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In these circumstances it is evident that the ability to limit the spread of the disease depends upon
the opportunity for early detection of the first case. The absence of a child from school is often the
first indication to others than members of the family that the child may be ill. Any arrangement
which can be made to secure earlier knowledge of the cause of this absence promises to lessen the
opportunity for infection of other members of the family if the school child is suffering from an
infective malady. In the same way such improved arrangements would lessen the probability that
a child suffering from a mild attack of scarlet fever would return to school after a few days' absence
and before it had ceased to be infectious.
Mention is made in several of the reports of schools and classes being temporarily closed on
account of scarlet fever prevalence among the scholars. Such prevalence is commented on in the
reports relating to Paddington, Chelsea, Westminster, Lambeth, Battersea and Wandsworth. Dr.Allan,
in discussing the prevalence of scarlet fever among the pupils of certain schools in Westminster, mentions
the results found on inquiries at the houses of pupils absent from these schools. In summary
—11 cases of scarlet fever occurred in a school in St. John's Ward, and 38 children absent from school
were visited. Among those visited was one child having a sore throat and enlarged glands. No medical
man had been in attendance. In connection with an outbreak of scarlet fever among children attending
the Buckingham-gate School, visits to the houses of absentees showed that other children were affected
than those previously known to be attacked, and similar cases were observed on visiting at the homes of
absentees from the Pulteney-street and St.George's-road schools, among the pupils of which, respectively,
22 and 25 cases of scarlet fever occurred in the months of October and November.
The occurrence of "return cases" is mentioned in several of the reports. In Fulham there
were 16, in Westminster a few, in Stoke Newington 3, in Holborn 6, in Stepney 9, in Bermondsey
15, in Battersea the return cases were slightly more numerous than in the two preceding years, inWoolwich
there were 38, and in Greenwich 8. Dr. Davies, in discussing the return cases in Woolwich,
refers to the information supplied to him by the superintendents of the fever hospitals when
any child is discharged from the hospitals while suffering from rhinorrhoea, and he expresses the
wish that he might also be informed of any cases in which this condition occurred during the illness
and appeared to have ceased. He mentions that of cases occurring in Woolwich, 515 were
removed to hospital and 81 isolated at home. Only one secondary case occurred among those isolated
at home and there was no "home return case.''
Proportion of cases of scarlet fever removed to hospital.
It will be seen from diagram X that the proportion of cases of scarlet fever admitted to the
hospitals of the Metropolitan Asylums Board was about the same as in the preceding year.
Diphtheria.
The cases of diphtheria (including membranous croup) notified in the Administrative County of
London in 1908 (53 weeks) numbered 8002,, compared with 8,771 in 1907. The number of deaths
registered from this cause was 724 in 1908 (53 weeks) compared with 781 in 1907 (52 weeks).
It is well to bear in mind that the case-rate and case-mortality may be affected by variations
in the extent of use of bacteriological methods of diagnosis, the effect of which is to increase the
notified number of clinically mild cases of the disease.

The death-rate in each year since 1858 in relation to the mean death-rate of the period 18591908
is shown for diphtheria and also for diphtheria and croup combined in diagram XII.
The monthly case-rate and case-mortality in each of the years 1891-1908 in relation to the mean
of the period is shown in diagram XIV.
If the London diphtheria death-rate be compared with the death-rates of the following large
English towns, it will be seen that in the decennium 1898-1907 the London rate was higher than
that of any except Leeds, Sheffield, Bristol, West Ham, Salford and Leicester, and in 1908 was
exceeded by the rates of Liverpool, Manchester, Birmingham, Bristol, West Ham, Hull and Salford.
1 The Infectious Disease (Notification) Act came into force in 1889. 2See footnote (1), page 8.