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89
hospital during the year, was available in the treatment of one of the cases. The respiratory
failure was improved by the application of the apparatus, but a well-marked toxic myocarditis
was present in addition and undoubtedly brought about the sudden syncope which was the
terminal feature. It is of importance to note that the patient was not distressed nor showed
any intolerance of the apparatus.
During 1934 the investigation into the correlation of the clinical form of the disease with the
bacteriological classification of strains of the diphtheria bacillus has been continued in conjunction
with Dr. W. Mair, of the Northern group laboratory. The cases completed up till the time of
making this report number 176, and were unselected except that only faucial and nasopharyngeal
forms in which there could be no doubt about the clinical diagnosis were chosen for investigation.
As was inevitable, this has resulted in a relatively larger number of severe and moderate cases
being included in the total than would be found in any consecutive series, as by the time many
of the mild cases of faucial diphtheria, diagnosed chiefly on bacteriological grounds, arrive in
hospital an absolute clinical diagnosis is impossible. This is reflected in the comparatively high
case-fatality rate of the series, viz., 10.2 per cent. Excluding 4 cases in which more than one
type of organism was present, the gravis and intermediate types predominated and were present
in 83 per cent, of the total. The cases in which the gravis type was present numbered 66 and
showed a case fatality of 9 per cent., whilst the paralysis rate in the recovered cases was 10-6
per cent. In cases showing the intermediate type, 77, the case fatality was 14'2 per cent, and the
paralysis rate in recovered cases 22 per cent. Only 29 of the cases were of the mitis type. None
was fatal, and none showed paralysis, nor did anv of them fall into the severe clinical types.
It should also be stated that whilst 74 of the cases examined were of the mild clinical type, 52
were almost equally distributed among the gravis or intermediate strains. Thus it seems fairly
clear that whilst the fatal cases were exclusively associated with gravis and intermediate types,
it was by no means the case that the mild non-fatal forms were related to mitis strains, and
whether the investigation of a higher proportion of mild clinical types would have revealed a
higher proportion ot mitis organisms is at least doubtful. The fact that diphtheria in London
has not taken on the characters of an epidemic type of exalted gravity, in spite of the predominance
of infective organisms which have been assumed to possess specially high invasive
properties, must be attributed to the natural herd immunity following on years of prevalence of
the disease. The question of how best to secure the universal application of the practical
measures necessary to increase this immunity remains the central problem in diphtheria.
The case mortality rate for verified clinical diphtheria at the Park hospital in
1934 was 4 per cent., compared with 2-98 per cent, in 1933. These figures—the
medical superintendent (Dr. H. S. Banks) suggests—become intelligible only when
each year's series of cases is classified to show the proportion of hypertoxic and
toxic cases, and also the proportion of laryngeal cases, since almost all the deaths
occur in these groups.
In the absence of any agreed scheme of classification of diphtheria, he has
continued to use that referred to in the last annual report (Vol. IV, Part I, p. 115),
and the following are the discharges, transfers and deaths for the year, thus
classified :—
Classification. Discharges. Transfers. Deaths.
Diphtheria, faucial—-
Hypertoxic 14 2 22
Moderately toxic 94 3 10
Slightly toxic 392 18 —
Non-toxic 280 11 —
Diphtheria, nasal 191 34 1
„ laryngeal 24 2 I
„ combined—
Hypertoxic 2 — 8
Moderately toxic 7 — 4
.Slightly toxic 24 6 1
Non-toxic 17 6 —
Diphtheria, aural 4 — —
1
Total 1,049 82 47
When the cases so classified are compared with those of last year, it is seen that
the proportion of hypertoxic and moderately toxic cases treated in 1934 was