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147
Report of the County Medical Officer—Education.
be protected from the possibilities of infection. So far as children are concerned a rigid policy of
exclusion from school is consistently adopted in such cases, but the problem of satisfactorily dealing with
cases outside the jurisdiction of the education authority by some comprehensive and co-ordinated system
has yet to be solved.
Special investigations, extending over several months, were carried out in the case of six schools
where diphtheria was particularly prevalent during 1911-12. The investigations involved many visits
and much bacteriological work. The outbreaks are fully described in the following pages, in order
to illustrate the marked tenacity with which the disease persists in certain schools and districts, and
to give prominence to its various characteristics.
(I) Princess-road School.—During the autumn and winter of 1910-11 this school was entirely
free from diphtheria. The first notified case was from room 6 of the infants' department on April 19.
By the end of the summer holidays (July 31, 1911)—that is, in eleven weeks—seventeen cases had
been notified in the whole school, with six deaths. Apparently no diphtheria occurred amongst
the scholars of this school during the summer holidays, but there is no doubt that a good deal of
infection prevailed in the immediate neighbourhood, for between August 28 and November 22 (twelve
weeks) twenty-five further cases were notified in the ward in which this school is situated, and of
these twelve children attended this school. Six of these children attended room 3 of the infants'
department, and two ended fatally. By January 8,1912,38 cases had been notified from this school,
and of this number 33 occurred in the infants' department. In addition to the ordinary medical
supervision, the department was thoroughly cleansed, and the use of the hall as a classroom was
discontinued. Special weekly cleansing was also carried out, and the drainage system of the school
was completely overhauled. Cases of diphtheria still continued to occur in spite of all vigilance and
care until July 10, 1912. The school was closed for the summer during August, 1912, and has
remained free since. The cases notified were distributed as follows:—
Cases. Deaths.
Infants 48 8
Boys 8 0
Girls 4 0
Total 60 8
Every care Was taken to discover mild, unrecognised, or carrier cases. This school was visited on
24 occasions, and the children in attendance examined. As had been the practice in such circumstances
for some years, a cultivation on serum was made in every case from both throat and nose. Every child
found to be carrying Klebs-Loeffler bacilli or germs suspicious of diphtheria was excluded until a satisfactory
certificate based on bacteriological examination had been produced. Several cases of clinical
diphtheria were discovered attending school and were also excluded. On two occasions children recently
discharged from hospital were subsequently found to be chronic carriers. These were again excluded
and kept out of school until the school doctor obtained satisfactory bacteriological results. One
child, E. L., remained infectious until lost sight of by the end of the summer term.
The cause of the epidemic prevalence of diphtheria in the neighbourhood of this school during
the autumn and winter of 1910—11 can only be surmised, but it is possible that the prevalence during
the spring and summer of 1911 was due to carriers of the kind referred to. When swabbing was undertaken
on a large scale a number of children who had returned to school either from hospital or with a
certificate based on bacteriological grounds were found to be carrying germs of diphtheria. The preventive
measures adopted did not produce immediate relief, perhaps for the reason that the infection was too
widespread and affected persons beyond the control of the school authorities.
(II) Stanhope-street School.—This school is situated in one of the poorer and more congested
neighbourhoods of London. The first case occurred early in January in an infant in room 3, and
then spread rapidly throughout the department. The school was frequently visited, and the children
in all the departments subjected to a frequent and careful scrutiny. Several cases of clinical
diphtheria were found to be in attendance, and immediately excluded. It is the practice in all Council
schools where diphtheria is prevalent for the teachers to keep a careful watch over the children, to
exclude immediately all cases of sore throat or suspicious illness, to notify them to the school medical
officer and the Medical Officer of Health, and not to readmit them until a satisfactory certificate has
been produced. In this school in view of the special circumstances all suspicious cases were
examined by the school doctor himself. It may be mentioned that diphtheria was at this time also
present in other schools in the immediate neighbourhood. This general prevalence, apart from school
influence, may therefore be partly responsible for the continuation of the cases in this school.
In all, 29 visits were made to the school; 253 children were bacteriologically tested, and 399
swabs taken, on 56 occasions Klebs-Loeffler bacilli were discovered, and on 42 occasions suspicious bacilli.
When germs suspicious of diphtheria were found, the infected children were excluded until a further
examination had been made.
The suggestion was made that both healthy and chronic carriers were responsible for this outbreak.
On four occasions secondary cases occurred in the homes of children immediately after the discharge of
the first case from hospital. Three of these primary cases were bacteriologically tested, but gave
negative results ; but the fourth gave, and continued to give, Klebs-Loeffler bacilli (chiefly from the nose)
for about six weeks after the occurrence of the secondary case.
(III) The Fox School.—The characteristics of the outbreak of diphtheria at this school were its
suddenness and severity whilst it lasted. At the time no diphtheria had been notified from the neighbourhood.
On December 4, 1911, three cases were notified, and by the evening of December 5 seven