What are those conditions? Dr Newsholme has advanced the theory, based on an elaborate examination of statistics in various countries, that the activity of diphtheria is connected with the rainfall, and he lays down the following general induction from the facts: “Diphtheria only becomes epidemic in years in which the rainfall is deficient, and the epidemics are on the largest scale when three or more years of deficient rainfall follow each other.” He points out that the comparative rarity of diphtheria in tropical climates, which are characterized by excessive rainfall, and its greater prevalence in continental than in insular countries, confirm his theory. His observations seem quite contrary to the view laid down by various authorities, and hitherto accepted, that wet weather favours diphtheria. The two, however, are not irreconcilable. The key to the problem—and possibly to many other epidemiological problems—may perhaps be found in the movements of the subsoil water. It has been suggested by different observers, and particularly by Mr M. A. Adams, who has for some years made a study of the subsoil water at Maidstone, that there is a definite connexion between it and diphtheria. In England the underground water normally reaches its lowest level at the end of the summer; then it gradually rises, fed by percolation from the winter rains, reaching a maximum level about the end of March, after which it gradually sinks. This maximum level Mr Adams calls the annual spring cleaning of the soil, and his observations go to show that when the normal movement is arrested or disturbed, diphtheria becomes active. Now that is what happens in periods of drought. The underground water does not rise to its usual level, and there is no spring cleaning. The hypothesis, then, is this: The diphtheria bacillus lives in the soil, but is “drowned out” in wet periods by the subsoil water. In droughty ones it lives and flourishes in the warm, dry soil; then when rain comes, it is driven out with the ground air into the houses. This process will continue for some time, so that epidemic outbreaks may well seem to be associated with wet. But they begin in drought, and are stopped by long-continued periods of copious rainfall. This is quite in keeping with the observed fact that diphtheria is a seasonal disease, always most prevalent in the last quarter of the year. The summer develops the poison in the soil, the autumnal rains bring it out. The fact that the same cause does not produce the same effect in tropical countries may perhaps be explained by the extreme violence of the alternations, which are too great to suit this particular micro-organism, or possibly the regularity of the rainfall prevents its development.
The foregoing hypothesis is supported by a good deal of evidence, and notably by the concurrence of the great epidemic or pandemic prevalence in Great Britain, culminating in 1859, with a prolonged period of exceptionally deficient rainfall. Again, the highest death-rate registered since 1865 was in 1893, a year of similarly exceptional drought. But it is no more than an hypothesis, and the fate of former theories is a warning against drawing conclusions from statistics and records extending over too short a period of time. The warning is particularly necessary in connexion with meteorological conditions, which are apt to upset all calculations. As it happens, a period of deficient rainfall even greater than that of 1854-1858 has recently been experienced. It began in 1893 and culminated in the extraordinary season of 1899. The dry years were 1893, 1895, 1896, 1898 and 1899, and the deficiency of rainfall was not made good by any considerable excess in 1894 and 1897. It surpassed all records at Greenwich; streams and wells ran dry all over the country, and the flow of the Thames and Lea was reduced to the lowest point ever recorded. There should be, according to the theory, at least a very large increase in the prevalence of diphtheria. To a certain extent it has held good. There was a marked rise in 1893-1896 over the preceding period, though not so large as might have been expected, but it was followed by a decided fall in 1897-1898. The experience of 1898 contradicts, that of 1899 supports, the theory. Further light is therefore required; but perhaps the failure of the recent drought to produce results at all comparable with the epidemic of the ’fifties may be due to variations in the resistance of the disease, which differs widely in different years. It may also be due in part to improved sanitation, to the notification of infectious diseases, the use of isolation hospitals, which have greatly developed in quite recent years, and, lastly, to the beneficial effects of antitoxin. If these be the real explanations, then scientific and administrative work has not been thrown away after all in combating this very painful and fatal enemy of the young.
The conditions governing the general prevalence of diphtheria, and its epidemic rise and fall, which have just been discussed, do not touch the question of actual dissemination. The contagion is spread by means which are in constant Dissemination. operation, whether the general amount of disease is great or small. Water, so important in some epidemic diseases, is believed not to be one of them, though a negative proof based on absence of evidence cannot be accepted as conclusive. On the other hand, milk is undoubtedly a means of dissemination. Several outbreaks of an almost explosive character, besides minor extensions of disease from one place to another, have been traced to this cause. Milk may be contaminated in various ways—at the dairy, for instance, or on the way to customers,—but several cases, investigated by the officers of the Local Government Board and others, have been thought to point to infection from cows suffering from a diphtheritic affection of the udder. The part played by aërial convection is undetermined, but there is no reason to suppose that the infecting material is conveyed any distance by wind or air currents. Instances which seem to point to the contrary may be explained in other ways, and particularly by the fact, now fully demonstrated, that persons suffering from minor sore throats, not recognized as diphtheria, may carry the disease about and introduce it into other localities. Human intercourse is the most important means of dissemination, the contagion passing from person to person either by actual contact, as in kissing, or by the use of the same utensils and articles, or by mere proximity. In the last case the germs must be supposed to be air-borne for short distances, and to enter with the breath. Rooms appear liable to become infected by the presence of diphtheritic cases, and so spread the disease among other persons using them. At a small outbreak which occurred at Darenth Asylum in 1898 the infection clung obstinately to a particular ward, in spite of the prompt removal of all cases, and fresh ones continued to occur until it had been thoroughly disinfected, after which there were no more. The part played by human intercourse in fostering the spread of the disease suggests that it would naturally be more prevalent in urban communities, where people congregate together more, than in rural ones. This is at variance with the conclusion laid down by some authorities, that in this country diphtheria used to affect chiefly the sparsely populated districts, and though tending to become more urban, is still rather a rural disease. That view is based upon an analysis of the distribution by counties in England and Wales from 1855 to 1880, and it has been generally accepted and repeated until it has become a sort of axiom. Of course the facts of distribution are facts, but the general inference drawn from them, that diphtheria peculiarly affects the country and is changing its habitat, may be erroneous. Dr Newsholme, by taking a wider basis of experience, has arrived at the opposite conclusion, and finds that diphtheria does not, in fact, flourish more in sparsely-peopled districts. “When a sufficiently long series of years is taken,” he says, “it appears clear that there is more diphtheria in urban than in rural communities.” The rate for London has always been in excess of that for the whole of England and Wales. Its distribution at any given time is determined by a number of circumstances, and by their incidental co-operation, not by any property or predilection for town or country inherent in the disease. There are the epidemic conditions of soil and rainfall, previously discussed, which vary widely in different localities at different times; there is the steady influence of regular intercourse, and the accidental element of special distribution by various means. These things may combine to alter the incidence. In short, accident plays too great a part to permit any general conclusion to be drawn from distribution, except from a very wide basis of experience. The variations are very great and sometimes very sudden. For instance, the county of London for some years headed the list,