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197
Report 0f the County Medical Officer—Education.
At this point it will be appropriate to refer to a group of cases occurring in the Ponton-road
Place of Detention in Wandsworth. Owing to the provision of observation wards for new admissions
these children were discovered to be suffering from scarlet fever before admission to the common dormitories
and the disease was not communicated to the other inmates. Such cases in spite of the mildness of
their symptoms are nevertheless of a highly infectious character and infectivity persists for long periods.
This was demonstrated a little later by the admission to the Home for Little Boys, Clapham-park of
two of the children, referred to above in connection with the Ponton-road Place of Detention, after
their return from hospital. In spite of every care on the part of the Metropolitan Asylum Board's
authorities and notwithstanding isolation of the children in the Home for a fortnight before allowing
them to mix with other inmates, within twenty-four hours of their release from isolation an outbreak
occurred in the dormitory to which they had been admitted. The Home was at once placed in quarantine
and the two suspected "carriers" were removed to hospital, yet the Home remained a source
of infection for further mild cases. Before the end of the summer term several other schools in
London, especially in Deptford and Lewisham were invaded.
The closure of the schools for the summer holidays cut off the means of investigation so far as
school children were concerned, but immediately upon the resumption of school after the holidays it
was observed that the incidence of the disease had become generalised throughout schools in all parts
of the metropolis, and more particularly in the borough of Islington.
School doctors, nurses and teachers frequently detected suspicious cases among the children, i.e.,
peeling, nasal or aural discharges, and other indications of post-scarlatinal complications. These were
excluded from school and reported to the medical officers of health of the boroughs in which the schools
were situated. In certain of the boroughs difficulties arose owing to the mildness of the attacks leading
to differences of opinion with regard to the nature of the cases. In several cases in which the school
doctor's diagnosis was disputed by medical practitioners the subsequent occurrence of desquamation
showed that the original diagnosis was correct. Meanwhile, the hospitals of the Metropolitan Asylums
Board rapidly filled with cases, the majority of which were of a mild type, and the medical superin
tendents of hospitals who were interviewed were agreed as to the mitigated type of the cases and the
difficulty of detecting them.
It was observed in most of the school outbreaks that the incidence was distributed over various
classes and departments, chiefly among friends or relatives. Unfortunately in many cases the possibility
of the existence of mild cases in the classrooms was not appreciated by the school teachers
who were prone to attribute the subsequent outbreak to other and imaginary causes. The consequence
was that attention had repeatedly to be drawn to the necessity of close supervision of the children themselves
and of excluding those who showed suspicious symptoms, until they had been seen by the school
doctor or had furnished satisfactory medical certificates. A considerable amount of the school doctors'
time was spent in visitation of schools for the purpose of investigating outbreaks and examining children
excluded by the teachers, or otherwise coming under suspicion.
There was a slight increase in the number of cases of diphtheria during 1913 as compared with
the preceding four years. The prevalence was more marked in London than in other parts of the
country, the case-rate in London being 1 per cent., as compared with 1.26 for the rest of England and
1.48 for the county boroughs. As in the case of scarlet fever, the incidence of this disease was greatest
during the autumn months. The number of cases of diphtheria reported among school children during
the year was 2,663, as compared with 7,654 in all persons. The number of schools under special observation
was 333, and 83 schools were specially visited by school doctors on account of their showing some
indications of possible spread of infection among the children, and 2,222 cultures were forwarded for
examination in the laboratory. True diphtheria germs were identified in 112 cases, whilst a further
212 cultures were found to contain germs not definitely distinguishable from the Klebs Loeffler bacillus.
The problem of dealing adequately with these bacteriological cases of diphtheria, in which the usual
clinical symptoms associated with the disease are not apparent,still remains unsolved,and further organised
research into this very important subject upon bacteriological and epidemiological lines would doubtless
be valuable.
Diphtheria.
Goodnch-road School, situated in the Borough of Camberwell, calls for special attention, as it
was the school which was most seriously affected by diphtheria during 1913, whereas schools in the
neighbourhood remained comparatively free from this disease. Children attending the infants' department
were the first to suffer ; 4 cases were notified in September, 16 in October, 9 in November, and
4 in December. Upon the first indication of the spread of the disease, instructions were issued to
the head teachers of departments to have each class watched, and to exclude every child from such
class showing any suspicious symptoms. In consequence of this action a large number of children
were excluded from school, i.e., 2 in September, 47 in October, 20 in November, 5 in December. These
exclusions are shown in the subjoined table. All of them were examined bacteriologically at some period
of their exclusion, with the result that in October 11 children, and in December 2 children, were found
to be carrying Klebs Loeffler bacilli.