frequently prevailed in many parts of Europe, particularly in Holland, Spain, Italy, France, as well as in England, and were described by physicians belonging to those countries under various titles; but it is probable that other diseases of a similar nature were included in their descriptions, and no accurate account of this affection had been published till M. Bretonneau of Tours in 1821 laid his celebrated treatise on the subject before the French Academy of Medicine. By him the term La Diphthérite was first given to the disease.
Great attention has been paid to diphtheria in recent years, with some striking results. Its cause and nature have been definitely ascertained, the conditions which influence its prevalence have been elucidated, and a specific “cure” has been found. In the last respect it occupies a unique position at the present time. In the case of several other zymotic diseases much has been done by way of prevention, little or nothing for treatment; in the case of diphtheria prevention has failed, but treatment has been revolutionized by the introduction of antitoxin, which constitutes the most important contribution to practical medicine as yet made by bacteriology.
The exciting cause of diphtheria is a micro-organism, identified by Klebs and Loffler in 1883 (see Parasitic Diseases). It has been shown by experiment that the symptoms of diphtheria, including the after-effects, are produced by a toxin derived from the micro-organisms which lodge in the air-passages Causation.and multiply in a susceptible subject. The natural history of the organism outside the body is not well understood, but there is some reason to believe that it lives in a dormant condition in suitable soils. Recent research does not favour the theory that it is derived from defective drains or “sewer gas,” but these things, like damp and want of sunlight, probably promote its spread, by lowering the health of persons exposed to them, and particularly by causing an unhealthy condition of the throat, rendering it susceptible to the contagion. Defective drainage, or want of drainage, may also act, by polluting the ground, and so providing a favourable soil for the germ, though it is to be noted that “the steady increase in the diphtheria mortality has coincided, in point of time, with steady improvement in regard of such sanitary circumstances as water supply, sewerage, and drainage” (Thorne Thorne). Cats and cows are susceptible to the diphtheritic bacillus, and fowls, turkeys and other birds have been known to suffer from a disease like diphtheria, but other domestic animals appear to be more or less resistant or immune. In human beings the mere presence of the germ is not sufficient to cause disease; there must also be susceptibility, but it is not known in what that consists. Individuals exhibit all degrees of resistance up to complete immunity. Children are far more susceptible than adults, but even children may have the Klebs-Loffler bacillus in their throats without showing any symptoms of illness. Altogether there are many obscure points about this micro-organism, which is apt to assume a puzzling variety of forms. Nevertheless its identification has greatly facilitated the diagnosis of the disease, which was previously a very difficult matter, often determined in an arbitrary fashion on no particular principles.
Diphtheria, as at present understood, may be defined as sore throat in which the bacillus is found; if it cannot be found, the illness is regarded as something else, unless the clinical symptoms are quite unmistakable. One result of this is a large transference of registered mortality from other throat affections, and particularly from croup, to diphtheria. Croup, which never had a well-defined application, and is not recognized by the College of Physicians as a synonym for diphtheria, appears to be dying out from the medical vocabulary in Great Britain. In France the distinction has never been recognized.
Diphtheria is endemic in all European and American countries, and is apparently increasing, but the incidence varies greatly. It is far more prevalent on the continent than in England, and still more so in the United States and Canada. The following table, compiled from figures Prevalence.collected by Dr Newsholme, shows how London compares with some foreign cities. The figures give the mean death-rate from diphtheria and croup for the term of years during which records have been kept. The period varies in different cases, and therefore the comparison is only a rough one.
Mean Death-Rates from Diphtheria and Croup per Million living.
| New York | 1610 | Munich | 990 |
| Chicago | 1400 | Milan | 990 |
| Buenos Aires | 1360 | Florence | 830 |
| Trieste | 1300 | Vienna | 770 |
| Dresden | 1290 | Stockholm | 720 |
| Berlin | 1190 | St Petersburg | 650 |
| Boston | 1160 | Moscow | 640 |
| Marseilles | 1130 | Paris | 630 |
| Christiania | 1090 | Hamburg | 490 |
| Budapest | 1880 | London | 386 |
There is comparatively little diphtheria in India and Japan, but in Egypt, the Cape and Australasia it prevails very extensively among the urban populations. The mortality varies greatly from year to year in all countries and cities. In Berlin, for instance, it has oscillated between a maximum of 2420 in 1883 and a minimum of 340 in 1896; in New York between 2760 in 1877 and 680 in 1868; in Christiania between 3290 in 1887 and 170 in 1871. In some American cities still higher maxima have been recorded. In other words, diphtheria, though always endemic, exhibits at times a great increase of activity, and becomes epidemic or even pandemic. The following table for 1859–99 shows fairly well the periodical rise and fall in England and Wales. Diphtheria and croup are given both separately and together, showing the increasing transference from one to the other of late years. Diphtheria was first entered separately in the year 1859.
Deaths from Diphtheria and Croup per Million living in
England and Wales.
| Years. | Diphtheria. | Croup. | Diphtheria and Croup. |
| 1859 | 517 | 286 | 803 |
| 1860 | 261 | 220 | 481 |
| 1861–70 | 185 | 246 | 431 |
| 1871–80 | 121 | 168 | 289 |
| 1881–90 | 163 | 144 | 307 |
| 1891–95 | 254 | 70 | 324 |
| 1896–97 | 269 | 43 | 312 |
| 1898 | 244 | 27 | 271 |
| 1899 | 293 | 32 | 325 |
The combined figures for diphtheria and croup in later years are:— (1900) 316; (1901) 296; (1902) 255; (1903) 195; (1904) 184; (1905) 174; (1906) 190; (1907) 175; (1908) 166.
Several facts are roughly indicated by the table. It begins with an extremely severe epidemic, which has not been approached since. Then follows a fall extending over twenty years. On the whole this diminution was progressive, though not in reality so steady as the decennial grouping makes it appear, being interrupted by smaller oscillations in single years and groups of years. Still the main fact holds good. After 1880 an opposite movement began, likewise interrupted by minor oscillations, but on the whole progressive, and culminating in the year 1893 with a death-rate of 389, the highest recorded since 1865. After 1896 a marked fall again took place. This is partly accounted for by the use of antitoxin, which only began on a considerable scale in 1895, and did not become general until a year or two later at least. Its effects were only then fully felt. The registrar-general’s returns record mortality, not prevalence—that is to say, the number of deaths, not of cases.
On the whole, we get clear evidence of an epidemic rise and fall, which may serve to dispose of some erroneous conceptions. The belief, held until recently, that diphtheria is steadily increasing in Great Britain was obviously premature; it did rise over a series of years, but has now ebbed again. Moreover, the general prevalence during the last thirty years has been notably less than in the previous twelve years. Yet it is during years since 1870 that compulsory education has been in existence and main drainage chiefly carried out. It follows that neither school attendance nor sewer gas exercises such an important influence over the epidemicity of diphtheria as some other conditions.
