Preventable Diseases

by Woods Hutchinson

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.