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137
but the figures suffice to indicate that whereas the actual prevalence remains
stationary within comparatively small limits, the mortality has progressively
declined during the past four quinquennia.

It is hoped that persistent intensive action by the adoption of improved
ethods of control will have the effect of still further reducing the mortality from
measles and its complications.
The Control of Measles.—The fact that measles is infectious as soon as the
catarrhal symptoms develop, when the patient appears to be suffering from an
ordinary "cold," and that the diagnostic rash is not seen for another three or four
days, renders any effective control of the actual occurrence of cases practically
impossible, as far as general administration and supervision are concerned. The
School Medical Service in London has had a unique opportunity of studying the
problem of the epidemicity and behaviour of measles throughout the last quarter
of a century and much useful information has been gained. As a result of the
observations made during this long period attempts have been made in a variety
of ways to prevent the spread of measles by direct action in the schools. For example,
school or class closure was at one time considered to be the only practicable method
of prevention until it was shown that this policy was valueless, inasmuch as closure
was not resorted to until the outbreak had become well established, and by that time
the damage had been done, all the "susceptibles" having already been exposed to
infection. School closure as a means of prevention was superseded by the policy
of excluding, for selected periods, unprotected children from classrooms on receiving
reports of the first cases of measles. This new scheme, however, was found to be
as ineffective as general school or class closure. A prominent obstacle to preventive
action was, and always has been, the difficulty of securing sufficiently early knowledge
of the first cases and, therefore, for some years past attention has been concentrated
upon speeding up the machinery of voluntary school notification. The
hopelessness of attempting to control the spread of measles by means of the school
organisation, having regard, inter alia, to the numerous opportunities of infection
outside the school, has led the Council to co-operate with metropolitan boroughs
through its school medical service and school attendance staff, in concentrating
upon the prevention of mortality and complications due to measles. The present
scheme, which was inaugurated in 1921 as a result of a conference between the Council
and the metropolitan borough councils, is an attempt to assist in the solution of the
problem. The scheme agreed upon has for its sole object the reduction of mortality
and mitigation of complications following measles, which give rise to many of the
physical disabilities found among school children, including tuberculosis, bronchitis,
deafness, blindness, general debility, etc.
The special procedure has been applied during the past three epidemics and an
endeavour has been made to profit by the experiences thus gained. One important
innovation which emerged as a result of observations of the working of the scheme
was one which it was thought, would have the dual effect of securing the desired
object more effectively and with more economy of effort. It was felt that by concentrating
upon the overcrowded insanitary and slum areas, where measles mortality
is notoriously high, owing to want of medical attention and proper nursing, and
paying less attention to the better class residential areas where parents can better
afford the services of a private doctor, greater efficiency would result. This is borne
out in a report on the epidemic in Lewisham by the medical officer of health of that