The curable disease that poverty sustains: Diphtheria's enduring social pathology

“ In addition to drugs, modern medicine is making great use of serums of various kinds, and antitoxin has rendered diphtheria, once a household terror, a relatively non-fatal malady. Further advances are being made daily along these lines, and great discoveries may be expected from the investigations of Metchnikoff into immunity and ferments.
Mental healing also errs in not employing to the full diet, fresh air, exercise and the other hygienic systems, which are rapidly growing to be our chief reliance in the control of illness. ”

“ One of these is diphtheria, and the statements and statistics in relation to the almost miraculous change which has come over our ideas on this affection are incontrovertible, and are fully set forth in the following pages. The disease no longer inspires the terror it used to do, for it is one which can be cured, and easily cured, by the method of serum therapy. It has not, it is true, been stamped out, for up till the present success has not attended efforts of prevention. Prevention is better than cure, but cure is better than suffering and death. ”

“ 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 Causation. a toxin derived from the micro-organisms which lodge in the air-passages 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. ”

“ Our bacteriological researches have, however, recently resulted in the discovery of a method of treatment which has been employed with remarkable success in two of the infectious diseases of man, and which there is reason to believe may eventually be found to have a more extended application. I refer to the therapeutic use of antitoxins contained in, or obtained from, the blood of animals rendered immune by repeated inoculations with cultures of a specific disease germ. The diseases in which the greatest success has been attained by this mode of treatment are tetanus and diphtheria. ”

“ But courage and industry have conquered these difficulties one after another, until now the fact that the prompt and intelligent use of antitoxin will effect a cure of from ninety to ninety-five per cent of all cases of diphtheria is as thoroughly established as any other fact in medicine. The mass of figures from all parts of the world in support of its value has become so overwhelming that it is neither possible nor necessary to specify them in detail. ”

“ It was not long ago that the idea of conquering diseases like malaria, yellow-fever, diphtheria and tuberculosis seemed a mere dream, a beautiful dream, yet control of them is now a reality, and is becoming almost daily more assured, complete and beneficent. ”

“ To interfere with or retard the progress of medical discovery is an inhuman thing. Within fifteen years medical research has made rapid progress, almost exclusively through the use of the lower animals, and what such research has done for the diagnosis and treatment of diphtheria it can probably do in time for tuberculosis, erysipelis, cerebro-spinal meningitis and cancer, to name only four horrible scourges of mankind which are known to be of germ origin. ”

“ And this is the moment which has been chosen for striving to arrest the march of Science: when epidemic disease, such as the plague and cholera, is checked; tuberculosis half-conquered; diptheria rendered inoffensive; operations become almost harmless; cancer on the eve of being understood and subjugated! And are we to stop there? Are we not to seek to fathom the many problems still waiting to be solved, and on which depend the lives of so many human beings, and so much human happiness? Do you believe that Science has come to an end? ”

“ There is another argument against diphtheria-antitoxin; we may call it, for brevity, the death-rate argument. It is this. The doctors say that the antitoxin does save lives; they give us statistics from every part of the world. But, if it saves lives, then the total mortality ought to go down. But the Registrar-General's returns do not go down; indeed, they tend to go up. Therefore diphtheria-antitoxin is useless, or worse than useless. ”

“ Social pathology is not an attractive study. The failure of the unfit to survive forms the subject of the dreariest chapter in social science. Indeed, it is so entirely dreary that it is seldom written. ”

“ A child is very susceptible to the influence of bad drainage. Bad drains are fruitful sources of scarlet fever, of diphtheria, of diarrhoea, &c. "It is sad to be reminded that, whatever evils threaten the health of population, whether from pollutions of water or of air,—whether from bad drainage or overcrowding, they fall heaviest upon the most innocent victims—upon children of tender years. Their delicate frames are infinitely more sensitive than the hardened constitutions of adults, and the breath of poison, or the chill of hardships, easily blights their tender life."—The Times. ”

“ A great part of our existing health codes and a very large part of the funds spent on health administration are designed to protect those of high income against disease incident to those of low income, high vitality against low vitality, houses with rooms to spare against houses that are overcrowded. To the small town and the country the slum means generally the near-by city whose papers talk of epidemic scarlet fever, diphtheria, or smallpox. ”

“ Personally, I should say that anæmia and malnutrition are the chief resulting evils, and that these conditions make us very vulnerable to infections. Sore-throat is certainly a drain disease, and thus a vulnerability to diphtheria is probably engendered. Puerperal disease of various kinds and rheumatic fever are among the diseases which have been attributed to sewer air, and it is probable that chronic enlargement of the tonsils and the surprising increase of adenoid growths in the pharynx and naso-pharynx are not without similar relationships. ”

“ With such more or less real affinities in the pathology and etiology, it may be made a question whether the recent increase of the death-rate by diphtheria in London and some other places has depended, as if in the way of correlation, upon the decrease in the [Pg 746] death-rates of scarlatina and of enteric fever [1385] . Diphtheria is perhaps the most obscure and complex of all the infective diseases in its causes and favouring conditions. A certain explanation may seem to suit one outbreak and be wholly irrelevant for another. ”

“ If we relied for the cure of the disease upon some drug, or antitoxin, even though we might save as many lives, the general reflex or secondary effect upon the community might not be in any way beneficial ”

“ For some reason, however, the subject of hygiene or the prevention of disease does not create the enthusiasm caused by methods advocated for its cure. A Koch, who publishes to the world a supposed means of curing tuberculosis, or a Behring, who introduces the serum therapy of diphtheria, arouses an interest which is limited only by the four corners of the world. The modest worker in sanitation, however, who explains the means of the development of these diseases, and the conditions and laws by means of which they may be prevented, is looked upon without interest and frequently with disfavor. ”

“ The prevention of grave throat diseases, such as diphtheria, necessarily forms a subject of much interest to the public in general and to mothers in particular. The causation of this disease has been much cleared up in later years, and we now know that the important factor is a bacillus—a small organism of the vegetable kingdom—which is the cause of this disease and a necessary material for its propagation. ”

“ When the infectious disease is the expression not of the combined effects of poison and bacteria but of the poison chiefly which enters the blood, the bacteria remaining without as in diphtheria, then the blood changes characterizing the immune state are simpler and consist in the accumulation there of antitoxins that constitute the most perfect antidote to poisons that are known. The condition of immunity produces no demonstrable change in the properties of the phagocytes through which they are better enabled to overcome the poisonous bacteria. ”

“ Sidney Martin suggests that anthrax produces albumoses and an alkaloidal substance, the former producing fever, the latter stupor. In tetanus the bacillus produces a secretion of the bacillus which causes the convulsions. The albumoses present in this disease are probably due to the secretory toxin. In diphtheria, too, we have a secretory poison in the membrane and in the tissues, and an albumose which is possibly the result of the secretion. ”

“ These soluble toxins affect, stimulate, the tissues of the victim, which, being living cells, react, and the expression of their reaction is the outpouring of a chemical something, appropriately called an antitoxin which, uniting with the bacterial toxin, neutralizes it and prevents it exercising its injurious powers. The infected organism thus works out its own chemical salvation by a vital, but no less chemical, response to the poison of the infection. ”

“ As soon as the diphtheria germ begins to grow in a throat, the little cells of the body begin to make a certain substance and to pour it into the blood. This substance we call antitoxin, which means opposed to the toxin in the blood. If the little cells make the substance fast enough, the germs will stop growing, or in some cases they never really get started growing, because they cannot exist where there is much antitoxin. ”

“ The human body keeps up a sort of drug-store of its own. As soon as disease fastens on it, it goes to work in a subtle and mysterious way, manufacturing a cure for that disease. If it’s diphtheria, the body produces antitoxin, and we give it more to help it on. If it’s jaundice, it produces a special quality of gastric juices to correct the evil conditions. In the vast majority of attacks, the body drives out the disease by its own efforts; yet, if the patient chances to have been idiot enough to take some quack ‘cure’ the credit goes to that medicine. ”

“ Man has taken advantage of this natural chemical immunity to confer an artificial immunity on himself. When a person gets over an attack of diphtheria, it is because his body-cells, stimulated by the poison of diphtheria (diphtheritin) , produced sufficient anti-diphtheritin to neutralize the poison ”

“ The diphtheria-antitoxin has already saved the lives of many thousands of human beings, yet it is produced through a moderate amount of inconvenience and suffering inflicted on horses and through the sacrifice of a moderate number of guinea pigs. ”

“ First, because it is sometimes possible to assist the body in its efforts to form antitoxines, by introducing into it antitoxines artificially prepared; and, second, because the body's power to form these substances is modified by mode of life. A horse that has been repeatedly injected with poison manufactured by the germs of diphtheria growing on an artificial culture medium, develops enormous amounts of diphtheria antitoxine. ”

“ Syphilis is one of these diseases. It is not to be understood that there is a sharp line of division between these three groups, since in every disease we try as far as possible to use all the methods we can bring to bear. [Pg 61] In pneumonia we have to let the body largely make its own fight, and simply help it to clear out the poisons formed by the germ, and keep the heart going until the crisis is past. In diphtheria, nowadays, we help the body out promptly by supplying it with antitoxin from an outside source, before it has time to make any for itself. ”

“ Now, if the cells in your body make antitoxin when you have diphtheria, it is probable that antitoxin is the very thing needed. And if you can help these cells by giving them antitoxin, ready-made, does it not seem a reasonable thing to do? People who give the name of poison to a substance which is known to have saved many lives are not worthy of attention. Anything may prove a poison if taken in excess; too much play will prove a poison, and too much work also. ”

“ Take a thousand cases of diphtheria from any civilised part of the world, in the days before antitoxin; how many of them died? Take a thousand cases now, treated with antitoxin; how many of them die? Why do Mr. Wood and Mr. Coleridge run away from that easy question? There is nothing unfair in it; they have all the reports before them; they know the facts well. We do not find any evidence that they are willing to acknowledge the truth of those facts. Follow Mr. Somerville Wood, from place to place, with his magic-lantern and his stock of lectures. ”

“ To get at the truth, we must reckon in thousands: take, out of a whole mass of evidence, all just alike, the reports from London, Berlin, Munich, Vienna, Strasbourg, Cairo, Boston, and New York; these to begin with. Or the following facts, cut almost at random out of the medical journals:—
"The medical report of the French army states that since the introduction of the serum-treatment of diphtheria, the mortality among cases of that disease had fallen from 11 per cent. to 6 per cent." ”

“ What about the general public?”
“Educate them to the necessity of watching for danger signals; the running nose, the sore throat, the tiny pimples on the inside of the mouth or cheek which are the first sign of measles. Above all, furnish free anti-toxin. Make it free to all. This is no time to be higgling over pennies.”
“I don’t like the principle of coddling our citizens by giving to those who can afford to pay.”
“Better coddled citizens than dead children. Unless you give out free anti-toxin, physicians to families where every dollar counts will say, ‘Oh, it may not be diphtheria. ”

“ In smallpox, on the other hand, the disease is so rapid that when contracted it is too late for vaccination to be of much value. In New York State, the Department of Health furnishes this horse antitoxin free of expense to health officers to use with persons or families unable to purchase the preventative, so that no longer does any need exist for the continuance of diphtheria as a cause of mortality. ”

“ Arm’s length is the striking distance of a contagious disease. There’s a truth for all of us to remember all the time.”
“If it is a truth,” challenged Mrs. Sharpless. “One of the surest and one of the most important,” averred the Health Master. “The only substance that carries the contagion of diphtheria or measles is the mucus from the nose or throat of an infected person. As far as that can be coughed or sneezed is the danger area. Of course, any article contaminated with it is dangerous also. But a hygienically conducted schoolroom is as safe a place as could be found. ”

“ As a single example, the transmission of disease at school may be cited. Measles, scarlet fever, whooping cough, and diphtheria are all children's diseases, easily carried and transmitted, and held in check only by preventing a sick child from coming in contact with children not sick. No law is sufficient. The matter must be left to the mother, who will retain children at home at the least suspicion of sickness and keep them there until after all traces of the disease have passed away. ”

“ Well persons who carry in their bodies pathogenic germs but who themselves have no symptoms of disease are called carriers. Thus typhoid carriers have typhoid bacilli in the intestinal tract, while they themselves show no symptoms of typhoid fever; diphtheria carriers have bacilli of diphtheria in the throat or nose, but have themselves no symptoms of diphtheria, and so on. It has now been proved that many patients harbor bacteria for weeks, months, or even years following an infection, and are dangerous distributors of [18] disease ”

“ The germs that cause diphtheria always come from some person or animal that carries diphtheria germs. 2. Diphtheria is always caused by the diphtheria germ, and the diphtheria germ cannot cause any other disease. 3. People are quarantined to prevent other people from getting the disease. 4. If there is diphtheria in your neighborhood, and your throat becomes sore, have the doctor examine it. 5. Every person who has been staying in a house where there is a case of diphtheria should have his throat examined to make sure he is not carrying germs. ”

“ Constipation, however produced, is a predisposing cause, and the continuance of the habits that have produced and now maintain it constitutes a sufficient exciting cause, of such diseases as neuralgia, rheumatism, erysipelas, fevers of various sorts (including scarlet fever and “head cold,”) and, with the aid of sewer gas insufficiently diluted with outdoor air—by means of ventilation—diphtheria, or any of the zymotic “diseases.” ”

“ 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. ”

“ As far as age is concerned, nearly all the zymotic diseases are seen most frequently in children. They exhibit a greater disposition to submit to diphtheria than adults, if we except those under ten months. Where, however, the disease has occurred previous to the seventh or eighth month, the greater number of cases has been found under three months. Tigri reports the disease in a child of fourteen days. A child of fifteen days was seen with diphtheritic laryngitis and oesophagitis by Bretonneau, one of seventeen days by Bednar, one of eight by Bouchut, one of seven days by Weikert ”

“ Still, catarrh and the vulnerability of mucous membranes must be considered as a frequent source of diphtheria; children will get numerous relapses often after a nasal or pharyngeal catarrh. Sudden changes in the temperature of the atmosphere or of the surface of the body are therefore dangerous in predisposed persons. And thus it is that while severe epidemics have spared no climate or land known to us, the majority of cases have occurred in winter and spring ”

“ As there are individuals, so there are families, which have a predisposition to diseases, as there are others in whom, notwithstanding ample exposure, infection does not easily take place. Yet in the families in which diphtheria is of frequent occurrence it cannot always be attributed to enlarged tonsils and a tendency to pharyngeal or nasal catarrh. ”

“ Occupations which involve deprivation of fresh air and sunlight, and all trades which enfeeble the individual, make him liable to all digestive disorders. A feeble constitution, debility from disease, from over-fatigue, or from loss of sleep, or any perturbing influence, puts the body in a state favorable to indigestion and diarrhoea. ”

“ Diphtheria frightens still more, thus assuring the doctor's presence oftener, and 168 in a million die. It is thus with every disease: the fewer it kills the more people fear it, because, if they did not fear it, they would play the fool, and give it a chance to kill more people. ”

“ It is the only scourge that drives us busy Americans to progress. It took an epidemic of typhoid, a shameful and dreadful one, to teach Ithaca that it must not drink filth. Only after Scranton faced a thousand cases of the fever did it assert itself and demand protection for its water supply. New Orleans would probably be having (and concealing) yellow fever yet, but for the paralysis of fright which the onset of three years ago caused. Boston's fine system of medical inspection in the schools is the outcome of a diphtheria scare. Smallpox is a splendid stimulator of vaccination ”

“ Where boards of health make it compulsory to report cases of sickness due to contagion, health records are a reliable index to "catching" diseases. But now that the chief infection is the kind that afflicts children, we can read the index before the outbreak that calls in a physician to diagnose the case. School examination shows which [58] children have defects that welcome and encourage disease germs. It points to homes that cultivate germs, and consequently menace other homes. To locate children who have enlarged tonsils may prevent a diphtheria epidemic. ”

“ As for reporting, you can’t combat a disease until you know where it is established and whither it is spreading. So, I say, any health officer who succeeds in spurring up the medical profession, and in dragging the Great White Plague out of its lurking-places into the light of day ought to have a medal.”
“What about the other diseases? Is the same true of them?”
“Not to the same extent. No man can tell when or why the epidemic diseases—scarlet fever, measles, whooping-cough, and diphtheria—come and go. By the way, what about your diphtheria death rate here?” ”

“ Say to them: ‘Do you want to get diphtheria? Well, you don’t need to. It’s just as easy to avoid it as to have it. Are you anxious to have measles in your house? It’s for you to decide. All you need is to take reasonable care against it. Infectious disease only kills foo—careless people.’”
“Let it go at ‘fools,’” interjected Mr. Snyder, smiting his thigh. “Go on.”
“Then I’d give them simple, straight advice; tell them how to recognize the early symptoms; how and where to get anti-toxin. ”

“ However, Bright’s disease, diabetes, and cancer are not more a mystery than diphtheria was before antitoxin was discovered. Bacteriology has its fields of further effort well laid out in those directions.
It is the contention of those that give their lives to the study of the subject that “public health is a purchasable commodity.” The struggle, then, is between the death-rate and the dollar rate. Contribute more money to the cause of public health, and the death-rate will go down. Forty thousand babies were saved in 1910 at an average cost of eighteen dollars. ”