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outbreak, and there would probably have been some fatal cases.
Opportunity was taken to protect a number of children in the school
who had not so far been presented for immunisation. At the same
time, children in this and other schools, who had been protected
in earlier years, received an additional injection to raise the level
of their defences, which had dropped to some extent, owing to the
very low incidence of diphtheria in the area for a number of years.
It must be remembered that the test which is always applied
after the completion of the course of injections, consists of an
accurately measured dose of standardised material, and is therefore
an arbitrary standard : if the test is negative, it indicates that there
is a definite degree of protection against Diphtheria in the body,
and this degree of protection has been found to be sufficient to
withstand any ordinary invasion by the bacillus of Diphtheria:
it is quite understandable that occasionally an exceptionally massive
infection of a highly virulent type will break through these defences
and cause an attack of the disease.
In the Special Report on Diphtheria immunisation in the
Schools, presented to the Council last year, it was mentioned that
conferred immunity might decline in an area which remained free
from Diphtheria over a number of years. Our experience last
autumn suggests that, although this can happen, it will probably
be limited to a small proportion of individuals, and that the reappearance
of the disease will soon restore the general degree of
protection to a satisfactory level.
Paradoxical as it may sound, the limited outbreak in the
autumn, actually testifies to the value of large scale immunisation
against Diphtheria.
SCARLET FEVER.
There were 261 cases notified during the year, compared with
75 in 1942 and 31 in 1941. Of these 199 were in original Beckenham
and 62 in West Wickham.
The incidence increased gradually throughout the year, rising
sharply in September and continuing at a high level for the remainder
of the year.

The disease is caused by a specific organism, known as the
Streptococcus : there are at least 30 strains of this organism which
are capable of producing the disease, and infection by any one
strain does not confer absolute protection against subsequent
infection by any one of the others. In this connection, it is worth
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