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London Countg Council
Public Health Department,
Spring Gardens, S.W.,
July, 1898.
DIPHTHERIA AND ELEMENTARY SCHOOLS.
In March, 1894, I presented to the Public Health Committee a memorandum on the increase of
diphtheria in London, and I gave reason for thinking that the aggregation of children in schools, which
had continuously increased since the Education Act of 1870, had contributed in important degree to
the prevalence of the disease. There has, in fact, with increase of school attendance, been
increased incidence of diphtheria mortality on children at school age, and an examination of
the statistics contained in the reports of the Registrar-General led me to think that this increase of
incidence was not wholly explained by changes in nomenclature or classification. Since this memorandum
was presented to the Committee I have shown, in annual reports, that when the schools of the London
School Board are closed for the summer holiday there is notable decrease in the prevalence of the
disease at all ages, and that the prevalence increases when the schools re-open at the conclusion
of the holiday, and further, that this decrease and subsequent increase is especially marked among
persons at the school age.
Further statistics have become available for the study of the subject since the above-mentioned
memorandum was written, and the question has, moreover, been discussed in a report presented to
the London School Board by the medical officer of that Board, who has stated in his report the
conclusion "that school influence, as such, plays but an unimportant part in the enormous increase
of the disease during recent years in London."
I propose in this report to restate the evidence which bears upon the subject, and to include the
statistics which have become available since March, 1894. In obedience to the instruction of the
Committee, I propose also to discuss the reasons given by the medical officer of the London School
Board for the conclusion at which he has arrived, and to state how far these reasons must be accepted
as militating against the view I have already expressed.
In the first instance it is necessary that I should state very clearly that I am not attempting to
urge that if children had not been more largely aggregated in schools than before 1870 there would
not have been a serious prevalence of diphtheria during the last few years. Experience of other
communicable maladies teaches that after intervals of many years, during which the extent of their
prevalence has been comparatively limited, they again attain epidemic proportions, and there is no
reason for thinking that diphtheria is not subject to the same natural laws as other epidemic diseases.
So far as any existing knowledge of this matter may guide us, it shows that these epidemic
prevalences will occur irrespective of social changes in the population, that they are probably largely due
to some altered condition of the virus which gives to it a greater power of diffusion and a greater
power of destroying life. Social changes may, however, give opportunity for this altered condition
to manifest itself in greater degree than it would otherwise have done. This is what I believe has
occurred in respect to diphtheria, that the disease has in recent years attained epidemic prevalence
irrespective of increased attendance at school, but that this prevalence has been considerably greater
than it would have been owing to this increased school attendance; firstly, through the larger
proportion of children who have contracted their disease at school; and secondly, through the
infection of persons not attending school by those who have themselves been infected at school.
The questions, therefore, which have to be determined are (a) whether the increase of school
attendance has caused increase of diphtheria mortality beyond that which would have been experienced
without such increase of school attendance, and (b) whether this increase of diphtheria mortality
is of such magnitude as to demand that health and school officers should especially devote themselves
to preventing diphtheria caused in this way; or whether, as the medical officer of the London School
Board concludes, " school influence, as such, plays but an unimportant part in the enormous increase of
the disease during recent years in London."
There is no mention of diphtheria in the statistics of the General Register Office until the
year 1855. Before that year deaths certified to be due to diphtheria were classified with the deaths
certified to be due to scarlet fever. In London the deaths from these diseases were not separated in
the returns of the General Register Office until the year 1859. In the following tables relating to
England and Wales the first period therefore considered is 1855-60, and in the tables relating to
London, and to England and Wales, excluding London, the first period is 1859-60.
The tables have been arranged to show the facts concerning diphtheria and croup combined.
The figures relating to diphtheria and croup are, I believe, much more reliable than those relating
to diphtheria alone, deaths which would in earlier years have been attributed to croup having in later
years been attributed to diphtheria. There has, in fact, been transference from croup to diphtheria,
and the two, for the purposes of this report, should be considered together.
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