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" Parenchymatous lonsilitis " for the condition in contradistinction from Membranous or Follicular
tonsilitis.
(7) Marked and persistent enlargement of glands at the angles of the jaw.
Particular stress is laid on the persistence of the enlargement of tonsils and lymphatic glands.
The enlargement seems to remain much longer than is the case in ordinary acute tonsilitis. The cases
are often designated mumps by the teachers in schools owing to the marked enlargement of glands at
the angles of the jaws. I have seen no case of parotid enlargement and none in any way resembling
sub-maxillary mumps. The practice of using this description should, if possible, be discouraged.
(8) Raised temperature. (9) Running at the eyes—conjunctival congestion is common. (10)
Cough (frequent). (11) Coryza (frequent). (12) Vomiting (occasional). I have had no opportunity
of testing for albuminuria and I have not in any case detected a rash.
Generalisations, concerning the Flora-gardens outbreak, based for the most part on information
supplied me by the head teacher, are alone possible. I understand that the earliest cases occurred in
October, amongst the youngest children in Class A. This class became bodily converted at the time of
the school remove in October into Class B, which is at once the youngest and largest class in the infant
school. It is not, therefore, surprising that the incidence of illness has been heaviest there. The
head teacher inclined to the opinion that infection had spread upwards through the infant school, Class
E being the penultimate class affected and Class D the ultimate.
Opportunities for free admixture of all the children in the department exist and, save that there
seemed little doubt that infection had spread from class to class at the remove and from child to child,
the exact path could not be traced, seating arrangements having undergone much alteration as the
attendances diminished from illness. Adult teachers, male and female, and older children in the
boys' and girls' departments have succumbed to sore throat with symptoms similar to those described
amongst the infants and, therefore, inferentially, to the same infection. Neither in numbers nor
severity were senior departments in any of the schools I have visited, attacked as were the youngest
children.
(Here there follows a detailed description of the Bacteriological methods of Investigation
employed).
A considerable literature is in existence on the part played by Micrococcus catarrhalis in
Epidemic disease, particularly in association with outbreaks resembling influenza, and writings on
the subject tend to confirm the view that the epidemic under investigation is of the nature suggested.
Particular reference is here made to a paper by R. A. Dunn and M. H. Gordon on " The Clinical
and Bacteriological aspects of an Epidemic simulating Influenza in the East Herts. district "(B.M.J.,
August 26th, 1905), wherein a very complete account of clinical features and bacteriological findings
is recorded.
In discussing the symptomatology of the outbreak, the authors make the significant observation
that " taken individually, many of the younger patients bore a striking resemblance to scarlet fever,
and the rash, sore throat, circumoral pallor, vomiting, strawberry tongue and desquamation, were
extremely suggestive." I have stated above that I did not observe any child with a rash among those
I examined.
It is of further importance to note that in the East Herts. epidemic severe cerebral symptoms
followed closely on tonsillotomy in two cases. The marked and persistent tonsillar enlargement combined
with relatively little evidence of acute inflammation which forms an outstanding feature of
the present outbreak, so far as I have observed (and this observation has, I know, been confirmed
by others of my colleagues in the school medical service), is likely to induce those who are unaware of
the cause, freely to advocate the operation of tonsillotomy.
In conducting this enquiry I have been very greatly indebted to the advice and experience of
Dr. Mervyn Gordon, Bacteriologist at St. Bartholomew's Hospital, and in particular have to acknowledge
my thanks for his permission to make use of the essential link in my chain of evidence afforded by
the results of his examination of cultures from the throats of acute cases of scarlet fever."
Measles.
After a period of very low prevalence in 1919, measles became epidemic in the spring of 1920.
During the year 28,888 cases of measles and German measles were reported from the schools, the
highest number recorded since 1915. The scheme providing for the better control of measles in the schools
through the co-operation of the school nursing service, school attendance officers, and the staffs of the
local sanitary authorities (described in the annual report for 1919), was put into operation for a period
of 6 weeks during April and May with very satisfactory results as will be seen in following statement.
(1) No. of schools visited by nurses 233
(2) No. of sessions devoted to work 673
(3) No. of cases of definite measles discovered to be in attendance at school,
excluded and reported direct to the borough medical officer 59
(4) No. of suspicious cases of measles discovered in school and excluded by
nurse 541
(5) No. of these suspicious cases referred to in (4) which subsequently
proved to be measles 139
(6) No. of doubtful absentees reported to school attendance authorities
for immediate visitation 4,296
(7) No. of these absentees referred to under (6) subsequently proved to be
measles 776
Unprotected children were temporarily excluded from 465 class-rooms and all children under
5 years of age were excluded from 72 schools as precautionary measures. Under regulations of the