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visits the house and sees that the necessary precautions of removal, disinfection, etc., are duly carried
out. He then requests the parents to send up those children attending school to the town-hall during
the second week after removal of the case, to have their throats examined by the medical officer. If no
diphtheria bacilli are found, the headmaster and parents are notified that the children may return to
school at once, but if they are found, a request is sent to the headmaster to exclude them until further
examination. The parents are at the same time notified of this, and asked to bring the children to
their medical attendant for an antiseptic gargle, and requested to bring them up for a second bacteriological
examination in 14 days. If, of course, any of these "contacts" at the time the inspector calls, or
during the subsequent period, develop sore throats, the parents are advised to call in their medical
attendant at once. Before carrying out this plan I consulted the medical officer of the School Board as
to its feasibility, and got encouragement and promise of help from him. The Board has now appointed
an assistant medical officer, who, when he sees any particular school or class attacked or threatened with
an outbreak of diphtheria, visits and examines the suspicious cases bacteriologically, and immediatelv
notifies the medical officer of health if diphtheria bacilli are found. These two plans so far have worked
very well, and I have experienced, as yet, no difficulty in carrying out my part, and hope to see it
before long adopted all over London and applied to all schools. I, of course, see difficulties in following
it very completely in a district like Bermondsey if there was anything like a large epidemic or a very
large number to be examined. If such, unfortunately, took place, the only plan would be to appoint a
temporary assistant to examine throats. Another difficulty would be if all the cases had to be visited,
but the parents so far have shown themselves willing to co-operate by bringing their children to the
town-hall, when the advantages of the early warning of an impending attack were explained to them.
The number of contacts examined during the year was 193, belonging to 64 families. Of these 20 were
found to have diphtheria bacilli in their throats, and of these, three developed sore throats and
were notified as diphtheria."
The use of antitoxin for prophylactic purposes is mentioned in a few of the reports of
medical officers of health. Thus Dr. Newman reports that antitoxin was used in Finsbury in
several cases, both for prophylactic and therapeutic purposes. Dr. Priestley states that antitoxin
has been distributed gratuitously by the Lambeth Borough Council for use both as a
remedy and a prophylactic during 1903, 45 vials having been so distributed within the borough.
The medical officers of health of Stoke Newington and Lewisliam recommend its use for prophylactic
purposes, and arrangements have been made in Lewisham for the free supply by the
borough council of this material "where it is thought desirable to give injections as a protective
agent."
In 18 annual reports the results are given of bacteriological examination of material from
the throats of persons suspected to be suffering from diphtheria. Of 1,382 cases thus examined
the results of 355 cases were positive, or 25'7 per cent.
The number of "return cases" are stated in a few of the reports to have occurred as
follows—Holborn, one; Shoreditch, one; Stepney, two; Wandsworth, eleven; Lewisham, twelve;
and in Woolwich six cases, all of which were attributed to infection from one child.
As a result of the arrangements made by the Metropolitan Asylums Board for every
medical officer of health to be informed of the discharge from hospital of patients admitted from
their districts, the homes of such persons have been brought under medical observation at the
time of the return of the patient. Dr. McCleary states that "the first intimation of discharge
was received from Battersea, on 15th March, and since then it has been a duty of the lady
sanitary inspector to visit the homes to which recovered patients are to return, and to advise
the mothers to take certain precautions, for instance, not to allow the child to sleep with other
children soon after his return. She also ascertains to what school it is proposed to send the
patient, and a letter is then addressed to the head teacher requesting that the child be excluded
from school for a fortnight after his return home. This procedure appears to have been beneficial."
Diphtheria and elementary schools.
The summer holiday of the schools of the London School Board began on Thursday, the
23rd July, i.e., the latter part of the 29th week, and the schools re-opened on Monday, the 24th
August, i.e., the beginning of the 34th week. If the number of cases in the four weeks preceding
and four weeks subsequent to the weeks most subject to holiday influence be compared, the
following results are obtained for the age periods of 0—3, 3—13, and 13 years and upwards. It
will be observed that the decrease in the number of cases notified during the period of holiday
influence and the increase in the subsequent period is most marked at the school age—

The interruption of the autumnal rise during the period of the summer holiday, previously
referred to in the case of scarlet fever, is equally conspicuous in the case of diphtheria, as will be
seen on reference to diagram IV., page 13.