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Chapter XXXII.
Special reports submittted by the Medical Officer of Health during the year 1910
I.—Report by Dr. Hamer on the Typhoid Fever Outbreak of 1910.
General Account of the Outbreak with Special Reference to the Bethnal Green Prevalence.
On September 15th examination of the weekly notification list showed unusual prevalence of
typhoid fever in East London; for there had been notified, in the week ending September 10th,
13 cases in Bethnal Green, 12 in Stepney and 5 in Poplar. The total number of cases in the "east
districts" during the week in question was 31 compared with 8, 6 and 8 in the three preceding
weeks. The total number for London as a whole, for the week in question, was 57 as compared with
31, 25 and 20 in the three preceding weeks. Having regard to the behaviour of typhoid fever in
relation to season, increase at this time was, of course, to be expected, but it is important to note that
the augmented figures, for London as a whole, manifested in the returns for the week in question, are to
a large extent accounted for by the heightened incidence in the three "east districts" already named.
The Medical Officer instructed me to proceed at once to the implicated districts and confer with
the medical officers of health. The facts thereupon elicited made it clear that some special cause or
causes of typhoid fever had commenced to operate in Bethnal Green, Stepney and Poplar, approximately
at some time during the second week in August. In Bethnal Green, where information already
relating to as many as 20 cases was at once available, it was clear that the sufferers belonged in the
main to the poorest class of the population, that they had in almost all instances been in London at
the time when infection was presumably contracted, and further that there was no reason for suspecting
that water or milk was at fault. It was noted, however, that several of the sufferers gave a history
of having recently eaten mussels, and many of them further stated that they had on one or more occasions
partaken of fried fish. Dr. Bate, Medical Officer of Health of Bethnal Green, had already communicated
with Dr. Collingridge, Medical Officer of Health of the City of London, suggesting that enquiries
should be made with regard to certain mussels, large quantities of which were being purchased by
Bethnal Green vendors at Billingsgate. After conference with Dr. Bate, it was decided it would be
well to have further investigation made, concerning the retail sources of milk supply to the sufferers,
with a view to learning whether by any possibility a particular wholesale supply was common to two
or more of the retailers. Furthermore, it was agreed that, with the assistance of the Bethnal Green
inspectors, I should at once commence detailed enquiries into the history of the movements and doings
of patients prior to the onset of their illness, so far as these facts could be elicited at the patients'
homes; it was later found necessary to follow up these enquiries in most instances by visits to the
hospitals to which patients had been removed.
It appeared, as the investigation proceeded, that the outbreak involved a larger area than had at
first been supposed. Attention was, in fact, speedily directed to small localised prevalences of typhoid
fever, practically coincident in time with those already under investigation, in Shoreditch, Islington,
Holborn, Finsbury, St. Pancras and Tottenham; moreover, on communicating with Dr. C. W. F.
Young, County Medical Officer of Middlesex, concerning the last-named district, he informed me that
there was some increased incidence of the disease in Edmonton also. I placed myself in communication,
therefore, with the medical officers of health of all these districts, and, with their co-operation,
systematic investigation of the circumstances of the outbreak was undertaken. These enquiries were
extended so as to include nearly 300 cases notified during the thirty-third to forty-second weeks of
the year, and some later cases also. Having regard to the behaviour of typhoid fever in these
localities during the period in question, as compared with preceding and succeeding periods in 1910,
and as compared with the behaviour of the disease in adjoining areas, it is clear that at least two-thirds
of the total 300 cases must be attributed to some special cause ; while the remaining 100 cases represent
the number which might reasonably be attributed to the causes ordinarily operating.
The result of the examination of possible explanations of the outbreak may be shortly summarised
as follows:—
Water.—The cases occurring in the localities affected by the special incidence of typhoid fever
between the thirty-third and forty-second weeks of the year showed a marked tendency to develop in
clusters or groups, of which, as will be seen later, there were 33 in all. This concentration of the cases
was especially marked in Bethnal Green, where some 50 cases occurred in a circumscribed area having
a population of about 30,000 persons; but there was also marked grouping of cases in Stepney, Poplar,
Shoreditch, and in parts of Islington, St. Pancras, Holborn, and (outside London) of Tottenham and
Edmonton. Furthermore, throughout all the areas, the exceptional incidence of cases in these groups
upon members of the poorest class of the population was conspicuously apparent. Among the 300
sufferers there were some 20 persons not belonging to this class; but the 200 associated with the
groups and clusters almost all belonged to the poorest class of the population. The circumstances
in 5 or 6 of the last-named cases were, it is true, of a special character (a) but this fact rather emphasises
than otherwise the limitation of the special prevalence to poor persons. This feature cannot be explained
(a) Four were nurses, and one was the wife of a fishvendor.