The term diphtheria, introduced by Pierre Bre-tonneau to replace his earlier term diphtheritis, derives from the Greek, literally "skin, hide," referring to the characteristic tough, white pseudomembrane of the trachea and other respiratory organs in advanced cases. There do not appear to be any classical Greek or Latin terms to designate this once-dreaded infectious disease. Aretaeus's terms (Egyptian and Syriac ulcers) were not adopted by later writers. Diphtheria seemingly was not always differentiated from other infectious diseases, and it was not unambiguously described until many centuries later.

The two best accounts of diphtheria in classical antiquity are those of Aretaeus and Aetius of

Amida. These two passages, supplemented by the more vague accounts of Hippocrates, described the principal signs and symptoms on the basis of which classical diagnoses were made before Friedrich Loffler's identification and isolation in 1884 oiBacillus diphtheriae, now Corynebacterium diphtheriae. The Hippocratic passages alluded to and a remotely possible reference by Soranus describe a condition that is not incompatible with diphtheria, but the absence of crucial data make a more positive identification impossible.

At any rate, these passages together provide a clinical picture similar to the early modern accounts of angina maligna, one of the many names in use before Bretonneau. Signs and symptoms as reported by Aretaeus and Aetius of Amida (Hirsch 1886) include the development of a phlegmatic, whitish film in the mouth and throat, rapidly spreading to the trachea, accompanied by a foul odor. The disease, often accompanied by fever, is rapidly fatal, especially among juveniles. Death is caused by suffocation, but weakness due to an aversion to food and drink may be a contributing factor. The voice is hoarse and strangely modulated; respiration is rapid but shallow; and liquids are sometimes passed out through the nose (due to a paralytic destruction of the soft palate, though not explicitly so stated by the classical authors).

As is well known, diphtheria epidemics have occurred, and both morbidity and mortality rates can be high, especially for children. For those reasons one would expect prima facie a larger number of classical references to diphtheria. There are perhaps two reasons for the paucity of data. First, diphtheria might have been confused with other diseases (e.g., aphthae, tonsilitis, candidasis). Second, the rapid course of fatal diphtheria did not permit the ancient physicians sufficient time to examine the patient with an eye on prognosis.

The source material at our disposal suggests that the etiology of diphtheria was somewhat uncertain. An overabundance of phlegm easily accounted for the development of the characteristic pseudomembrane. A further explanation is provided by Aretaeus's remark that the natural heat of young children is cooled by the rapid respiration and inspiration of cold air (apparently thus hastening the development of the phlegmatic pellicle). Finally, a dietetic cause is subjoined by Aretaeus: The thick and impure food and drink of the Egyptians lead to morbid changes, the so-called Egyptian ulcers.

Only the barest facts on incidence are available, but they highlight two important facts: Children, especially infants, were highly susceptible, and the season of highest incidence was winter. There seems to be no evidence for a disproportionate sexual incidence.

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