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36
in the first group. The sanitary condition of these houses was found to be faulty, the drains defective
and the sewer unventilated.
In several of the reports of medical officers of health reference is made to the existence of
insanitary conditions in houses in which cases of diphtheria occurred and the medical officers of health
of Poplar (Bow) contains a tabular statement showing the state of each house invaded by the disease.
Diphtheria, and elementary schools.
The annual reports of medical officers of health contain the following references to diphtheria
in association with schools.
Paddington.—The medical officer of health gives account of nine cases and four deaths occurring
in the "baby class" of the infant school Sultram-crescent High School. Due to the nine primary
cases there were seven secondary cases occurring in the families of these infants. There were besides
four other cases with two deaths among children living in Willesden, but attending this class, which had
an average attendance of forty-five children. The class was closed by resolution of the sanitary
authority from the 18th June to the 10th August. During August considerable defects were
found in the drains of the school. The circumstances in which disease first came to be introduced into
the school are not clear, but it is noted that the teacher had a sore throat some weeks before the outbreak,
but her medical attendant was satisfied that this illness was not diphtheria.
Fulham.—The medical officer of health writes—
There was an outbreak of diphtheria among children attending the infants' department of Hugonroad
Board School, in December, 1895; it was hoped that, as the school was closed from December 20th
to January 6th this would have the effect of checking the disease, but a week after the school re-assembled
several more cases were notified, and arrangements were made to close the school should any further
cases occur; this, however, was not found to be necessary.

He states that closure of the schools in August had but little enect in arresting the progress of
the epidemic, but among children from 3 to 13 years of age, there was diminution of cases in the
period comprising the 33rd to 36th weeks, namely, 31 cases as compared with 38 cases in the
tour-weekly period preceding. During February, March and April the cases at school age (3 to 13
years) formed 52 per cent. of the total cases. In May this percentage was increased to 58, in June
to 69, and in July when the full force of the epidemic began to be felt, to 76 per cent. He adds—
In view of this progressive increase in the proportionate numbers of cases at school-age, at a time
when the epidemic was rapidly increasing in intensity, and having regard to other circumstances which
are within my knowledge, I am much inclined to the opinion that the epidemic in July was, in some degree,
facilitated by the existence at that time of mild unrecognised cases of the disease among children who continued
school attendance. The marked increase in the number of cases at school age in June and July is
very suggestive, whilst in August, when the schools were closed, the percentage of cases at school age at
once fell to 63 from 76 in July, In view, then, of the very strong probability that the July outburst was
facilitated by the continued attendance at school of cases of sore throat, which were in reality mild cases
of diphtheria, it is my intention in future, should circumstances appear to demand it, to ask the school
authorities to co-operate with me in an endeavour to exclude from attendance at school all children
suffering from sore throat, and to concert such measures as may appear to be needful to carry this
endeavour into practice. With diphtheria, as with other infectious diseases, an epidemic may be
stamped out at its commencement by measures designed to prevent the diffusion of infection among
the susceptible population, but once allowed to obtain headway, an epidemic gets beyond control, as
indeed occurred in July last.
In an interesting special report to the vestry on "Diphtheria in Chelsea from 1890 to 1896" the
medical officer of health shows the annual average number of cases of this disease among children aged
from 3-13 years which were notified in successive periods of four weeks during this time—
Weeks 1-4 7
5-8 7
7-12 8
13-16 8
17-20 8
21-24 8
25-28 11
Weeks 29-32 15
33-36 6
37-40 13
41-44 14-5
„ 45-48 16
49-52 14
Hackney.—The medical officer of health gives a detailed account of the circumstances of
prevalence of diphtheria in the fourth quarter of 1896. Examination of the distribution of these cases
showed a special prevalence of the disease in Clapton-park and among the scholars of the Daubeneyroad
Board School. A special area of six enumeration districts was selected for closer study, and it was
found that in a period of eight weeks the attack rate per 1,000 persons was in the selected area 3'8,
and in the remainder of Hackney .38. Again it was found that of children from 3 to 15 years of age
the attack rate was in the affected area 11.05, and in the rest of Hackney .84 per 1,000. Of 48
children attacked with diphtheria in the selected area, 36 attended the Daubeney-road Board School,
and 6, 5 and 1 attended three other schools, the average number of children attending each of which
was in excess of that of the Daubeney-road Board School. Careful inquiry was made into the distribution
of these 36 cases among the infants', girls' and boys' departments of this school, and it was found
that while the percentage attacked was in the infants' department 7.5, it was 1.5 and .47 respectively
in the girls' and boys'.
Inquiry into milk supply and other possible causes was made, with the result that milk could
be excluded, and only exceptionally were faulty conditions found in the houses. The drainage of the
school was found to be satisfactory, but the latrines were very foul.