Bacteria: Chapter VII - THE QUESTION OF IMMUNITY AND ANTITOXINS by@sirgeorgenewman

Bacteria: Chapter VII - THE QUESTION OF IMMUNITY AND ANTITOXINS

THE term natural immunity is used to denote natural resistance to some particular specific disease. It may refer to race, or age, or individual idiosyncrasies. We not infrequently meet with examples of this freedom from disease. Certain races of men do not, as a rule, take certain diseases. For example, plague and leprosy, though endemic in some countries, fail to get a footing in England. This, of course, is due in great measure to the sanitary organisation and cleanly customs of the English people. Still, it is also due to the fact that the English appear in some degree to be immune. Some authorities hold that the immunity against leprosy is due to the fact that the disease has exhausted itself in the English race.
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Sir George Newman

Bacteria

Bacteria, by George Newman is part of the HackerNoon Books series. You can jump to any chapter in this book here. Chapter VII: THE QUESTION OF IMMUNITY AND ANTITOXINS

CHAPTER VII. THE QUESTION OF IMMUNITY AND ANTITOXINS

THE term natural immunity is used to denote natural resistance to some particular specific disease. It may refer to race, or age, or individual idiosyncrasies. We not infrequently meet with examples of this freedom from disease. Certain races of men do not, as a rule, take certain diseases. For example, plague and leprosy, though endemic in some countries, fail to get a footing in England. This, of course, is due in great measure to the sanitary organisation and cleanly customs of the English people. Still, it is also due to the fact that the English appear in some degree to be immune. Some authorities hold that the immunity against leprosy is due to the fact that the disease has exhausted itself in the English race.

However that may be, we know that immunity, entire or partial, exists. Children, again, are susceptible to certain diseases and insusceptible to certain others to which older people are susceptible. We know, too, that some individuals have a marked protection against some diseases. Some people coming into the way of infection at once fall victims to the disease, whilst others appear to be proof against it. It is only in recent times that any very intelligent explanations have been offered to account for this phenomenon. The most recent of these, and that which appears to have most to substantiate it, is known as immunity due to antitoxins.

The products of bacteria are chiefly six:

1. Pigment. We have already seen how many organisms exhibit their energy in the formation of many coloured pigments. They are, as a rule, "innocent" microbes. Oxygen is required for some, darkness for others, and they all vary according to the medium upon which they are growing. Red milk, yellow milk, and green pus afford examples of pigment produced by bacteria.

2. Gas. Quite a number of the common bacteria, like Bacillus coli, produce gas in their growth; hydrogen (H), carbonic acid (CO2), methane (CH4), and even nitrogen (N) being formed by different bacteria. Many gases produced during fermentative processes are the result, not directly of the growth of the bacillus causing the fermentation, but indirectly owing to the splitting up of the fermenting fluids.

3. Acids. Lactic, acetic, butyric, etc., are common types of acids resulting from the growth of bacteria.

4. Liquefying Ferment. As we have seen, bacteria may be classified with regard to their behaviour in gelatine medium, whether or not they produce a peptonising ferment which liquefies the gelatine.

5. Phosphorescence. Some species of bacteria in sea-water possess the power of producing light.

6. Organic Chemical Products. When a pathogenic bacillus grows either in the body or in a test-tube, it produces as a result of its metabolism certain poisonous substances called toxins. These may occur in the blood as a direct result of the life of the bacillus, or they may occur as the result of a ferment produced by the bacillus. They are of various kinds according to the various diseases, and by their effect upon the blood and body tissues they cause the symptoms of the disease in question.

We know, for instance, that a characteristic symptom common to many diseases is fever. Now, fever is produced by the action of the albumoses242 (bodies allied to the proteids) upon the heat-regulating centres in the brain. Whenever we get a bacillus growing in the body which has the power of producing a toxin albumose, we get fever as a result of that product acting upon the brain. Albumoses, as a matter of fact, cause a number of symptoms and poisonous effects, but the mention of one as an illustration will suffice. Toxins act, roughly speaking, in two ways:

(1) They have a local action, as, for example, in the formation of an abscess. The presence of the causal bacteria in the tissue brings about very marked changes. There is a multiplication of connective-tissue corpuscles, an emigration of leucocytic cells, a congestion of blood corpuscles. All these elements assist in creating a swelling and redness, and pain by the subsequent pressure upon the delicate nerve endings. These, as we all know, are the symptoms of a "gathering" or abscess. It is a "gathering" in a strict pathological sense—a gathering of cells to oust the intruder or build around it a wall or capsule as a protective measure. Now the toxin will commence its local action.

The oldest cells in the mass of congestion will be caused to break down into liquid; what is called a necrosis, or death, will rapidly set in; and we shall have the connective-tissue cells, leucocytes, blood corpuscles, etc., losing their form and function, and "coming to a point" as matter, or pus. The local breaking down of these gatherings of cells into fluid matter is believed to be the work, not of the bacteria themselves, but of their toxins.

(2) Toxins may be absorbed and distributed generally throughout the body. They produce degenerative changes in muscles, in organs, and in the blood itself. Let us take diphtheria as an example. The bacillus occurs in a false membrane in the throat and occasionally other parts. It causes first the inflammatory condition giving rise to the membrane, and then it breaks it down. In the body of the membrane the bacillus appears to secrete a ferment which by its action and interaction with the body cells and proteids, chiefly those of the spleen, produces albumoses and an organic acid.

These latter bodies are the toxins. They are absorbed, and pass throughout the body. There are albumoses, therefore we get the frequent pulse and high temperature of fever; the toxins irritate the mucous membrane of the intestine, and cause various fermentative changes in the contents of the intestine, therefore we get the symptoms of diarrhœa; they penetrate the liver, spleen, and kidney, therefore we get fatty degeneration and its results in these organs; they finally affect many of the motor and sensory nerves, breaking up their axis cylinders into globules, and therefore we get the characteristic paralysis. Loss of weight naturally follows many of these degenerative or wasting changes. Here, then, we have some of the chief changes set up by the toxins, and these changes constitute the leading symptoms in the disease as it is known clinically.

In addition to the presence of the specific bacillus in the membrane, we also have a number of other organisms, like the Bacillus coliCoccus BrissouStreptococcus pyogenes, and various staphylococci, diplococci, etc. Each of these produces or endeavours in the midst of keen competition and strife to produce, its own specific effect. Thus we obtain the complications of diphtheria, for example various suppurative and septic conditions. The whole of this compound process we may tabulate roughly as follows:

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Such is the general effect of toxins in diphtheria. The same principles apply with equal force in tetanus, typhoid, etc., the only differences being in degree of virulence, mode of onset, and portions of the body chiefly affected.

Sidney Martin has recently elaborated the views announced by him in 1892, and it is right that reference should be made to his new classification of bacterial poisons. This may be represented as follows:—

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The poisons of bacteria are, according to Sidney Martin, of a kind which cannot be fully expressed chemically, but only pathologically. They may be of a ferment nature in diphtheria and tetanus. The arguments in support of that view are—(1) that they act in infinitesimal doses, (2) that they may act slowly and produce death after many days by profoundly affecting the general nutrition, and (3) that they are sensitive to the action of heat in a way that no chemical poisons are known to be. If they are considered as ferments, they must be substances which have a peculiar affinity for certain tissues of the body on which they produce their special toxic effect. As for the products of digestion, they are formed either by the bacillus ingesting the proteid and discharging it as albumose, or the digestion occurs by means of a ferment secreted by the bacillus in the body of an individual or animal suffering from the disease.

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. It will be seen that these views differ in some particulars from those to which we have already referred.

However the details of the modus operandi of the formation of toxins are finally settled, we know that there comes a time when the disease symptoms vanish, the disease declines, and the patient recovers. Many of the older schools of medicine explained this satisfactory phenomenon by saying that this disease exhausted itself after having "gone through" the body. In a sense that idea is probably true; but recently a large number of investigators have applied themselves to this problem, and with some promising results.

Various protective inoculations against anthrax were practised as early as 1881, and the protected animals remained healthy. In 1887 Wooldridge succeeded in protecting rabbits from anthrax by a new method, by which he showed that the growth of the anthrax bacillus in special culture fluids gave rise to a substance which, when inoculated, conferred immunity. In 1889 and 1890 Hankin and Ogata worked at the subject, and announced the discovery in the blood of animals which had died of anthrax of some substances which appeared to have an antagonistic and neutralising effect upon the toxins of anthrax and upon the anthrax bacilli themselves. These substances, they afterwards found, were products of the anthrax bacillus. Behring and Kitasato arrived at much the same results for tetanus and diphtheria.

The next step was to isolate these substances, and, separating them from the blood, investigate still further their constitution. A number of workers were soon occupied at this task, and since 1891 Buchner, Hankin, the Klemperers, Roux, Sidney Martin, and others have added to our knowledge respecting these toxin-opposing bodies known as antitoxins. In diphtheria, as we have seen, the toxins turned out to be soluble bodies allied to the proteids, albumoses, and an organic acid. Then arose the question of the source of antitoxins.

Some believed they were a kind of ultratoxin—bodies of which an early form was a toxin; others held that, as the toxins were products of the bacteria invading the tissues, the antitoxins were of the nature of ferments produced by the resisting tissues. Finally, they came to be looked upon as protective substances produced in the body cells as a result of toxin action, and held in solution in the blood, and there and elsewhere exerting their influence in opposition to the toxins. The progress of disease is therefore a struggle between the toxins and the antitoxins: when the toxins are in the ascendency we get an increase of the disease; when the antitoxins are in the ascendency we get a diminution of disease. If the toxins triumph, the result is death; if the antitoxins and resistance of the tissues triumph, the result is recovery.

We may now consider shortly how these new facts were received and what theories of explanation were put forward to explain continued insusceptibility to disease. It had of course been known for a long time past that one attack of small-pox, for example, in some degree protected the individual from a subsequent attack of the same disease. To that experience it was now necessary to add a large mass of experimental evidence with regard to toxins and antitoxins. The theories of immunity were as follows:

1. The Exhaustion Theory. The supporters of this idea argued that bacteria of disease circulating in the body exhausted the body of the supply of some substance or condition necessary for the growth and development of their own species.

2. The Retention Theory. It was surmised that there were certain products of micro-organisms of disease retained in the body after an attack which acted antagonistically to the further growth in the body of that same species.

3. The Acquired Tolerance Theory. Some have advanced the theory that, after a certain time, the human tissues acquired such a degree of tolerance to the specific bacteria or their specific products that no result followed their action in the body. The tissues become acclimatised to the disease.

4. The Phagocyte Theory. This theory, which gained so many adherents when first promulgated by Metschnikoff, attributes to certain cells in the tissues the powers of "scavenging," overtaking germs of disease, and absorbing them into their own protoplasm. This, indeed, may be actually witnessed, and had been observed before the time of Metschnikoff. But it was he who applied it to disease. He came to the conclusion that the successful resistance which an animal offered to bacteria depended upon the activity of these scavenging cells, or phagocytes. These cells are derived from various cellular elements normally present in the body: leucocytes, endothelial cells, connective-tissue corpuscles, and any and all cells in the body which possess the power of ingesting bacteria. If they are present in large numbers and active, the animal is insusceptible to certain diseases; if they are few and inactive, the animal is susceptible.

It appears that the bacteria or other foreign bodies in the blood which are attacked by the phagocyte become assimilated until they are a part of the phagocyte itself. Metschnikoff explained also how it comes to pass that the phagocyte is able to encounter bacteria when both are circulating through the blood. It is guided in this attack upon the organisms by a power termed chemiotaxis.

The bacteria elaborate a chemical substance which attracts the phagocyte, and this is termed "positive chemiotaxis." But it may occur that the chemical substance produced by the bacteria may have an opposite, or repellent, effect upon the leucocytes, in which case we have "negative chemiotaxis." It is not to be wondered at that such a theory of immunity based upon microscopical observations, should at first have been widely accepted, and there can be no doubt that Metschnikoff has collected a considerable mass of evidence in support of a theory of phagocytosis.

But when it came to be known that blood serum, from which all leucocytes (phagocytes) had been removed, possessed the same immunising effect as before, it was clear that such effect was a property of the serum per se, and not only or wholly due to the scavenging power of certain cells in it. Even the phagocyte theory depends largely for its validity upon chemiotaxis, which latter was a property of the products of the bacteria contained in the blood serum.

5. The Antitoxin Theory. We have gathered, then, that whenever bacteria, introduced into the blood and tissues, fail to multiply or produce infection (as in saprophytic bacteria, or in immunity of a particular animal from a specific microbe), this inability to perform their rôle is brought about by some property in the living and normal blood serum which opposes their life and action; and further we have learned that this protective property is exhaustible according to the number of bacteria, and differs with various species of bacteria, and in different animals.

Buchner designates these protective bodies, held in solution in the blood, alexines, and regards them as belonging to the albuminous bodies of the lymph and plasma. Where the blood and tissues do not possess this power, the animal is susceptible. Now, as we have already seen from the experiments of Ogata, Kitasato, and others, the blood of an animal dead of anthrax is protective against anthrax, from which and the foregoing it appears that microbes produce by their growth in the tissues poisonous substances we term toxins, which have the power of producing in the blood and body cells substances inimical to themselves, named antitoxins, and so long as these latter substances remain in the tissues the body remains insusceptible to further attacks of the same disease. Alexines are naturally produced antitoxins; antitoxins are acquired alexines.

Hence we have the well-known terms "natural" and "acquired immunity." Of the former we have already spoken. Acquired immunity is a protection not belonging to the tissues of individuals naturally and as part of their constitution, but it is acquired during their lives as a further accomplishment, so to speak, of their tissues. This may happen in one or both of two ways. Either it may be an involuntary acquired immunity, or a voluntary acquired immunity. For example, the former is at once illustrated by an attack of the disease.

Small-pox, typhoid fever, even scarlet fever, are diseases which very rarely attack the same individual twice. That is because each of these diseases leaves behind it, on its first appearance, its antitoxic influence. Hence the individual has involuntarily acquired immunity against these diseases. An example of voluntary acquired immunity is also at hand in the old method of preventive inoculation for small-pox, or variolation. This was clearly an inoculation setting up an artificial and mild attack of small-pox, by which the antitoxins of that disease were produced, and protected the individual against further infection of small-pox; that is to say, it was a voluntary acquired immunity. This form of artificial production of protection is generally called artificial immunity. Let us now marshal together these various terms in a table as follows:

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It is hoped that previous remarks will have explained the meaning of the terms used in the above table, with the exception of the last two phrases of active and passive immunity. We propose now to consider in some detail the four illustrations quoted under these two headings, viz., vaccination, Pasteur's treatment of rabies, anti-cholera inoculation, and antitoxin inoculation. From all accounts, it is to be feared that these four phases of artificial immunity are hopelessly confused in the educated public mind. Nor is this to be wondered at when we reflect upon the rapid growth of the whole science of immunity, and upon the ever-varying forms of nomenclature through which it has passed.

Vaccination for Small-pox. In 1717 Lady Mary Wortley Montagu described the inoculation of small-pox as she had seen it practised in Constantinople. So greatly was she impressed with the efficacy of this process that she had her own son inoculated there, and in 1721 Mr. Maitland, a surgeon, inoculated her daughter in London. This was the first time inoculation was openly practised in England. For one hundred and twenty years small-pox inoculation (or variolation, as it is more correctly termed) was practised in England, until by Act of Parliament in 1840 it was prohibited.

There were different ways of performing variolation, but the most approved method was similar to the modern system of arm-to-arm vaccination, the arm being inoculated with a lancet in one or more places with small-pox lymph instead of, as now, with vaccine lymph. As a rule, only local results or a mild attack of small-pox followed, which prevented an attack of natural small-pox. Its disadvantage is apparent on the surface. It was a means of breeding small-pox, for the inoculated cases were liable to create fresh centres of infection.

In 1796 Edward Jenner, who was a country practitioner in Gloucestershire, observed that those persons affected with cow-pox, contracted in the discharge of their duty as milkers, did not contract small-pox, even when placed in risk of infection. Hence he inferred that inoculation of this mild and non-infectious disease would be preferable to the process of variolation then so widely adopted in England. Jenner therefore suggested the substitution of cow-pox lymph (vaccine) in place of small-pox lymph, as in ordinary variolation.

It should not be forgotten that variolation was thus the first work done in this country in producing artificial immunity, and was followed by vaccination, which was only partly understood. Even to-day there is probably much to learn respecting it. Both variolation and vaccination may be described as active immunisation by means of an attenuated form of the specific virus causing the disease.

The nature of the specific virus of both small-pox and cow-pox awaits discovery. Burdon Sanderson, Crookshank, Klein, and Copeman have all demonstrated bacteria in cow-pox or vaccine lymph, and in 1898 Copeman announced that he had isolated a specific bacillus and grown it upon artificial media. Numerous statements have been made to the effect that a specific bacillus has been found in small-pox also. But neither in small-pox nor cow-pox is the nature of the contagion really known.

These facts, however, do not remove the suspicion which has hitherto rested upon vaccine lymph as a vehicle for bacteria of other diseases which by its inoculation may thus be contracted. A few remarks are therefore called for at this juncture upon the recent work of Dr. Monckton Copeman and Dr. Frank Blaxall in respect to what is known as glycerinated calf lymph. Evidence has been forthcoming to substantiate in some measure the distrust which many of the public have from time to time felt in the vaccine commonly used in vaccination, hence the new form as above designated. This retains the toxic qualities required for immunity, but is so produced that it possesses in addition three very important advantages; namely, it is entirely free from extraneous organisms, it is available for a large number of vaccinations, and it retains full activity for eight months. It is prepared as follows:

A calf, aged three to six months, is kept in quarantine for a week. If then found upon examination to be quite healthy, it is removed to the vaccination station, and the lower part of its abdomen antiseptically cleaned. The animal is now vaccinated upon this sterilised area with glycerinated calf lymph.

After five days the part is again thoroughly washed, and the contents of the vesicle, which have of course appeared in the interval, are removed with a sterilised sharp spoon, and transferred to a sterilised bottle. This is now removed to the laboratory, and the exact weight of the material ascertained. A calf thus vaccinated will yield from 18 to 24 grams of vaccine material. This is now thoroughly triturated and mixed with six times its weight of a sterilised solution of 50 per cent. chemically pure glycerine in distilled water. The resulting emulsion is aseptically stored in sealed tubes in a cool place. For four weeks it is carefully examined bacteriologically until the glycerine has absolutely killed any possible germ that may have obtained entrance. When by agar plates it is demonstrably sterile it is ready for distribution.

Pasteur's Treatment of Rabies. Rabies is a disease affecting dogs (in Western Europe) and wolves (in Russia), and can be transmitted to other animals and man, infection being carried by the bite of a rabid animal. It takes two chief forms: (1) furious rabies and (2) paralytic rabies. The former is more common in dogs. The animal becomes restless, has a high-toned bark, and snaps at various objects. Sometimes it exhibits depraved appetite; spasms of the throat follow, and these soon develop into convulsions, which are followed by coma and death. In man the incubation period is fortunately a very long one, averaging about forty days. Nervous irritability is the first sign; spasms occur in the respiratory and masticatory muscles, and the termination is similar to rabies in the dog. The symptom of fear of water is a herald of coming fatality.

Although a number of the workers at the Pasteur Institute and elsewhere have addressed themselves to the detection of a specific microbe, none has as yet been found, although, in the opinion of Pasteur, such an agent may be suspected as the cause.

Pathologically rabies and tetanus (see page 168) are closely allied diseases, and the recent remarkable additions to our knowledge of the latter disease only make the similarity more evident. There are in rabies three chief sets of post-mortem signs. First, and by far the most important, are the changes in the nervous system. Here we find patches of congestion in the brain, and breaking down of the axis cylinders of the nerves. The stomach, in the second place, exhibits hæmorrhagic changes, not unlike acute arsenical poisoning. Thirdly, the salivary glands show a degenerative change in a breaking down of their secreting cells. Roux has pointed out that in life the saliva of a mad dog becomes virulent three days before the appearance of the symptoms of disease.

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Pasteur's treatment of rabies by inoculation of emulsions of dried spinal cord is, therefore, a "vaccination" of attenuated virus, resulting in antitoxin formation, to the further protection of the individual against rabies.

One further example of the modern application of the principles of active acquired immunity may be shortly mentioned. We refer to the cholera and plague vaccinations. The vaccination in small-pox is an inoculation of the virus of the disease; the rabies inoculation is a transmission of the vital products of the disease attenuated; the plague and cholera vaccinations are inoculations of pure cultures of living virus from outside the body. Inoculating cholera virus against cholera has been made illegal, as variolation was in 1840. But Haffkine has prepared two vaccines.

The weak one is made from pure cultures of Koch's spirillum of Asiatic cholera, attenuated by growth to several generations on agar or broth at 39°C. The strong one is from similar culture the virulence of which has been increased. One cubic centimetre of the first vaccine is injected hypodermically into the flank, and the second vaccine three or four days afterwards. The immunisation is prophylactic, not remedial, and its action takes effect five or six days after the second vaccine has been injected.

INOCULATION TREATMENT FOR PERSONS AFFECTED WITH RABIES

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In plague the same plan has been followed. Luxurious crops of Kitasato's plague bacillus are grown on ordinary nutritive media plus large quantities of fat. The fat of milk, as clarified butter, is that generally used. Under the globules of fat flakes of culture grow like stalactites, hanging down into the clear broth. These are in time shaken to the bottom, and a second crop grows on the under-surface of the fat. In the course of a month perhaps half a dozen such crops are obtained and shaken down into the fluid, until the latter assumes an opaque milky appearance.

This is now, unlike the cholera vaccine, exposed to a temperature of 70° C., by which the microbes are killed. The culture contains all the toxins, and the dose is 3 cc. This preparation has the advantage of being easily prepared, obtainable in large quantities, and requires no animals in its preparation. When inoculated it produces local pain and swelling at the site of inoculation, and general reactive symptoms such as fever. From a careful analysis of the results of this inoculation, it is shown that the efficacy of the prophylactic depends upon the virulence of the bacillus culture from which the vaccine is prepared, and upon its dose and ability to produce a well-marked febrile reaction. It appears to be more effective in the prevention of deaths than of attacks.

The anti-typhoid vaccination is another example of inoculation to secure active immunity. It is needless, perhaps, to point out that all these vaccinations, except rabies, are prophylactic, and not curative.

Passive Immunity; Preparation of Antitoxins. We must now consider the question of passive immunity. This, it will be remembered, may be defined as a protection (against a bacterial disease) produced by inoculation, not of the disease itself, as in small-pox inoculation, nor yet of its weakened toxins, as in rabies, but of the antitoxins produced in the body of an animal suffering from that particular disease. Examples of this treatment are increasing every year, and the term "antitoxin" has now become almost a household word. The chief examples are to be found in diphtheria, tetanus, streptococcus, and pneumococcus.

To be of value, antitoxins must be used as early as possible, before tissue change has occurred and before the toxins have, so to speak, got the upper hand. When the toxins are in the ascendency the patient suffers more and more acutely, and may succumb before there has been time for the formation in his own body of the antitoxins.

If he can be tided over the "crisis," theoretically all will be well, because then his own antitoxin will eventually gain the upper hand. But in the meantime, before that condition of affairs, the only way is to inject antitoxins prepared in some animal's tissues whose disease began at an earlier date, and thus add antitoxins to the blood of our patient, early in the disease, and the earlier the better, for, however soon this is done, it is obvious that the toxins begin their work earlier still. It should not be necessary to add that general treatment must also be continued, and indeed local germicidal treatment, e. g., of the throat in diphtheria and the poisoned wound in tetanus. Further, in a mixed infection, as in glandular abscesses with diphtheria, it must be borne in mind that the antitoxin is specific and may therefore probably fail in such mixed cases.

After these preliminary remarks we will now consider shortly some of the methods employed for the production of antitoxins. An animal is required from whose body a considerable quantity of blood can be drawn without injurious effect.

Moreover, it must be an animal that can stand an attack of such diseases as diphtheria and tetanus. Such an animal is the horse. Now, by injecting into the horse (a) living organisms of the specific disease, but in non-fatal doses, or (b) dead cultures, or (c) filtered cultures containing no bacteria and only the toxins, we are able to produce in the blood of the horse first the toxins and then the antitoxins of the disease in question. The non-poisonous doses of living organisms can be weakened, or, as we say, attenuated, by various means. Dead cultures have not been much used to produce immunity except by Pfeiffer.

In actual practice the third method is much the most general, viz., filtering a fluid culture free from the bacteria, and then inoculating this in ever-increasing doses. The preparation of diphtheria antitoxin may be taken as an example, but what follows would be equally applicable to other diseases, such as tetanus.

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Newman, George. 2015.Bacteria. Urbana, Illinois: Project Gutenberg. Retrieved May 2022 from https://www.gutenberg.org/files/48793/48793-h/48793-h.htm

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