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18
In 37 houses where diphtheria occurred the drainage system presented defects which were
remedied in response to notices from the sanitary inspectors.
During the last week of November and the first week in December an outbreak of diphtheria
occurred in the Fox London County Council School which eventually lead directly or indirectly to
the infection of 21 children. Of this number two died. The epidemic began in two class-rooms
described respectively as Room A and Room Al. In Room A1 a child G.G., who appears to have
developed the first symptoms of diphtheria on November 27th, continued to attend in an infectious
state until November 29th. On December 1st she was notified as suffering from diphtheria and
removed to hospital. No further notifications in regard to children in this room were received
until December 5th, but subsequent inquiries proved that two girls who attended the infected class
for the last time, on November 30th in one case and December 1st in the other, both developed
diphtheria on their last day of attendance. Since December 1st was a Friday the absence of these
children did not arouse suspicion until Monday morning, December 4th. On Saturday, December
2nd, the first case in Room A was notified in the person of a girl I.H. who attended school for the
last time on November 29th, which was also the last day of attendance of two further girls in the
same room who were notified as suffering from diphtheria on December 4th and December 5th
respectively. On December 5th material for bacteriological examination was taken from the
throats of all the children present in Rooms A and Al by one of the County Council's school
medical inspectors. By order of two members of the Public Health Committee acting upon my
recommendation, the affected rooms were closed from December 6th until Monday, December 11th,
in order to prevent the children who had been examined from reassembling before the bacteriological
results had been obtained. The bacteriological report showed that in Room Al no less than six
children were harbouring diphtheria bacilli in their throats. In the adjacent Room A the results
were in every case negative. When the children reassembled on Monday, December 11th, those
who had been absent on the previous Tuesday were examined with the result that two girls in Room
Al and three in Room A were found to be harbouring diphtheria bacilli and were excluded. In
addition to this number, 26 other children who were absent from the same rooms for various
reasons were visited in their homes. Bacteriological examinations were made in nine cases, with
the result that one child with a mild form of sore throat proved to be suffering from diphtheria.
One school child infected three others in the orphanage where she resided, whilst two other children
in the same Institution were found to have diphtheria bacilli in their throats and were isolated in a
separate dormitory. It is a remarkable fact and one which deserves to be recorded that when at
the end of 12 days these children were again examined with a negative result and set free both
developed diphtheria within 20 days. No other carrier could be found in the Institution, neither
had any one of the children removed in December returned from hospital. They must accordingly
be regarded as either having been self infected or as having derived a fresh infection from some
unknown source. In either case their history points to the conclusion that healthy carriers cannot
be sent to a hospital ward reserved for diphtheria without risk of infection. It is true that such
children could be protected for the first weeks of their stay in hospital by the injection of antitoxin,
but it is to say the least doubtful whether the accidental circumstance that artificial protection can
be conferred could be held to justify the segregation of healthy carriers in diphtheria wards, if as
the histories related suggest they may in certain cases be naturally liable to diphtheria.
The history of another case illustrates the difficulty of diagnosis and the length of time during
which a patient who has suffered from diphtheria may continue to be capable of infecting others.
The circumstances were as follows:—
A girl, E.W. attending in Room A, was reported as absent from school with a sore throat, on
December 5th. She was attended by a medical practitioner with a considerable experience of the
bacteriological examination of suspicious throats in a large children's hospital. In the swab which
he took from the patient's throat and forwarded to the Lister Institute, the bacillus of diphtheria was
not found. The recognised clinical signs of diphtheria were not present and in these circumstances
the parents were informed by their doctor that in his opinion the fact that their child had
been exposed to infection at school did not in the absence of bacteriological and clinical signs justify
a diagnosis of diphtheria. The child was accordingly not notified. On December 23rd her brother
developed diphtheria and was removed to hospital. In my view there is no doubt that E.W.'s
illness was also due to diphtheria. During the month of April she was engaged in taking out daily
a small child aged two years who lived in a street more than half a mile away from E.W.'s home.
On April 14th this child developed laryngeal diphtheria and died in hospital after four day's illness.
At the same time E.W. continued to attend the Fox school, and on April 17th a girl in the same
class developed diphtheria. This was the only case that occurred and no suspicion attached to
E.W. or any particular girl in the same room. On April 25th every child in the class was examined
bacteriologically and E.W. was found to be carrying diphtheria bacilli both in the throat and nose.