SIR,—For the past two years it has been impressed upon me that sufferers from diphtheria have been arriving at my hospital, on the whole, rather later in the disease than was the case for a good many years previously. The death-rate in 1919 was 13'6 per cent., and I have to go back to 1901 to find a death-rate either exceeding or equalling it. In 1920 the death-rate was 11'2, and I have to go back to 1903 to find that exceeded or equalled. Certainly the death-rates of 1919 and 1920 were higher

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... han one would have expected, and naturally one looks for some explanation. A simple one would be that the disease was more severe in type, but though I am not prepared to deny that the type may have been somewhat more severe I am satisfied it was not the main cause, if, indeed, it affected it at all materially. The real explanation appears to be what I have just called attention to-the fact of so many patients arriving at the hospital after the disease was well advanced and without previous antitoxin treatment. This slower recognition of diphtheria of late has puzzled my mind, and I have striven to find the explanation, but evidently no one reason by itself gives a satisfactory explanation. It is not to be assumed that only the milder forms come in late ; it is any kind of diphtheria, and quite commonly the most severe. This cannot all be laid at the door of the practitioner, for it is quite clear that on many occasions he is not called in at the commencement of the disease, but for what proportion this accounts he would naturally be a better judge than I. There can be no doubt, however, that delay is greatly attributable to awaiting the result of a bacteriological examination. At first sight it seems curious that this should have increased, but it may be that so many practitioners were not in civil practice during the war, and consequently had-not the opportunity to study diphtheria clinically. Yet I do not think that is the sole cause of the tendency to wait for bacteriological examination, , , for some scientific books lay too much stress on the finding of the bacillus, and I have even been told by a medical man that the medical officer of health expected it. I do not know how far the medical officer of health may be considered responsible, but an excellent scientific text-book states that examination of the membranous exudation with the demonstration of the presence of the diphtheria bacillus is the only reliable method of diagnosis. This kind of erroneous statement might best be met by the epigrammatic remark of an authority on diphtheria: " Were it not that the diphtheria bacillus had given us antitoxin, it would have been well had it never been discovered." I have no wish to discourage bacteriological examination ; indeed, I always carry it out, but to let treatment wait upon the result of the examination means delay, and delay in diphtheria often means death. For 15 years MacCombie kept records of the diphtheria death-rates according to the day on which the disease was treated with antitoxin, and as these results were founded on over 7000 cases they may be taken as conclusive. The death-rate when antitoxin was given on the first day was 0'5 per cent. ; on the second day 4 per cent.; on the third day 10 per cent.; on the fourth day 15 per cent. ; and on the fifth and succeeding days 16 per cent. My own experience of treatment on the first day has not been quite so good as MacCombie's, but his figures demonstrate what waiting without treatment for a bacteriological examination means. Moreover, it must be remembered that the bacteriologist, at all events at first, may fail to find the bacillus in well-marked diphtheria, and maybe another swab is taken with further delay. As a matter of fact, failure to find the bacillus in a culture taken early in the disease is not uncommon. It may not be found even in a second or third culture, and rarely not at all. Failure to find the bacillus in purely laryngeal diphtheria is common and well known, but perhaps it is not so well known that in the severest form of faucial diphtheria cultures taken on the first day are not uncommonly negative. On the other hand, the case for examination may be a carrier and the finding of the bacillus of no value. Nevertheless, a culture should always be taken, and care should be exercised in the choice of examiner, the dabbler in bacteriology being avoided.