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Some of the remarkable diminution in the sickness from
scarlet fever may truly be ascribed to the more prompt measures
against spread that we have been enabled to take since we have
been constituted a separate sanitary area; for the principles of
preventive medicine can always be more efficiently applied to small
sanitary areas than to large ones, and for the best fruits of public
health administration many of the London sanitary areas are
unquestionably too large.
Diphtheria.—It will be noted that our death-rate ((H6) from
diphtheria is not a high one, and that it compares most favourably
with the corresponding rates of London generally (0.60), and of
the 33 great Towns (0.37). The increase in diphtheria during
the past few years, more especially in town districts, has been a
matter of great concern among health officers. That this increase
should grow at the same time that the principles of sanitation
are becoming more and more appreciated by the general public,
and more efficiently applied by sanitary authorities, appears at
first sight to be almost a public-health paradox, for there is no gainsaying
that diphtheria is a disease, the true origin of which is
associated with the insanitary conditions of dirt, dampness, and
foul air. The cause of the increase of the disease must doubtless
be sought, therefore, in increased facilities of spread from primary
cases. I think that the increase in the number of houses which
were originally planned and built to accommodate one family, and
which now, owing to the exigencies of the times, are converted into
tenement dwellings for several families, may in itself, by reason of
the overcrowding and the insanitary conditions which are almost
inseparable from such a state of things, be responsible for some of
the increase in diphtheria in our large towns ; but the main cause
for the increase will probably be found in school attendance. Quite
apart from any statistical evidence that may be collected to support
this latter view, it stands to reason that where a disease is concerned
that mainly affects children at ages when they attend school,
and which can be communicated in its severest form by those who