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three days after he sickened with diphtheria, and on April 28th he was notified. Careful inquir;
elicited no other possible source of infection than that which had been obtained from M. L. Further
there was now evidence of sore throats in several persons who had come into contact with M. L
Accordingly, the medical man and myself agreed that bacteriological examination should be mad'
of the throats of the other inmates of the home. This was carried out on April 26th, 28th, 29th anc
30th, with the result that the diphtheria bacillus was found in the sore throats of B. H., N. N., anc
N. V., and these three patients were notified and removed to hospital. It was also found in the throati
of four other persons who showed no clinical symptoms. It was absent in the throats of six othe
persons in the home. Of all these, seven persons were at once inoculated with anti-toxin as prophylactic
and antiseptics applied to their throats. One of these (O. A.) having the diphtheria bacillus in he:
throat (on April 29th), but who showed no signs of illness, slept away from the home, and came int<
contact with Miss C., who slept in Poplar, and she apparently took infection from O. A. and sickenec
with diphtheria. Here, then, we have a history of one little boy in an institution contracting infectior
from a diphtheria nurse, and through him and through the nurse 15 other persons came into the wa\
of infection. Five remained quite well. Six others had sore (diphtheritic) throats. Four others goi
true diphtheria. Prompt investigation, coupled with antiseptic applications to the throats and inocu
lation of anti-toxin, stamped out what, in all probability, would have been a considerable outbreak o:
diphtheria."
As matter of course, diphtheria, due to infection transmitted from person to person, finds
in schools the largest opportunity for spreading, and it is under these conditions that unrecognised
and " carrier " cases are able to do the greatest mischief. l)r. Caldwell Smith gives account
of three outbreaks of diphtheria among the children attending schools in Wandsworth. Among
the children attending St. Anne's School, Wandsworth, 32 cases occurred, these cases being
distributed throughout the year. The infants' department was most affected, but personal infection
in school did not seem to be causing the spread of the disease, and there were ample
opportunities of infection other than in school hours. In another school, the Swaffield-road Board
School, 34 children were attacked in November and December. The first case was notified on the
9th October, the child having been at school last on the 3rd. Dr. Caldwell Smith writes—" This
case, although the first notified, was not the first actual case, but it was not till the 27th October
that the cause of the first series of cases was discovered. On that date, in consequence of inquiries
as to school absentees, I received information that three children in one family were suffering from
sore throat, and I ascertained that one of them had been ill since the 2nd, and that he had been
at school in the infants' department on that date. His sister, however, was allowed to attend school
till the 13th, and she had suffered from sore throat since October 6th. Another unrecognised case
was the cause of a second series of cases, the girl having been taken ill on the 13th October, and
although she was not at school from the 13th to the 20th, she returned on the latter date, and was
at school while she was still in an infective condition till the 27th. A third unrecognised case was
notified on the Gth November, having been taken ill on the 12th October; but this case only
infected three children in the same house, as the child did not go to school after the first symptoms
appeared.'' The third school outbreak occurred among the pupils of the Cavendish-road Hoard
School, 70 of whom were attacked in 1902, 22 of the children attending the infants' department
being attacked in November. The infants' department was closed from November 28th to
December 15th; eight cases were notified after the closing of the school, but five of these were
possibly infected previously. Dr. Caldwell Smith also comments on the continued prevalence of
diphtheria since 1890 on the Hyde Farm estate on which this school is situated, and he states that
the wetness of the soil is no doubt one of the chief causes of this undue prevalence of diphtheria.
He writes : tk I had come to the conclusion that in houses built upon a wet soil which contains
a large portion of organic matter, cases of diphtheria may be looked for, the germ existing in the
superficial layers of the soil. It is probable that the infection is conveyed to the mouth by the
hands of the children playing with this soil, and consequent infection from person to person." He
adds: "Unrecognised cases in this outbreak were responsible for a large proportion of the cases.
In the house where eight cases occurred one unrecognised case infected the others, and it was only
by a bacteriological examination after a second case occurred that the original case was detected.
In several of the cases the diagnosis was made only after bacteriological examination."
The occurrence of cases of diphtheria among the children attending the Ancona-road Board
School, Woolwich, led Dr. Davies to communicate with the medical officer of the London School
Board, and Dr. Thomas, assistant medical officer, forthwith examined all the children in two classrooms
of the infants' department. Dr. Davies writes: 44 He picked out 10 cases for bacteriological
examination, one of which had obvious diphtheria when 1 saw her, and one was found to have the
diphtheria germs in a nasal discharge. Four others were found to have pseudo diphtheria germs
in nasal discharges from which they suffered. In addition to these I found, on visiting the houses,
three pupils of this school and one pupil at another school with undetected diphtheria not under
medical treatment. Three of these were in attendance up to the day preceding my visit, With
the exclusion of the children above mentioned, the outbreak at the Ancona-road School was abated.
The measures described above had the desired effect, and during January of the current year there
was only a total of 17 cases of diphtheria in the borough, and only one was a pupil of Ancona-road
School. Dr. Davies also records three outbreaks in families in Woolwich in which unrecognised
cases played an important part. In the first, the attack of three children was obviously due to
infection from an older brother, who was not suspected as the cause before Dr. Davies' inquirv.
He found the boy to have soreness and running at the nose, but with a normal throat. Two weeks
before, however, he had a slight sore throat, for which he had stayed away from school for half a
day. His nasal discharge was found to contain diphtheria bacilli. In the second outbreak, the
second of a series of five cases was a similar case to that mentioned above. The discovery of this
second case explained the interval between the first and subsequent cases. In the third outbreak
the cause was a previously unsuspected case, that of a boy who had been attending a school in
which cases of diphtheria had occurred among the pupils; diphtheria bacilli were found to be
present in his throat.