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spread amongst the scholars throughout the school, and was also conveyed
to children living in the same tenement houses as those from the affected
school. In some instances, cases arose through the children playing
together in the streets, although there was no history of close contact,
such as is possible in school or in the same dwelling house. There were four
deaths in school children, aged 4, 5, 5| and 11 years, and in one of those
instances the death might have been prevented, had medical aid been
sought at an earlier stage of the illness. While the outbreak was being
controlled, there was the closest co-operation between the officers of the
London County Council School Medical Service and those of the City
Council. The Assistant Medical Officer of Health personally visited each
home from which a case of diphtheria was notified, examining and swabbing
the throats of all contacts. Those visits were additional to those of the
Sanitary Inspectors, who paid repeated visits of inquiry to infected
households. He also kept closely in touch with the school medical officers
when they paid their daily visits to the school for the purpose of examining
and swabbing suspicious throats. In this way several carriers of infection
were discovered, and the interchange of information regarding the infection
from the sources at school and in the homes proved of the greatest use
in dealing with the outbreak. The virulence tests which were carried
out by the school authorities were of the utmost value. Several of the
carriers, who were apparently healthy, proved to be harbouring virulent
germs in their throats and noses, and although in these cases it was not
always easy to persuade parents that their children were in a highly infectious
state, yet isolation in hospital was effected in every instance of
a virulent carrier. The matter of isolation and treatment of carriers
is still in a very unsatisfactory state. It frequently happens that carriers
who show germs intermittently when swabbed are discharged from the
fever hospitals after a few days' stay—say, after three negative swabs
have been taken. They are not regarded by the hospital authorities as
" suffering from " diphtheria, but on return home they may again prove
positive on swabbing. The vital question is, whether the strain of germ
which they possess is virulent or non-virulent. One is glad to record
that in every case where a known virulent carrier was sent into hospital,
that patient was retained for a period sufficient to permit of the infection
being cleared up or its virulence destroyed. It is generally accepted that
most carriers show some abnormalities of the throat or nasal passages;
and septic tonsils or chronic inflammation of the mucous membrane of
the nose offer favourable lodgment for diphtheria germs. Those conditions
can frequently be remedied by surgical treatment. It is very
desirable that provision should be made in the hospitals of the Metropolitan
Asylums Board for the services of a surgical specialist to deal with
those cases. By this means many sources of infection through carriers