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5
Dr. HAMER'S REPORT.
On the 20th September, 1900, the medical officer of health received from Dr. Parkes,
medical officer of health of Chelsea, a list of 15 cases of enteric fever which had been notified since
the first day of the month in Kensal Town. Dr. Parkes wrote saying that he had made careful
inquiry concerning this outbreak, but was unable to find anything definitely pointing to a particular
cause. He discussed the question of milk supply in some detail, inasmuch as he had at that time
found that 7 of the 15 cases had been obtaining milk from a particular local vendor; moreover,
milk from one of the sources of supply of this vendor was traced to four other cases supplied
through the agency of a second local vendor.
On this day, September 20th, and the following day, more or less contradictory statements
appeared in the press concerning prevalence of enteric fever in various parts of South London,
and I was instructed to inquire into the question generally. The Council not being the authority
receiving copies of certificates under the provisions relating to notification, some difficulty was at
first experienced in following the matter up, but ultimately it was ascertained shortly before
two o'clock on Saturday, the 22nd September, that upwards of 20 cases had been notified within
the past few days in St. George-the-Martyr, Southwark, while it was also observed that in London
as a whole the cases notified during the week ending September 15th showed a marked increase
as compared with the preceding week, the numbers notified in the two weeks being 74 and 128.
As question was thus raised as to the possible distribution over widely-separated areas of some
infected article of drink or food, further inquiry was obviously necessary. Here again difficulty
was experienced, as Dr. Waldo, the medical officer of health of the district in which the larger
outbreak had thus suddenly declared itself, had been ill, and was out of town. I was, however,
afforded every assistance by the chief inspector and other officers of the authority of the district,
and was able, having in view the facts already ascertained by them, to form a rough provisional
conclusion that milk, which was especially the object of suspicion at the moment, was not at fault.
On reporting the result of my inquiries to Mr. Shirley Murphy, he decided to himself prosecute
further inquiry the same evening, at certain hospitals to which the patients had been removed,
and it was arranged that we should meet the following day (Sunday, 23rd September), and
endeavour to learn certain additional particulars in the affected area.
The age distribution of the cases in Southwark was from the first seen to be quite exceptional,
the age groups 5-10 years, 10-15 years and 15-20 years being especially affected,
and this, as well as certain other considerations, led to careful investigation being made concerning
ice-cream. As the result of inquiry on September 23rd, it became, however, practically
certain that neither milk nor ice-cream had caused the outbreak. The question of water supply
was not, of course, lost sight of, but here again the facts as they came to light pointed to a negative
conclusion. Exact knowledge as to the origin of the water supplied to all the houses in the area
was not forthcoming until some days later, when it was obtained from the officers of the Lambeth
Water Company. It was then quite clear that water had not been concerned in conveying
infection.
On conferring with Dr. Waldo on the morning of the 24th September, water, milk and icecream
could be practically excluded from consideration as causes of the observed prevalence. The
sudden appearance of the outbreak and the simultaneous attack in several instances of two or
more members of one family were facts strongly suggestive of food as the medium of infection.
We decided therefore to make thorough inquiry as to possible collections of persons—and more
particularly, having regard to the age distribution of the cases, of young persons—at "parties"
and "school treats," and in connection with "days in the country" and the like. The question
of shell-fish also presented itself, and a suggestion was made by Dr. Waldo that the subject of
public swimming-baths required to be considered. This last-named hypothesis seemed to somewhat
closely fit the facts as to the age incidence of the disease in the light of such knowledge as
in the first instance came to hand; when, however, more extended inquiry was made, it was found
to altogether fail to explain the phenomena observed.
Meantime it had become apparent, as the result of examination of the notification returns,
that there was a third well-marked localised prevalence of enteric fever in London, affecting
certain streets in Lambeth, and this third outbreak was found to present, though in much less
marked degree, peculiarity of age incidence similar to that observed in the Southwark outbreak.
The age and sex incidence in the three outbreaks is shown in diagram I., the age
and sex distribution in London as a whole, in 1899, being given for purposes of comparison. In
diagram II. the extent to which the prevalence of enteric fever, in the three sanitary districts
concerned, affected the notifications (in the 37th, 38th and 39th weeks) for the whole of London, is
shown.
In Kensal Town the question of milk supply was still the subject of careful attention. As
case after case was notified and inquired into, the judgment leaned now on the side of suspicion
and now on that of complete acquittal of the milk. The problem was a very difficult one,
inasmuch as though a large percentage of the persons attacked in Kensal Town had, it was
ultimately found, been supplied with milk derived from one company, that company was ascertained
to be supplying, through the agency of various retail vendors, at the very least, more than
half the inhabitants of the streets attacked. Again matters were complicated by the fact
that a group of cases occurred in St. Pancras, at about this time, and among the sufferers were
eight consumers of milk supplied by a particular local vendor; question arose as to whether the
source from which this vendor obtained his milk was identical with the source from which the
Kensal Town supply was derived.* In North Kensington too a slightly increased prevalence
* It transpired that the St. Pancras vendor, whose main supply was from his own cows, 14 in number,
supplemented this to the extent of about two gallons daily, and from time to time obtained the additional milk
from the company which was supplying the Kensal-town vendor. This company conducted a very large business
and, in the north-west of London more particularly, was supplying a great many local vendors with milk.