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155
Report of the County Medical Officer—Education.
The waves of measles recur at intervals of 2 years or 18 months and it is seen from study of both
charts that at two periods of the year there is a special tendency for the time of maximum prevalence
of measles to occur; one period of maximum death-rate being noted in May and one in December,
with corresponding minima about September and March. When, however, the two charts are compared
one with another it is seen that in the earlier series of years the range of variation in the weekly
average is much smaller than in the later series. In the latter the maxima and minima become much
more pronounced and the characteristic deviations of the curve from the mean thus becomes much
more accentuated.
It may be taken that the Elementary Education Act began to exert its influence about the year
1874. The accentuation of the curve of measles mortality during the later series of years may
in all probability be attributed to the increasing aggregation of the population, combined with the
effects produced by compulsory school attendance. Under modern conditions the natural tendency
of measles to exhaust the susceptible cases finds freer expression, with the result that outbreaks climb
more readily to their maxima, and correspondingly intervals are left in which the disease is less active
than formerly. It will be seen that the two times of minimal death-rates occur three or four weeks
after the two main school holiday periods. The minimal depressions in the lower chart correspond,
roughly speaking, in point of time with those in the upper chart, but the point to be observed is that
they are sensibly deepened in the lower chart.
Diagram E shows the incidence of measles month by month during the seven years
1906-1912. The uppermost curve gives the deaths, the middle curve the cases notified from the
elementary schools and the bottom curve the cases as calculated from the deaths; for the last named
Dr. Butler's experience in Willesden, as to average interval between notification and death, has been
used as a basis.
Measles in
London,
1903-1912.
The curves show a considerable degree of correspondence. The most noteworthy difference is
that to be seen in the greater irregularity of the curve of notified cases. Especially is this observed
in a drop in the curve which occurs year by year between Easter and Whitsun, with a subsequent rise
in the month of June. This regularly recurring phenomena has no counterpart in the other two curves
and requires explanation. Teachers are required to notify the school medical officer immediately upon
becoming aware of the occurrence of a case of infectious illness in a scholar; they are debarred, however,
from sending to the homes in these cases, and are dependent for their information upon visitation by
the attendance officers ; this brings about delay in notification and in some cases it may be a fortnight
after the date of last attendance before the results of visitation in a specific case are known to them.
But during the period about the Easter holiday this source of information practically ceases inasmuch as
the attendance staff are engaged in "scheduling" in their respective districts and visitation of the homes
of absentees remains in abeyance during this time. This results in a cessation of notification of cases, and
produces a depression of the curve during scheduling time with a corresponding rise in the curve owing
to the belated notification of cases when normal visitation of absentees is again resumed after W hitsun.
Inasmuch as early knowledge of cases is the starting point from which all preventive action
must take place, the cessation of notification during the scheduling period is a serious blot upon the
system upon which reliance is placed for the control of measles.
During the latter part of the past year an arrangement was effected whereby each attendance
officer notifies the school medical officer directly a case of measles is encountered by him during visitation.
In the Southwark area an experiment has, moreover, been initiated with the co-operation of teachers and
attendance officers, whereby infant absentees receive preferential visitation, with the result that
notification of measles is speeded up and in many instances as much as ten days is gained. This procedure
has been continued throughout the period usually devoted to scheduling. It is very desirable
that there should in future be an extension of this procedure.
Whooping cough was prevalent during the spring and summer months. This disease is one
which is difficult to control in schools, inasmuch as the patient is frequently capable of spreading
infection during unrecognised stages of the disease, and for this reason it is specifically provided in the
regulations in regard to infectious diseases framed for the guidance of teachers that, during the prevalence
of the disease, children suffering from bad coughs, whether or not the characteristic "whoop" is
heard, should be temporarily excluded from school as a precautionary measure. In addition, however,
in view of the high mortality for which the disease is responsible among children of tender years it
has been thought necessary in some instances to exclude from attendance during school outbreaks all
children under the age of five. The efficacy of this procedure depends in urban communities upon
social conditions; in congested areas the opportunities for infection encountered in streets, tenement
dwellings, etc., are very considerable. This factor was usually borne in mind and such exclusions
were upon occasions only carried out after consultation with the local medical officer of health.
Whooping
cough.
Whooping cough was made a notifiable disease in Greenwich and Lambeth by order of the borough
councils.
Chickenpox ranks among the infectious diseases associated with school life next to smallpox in its
infectivity. The disease is probably infectious a day or two before the appearance of the typical rash.
If a child attends school during the infectious stage, whether that be before the appearance of the rash,
with the disease fully established, or whether as a missed case, secondary cases are sure to crop up in large
numbers about 14 days afterwards. A good instance in point occurred at the Royal Victoria Patriotic
Asylum in July, 1912, where out of 264 children at this home 104 contracted chickenpox (40 per cent.)
probably as the result of a missed but undetermined case on or about 28th June.
Chickenpox
An analysis of 73 of the cases was made as follows:-On the 13th day after exposure, 2 cases;
on the 14th day after exposure, 62 cases; on the 17th day after exposure, 5 cases; on the 18th day
after exposure, 3 cases; on the 19th day after exposure, 1 case; total 73 cases,
18820 U 2