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diphtheria. It will be observed also that ray conclusions are not based upon
notifications, but upon deaths, that the fatal—not the benign — forms of
disease are in question
2. — The effect of the reception of Cases into the Hospitals of the Metropolitan
Asylums Board. — It may be that the admission of cases to the hospitals of the
Metropolitan Asylums Board at the end of 1888 may have had some slight
indirect effect in directing more care and attention to sore throats, but the
upward tendency of diphtheria commenced prior to this date, and therefore
this effect would be only part of the generally increasing attention already
being paid to the disease.
3.—The effect of Sanitary Legislation generally.—This must also be taken
into account, for the Public Health Act, 1875, came into force during the very
decennium when compulsory education (1871) came into force, and the effect
of the Act was to stimulate the recognition and prevention of infectious
diseases in England, especially in large towns. This stimulus, doubtless,
extended to the Metropolis, and, in conjunction with additional sanitary
legislation, directed closer attention to infectious diseases in London also.
4.— The effect of Elementary Schools.—The Medical Officer of the Local
Government Board, Dr. Thorne Thorne, has so fully and so carefully entered
into this subject that his conclusion that increased school attendance has had
a material influence in increasing the spread of diphtheria is irresistible
6.—Alt ration Classification.—Any changes made in classification by the
Registrar-General are usually commenced at the beginning of a decennium,
and therefore would not affect the detailed London figures of throat diseases
in this Report. The Superintendent of Statistics, Dr Tatham, has kindly
informed me that " membranous croup " was not classed with diphtheria until
the commencement of the present year (1894), although " diphtheritic croup "
has been classed with diphtheria for a long period, so that classification can
have had little or no effect upon the returns of mortality.
6.— Variation in Nomenclature. - Improved medical diagnosis, due to improved
medical education and increased knowledge of diseases of the throat, enables
these diseases to be more readily differentiated than formerly Now, most
forms of infectious sore throat are regarded as diphtheritic, and the fatality of
such diseases is recognised, whereas formerly the term was restricted to
typical cases. The danger of the earlier practice has been pointed out in the
many instances brought to light, in which apparently simple sore throats in
schools have culminated in serious and fatal epidemics
7.—Change of Tupe.— In the last place, the question may be seriously asked
whether the variation in nomenclature may not be due to a change of type in
disease of the throat. Dr. Thorne Thorne says " that there is reason to believe
that attacks of so-called sore throat exhibit under certain favouring conditions
a progressive development of the property of infectiveness, culminating in a
definite specific type which is indistinguishable from true diphtheria." A
change of type is probably taking place as the result of increased density of
population, especially in towns, more particularly of the aggregation in schools,
and of the effects of personal infection consequent on these. There is also a
strong probability, and it only remains to be definitely proved, that a sore throat