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character. The provision of isolation hospitals depended upon the belief that all cases of diphtheria
partook of the nature of a dangerous illness, and if only the cases were isolated the spread would be
controlled. It is now quite certain that the chief agents of spread are individuals suffering so
slightly that they may go about their daily avocations, and while in themselves suffering only from
slight malaise, may be sources of danger to more susceptible persons; also, though more rarely than
the foregoing, those who have been in contact with cases of diphtheria without themselves appearing
to suffer in the slightest degree may yet afford, in their buccal cavities, a suitable hiding for the
growth of the micro-organism, and these individuals become the "carriers" of infection to others.
In view of the number of such cases probably preponderating over the actual cases of severe
diphtheria, isolation hospitals must be looked upon as much less important in the prevention of the
disease than has hitherto been assumed, they receive mainly the severe cases, which, by the nature
of things, must be limited in their power of spreading diphtheria, inasmuch as they are so ill as to
be confined to the sick-room, while the slight cases, which are much more dangerous to the
community, remain undetected and roam at large. Moreover, it often happens that a child who
returns from a fever hospital remains still infectious, and sets up return cases. As Newsholme has
pointed out, there are such things as chronic diphtheria and chronic scarlet fever.
Much more important than isolation hospitals, therefore, are facilities for bacteriological
examination. There is no doubt that these are quite insufficient in the metropolis, and it is a
question worthy of the attention of the Council whether a central, well-equipped laboratory, freely
available for all suspected cases, is not needed to cope with this widespread danger.
Unfortunately, too, these facts in the natural history of the disease are as yet unknown to
practitioners, who are generally unaware that diphtheria may be a mild complaint which cannot be
clinically recognised, or that healthy contacts may be "carriers" of the complaint. The very slightest
catarrh occurring in a member of a household where a case of diphtheria has occurred should be
at once isolated, and treated very circumspectly until bacteriological examination has been made;
and if we are to hope to have the disease stamped out, no member of a diphtheria household should
be allowed to go about his daily employment without first having been tested bacteriologically, and
no sufferer should be allowed to mix again in the general community until a succession of testings
ha3 given a uniformly negative result.
MEASLES.
Measles is the most fatal disease of childhood, and the one which plays the greatest
havoc with school attendance. Two months after my appointment, the late School Board approved of
a scheme for a thorough inquiry in a limited area, to extend over about five years. The area selected
was Woolwich, and the Medical Officer of Health has co-operated, so that the measles history of
each child is kept on a card from the day of its entering the infant school. In one half of this
district it has been attempted to suppress every appearance of measles by rigorous class closure; in
the other half individual exclusion is followed, and the schools are not closed if this can be avoided.
The inquiry began in the autumn of 1902.
It was soon found that 50 per cent. of children had already had measles before coming to the
Infants' Department, and 84 per cent. had it before passing out of the infant school. These figures
will, of course, vary considerably according to whether the disease has been recently prevalent or
not. The cards show at any time the susceptible material present in each class.
During the following year each outbreak was followed as well as possible, and the conclusion
arrived at that the only successful cases of closure depended on closure on the appearance of the
first case in a susceptible class, and experience showed that closure for measles, which hitherto had
only been resorted to as a panic measure when the disease becomes prevalent is, under such
circumstances, of no avail. The necessity for the prompt notification of every case of measles
became apparent, and the fact that where the head mistresses had special knowledge they prevented
the spread of the disease in their schools, which suffered much less than the other schools.
Now, during the past year increasing duties have made it more difficult for Dr. Thomas to
follow up this work, but he has had the aid of a sanitary inspector, and each school has had the