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The case mortality per cent., at "all ages" and both sexes, therefore, assuming the same case
mortality at each age-period in each of the three months as was observed for the whole year, works out
as follows—
March 24 76 per cent.
May 23.50 „
October 23.70 „
The variation shown in these estimated case mortalities is solely due to differences in the age
and sex distribution of the cases notified, but that these differences are obviously insufficient to account
for the variation in the actual case mortality shown for each of the three months (i.e., March, 28-09,
May, 19*91, and October, 21-22) will be seen more clearly by applying to the actual case mortalities a
factor, calculated from the estimated case mortalities, for the approximate correction of differences of

Hospital accommodation.
During 1894 3,666 cases of diphtheria were admitted into the hospitals of the Metropolitan
Asylums Board, or 32.8 per cent. of the cases notified. The proportion of the total deaths from
diphtheria which occurred in these hospitals was 39.2 per cent., a greater proportion than in any previous
year, as will be seen by reference to diagram XI.
Diphtheria and elementary schools.
In my last report I discussed the relation of school attendance to an increased incidence
of death from diphtheria on the school age period of life since the Elementary Education Act came into
force, and I stated my reasons for thinking that the aggregation of children in schools played an
important part in the dissemination of diphtheria in London. It may be recollected that the notification
statistics of the year ] 893 showed that when school operations were suspended by the summer
holidays there was a notable diminution in the prevalence of diphtheria at " all ages," and especially
among children at the school age period of life, and that a marked increase followed the re-assembling
of children at the conclusion of the holidays. With a view to learning whether the experience of 1894
affords similar evidence, the cases of diphtheria in that year have been cast into weeks, and grouped
into three periods of four weeks, corresponding with the four weeks immediately before the effect of
the summer holidays would be manifested, the four weeks during which this effect would be manifested,
and the four subsequent weeks.

It will be seen that the number of attacks among children under three years of age was decreased
in the third period of four weeks, and reference to diagram XII., shows that the August depression of
the curve, showing attacks in children at this age, occurs somewhat later than the depression in
the curve showing attacks in children from 3-13, in a way to suggest that the attacks in children
at the earlier age were due to infection from the older children, and that the decrease in the attacks
of the former was due to diminished opportunities of infection from the latter. This behaviour of
diphtheria in children at the two ages was also manifested in 1893.
The year 1894, therefore, teaches the same lesson as the preceding year, so that the attention
of medical officers of health and of school authorities should be especially directed to a study of the
conditions required to lessen as far as possible the opportunity which school attendance affords for the
communication of this disease from one child to another.
In many of the annual reports of London medical officers of health relating to the year 1894,
opinions are expressed as to the circumstances that have contributed to diphtheria prevalence. In
particular instances defects in the sanitary condition of houses are referred to. In the report relating
to Poplar and Bromley the medical officer of health notes that the Isle of Dogs, which is the dampest
part of the district, suffered the least, and that North Bromley and Bow suffered most, his opinion being
that the greater prevalence "was due to the inadequacy of the County Council's main sewers which
run through these sub-divisions." In the annual report relating to Hackney account is given of the