London's Pulse: Medical Officer of Health reports 1848-1972

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London County Council 1900

[Report of the Medical Officer of Health for London County Council]

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8
to about 3,000 persons, and were fully occupied at the time of inspection. The area also contains
several streets of tenement houses, occupied to a large extent, by families apparently possessed of
the very narrowest means, and some courts and alleys which have been officially represented as
constituting an unhealthy area under the Housing of the Working Classes Act. It includes, moreover,
large business premises, the fire brigade headquarters, and a limited number of houses, for
the most part fronting upon main thoroughfares, occupied by tradespeople and others above the
border line of poverty.
The behaviour of enteric fever in this area may be best appreciated by reference to the
table annexed. On the left-hand side of the page on this table are exhibited the cases of enteric
fever developing within the circular area in Southwark on successive days between August 16th
and October 10th.* The cases are numbered consecutively, and are grouped in three columns;
the first and third columns contain "primary cases," the second column cases in which the
sufferer was apparently infected by a person previously attacked and living (save in three
instances specified in the appended notes) in the same house as that in which the presumed
"secondary case" occurred. The reason for grouping the primary cases in two columns and for
printing the numbers in different colours will presently appear, but for the purpose of indicating
the time relations of the onset of attacks of enteric fever in the area, these distinctions may be
disregarded. It will be seen for example that in the latter part of August enteric fever was of
relatively rare occurrence in the area, only three cases developing between August 16th and the
end of the month. Early in September, however, marked increase in prevalence of the disease
manifested itself, and on September 6th two persons (Nos. 8 and 9), on September 7th three
persons (Nos. 1(0 to 12), and on the 8th four persons (Nos. 13 to 16) were attacked on one and the
same day. The number of persons attacked (and subsequently notified) reached a maximum on
September 15th; the daily number then somewhat irregularly declined until, on September 24th
(for the first time for nearly three weeks) only one patient was attacked in the twenty-four hours.
From this time onwards the number of attacks did not exceed two in the day. Indeed, if
secondary cases (in column 2) be excluded from consideration, it will be seen that the number of
cases developing in the area had, at the end of September and in October, returned to what may
be thought of as approaching normal limits; for though the cases are of somewhat more frequent
occurrence in this post-epidemic period than they were in the pre-epidemic period, it must be
remembered that seasonal influence has to be taken into account, and that the period to which
the lower part of the table relates would, on this account, be expected to yield more cases than
the period covered by the upper part.
The dates to which cases have been allocated in the table just referred to are dates of
onset of symptoms; these dates have been determined, in those cases in which patients were
removed to hospital (and they form the large majority of the cases), after consideration of the
hospital notes and temperature charts, and from information kindly furnished by the medical
superintendents of the hospitals. The dates of notification of the cases are given in the appended
notes. The two cases marked with an asterisk (*) proved not to be cases of enteric fever. The
red dagger (t) which adjoins case 39 indicates another case, one which was not notified but was
probably a case of enteric fever.
Drainage and refuse removal.—Direct means of access of sewer air to the interior of houses
was only quite exceptionally found to exist; sink wastes were disconnected, and water-closet
appliances as a rule of a fairly satisfactory character. The drains themselves were in certain
instances found to be faulty. Dr. Waldo, in reporting to the vestry on the drainage of the
affected locality on October 18th, remarked that "several of the house drains—which are both
separate and combined—are only imperfectly ventilated and are apparently not disconnected
by any trap from the sewers. In 17 instances the house drain was found on examination with
the chemical test (an imperfect one) in use by your authority to be defective. Steps have been
taken to remedy these defects. The sewers into which the sewage drains are mostly imperfectly
ventilated or not ventilated at all, and some of them (three particular sewers are specified) have
been condemned by your surveyor." These conditions do not, of course, afford adequate explanation
of the outbreak.
As regards refuse disposal, it should be noted that there are dust shoots in the blocks of
buildings referred to above, and serious nuisance was caused by these in several instances.
Speaking generally, but few accumulations of dust were noted in the course of inspections made
in the area.
Water supply.—It was found that about half the houses in the area specially invaded
were supplied by the Lambeth, and the other half by the Southwark and Vauxhall Water
Company. The cases of enteric fever were distributed just about equally between the two
companies—i.e., practically in the proportion in which they might a priori have been expected to
be distributed. Complaints were made concerning pollution of water in storage cisterns in some
of the blocks of dwellings above referred to; this question, however, while serious in itself, could
not be regarded as of importance in connection with the outbreak of enteric fever.
Milk supply.—The milk supply of infected houses was very varied. In about one-third
of the houses involved in the outbreak condensed milk only was consumed. The
brand of condensed milk used was ascertained in many instances, and it was found that at
least four different brands were represented, though one brand attained a decided position of
predominance. As regards the remaining two-thirds of the houses involved, in a few both condensed
milk and ordinary milk were used, in the large majority cows' milk only was employed
A particular local vendor, indicated by the letter B in the appended notes, supplied rather more
than half these houses—i.e., about one-third of the total number of houses involved in the
* This period includes rathpr more than a fortnight before, and after, the period of special prevalence in
Southwark.