problems, and with a realisation that there are manymatters on which the last word cannot yet be spokenand which will need constructive discussion and
negotiation for their settlement. In their readinessto submit these matters to calm negotiation, and theirchoice of subjects to be discussed first, the representa-tives set an example of medical statesmanship. Wehope that this example will be followed next monthby the annual representative meeting of the BMA inits more arduous and detailed deliberations. ,
Diphtheria in GermanyTHE latest official figures on the incidence of
diphtheria in Germany show a remarkable rise. Thusfor the first 23 weeks of this year 126,913 cases werenotified, an increase of 7637 over the total for thefirst six months of 1943, and 51,894 more than in thecorresponding period of 1939. In Germany, unlikemost western European countries, diphtheria hadbeen steadily increasing in the years before the waruntil in 1934 it exceeded 100,000 cases annually.Case-mortality was also high in certain Germantowns, and the greater incidence and severity wereapparently associated with an epidemic spread of
gravis infection. Since the war began the rise inincidence has been shared by other countries inwestern Europe ; thus in France the rates per100,000 jumped from 35-9 in 1939 to 118-7 in 1943 ;in Germany from 180-9 to 287-1’; in the Netherlandsfrom 16-6 to 638-9 ; and in Norway from 1-8 to 752-8.By contrast the rates for Britain have fallen from114 to 84. The age-distribution of diphtheria inGermany is not known here, but it may be assumedthat a variety of causes have contributed to thehigher incidence-industrial concentration of mixedpopulations from town and country and from different
countries, overcrowding in the factories, in the homeand in air-raid shelters, and a general lowering of
. hygienic standards and of host resistance frommalnutrition. That malnutrition is not yet a factorof prime importance is suggested by the absence ofany significant rise in the case-mortality, althoughfigures from Germany for the first 15 weeks of 1944show a fatality-rate of 6-0% compared with 4-4% for1939. A state of chronic malnutrition may lead toan increase in both morbidity and mortality, forthere is experimental evidence that malnutritionadversely affects the immunity response so thatlatent or subclinical infection may not prove as
important as it ordinarily is in raising the specificresistance of the communityThe spread of diphtheria among the peoples of
western Europe must be considered in relation to itspossible effects on the occupying armies of British,Canadian and American troops. Diphtheria has notbeen a serious menace to our troops in the Middle East,yet ,an annual incidence of 4-5 per 1000 British (itwas very rare among the Indians) and a case-mortalityover 2% indicates that it has not been a negligibleinfection. Cutaneous diphtheria received a good dealof publicity, but careful checking of the virulence ofstrains isolated from " desert sore " and the likeshowed that much of it was spurious. In Italy, onthe other hand, recent figures show a much higher incidence of faucial diphtheria than was seen in Africa,and this may be a warning of what to expect inwestern Europe where conditions during the coming
winter may favour its spread. If results of Schicktests among nursing staff are any guide, we mayestimate that 40-50% of young adults are susceptibleto diphtheria. It is true that adults seem to have a -
greater non-specific resistance to diphtheria thanchildren, and this large proportion of susceptiblesneed not in itself cause alarm. But if diphtheriabegins to spread in any group of Service men, activeor combined active-passive immunisation would haveto be considered. The prophylactic available for theBritish Army is TAF, which could be given withoutpreliminary Schick test in three 1 c.cm. doses at
three-weekly intervals to all men at risk withoutmuch danger of local or systemic reaction. The’Canadian Army prefers APT in two doses at onemonth’s interval to Schick-positive soldiers, whilethe American Army would first use a detector dose of0-1 c.cm. of formol toxoid and proceed to immunisethe non-reactors with three doses of toxoid at three-weekly intervals.
Besides these precautionary measures, arrangementshave been made for the issue of new scales of dosageof antitoxin which in future will be available to fieldmedical units of all kinds. The important pointabout the use of antitoxin therapeutically is to giveit at once whenever there is any clinical suspicion ofdiphtheria. The disease is unfortunately insidiousand in the adult is often atypical ; a small dose of8000-16,000 units in an early doubtful case willcause no upset and is worth much more to the patientthan 50,000’ units some days later. If infection is
already advanced, especially if it is of the naso-
pharyngeal type with " bull neck " and nasal
discharge, the best hope of recovery lies in a singlemassive dose (50,000 units) intravenously together-with expert nursing during at least the first fortnight °
to minimise the risk of cardiac failure.
The Menace of RabiesRABIES affects primarily the canine, feline and
vulpine species, but man and all the domestic animalsare susceptible if bitten by a rabid animal. ARISTOTLEdescribed, the disease in animals, and CELSUS (100 BC)realised that the bite of a rabid dog was dangerous toman and advocated local measures similar to thosestill employed to reduce the probability of infection.ZINKE in 1804 showed experimentally that the salivawas infective, but despite this early recognition of themethod of spread the disease has seldom beeneradicated or even effectively controlled when onceit has gained a foothold. The United States Bureauof Animal Industry has been particularly successfulin stamping out a large number of animal diseases,but during the past ten years human cases in thatcountry have averaged 57 annually and individualstates have reported a yearly average of over 1000proved cases in animals.1 According to FLEMING 2rabies was first described in Great Britain aboutAD 1000, but probably existed much earlier. In themiddle of the eighteenth century " madness ragedamongst dogs in London " as well as the rest of
England and a reward of 2s. (quite a large sum inthose days) was offered for the destruction of straydogs ; this led to much brutality but was ineffectivein controlling the disease. In the nineteenth century
1. Webster, L. T. Rabies, New York, 1942.2. Fleming, G. Rabies and Hydrophobia, London, 1872.