DIPHTHERIA
That was a dark and stern saying, "Without the shedding of blood there
is no remission," and, like all the words of the oracles, of limited
application. But it proves true in some unexpected places outside of the
realm of theology. Was there something prophetic in the legend that it
was only by the sprinkling of the blood of the Paschal Lamb above the
doorway that the plague of the firstborn could be stayed? To-day the
guinea-pig is our burnt offering against a plague as deadly as any sent
into Egypt.
Scarcely more than a decade ago, as the mother sat by the cradle of her
firstborn, musing over his future, one moment fearfully reckoning the
gauntlet of risks that his tiny life had to run, and the next building
rosy air-castles of his happiness and success, there was one shadow that
ever fell black and sinister across his tiny horoscope. Certain risks
there were which were almost inevitable,--initiation ceremonies into
life, mild expiations to be paid to the gods of the modern underworld,
the diseases of infancy and of childhood. Most of these could be passed
over with little more than a temporary wrinkle to break her smile. They
were so trivial, so comparatively harmless: measles, a mere reddening of
the eyelids and peppering of the throat, with a headache and purplish
rash, dangerous only if neglected; chicken-pox, a child's-play at
disease; scarlatina, a little more serious, but still with the chances
of twenty to one in favor of recovery; diphtheria--ah! that drove the
smile from her face and the blood from her lips. Not quite so common,
not so inevitable as a prospect, but, as a possibility, full of terror,
once its poison had passed the gates of the body fortress. The fight
between the Angel of Life and the Angel of Death was waged on almost
equal terms, with none daring to say which would be the victor, and none
able to lift a hand with any certainty to aid.
Nor was the doctor in much happier plight. Even when the life at stake
was not one of his own loved ones,--though from the deadly
contagiousness of the disease it sadly often was (I have known more
doctors made childless by diphtheria than by any other disease except
tuberculosis),--he faced his cases by the hundred instead of by twos and
threes. The feeling of helplessness, the sense of foreboding, with which
we faced every case was something appalling. Few of us who have been in
practice twenty years or more, or even fifteen, will ever forget the
shock of dismay which ran through us whenever a case to which we had
been summoned revealed itself to be diphtheria. Of course, there was a
fighting chance, and we made the most of it; for in the milder epidemics
only ten to twenty per cent of the patients died, and even in the
severest a third of them recovered. But what "turned our liver to
water"--as the graphic Oriental phrase has it--was the knowledge which,
like Banquo's ghost, would not down, that while many cases would recover
of themselves, and in many border-line ones our skill would turn the
balance in favor of recovery, yet if the disease happened to take a
certain sadly familiar, virulent form we could do little more to stay
its fatal course than we could to stop an avalanche, and we never knew
when a particular epidemic or a particular case would take that turn.
"Black" diphtheria was as deadly as the Black Death of the Middle Ages.
The disease which caused all this terror and havoc is of singular
character and history. It is not a modern invention or development, as
is sometimes believed, for descriptions are on record of so-called
"Egyptian ulcer of the throat" in the earliest centuries of our era; and
it would appear to have been recognized by both Hippocrates and Galen.
Epidemics of it also occurred in the Middle Ages; and, coming to more
recent times, one of the many enemies which the Pilgrim Fathers had to
fight was a series of epidemics of this "black sore throat," of
particularly malignant character, in the seventeenth century.
Nevertheless, it does not seem to have become sufficiently common to be
distinctly recognized until it was named as a definite disease, and
given the title which it now bears, by the celebrated French physician,
Bretonneau, about eighty years ago. Since then it has become either more
widely recognized or steadily more prevalent, and it is the general
opinion of pathologists that the disease, up to some thirty or forty
years ago, was steadily increasing, both in frequency and in severity.
So that we have not to deal with a disease which, like the other
so-called diseases of childhood, has gradually become milder and milder
by a sort of racial vaccination, with survival of the less susceptible,
but one which is still full of virulence and of possibilities of future
danger.
Unlike the other diseases of childhood, also, one attack confers no
positive immunity for the future, although it greatly diminishes the
probabilities; and, further, while adults do not readily or frequently
catch the disease, yet when they do the results are apt to be
exceedingly serious. Indeed, we have practically come to the conclusion
that one of the main reasons why adults do not develop diphtheria so
frequently as children, is that they are not brought into such close and
intimate contact with other children, nor are they in the habit of
promptly and indiscriminately hugging and kissing every one who happens
to attract their transient affection, and they have outgrown that
cheerful spirit of comradeship which leads to the sharing of candy in
alternate sucks, and the passing on of slate-pencils, chewing-gum, and
other _objets d'art_ from hand to hand, and from mouth to mouth.
Statistics show that of nurses employed in diphtheria wards, before the
cause or the exact method of contagion was clearly understood, nearly
thirty per cent developed the disease; and even with every modern
precaution there are few diseases which doctors more frequently catch
from their patients than diphtheria. It is a significant fact that the
risk of developing diphtheria is greatest precisely at the ages when
there is not the slightest scruple about putting everything that may be
picked up into the mouth,--namely, from the second to the fifth
year,--and diminishes steadily as habits of cleanliness and caution in
this regard are developed, even though no immunity may have been gained
by a mild or slight attack of the disease. The tendency to discourage
and forbid the indiscriminate kissing of children, and the crusade
against the uses of the mouth as a pencil-holder, pincushion, and
general receptacle for odds and ends, would be thoroughly justified by
the risks from diphtheria alone, to say nothing of tuberculosis and
other infections.
In addition to being almost the only common disease of childhood which
is not mild and becoming milder, diphtheria is unique in another
respect, and that is its point of attack. Just as tuberculosis seizes
its victims by the lungs, and typhoid fever by the bowels,
diphtheria--like the weasel--grips at the throat. Its bacilli, entering
through the mouth and gaining a foothold first upon the tonsils, the
palate, or back of the throat (pharynx), multiply and spread until they
swarm down into the larynx and windpipe, where their millions, swarming
in the mesh of fibrin poured out by the outraged blood-vessels, grow
into the deadly false membrane which fills the air-tube and slowly
strangles its victim to death.
The horrors of a death like that can never fade from the memory of one
who has once seen it, and will outweigh the lives of a thousand
guinea-pigs. No wonder there was such a widespread and peculiar horror
of the disease, as of some ghostly thug or strangler.
But not all of the dread of diphtheria went under its own name. Most of
us can still remember when the commonest occupant of the nursery shelf
was the bottle of ipecac or soothing-syrup as a specific against croup.
The thing that most often kept the mother or nurse of young children
awake and listening through the night-watches was the sound of a cough,
and the anxious waiting to hear whether the next explosion had a
"croupy" or brassy sound. It was, of course, early recognized that there
were two kinds of croup, the so-called "spasmodic" and the "membranous,"
the former comparatively common and correspondingly harmless, the latter
one of the deadliest of known diseases. The fear that made the mother's
heart leap into her mouth as she heard the ringing croup-cough was lest
it might be membranous, or, if spasmodic, might turn into the deadly
form later. To-day most young mothers hardly know the name of wine of
ipecac or alum, and the coughs of young children awaken little more
terror than a similar sound in an adult. Croup has almost ceased to be
one of the bogies of the nursery. And why? Because membranous croup has
been discovered to be diphtheria, and children will not develop
diphtheria unless they have been exposed to the contagion, while, if
they should be, we have a remedy against it.
He was a bold man who first ventured to announce this, and for years the
battle raged hotly. It was early admitted that certain cases of
so-called membranous croup in children occurred after or while other
members of the family or household had diphtheria; and for a time the
opposing camps used such words as "sporadic" or scattered croup, which
was supposed to come of itself, and "epidemic" or contagious croup,
which was diphtheria. Now, however, these distinctions are swept away,
and boards of health require isolation and quarantine against croup
exactly as against any other form of diphtheria.
Cases of fatal croup still occasionally occur which cannot be directly
traced to other cases of diphtheria, but the vast majority of them are
clearly traceable to infection, usually from some case in another child,
which was so mild that it was not recognized as diphtheria until the
baby became "croupy" and search was made through the family throats for
the bacilli.
For years we were in doubt as to the cause of diphtheria. Half a dozen
different theories were advanced, bad sewerage, foul air, overcrowding;
but it was not until shortly after the Columbus-like discovery, by
Robert Koch, of the new continent of bacteriology, that the germ which
caused it was arrested, tried, and found guilty, and our real knowledge
of and control over the disease began. This was in 1883, when the
bacteriologist Klebs discovered the organism, followed a few months
later (in 1884) by Löffler, who made valuable additions to our knowledge
of it; so that it has ever since been known as the Klebs-Löffler
bacillus. This put us upon solid ground, and our progress was both sure
and rapid: in ten years our knowledge of the causation, the method of
spread, the mode of assault upon the body-fortress, and last, but not
least, the cure, stood out clear cut as a die, a model and a prophecy of
what may be hoped for in most other contagious diseases.
Great as is the credit to which bacteriologists are entitled for this
splendid piece of scientific progress, there was another co-laborer, a
silent partner, with them in all this triumph, an unsung hero and martyr
of science who deserves his meed of praise--the tiny guinea-pig. He well
deserves his niche in the temple of fame; and as other races and ages
have worshiped the elephant, the snake, and the sacred cow, so this age
should erect its temples to the guinea-pig. From one of the most
trifling and unimportant,--kept merely as a pet and curiosity by the
small boys of all ages,--he has become, after the horse, the cow, the
pig, and the sheep, easily our most useful and important domestic
animal. It may be urged that he deserves no credit, since his
sacrifice--though of inestimable value--was entirely involuntary on his
own part; but this should only make us the more deeply bound to
acknowledge our obligation to him.
By a stern necessity of fate, which no one regrets more keenly than the
laboratory workers themselves, the guinea-pig has had to be used as a
stepping-stone for every inch of this progress. Upon it were conducted
every one of the experiments whose results widened our knowledge, until
we found that this bacillus and no other would cause diphtheria; that
instead of getting, like many other disease-germs, into the blood, it
chiefly limited itself to growing and multiplying upon a comparatively
small patch of the body-surface, most commonly of the throat; that most
of its serious and fatal results upon the body were produced, not by the
entrance of the germs themselves into the blood, but by the absorption
of the toxins or poisons produced by them on the moist surface of the
throat, just as the yeast plant will produce alcohol in grape juice or
sweet cider.
Here was a most important clew. It was not necessary to fight the germs
themselves in every part of the body, but merely to introduce some
ferment or chemical substance which would have the power of neutralizing
their poison. Instantly attention was turned in this direction, and it
was quickly found that if a guinea-pig were injected with a very small
dose of the diphtheria toxin and allowed to recover, he would then be
able to throw off a still larger dose, until finally, after a number of
weeks, he could be given a dose which would have promptly killed him in
the beginning of the experiments, but which he now readily resisted and
recovered from. Evidently some substance was produced in his blood which
was a natural antidote for the toxin, and a little further search
quickly resulted in discovering and filtering out of his body the now
famous antitoxin. A dose of this injected into another guinea-pig
suffering from diphtheria would promptly save its life.
Could this antitoxin be obtained in sufficient amounts to protect the
body of a human being? The guinea-pig was so tiny and the process of
antitoxin-forming so slow, that we naturally turned to larger animals as
a possible source, and here it was quickly found that not only would the
goat and the horse develop this antidote substance very quickly and in
large amounts, but that a certain amount of it, or a substance acting as
an antitoxin, was present in their blood to begin with. Of the two, the
horse was found to give both the stronger antitoxin and the larger
amounts of it, so that he is now exclusively used for its production.
After his resisting power had been raised to the highest possible pitch
by successive injections of increasing doses of the toxin, and his serum
(the watery part of the blood which contains the healing body) had been
used hundreds and hundreds of times to save the lives of
diphtheria-stricken guinea-pigs, and had been shown over and over again
to be not merely magically curative but absolutely harmless, it was
tried with fear and trembling upon a gasping, struggling, suffocating
child, as a last possible resort to save a life otherwise hopelessly
doomed. Who could tell whether the "heal-serum," as the Germans call it,
would act in a human being as it had upon all the other animals? In
agonies of suspense, vibrating between hope and dread, doctors and
parents hung over the couch. What was their delight, within a few hours,
to see the muscles of the little one begin to relax, the fatal blueness
of its lips to diminish, and its breathing become easier. In a few hours
more the color had returned to the ashen face and it was breathing
quietly. Then it began to cough and to bring up pieces of the loosened
membrane that had been strangling it. Another dose was eagerly injected,
and within twenty-four hours the child was sleeping peacefully--out of
danger. And the most priceless and marvelous life-saving weapon of the
century had been placed in the hand of the physician.
Of course there were many disappointments and failures in the earlier
cases. Our first antitoxins were too weak and too variable. We were
afraid to use them in sufficient doses. Often their injection would not
be consented to until the case had become hopeless. 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. The series of Bayeaux, covering two hundred and thirty
thousand cases of diphtheria, chiefly from hospitals and hence of the
severest type, showing that the death-rate had been reduced from over
_fifty-five_ per cent to below _sixteen_ per cent already, and that this
decrease was still continuing, will serve as a fair sample.
Three-quarters of even this sixteen per cent mortality is due to delay
in the administration of the antitoxin, as is vividly shown in thousands
of cases now on record, classified according to the day of the disease
on which the antitoxin was given, of which MacCombie's "Report of the
London Asylums Board" is a fair type. Of one hundred and eighty-seven
cases treated the first day of the disease, none died; of eleven hundred
and eighty-six injected on the second day of the disease, four and a
half per cent died; of twelve hundred and thirty-three not treated until
the third day of the disease, eleven per cent died; of nine hundred and
sixty-three cases escaping treatment until the fourth day, seventeen per
cent died; while of twelve hundred and sixty not seen until the fifth
day, twenty per cent died. In other words, the chances for cure by the
antitoxin are in precise proportion to the earliness with which it is
administered, and are over four times as great during the first two days
of the disease as they are after the fourth day. One "stick" in time
saves five.
This brings us sharply to the fact that the most important factor in the
cure of diphtheria, just as in the case of tuberculosis, is early
recognition. How can this be secured? Here again the bacteriologist
comes to our relief, and we needed his aid badly. The symptoms of a mild
case of diphtheria for the first two, or even three, days are very much
like those of an ordinary sore throat. As a rule, even the well-known
membrane does not appear in sufficient amounts to be recognizable by the
naked eye until the middle of the second, or sometimes even of the
third, day. By any ordinary means, then, of diagnosis, we would often be
in doubt as to whether a case were diphtheria or not, until it was both
well advanced and had had time to infect other members of the family.
With the help of the laboratory, however, we have a prompt, positive,
and simple method of deciding at the very earliest stage. We merely take
a sterilized swab of cotton on the end of a wire, rub it gently over the
surface of the throat and tonsils, restore it to its glass tube,
smearing it over the surface of some solidified blood-serum placed at
the bottom of the tube, close the tube and send it to the nearest
laboratory. The culture is put into an incubator at body heat, the germs
sown upon the surface of the blood-serum grow and multiply, and in
twelve hours a positive diagnosis can be made by examining this growth
with a microscope. Often, just smearing the mucus swabbed out of the
throat over the surface of a glass slide, staining this smear, and
putting it under a microscope, will enable us to decide within an hour.
These tubes are now provided by all progressive city boards of health,
and can be had free of charge at depots scattered all over the city, for
use in any doubtful case, within half an hour. Twelve hours later a free
report can be had from the public laboratory. If every case of
suspicious sore throat in a child were promptly swabbed out, and a smear
from the swab examined at a laboratory, it would not be long before
diphtheria would be practically exterminated, as smallpox has been by
vaccination, and this is what we are working toward and looking forward
to.
Our knowledge of the precise cause of diphtheria, the Klebs-Löffler
bacillus, has furnished us not only with the cure, but also with the
means of preventing its spread. While under certain circumstances,
particularly the presence of moisture and the absence of light, this
germ may live and remain virulent for weeks outside of the body, careful
study of its behavior under all sorts of conditions has revealed the
consoling fact that its vitality outside of the human or some other
living animal body is low; so that it is relatively seldom carried from
one case to another by articles of clothing, books, or toys, and
comparatively seldom even through a third party, except where the latter
has come into very close contact with the disease, like a doctor, a
nurse, or a mother, or--without disrespect to the preceding--a pet cat
or dog.
More than this, the bacillus must chiefly be transmitted in the moist
condition and does not float in the air at all, clinging only to such
objects as may have become smeared with the mucus from the child's
throat, as by being coughed or sneezed upon. As with most of our
germ-enemies, sunlight is its deadliest foe, and it will not live more
than two or three days exposed to sunshine. So the principal danger
against which we must be on our guard is that of direct personal
contact, as in kissing, in the use of spoons or cups in common, in the
interchange of candy or pencils, or through having the hands or clothing
sprayed by a cough or a sneeze.
The bacillus comparatively seldom even gets on the floor or walls of a
room where reasonable precautions against coughing and spitting have
been taken; but it is, of course, advisable thoroughly to disinfect and
sterilize the room of a patient and all its contents with corrosive
sublimate and formalin, as a number of cases are on record in which the
disease has been carried through books and articles of clothing which
had been kept in damp, dark places for several months. The chief method
of spread is through unrecognized mild cases of the disease, especially
of the nasal form. For this reason boards of health now always insist
upon smears being made from the throats and noses of every other child
in the family or house where a case of diphtheria is recognized. No
small percentages of these are found to be suffering from a mild form of
the disease, so slight as to cause them little inconvenience and no
interference with their attending school. Unfortunately, a case caught
from one of these mild forms may develop into the severest laryngeal
type. If a child is running freely at the nose, keep it at home or keep
your own child away from it. A profuse nasal discharge is generally
infectious, in the case of influenza or other "colds," if not of
diphtheria.
This also emphasizes the necessity for a thorough and expert medical
inspection of school-children, to prevent these mild cases from
spreading disease and death to their fellows. By an intelligent
combination of the two methods, home examination of every infected
family and strict school inspection, there is little difficulty in
stamping out promptly a beginning infection before it has had time to
reach the proportions of an epidemic.
One other step makes assurance doubly sure, and that is the prompt
injection of all other children and young adults living in the family,
where there is a case of diphtheria, with small doses of the antitoxin
for preventive purposes. Its value in this respect has been only
secondary to its use as a cure. There are now thousands of cases on
record of children who had been exposed to diphtheria or were in
hospitals where they were in danger of becoming exposed to it, with the
delightful result that only a very small per cent of those so protected
developed the disease, and of these not a single one died! This
protective vaccination, however, cannot be used on a large scale, as in
the case of smallpox, for the reason that the period of protection is a
comparatively short one, probably not exceeding two or three weeks.
Suppose that, in spite of all our precautions, the disease has gained a
foothold in the throat, what will be its course? This will depend, first
of all, upon whether the invading germs have lodged in their commonest
point of attack, the tonsils, palate, and upper throat, or have
penetrated down the air-passages into the larynx or voice-organ. In the
former, which is far the commoner case, their presence will cause an
irritation of the surface cells which brings out the leucocyte cavalry
of the body to the defense, together with squads of the serum or watery
fluid of the blood containing fibrin. These, together with the
surface-cells, are rapidly coagulated and killed by the deadly toxin;
and their remains form a coating upon the surface, which at first is
scarcely perceptible, a thin, grayish film, but which in the course of
twenty-four to forty-eight hours rapidly thickens to the well-known and
dreaded false membrane. Before, however, it has thickened in more than
occasional spots or patches, the toxin has begun to penetrate into the
blood, and the little patient will complain of headache, feverishness,
and backache, often--indeed, usually--before any very marked soreness in
the throat is complained of. Roughly speaking, attacks of sore throat,
which begin first of all with well-marked soreness and pain in the
throat, followed later by headache, backache, and fever, are not very
likely to be diphtheria. The bacilli multiply and increase in their
deadly mat on the surface of the throat, larger and larger amounts of
the poison are poured into the blood, the temperature goes up, the
headache increases, the child often begins to vomit, and becomes
seriously ill. The glands of the neck, in their efforts to arrest and
neutralize the poison, become swollen and sore to the touch, the breath
becomes foul from the breaking down of the membrane in the throat, the
pulse becomes rapid and weak from the effect of the poison upon the
heart, and the dreaded picture of the disease rapidly develops.
This process in from sixty to eighty per cent of cases will continue for
from three to seven days, when a check will come and the condition will
gradually improve. This is a sign that the defensive tissues of the body
have succeeded in rallying their forces against the attack, and have
poured out sufficient amounts of their natural antitoxin to neutralize
the poisons poured in by the invaders. The membrane begins to break down
and peel off the throat, the temperature goes down, the headache
disappears, the swelling in the glands of the neck may either subside or
go on to suppuration and rupture, but within another week the child is
fairly on the way to recovery.
Should the invaders, however, have secured a foothold in the larynx,
then the picture is sadly different. The child may have even less
headache, temperature, and general sense of illness; but he begins to
cough, and the cough has a ringing, brassy sound. Within forty-eight, or
even twenty-four, hours he begins to have difficulty in respiration.
This rapidly increases as the delicate tissues of the larynx swell under
the attack of the poison, and the very membrane which is created in an
attempt at defense becomes the body's own undoing by increasing the
blocking of the air-passages. The difficulty of breathing becomes
greater and greater, until the little victim tosses continually from
side to side in one constant, agonizing struggle for breath. After a
time, however, the accumulation of carbon dioxide in the blood produces
its merciful narcotic effect, and the struggles cease. The breathing
becomes shallower and shallower, the lips become first blue, then ashy
pale, and the little torch of life goes out with a flicker. This was
what we had to expect, in spite of our utmost effort, in from seventy to
ninety per cent of these laryngeal cases, before the days of the blessed
antitoxin. Now we actually reverse these percentages, prevent the vast
majority of cases from developing serious laryngeal symptoms at all, and
save from seventy to eighty per cent of those who do.
Our only resource in this form of the disease used to be by mechanical
or surgical means, opening the windpipe below the level of the
obstruction and inserting a curved silver tube--the so-called
tracheotomy operation; or later, and less heroic, by pushing forcibly
down into the larynx, and through and past the obstruction at the vocal
cords, a small metal tube through which the child could manage to
breathe. This was known as intubation. But these were both distressing
and painful methods, and, what was far worse, pitifully broken reeds to
depend upon. In spite of the utmost skill of our surgeons, from fifty to
eighty per cent of cases that were tracheotomized, and from forty to
sixty per cent of those that were intubated, died. In many cases they
were enabled to breathe, their attacks of suffocation were relieved--but
still they died.
This leads us to the most important single fact about the course of the
disease, and that is that the chief source of danger is not so much from
direct suffocation as from general collapse, and particularly failure of
the heart.
This has given us two other data of great importance and value, namely,
that while the immediate and greatest peril is over when the membrane
has become loosened and the temperature has begun to subside, in both
ordinary throat and in laryngeal forms of the disease, the patient is by
no means out of danger. While the antitoxins poured out by his body have
completely defeated the invading toxins in the open field of the blood,
yet almost every tissue of the body is still saturated with these latter
and has often been seriously damaged by them before their course was
checked. For instance, nearly two-thirds of our diphtheria cases, which
are properly examined, will show albumin in the urine, showing that the
kidney-cells have been attacked and poisoned by the toxin. This may go
on to a fatal attack of uremia; but fortunately, not commonly, far less
so than in scarlet fever. The kidneys usually recover completely, but
this may take weeks and months. Again, many cases of diphtheria will
show a weak and rapid pulse, which will persist for weeks after the
patient has apparently recovered; and if the little ones are allowed to
sit up too soon, or to indulge in any sudden movements or muscular
strains, this weak and rapid pulse will suddenly change into an attack
of heart failure and, possibly, fatal collapse. This, again, illustrates
the saturation of the poison, as these effects are now known to be due
in part to a direct poisoning of the muscle of the heart itself, and
later to serious damage done to the nerves controlling the heart,
chiefly the pneumo-gastric. Moral: Keep the little patient in bed for at
least two weeks or, better, three. He will have to spend a month or more
in quarantine, anyway.
Last of all, and by no means least interesting, are the effects which
are produced upon the nervous system. One day, while the child is
recovering, and is possibly beginning to sit up in bed, a glass of milk
is handed to him. The little one drinks it eagerly and attempts to
swallow, but suddenly it chokes, half strangles, and back comes the
milk, pouring out through the nostrils. Paralysis of the soft palate has
occurred from poisoning of the nerves controlling it, caused by direct
penetration of the toxin. Sometimes the muscles of the eye become
paralyzed and the little one squints, or can no longer see to read.
Fortunately, most of these alarming results go only to a certain degree,
and then gradually fade away and disappear; but this may take months or
even longer. In a certain number, however, the nerves of respiration, or
those controlling the heart-beat, become affected, and the patient dies
suddenly from heart failure.
This strange after-effect upon the nervous system, which was first
clearly noticed in diphtheria and syphilis, has now been found to occur
in lesser degree in a large number of our infectious diseases, so that
many of our most serious paralyses and other diseases of the nervous
system are now traceable to such causes.
These effects of the diphtheria toxin are also of interest for a
somewhat unexpected reason, since it has been claimed that they are
effects of the antitoxin, by those who are opposed to its use. Every one
of them was well recognized as a possible result of diphtheria long
before the antitoxin was discovered, and every one of them can be
readily produced by injections of diphtheria bacilli or their toxin into
animals.
It is quite possibly true that there are more cases of nerve-poisoning
(neuritis) and of paralysis following diphtheria than there were before
the use of antitoxin, but that is for the simple and sufficient reason
that there are more children left alive to display them! And between a
child with a temporary squint and a dead child few mothers would
hesitate long in their choice.