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Tables V. (a) and (6) serve to bring out conspicuously the following facts—
1. That antecedent to 1871-80, in groups of population where the diphtheria death
rate at all ages was rising, the rate at ages 3-10 years, though generally rising also, rose in
less degree than the all age rate; and that when the all age rate was falling, the rate at ages
3-10 years fell in even greater degree than the all age rate.
2. That in 1871-80, with a general decline of the diphtheria mortality at all ages, in the
several groups of population, there occurred in each group at ages 3-10 years a relatively
higher diphtheria death rate than before: that is, the diphtheria mortality at ages 3-10
years did not fall in 1871-80 in anything like the same degree as the diphtheria mortality at
all ages.
This new departure is most notable in London, least notable in the rural groups; and inasmuch
as it is suggestive of a fresh factor of diphtheria at ages 3-10 years becoming operative in the decennium
1871-80, there is room for more regret that data for the decennium 1881-90 are not available for all the
groups of population that are in question. As regards England and Wales and London, however, in
1881-90 it may be pointed out that as compared with 1855-60 and 1861-70 the special incidence on
the age 3-10 years is practically maintained.
Inasmuch as the England and Wales and urban populations are made up of other of the five
groups under consideration, it is convenient to compare the urban (excluding London), the rural and
the London diphtheria rates. It is then seen that the mortality at ages 3-10 years was in 1871-80
maintained in the highest degree in London next in the "urban" (excluding London) population, and
least in the "rural," a fact which is suggestive of some new condition coming into existence operating
unequally upon this age-period in these different communities, or that such condition had been in
1861-70 already more strongly in operation in the districts inhabited by the rural population, less in
operation in the "urban" (excluding London) districts, and least in London; and that its influence in
1871-80 on the two last and especially London prevented these groups of population from sharing
in the fall experienced by the "rural" population at 3-10.
The well recognised tendency of diphtheria to spread in schools naturally presents itself for
examination, and the new departure I have noted needs to be considered in connection with the
Elementary Education Act of 1870.t This Act came into operation in 1870, and since that time
children have been increasingly aggregated in schools where opportunity for the communication of
the disease from one to another necessarily occurs.
If increased school attendance has been responsible for the greater incidence of diphtheria on
children at school ages, it is to be expected that the increase of diphtheria at these ages would in
point of time correspond with this increased attendance.
Table VI. relating to London shows a notable increase on the age period 3-10 in the year
1871, which has been maintained more or less ever since, and has in later years been much accentuated.

† The influence of school attendance was pointed out by Mr. W. H. Power as early as 1876, and its effects
have been recognised in a number of investigations made since. Dr. Thorne in his Milroy lectures published
in 1891, in discussing the prevalence of diphtheria, refers to the increased opportunity for the dissemination of
the disease by schools which has been given by the Elementary Education Act, and I have already in the same
year (Presidential address to the Society of Medical Officers of Health; pointed out the change in the age
incidence of diphtheria mortality in London since the passing of that Act.