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The following table gives the death rates of these towns per 1,000 living—

Notwithstanding the exceptionally high death rate of London from diphtheria in 1893, it will
be observed from the following table that the London death rate was below that of certain foreign cities,
and in the ten year period 1883-92, below the death rates of the majority—

Judged by the number of deaths attributed to diphtheria, the diphtheria death rate of 1893 is
greater than that of any year since the Registrar-General, in his annual reports, began to separate
deaths attributed to diphtheria from those attributed to scarlet fever, as will be seen by reference to
diagram X. There is reason for thinking that some of this increase is apparent only, and that it is
due in part to change in nomenclature, especially by transference to diphtheria of deaths which in
former years would have been registered as croup. But even when correction for this transference is
made by the addition of croup to diphtheria, it is found that the death rate from the two diseases is in
1893 considerably greater than that of the death rate of these diseases in any year in the period
1859-93.
Reference to the table on page 30 shows that although the disease has not been uniformly
distributed throughout London, the increase of 1893 has not been limited to any one part of London,
but has occurred in almost all the London districts.
The circumstances which may have contributed to the present prevalence of diphtheria deserve
close examination. It is probable that among the factors concerned is some change in the type of the
disease; the records of notification do not, howTever, extend far enough into the past to enable
the fatality of later years to be compared with that of the time when the London death rates
were at their minimum. The conditions which may cause an alteration in the quality of the contagium are
not understood, but there is reason for thinking that epidemic diseases have a more or less regular
periodicity with which increased virulence is associated. Among other factors concerned in determining
the amount of prevalence of epidemic disease is undoubtedly the opportunity which may exist for the
communication of infectious disease from person to person. In my last report I stated that I was
examining for the Public Health Committee the statistics relating to diphtheria, and I now append
to this report a preliminary memorandum which I presented to the Committee on this subject. (See
Appendix I.)
In this memorandum, diphtheria death rates in several groups of population, and at several ages
in different periods, are compared. The groups of population are—England and Wales, urban, rural,
urban excluding London, and London, the word "urban " denoting towns each of which has a population
of more than 50,000, the word " rural " denoting the rest of the population of England and Wales. The
periods selected for comparison are 1855-00, 1861-70, 1871-80, 1881-90, and 1891-93, the
lirst period being determined by the fact that it is the earliest for which it is possible to obtain statistics
* Including deaths from crcup. † Including deaths from croup 1891-2.
‡ See footnote (*), page 6.