View report page

4
of infection at school when he says infection by a class-mate can be excluded, and
apparently one case in the infants' department of the St. Stephen National School. This
possibility of school infection as distinguished from class-room infection is, however,
altogether ignored in his discussion of the details relating to the Board school, boys' and
infants' departments ; in these schools the possibility of infection by class-room mates only is
studied.
This method of treatment requires no further comment from me; but it may be pointed out that
even if other opportunities of infection in school be excluded than those the class-room itself affords,
Dr. Hamer's notes supply evidence that Dr. Smith's figures require amendment. It should be noted
that Dr. Smith is here only dealing with notified cases of diphtheria, and thus he obtains intervals
between successive cases in class-rooms which exceed seven days ; while Dr. Hamer, who includes cases
of sore throat occurring in families in which a case of recognised diphtheria subsequently occurred, in
certain instances bridges over these intervals. Limiting consideration to children in the three
schools specially affected: Lewisham-bridge (boys), Lewisham-bridge (infants), and the St. Stephen's
National school, whereas Dr. Smith's Table VI, shows, only 10 cases, in which he will admit the
possibility of class or school infection, out of 53 children attacked, Dr. Hamer finds 29 cases, which on
this basis might be regarded as cases of class-room infection out of a total of 59 attacked. This 59,
moreover, included, to comply with the conditions imposed by Dr. Smith, 14 or 15 children who were
the first subjects of attack in their class-rooms, and who cannot, therefore, if his view is to obtain, have
received infection in the school.*
(8.) A further point to which reference is made by Dr. Smith is the question how far the opening
of a cottage hospital by the sanitary authority and the removal of cases of diphtheria to the
hospital brought the outbreak to an end. He writes (page 11, par. 2)—
"In the latter weeks of September, owing to the great pressure on the space of the
Metropolitan Asylums Board hospitals, cases of diphtheria in Lewisham were obliged to
remain six, seven and eight days in their homes before removal was possible. The Lewisham
Board of Works decided, therefore, to open one of the wards of their cottage hospital for the
reception of these patients. This was done on October 4th, and as soon as the cases were
promptly removed, so did the notification of fresh cases decrease—from twenty-one in the
week ending October 11th, to five in the week ending October 25th. By this latter date,
however, the ward was full, and the district becoming once more congested, fresh cases began
to increase. A second ward was therefore opened, and—immediately on removal of the cases
to hospital—a marked decrease in the notifications again occurred. The part played by cases
which were nursed at home for a longer or shorter period in aiding the spread of the disease
seems, therefore, to be clearly indicated."
Dr. Hamer has expressed the opinion that the keeping away from school of so large a number
of children was one of the factors at work in serving to check the spread of diphtheria. That this view
is correct is, I think, sufficiently shown by the fact that when the dates of beginning of illness of first
sufferers among the children at the two schools is considered, it is found (see Dr. Hamer's chart) that
first attacks had practically ceased among the boys in the Board school and among the children in the
National school by the end of September, when the reduction in attendance had occurred, and before
the date (4th October) when the hospital was first opened. In the case of the infants' department of
the Board school, first cases only subsequently manifested themselves during the first nine days of
October.
The remaining paragraphs in Dr. Smith's report are devoted (a) To a statement of what he
"gathers" are the "suggestions" in Dr. Hamer's report as to administrative procedure, with a view
to the limitation of the spread of diphtheria by school attendance; and (b) To a statement of the rules
of the Board on this subject. Dr. Hamer did not discuss in all its details the general question of the
prevention of the spread of diphtheria by school attendance; he commented upon the circumstances
of the Lewisham outbreak, and upon those only, in order that any lesson they taught might not be
lost. His view was, that the early closing of the affected classes would have more speedily brought
the outbreak to an end. This opinion was, I submit, amply justified by the history of the outbreak.
I would desire in conclusion to refer to the following methods adopted by Dr. Smith in his statement
of the circumstances of this outbreak.
(a) In his examination of a report dealing with a localised outbreak of diphtheria,
which had in this report been attributed to a particular cause, he includes in his figures the
cases occurring in a large area, and during a period which extends beyond that in which this
cause had been said to be directly operative.
(b) By excluding, save in a trifling number of instances, any consideration of the effect
which may be produced by a child suffering from diphtheria upon its school-mates, who do not
actually happen to share the same class-room with such child, he reduces the number of cases
which may otherwise reasonably be thought of as school-infected.
(c) In this manner he excludes from the number of children who may be reasonably
thought of as school-infected every child who is the first recognised sufferer from disease in
its class-room. Thus, inasmuch as 14 or 15 class-rooms in the schools above referred to were
infected, this number of cases of diphtheria is included among his "cases in which the evidence
excludes the school as the source of infection."
(d) By exclusion from consideration of throat illness, other than recognized diphtheria,
occurring among children attending school, even when these cases of throat illness are
followed by recognized cases of diphtheria in the same homes, he is able to show, in a greater
number of instances than he otherwise could, certain intervals of time between successive
*Dr Smith may have treated one of these cases exceptionally.