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17
Going back to the next preceding pandemic (that of the early nineties)
phenomena resembling those noted above have been observed. The prevalence of
sore throat during the great epidemic of 1847 was commented upon by Thomson.
Graves noted the severity of scarlet fever about 1803, and then again some thirty
years later, and these two points of time correspond with pandemic prevalences of
influenza. Study of the history of epidemic throat disease in the 18th century
shows some similar correspondences of "influenza constitutions" and "epidemic
throat-disease constitutions," though they are not so marked as in the 19th century.
Even as far back as the early 16th century there was a correspondence in time,
which is noted in Hecker's Table, of sweating sickness in England and of a great
prevalence of malignant sore throat in Holland. It should be added, however,
that the epidemic throat constitutions, generally speaking, tend rather to follow
shortly after the influenza constitutions than to be precisely simultaneous with
them.
There are yet other disturbing influences affecting the figures in urban districts
as compared with rural districts, some of which become apparent when London
is contrasted with England and Wales as a whole. The Registrar-General in his
annual report for 1922 (p. 63), gives the attack-rate and fatality-rate from
diphtheria in London, in the aggregate of county boroughs and of rural districts
in England and Wales. With regard to the notable excess in London mortality
in that year, he observes that this " has been due entirely to greater prevalence of
the disease, for the fatality rate in London was slightly below that for England and
Wales, indeed almost the lowest in the table." It will be seen that the casemortality
in the rural districts of England and Wales exceeds that of London,
and this is not what would have been expected, in view of the fact that the ageincidence
of death in rural areas in higher than in London. The disease is far
more fatal at younger ages, and the mortality in an area in which the average age
of attack was high on that account tends to be less—the attack rate of the rural
areas should thus have been less than in the urban areas and certainly considerably
less than that of London. The fact that bacteriological methods are used to a far
greater extent in urban areas than in rural districts would on the other hand tend
to make the urban case-mortality rates lower.
There are other considerations affecting comparisons of the different classes
of area. In London, in cases of illness where diphtheria is suspected, notification
and removal to hospital follow immediately in the majority of cases. Thus of the
total deaths from diphtheria in the course of the year over 90 per cent, in London
occur in institutions. In rural areas, on the other hand, the percentage of deaths
occuring in institutions is less than 40. With the complete hospital equipment
available in London, not only is there more inducement to the practitioner to notify
a suspicious case, but the diagnosis and certification of cause of death in fatal cases,
being mostly in the hands of the medical staff of the fever hospitals of the Metropolitan
Asylums Board, is far more certain. The operation of this factor in
determining more accurate diagnosis is apparent upon a consideration of the figures
relating to deaths from certain assigned causes in rural districts. It is found, for
example, that during the ten years 1914-1923 there were 74 deaths in London among
children between 5 and 10 years of age classed as due to diseases of the larynx,
or 18 per million living, while in rural areas there were 385 deaths, or 50 per million,
returned as due to this cause at the same ages: a small excess in the mortality rate
from diseases of the pharynx and tonsils is also found in the rural areas. For this
period of years and for the same ages the deaths certified as due to diphtheria in
London, per million living, considerably exceed those in rural districts, the mortality
rates being 690 and 430 respectively.
It is difficult to explain the higher mortality in the rural districts in the years
in question from diseases of the larynx and tonsils, except on the assumption that,
to a large extent, they were diphtheritic in origin. On the whole the mortality