration are to be learnt from the
Lewisham outbreak. Difficulties in connection with the isolation of cases were acutely felt in
Lewisham in September and October last. There was unavoidable delay therefore in connection with
the removal of some of the cases. The Board fortunately had at its disposal a cottage hospital to
which a number of cases were removed. There is, moreover, no public mortuary in Lewisham, and
this fact led to the retention of dead bodies in houses under circumstances in wbich, had a mortuary
been available, there would have been opportunity for the exercise of the powers of section 89 of the
Public Health (London) Act, 1891, which relate to the removal of a dead body to a mortuary. It is
due to the Lewisham Board to point out that they are not responsible for the temporary dearth of
hospital accommodation ; and that the Board has decided to provide a mortuary and coroner's court at
Ladywell, and has applied to the Council for a loan for this purpose. The delay in the erection of the
building is due to an unexpected legal difficulty connected with the granting of loans by the Council.
No shelter for the accommodation of persons who are compelled to leave their dwellings for the
purpose of enabling such dwellings to be disinfected by the sanitary authority has been erected in
Lewisham. The want of such a shelter was much felt during the recent outbreak. In several of the
households invaded difficulties were experienced in carrying out the work of disinfection which would
not have been felt had a shelter been available. Moreover there appears to be need for consideration
being given to the question whether the system of disinfecting rooms which has been practised in
Lewisham is sufficiently complete.
I ought not to omit reference to the opinion as to the sufficiency of the sanitary staff, to which I
was led as the result of my inquiry. The duties in connection with that part of the Lewisham district
which is known as Lewisham and Blackheath were allotted to an inspector and an assistant inspector.
The latter was mainly engaged in house to house inspection, and all the other ordinary duties of a
sanitary inspector in a district containing upwards of 40,000 inhabitants thus had to be performed by a
single individual. When the need for increased assistance became apparent, it was temporarily supplied
by taking inspectors from other parts of the district over which the Lewisham Board has jurisdiction,
and, shortly after the outbreak, a second assistant inspector was appointed for the purposes of inspection
in Lewisham and Blackheath. I was much impressed with the excellent services rendered by the
inspector of the district, but experience of the administration gained during my inquiry satisfied me
that even at times when there is no exceptional prevalence of disease, the work, which under ordinary
circumstances he is called upon to undertake, is in excess of that which can be efficiently performed by
one inspector.
In conclusion, I have to express my indebtedness to the officers of the Lewisham Board and the
teachers in the schools for the assistance they have rendered in the course of this inquiry.
W. H. Hamer,
Public Health Department, Assistant Medical Officer of Health.
Spring Gardens, S.W.,
12th November, 1896.