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These boroughs contributed the relatively small total of 509 cases during the
epidemic period. It is also remarkable that, after 1928 (with the exception of
limited outbreaks in St. Pancras and Holborn during 1929 and 1930, and in Hammersmith
during 1931), only sporadic cases of the disease appeared in the boroughs
to the west of Islington, Finsbury and Lambeth. The total number of cases
admitted throughout the period from the 14 boroughs which contributed less than
50 per annum during every year of the period was 381.
During the period 37 patients suffering from smallpox died. Three of the fatal
cases occurred among the passengers and crew of a liner which brought the infection
of the severe toxic type of the disease from Bombay, and 34 were patients infected
by the mild type of the disease then prevalent in Greater London. In 12 of these
the fatal result was primarily due to the toxaemia of smallpox, and in 22 the attack
of smallpox was at most a secondary and adjuvant cause of death, which was
primarily due to serious organic disease, to premature birth or to senility.
In previous annual reports, covering the period under review, reference has
been made to the type of the disease, i.e., to the low degree of virulence which is
demonstrated by the case fatality throughout the whole epidemic period. This cardinal
feature was maintained with no appreciable variation for upwards of six years
in greater London, just as it had been maintained throughout the provinces since
1919, when the type was noted in the eastern counties. There has been no evidence
of any exacerbation of virulence either in the clinical features of the disease or in
the case fatality of our modern native smallpox. Cases of this mild type, cases of
the severely toxic type and cases of vaccinia are all mutually protective. The severe
cases of the disease, carrying the highly virulent infection brought from India in the
spring of 1929, were accommodated in the wards of the hospital which were already
occupied by cases of the mild type prevailing at that time in London. The only
distinction between the two types lies in the virulence of the infection, i.e., in the
severity of the reaction of the patient to the virus, a distinction which cannot usually
be recognised in individual cases, but only by observation of case severity and case
fatality extending into at least the second generation of an outbreak of the disease.
Under any conditions, in dealing with smallpox, varicella (chickenpox) is the
disease which gives rise to the greatest difficulty in diagnosis, and, when the prevailing
type of the disease is mild, it is inevitable that the number of cases in which difficulty
occurs must increase. Experience during the period under review showed that
in a proportion of cases, more especially when leave to use vaccination for diagnostic
purposes was refused, differentiation became too entirely a matter of opinion to be
administratively reliable. It is satisfactory to note that the use of the variolavaccinia
flocculation reaction, in the technique perfected by Professor W. J. Tulloch,
of St. Andrew's University, was found to be a reliable diagnostic criterion. Experience
at the smallpox receiving station suggests that this test might, with advantage, be
more extensively used in the differentiation of variola before removal of a suspected
case to the receiving station, particularly in patients who refuse the protection of
vaccination.
Responsibility for the treatment of infectious diseases.
From time to time difficulties had arisen with extra-metropolitan local authorities
as to the responsibility for the treatment of inhabitants of London who had contracted
infectious disease while temporarily resident outside the county. The Council
therefore decided to ask the Minister of Health to consider the possibility and desirability
of issuing regulations under Section 130 of the Public Health Act, 1875, dealing
with the matter. On 25th June, 1934, the Minister issued such regulations (which
came into force on 1st July, 1934), the operative clause in which is as follows :—
The London County Council, the council of every borough or urban or rural
district, and every Joint Hospital Board constituted under the Public Health
Act, 1875, and having the powers of Section 131 of that Act, shall have the
same powers and duties in relation to the provision of hospitals or temporary
places for the use of persons who are for the time being within their county,
borough or district, as the case may be, and are suffering from infectious disease,
as they have for the use of the inhabitants of that county, borough or district.