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8 DIPHTHERIA.
Institutional Treatment.—Of the 445 cases reported during the year 424 (95*2 per cent.)
received treatment in hospitals, including the "carrier cases" reported from local institutions
which were not sent to a "fever" hospital. The percentage just quoted showed a considerable
increase above the percentages for 1918 (86'1) and 1920 (87*9) but is a little below the
percentage (95*4) for 1914-18. The proportion for 1909-13 was 93'5 per cent. The proportion
of cases removed to hospital last year would have been even higher than that stated above but
for the fact that after consultation with the practitioners concerned it was decided to keep
certain "carrier'' cases at home and send them to the "Carrier Clinic" at St. Mary's Hospital.
That practice was not adopted as freely as was desired as many practitioners sent their patients
to the "fever" hospital as soon as the result of the bacteriological test had been received by
them and before the Medical Officer of Health could intervene.
An analysis has been made showing the duration of treatment at the Hospitals of the
Metropolitan Asylums Board during the past year. The analysis related to 318 cases admitted
but excluded cases which terminated in death and those which were reported by the Medical
Superintendents as "errors." The average duration of treatment for the series of 318 cases
was 57'4 days, but on dividing the cases into two groups (a) patients sent to hospital on
a diagnosis following a positive bacteriological test (B.E.+cases) and (6) those in which there
was no record of such a test (B.E.O cases), results which appear to be somewhat anomalous are
obtained. For 120 cases sent to hospital after positive test, the average duration of stay in
hospital was 51*7 days, while for 198 other cases without history of such test, the duration was
60-9 days. The distribution of the cases according to length of stay in hospital—when
tabulated in weekly periods shows three maxima in the B.E.-|-series in the third, fifth and
ninth weeks, whereas the distribution for B.E.O cases shows but two peaks at the fifth and
seventh weeks. There can be little doubt about the presence of numerous "bacteriological
diphtheria" being included among the cases sent to hospital after bacteriological test.
Fatality, Mortality.—The deaths certified due to diphtheria numbered 22, but of that
number 2 were after cases certified during 1920, and a third occurred to a patient certified in
1920 to have scarlet fever whose attack of diphtheria was not notified. After making the
necessary adjustments it appears that among the 445 cases notified last year (including 56
errors) there were 19 deaths from diphtheria and 10 from other causes among the "errors".
The fatality from diphtheria was, therefore, at the rate of 4-8 per cent of the verified cases (389).
In 1920 the fatality was 6"2 per cent, and in 1919, 6"0. For the quinquennium 1916-20 the
fatality averaged 7*9 per cent. Much of the lowering of the fatality was due to the frequency
of "bacteriological diphtheria" but it is surmised that the virulence of true diphtheria was
below what has been observed in earlier years. Particulars of the distribution of deaths
according to Wards will be found in Table VIII.
Table IX. shows the sex-age distribution of the deaths (22) recorded during the year, and
Table IXa compares by means of Index Numbers the mortality during the past year with the
averages for 1909-13 and 1914-18.
Bacteriological Diphtheria.—In the absence of any notification from the Medical
Superintendents of the Hospitals of the Metropolitan Asylums Board as to patients sent in for
diphtheria having no clinical symptoms i.e. that the cases are no more than instances of
"bacteriological diphtheria," it is not possible to do more than guess at the number of such
cases sent into the Board's Hospitals. That a considerable number of such cases are so sent,
is well known, the fact having been officially brought to the notice of the Minister of Health
and certain preliminary inquiries instituted by the Ministry as to possibility of relieving what
is at certain times a serious handicap to the Board, beds being occupied by persons who are
not "ill"—but at the same time possible sources of infection—which are required for the
reception of "sick" patients.
Reference has been made already to an analysis of the duration of stay in the Board's
Hospitals during the past year. It might be thought that the length of stay would furnish a
means of distinguishing between the two classes of cases, but, unfortunately for the present
purpose, instances are known of cases which were recognised before being sent to the Board's
Hospitals as "bacteriological diphtheria," being kept in hospital for exceptionally long periods.
No case of "diphtheria" can be regarded as one of "bacteriological diphtheria" unless
there has been a test demonstrating the presence of the Klebs-Loffler bacillus in one or other
of the usual sites. During the past year bacteriological tests were made in connexion with
201 of the 445 notified cases, i.e. 45-l per cent, of cases notified. In 5 instances the test was