Chapter 9

There were cases in which the lower segment of the small intestine, most marked immediately above the ileocæcal valve, extending thence upward, was of a dark reddish-brown color, the mucous membrane being covered with superficial hæmorrhages. In many cases the mucous membrane appeared to be superficially necrosed, and covered with diphtheritic patches. The intestinal contents in such cases were not colorless, but consisted of a sanguinolent, ichorous, putrid fluid. Other cases showed a gradual transition to a less marked change. The redness was less intense, and was in patches, while in others the injection was limited to the margins of the follicular and Peyerian glands, giving an appearance which is quite peculiar to cholera. In comparatively few cases were the changes so slight as to consist in a somewhat swollen and opaque condition of the superficial layers of the mucous membrane, with delicate rosy-red injection, and some prominence of the solitary follicles and Peyer's patches. In such cases the intestinal contents were colorless, but resembling meal-soup rather than rice-water. In only a solitary instance were the contents watery and mucoid. Microscopical examination of the intestine and its contents revealed, especially in the cases where the margins of Peyer's patches were reddened, a considerable invasion of bacteria, occurring partly within the tubular glands, partly between the epithelium and basement membrane, and in some parts deeper still. Then he found cases in which, besides bacteria of one definite and constant form, there were others also accumulated within and around the tubular glands, of various size, some short and thick, others very fine; and be soon concluded that he had to do here with a primary invasion of pathogenic bacilli, which, as it were, prepared the tissues for the entrance of the non-pathogenic forms, just as he had observed, in the necrotic, diphtheritic changes in the intestinal mucosa and in typhoid ulcers.

Passing to speak of the microscopical character of the contents of the bowel, Dr. Koch said that owing to the sanguinolent and putrescent character of these in the cases first examined, no conclusion was arrived at for some time. Thus he found multitudes of bacteria of various kinds, rendering it impossible to distinguish any special forms, and it was not until he had examined two acute and uncomplicated cases, before hæmorrhage had occurred, and where the evacuation had not decomposed, that he found more abundantly the kind of organism which had been seen so richly in the intestinal mucosa. He then proceeded to describe the characters of this bacterium. It is smaller than the tubercle bacillus, being only about half or at most two-thirds the size of the latter, but much more plump, thicker, and slightly curved. As a rule, the curve is no more than that of a comma (,) but sometimes it assumes a semicircular shape, and he has seen it forming a double curve like an S, these two variations from the normal being suggestive of the junction of two individual bacilli. In cultures there always appears a remarkably free development of comma shaped bacilli. These bacilli often grow out to form long threads, not in the manner of anthrax bacilli, nor with a simple undulating form, but assuming the shape of delicate long spirals, a corkscrew shape, reminding one very forcibly of the spirochaete of relapsing fever. Indeed, it would be difficult to distinguish the two if placed side by side. On account of this developmental change, he doubted if the cholera organism should be ranked with bacilli; it is rather a transitional form between the bacillus and the spirillum. Possibly it is a true spirillum, portions of which appear in the comma shape, much as in other spirilla--_e. g_., spirilla undula, which do not always form complete spirals, but consist only of more or less curved rods. The comma bacilli thrive well in meat infusion, growing in it with great rapidity. By examining, microscopically, a drop of this broth culture the baccilli are seen in active movement, swarming at the margins of the drop, interspersed with the spiral threads, which are also apparently mobile. They grow also in other fluids--_e. g_., very abundantly in milk, without coagulating it or changing its appearance. Also in blood serum they grow very richly.

Another good nutrient medium is gelatine, wherein the comma bacilli form colonies of a perfectly characteristic kind, different from those of any other form of bacteria. The colony when very young appears as a pale and small spot, not completely spherical as other bacterial colonies in gelatine are wont to be, but with a more or less irregular, protruding, or jagged contour. It also very soon takes on a somewhat granular appearance. As the colony increases, the granular character becomes more marked, until it seems to be made up of highly refractile granules, like a mass of particles of glass. In its further growth the gelatine is liquefied in the vicinity of the colony, which at the same time sinks down deeper into the gelatine mass, and makes a small thread-like excavation in the gelatine, in the center of which the colony appears as a small white point. This again is peculiar; it is never seen, at least so marked, with any other bacterium. And a similar appearance is produced when gelatine is inoculated with a pure culture of this bacillus, the gelatine liquefying at the seat of inoculation, and the small colony continually enlarging; but above it there occurs the excavated spot, like a bubble of air floating over the bacillary colony. It gives the impression that the bacillus growth not only liquefies the gelatine, but causes a rapid evaporation of the fluid so formed. Many bacteria also have the power of so liquefying gelatine with which they are inoculated, but never do they produce such an excavation with the bladder-like cavity on the surface.

Another peculiarity was the slowness with which the gelatine liquefied, and the narrow limits of this liquefaction in the case of a gelatine disk. Cultures of the comma bacillus were also made in agar-agar jelly, which is not liquefied by them. On potato these bacilli grow like those of glanders, forming a grayish-brown layer on the surface. The comma bacilli thrive best at temperatures between 30° and 40° C., but they are not very sensitive to low temperatures, their growth not being prevented until 17° or 16° C. is reached. In this respect they agree with anthrax bacilli. Koch made an experiment to ascertain whether a very low temperature not merely checked development but killed them, and subjected the comma bacilli to a temperature of 10° C. They were then completely frozen, but yet retained vitality, growing in gelatine afterward. Other experiments, by excluding air from the gelatine cultures, or placing them under an exhausted bell jar, or in an atmosphere of carbonic acid, went to prove that they required air and oxygen for their growth; but the deprivation did not kill them, since on removing them from these conditions they again began to grow.

The growth of these bacilli is exceptionally rapid, quickly attaining its height, and after a brief stationary period as quickly terminating. The dying bacilli lose their shape, sometimes appearing shriveled, sometimes swollen, and then staining very slightly or not at all. The special features of their vegetation are best seen when substances which also contain other forms of bacteria are taken--_e. g_., the intestinal contents or choleraic evacuations mixed with moistened earth or linen and kept damp. The comma bacilli in these conditions multiply with great rapidity so as to far outnumber the other forms of bacteria, which at first might have been in far greater abundance. This state of affairs does not last long; in two or three days the comma bacilli began to die off, and the other bacteria began to multiply. Precisely the same thing takes place in the intestine, where, after the rapid initial vegetation is over, and when exudation of blood occurs in the bowel, the comma bacilli disappear and putrefactive bacteria predominate. Whether the occurrence of putrefaction is inimical to the comma bacilli has not been proved, but from analogy it is very probable. At any rate, it is important to know this for certain, for if it be so, then the comma bacilli will not thrive in a cesspit, and then further disinfection would be unnecessary. These bacilli thrive best in fluids containing a certain amount of nutriment. Experiments have not yet shown the limits in this respect, but Koch has found them capable of growing in meat broth diluted ten times.

Again, if the nutrient medium become acid in reaction their growth is checked, at least in gelatine and meat infusion; but singularly enough, they continue to grow on the surface of a boiled potato which has become acid, showing that all acids are not equally obnoxious to them. But here, as with other substances which hinder their growth, they do not kill the bacilli. Davaine has shown that iodine is a strong bactericide. He experimented with anthrax bacilli in water to which iodine was added, and the bacilli were destroyed. But practically the organisms have to be dealt with in the alkaline contents of the bowel, or in the blood or fluids of the tissues, where iodine cannot remain in the free state. Koch found that the addition of an aqueous solution of iodine (1 in 4,000) to meat infusion, in the proportion of 1 in 10, did not in the least interfere with the growth of the bacilli in that medium. He did not pursue this line of inquiry, seeing that in practice larger quantities of iodine than that could not be given. Alcohol first checks the development of the comma bacilli when it is mixed with the nutrient fluid in the proportion of 1 in 10, a degree of concentration which renders it impracticable for treatment. Common salt was added to the extent of 2 per cent. without influencing the growth of the bacilli. Sulphate of iron, in the proportion of 2 per cent., checks this growth, probably by precipitating albumimites from the fluids, and possibly also by its acid reaction; certainly it does not seem to have any specific disinfecting action--i.e., in destroying the bacilli. Indeed, Koch thinks that the admixture of sulphate of iron with fæcal matter may arrest putrefaction, and really remove what may be the most destructive process to the comma bacilli. Hence he would distinguish between substances which merely arrest putrefaction and those which are bactericidal; for the former may simply serve the purpose of preserving the infective virus. Among other substances which prevent the growth of the comma bacilli may be mentioned alum, in solutions of the strength of 1 in 100; camphor, 1 in 300; carbolic acid, 1 in 400; oil of peppermint, 1 in 2,000; sulphate of copper, 1 in 2,500 (a remedy much employed, but how much would really be needed merely to hinder the growth of the bacilli in the intestine!); quinine, 1 in 5,000; and sublimate, 1 in 100,000. In contrast with the foregoing measures for preventing the growth of these bacilli is the striking fact that they are readily killed by drying. This fact is proved by merely drying a small drop of material containing the bacilli on a cover-glass, and then placing this over some of the fluid on a glass slide. With anthrax bacilli vitality is retained for nearly a week; whereas, the comma bacillus appears to be killed in a very short time. Thus it was found that although vitality was retained--depending largely upon the number of bacilli--for a short time, yet withdrawal of the nutrient fluid for an hour or even less often sufficed; and it never happened that the bacilli retained vitality after a deprivation lasting twenty-four hours. These results would seem to point to the fact that the comma bacillus does not, like the organisms of anthrax and vaccinia, pass into the resting state (Daner-zustande) by drying; and if so, it is one of the most important facts in the etiology of cholera. Much, however, remains to be done, especially with regard to the soiled linen of cholera patients being kept in a damp state. He found that in soiled articles, when dried for a time, varying from twenty-four hours and upward, the comma bacilli were quite destroyed. Nor was the destruction delayed by placing choleraic excreta in or upon earth, dry or moist, or mixed with stagnant water. In gelatine cultures the comma bacilli can be cultivated for six weeks, and also in blood serum, milk, and potato, where anthrax bacilli rapidly form spores. But a resting state of the comma bacilli has never been met with--a very exceptional thing in the case of bacilli, and another reason why the organism must be regarded rather as a spirillum than a bacillus, for the spirilla require only a fluid medium, and do not, like the anthrax bacilli, thrive in a dry state. It is quite unlikely that a resting state of the comma bacillus will ever be discovered; and, moreover, its absence harmonizes with our knowledge of cholera etiology.--_The Lancet_.

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[THE MEDICAL RECORD.]

MALARIA.--THE NATURAL PRODUCTION OF MALARIA, AND THE MEANS OF MAKING MALARIAL COUNTRIES HEALTHIER.

[Footnote: An Address delivered at the Eighth Session of the International Medical Congress, Copenhagen, August 12, 1884.]

By Conrad Tommasi Crudeli, M.D., Professor of Hygiene, University of Rome, Italy.

Before entering upon my subject, I must crave the indulgence of those of my colleagues whose language I have borrowed for any italicisms that I may use, as well as for the foreign accent which must strike their ears more or less disagreeably. Desiring to respond as well as lay in my power to the invitation with which I have been honored to discuss the hygienic questions relating to malaria, I have chosen the French language as being the one in which, apart from my mother tongue, I could express myself with the greatest ease and precision.

I shall be pardoned also, I hope, for having employed the terms "malaria" and "malarial districts" in place of the more commonly used expressions "paludal miasm" (_miasme paludeen_) and "marshy regions" (_contrées marécageuses_). The substitution is not a happy one from a literary point of view, but I have made it deliberately and for the following reason: The idea that intermittent and pernicious fevers are engendered by putrid emanations from swamps and marshes is one of those semi-scientific assumptions which have contributed most to lead astray the investigations of scientists and the work of public administrations. This idea, so widespread and so well established by the traditions of the school, is radically false. The specific ferment which engenders those fevers by its accumulation in the atmosphere which we breathe is not exclusively of paludal origin, and still less is it a product of putrefaction. Indeed, in every region of the globe between the two Arctic circles there are swamps and marshes, steeping-tanks of hemp and flax, large deltas where salt and fresh waters mix, and yet there is no malaria there, although putrid decomposition is on every side. On the other hand, in the same parts of the globe there are places which are not and never were marshy, and in which there is not the least trace of putrefaction, but which, nevertheless, produce malaria in abundance. I reject, therefore, wholly the paludal assumption, and in order to express this view in the title of my paper, have been forced to employ terms which to my hearers may sound like italicisms.

The Italians generally have not this paludal notion, for experience taught them long ago that malaria is produced nearly everywhere--in marshy districts as well as in those which might almost be called arid; in a volcanic soil as well as in the deposits of the Miocene and Pliocene periods and the ancient and modern alluvia; in a soil rich in organic matters as well as in one containing almost none; in the plains as well as on the hills or mountains. The word malaria (bad air), which it is the sad privilege of Italy to have lent to all languages to express the cause of intermittent and pernicious fevers, represents, then, among the majority of our rural populations, the idea of an agent which may infect any sort of country, whatever may be its hydraulic and topographical conditions, and whatever may be its geological formation. This word, therefore, is the one best suited to designate this specific ferment in question, and I have on this account, employed it and its adjectival derivatives in order not to resuscitate the idea of the exclusively paludal origin of the morbific agent.

I shall not tarry long to speak of the nature of this ferment, for the studies bearing upon that point, although far advanced, are not yet completed. I may remark, however, that the idea that the ferment is formed of living organisms is a very old one, and has not arisen suddenly because of the modern theories of the parasitic nature of disease. From the time of Varrar (who believed that malaria was made up of invisible mites suspended in the atmosphere) to our own day this theory has been several times advanced by hygienists. Independently of the general considerations which led Rasori, and later Henle, to formulate the doctrine of the _contagium vivum_ of infection (long before the progress of microscopical science had revealed the existence of living ferments), there were peculiar circumstances as regards malaria which should have impelled minds to look in that direction, even in times long past.

Some of these circumstances are of a nature to strike every serious observer, and deserve a few moments' attention. How could one maintain, for example, that this ferment is a product of chemical reactions taking place in the ground, when it is seen to remain constantly the same whatever may be the composition of the soil from which it emanates! As long as the paludal theory held sway, the chemical interpretation of this identity of the product in every latitude was easy. Rica does not hesitate to admit that when a swampy tract is heated by the sun's rays to the necessary point for the putrid decomposition of the organic matters contained in it, the "chemical ferment," or rather the "mephitic gases," to which is attributed the morbific action, are developed, whatever may be the distance from the equator at which this marshy region lies. But since it has been ascertained that malaria is produced in soils of the most varied chemical composition, _the persistent identity of this product_ has become chemically inexplicable; while it is however readily conceivable, if one admits that malaria is an organized ferment which easily finds the necessary conditions for its life and multiplication in the most varied soils, as is the case with millions of other organisms vastly superior to the rudimentary vegetables which constitute the living ferments.

The same thing may be said of _the progressive intensity of the morbific production in abandoned malarious districts_. This fact has been historically proved in several parts of the earth, and especially in Italy. A large number of Grecian, Etruscan, and Latin cities, even Rome itself, sprang up in malarious territories and attained a high state of prosperity. First among the reasons for this success must be placed the works undertaken with a view of rendering these places more salubrious, and which lessened the evil production, _but almost never extinguished it completely_. After the abandonment of these localities, the production of malaria recommenced in a degree which went on increasing from age to age, and which has rendered some of these places actually uninhabitable. This was seen, in the time of the ancient Romans, in Etruria, when it was conquered and laid waste, and in several parts of Magna Græcia, and of Sicily. From the fall of Rome even to the present day, this phenomenon has been manifested in a very evident manner in the Roman Campagna, in certain parts of which, even up to the time of the Renaissance, it was possible to maintain pleasure houses, but which are now unhabitable during the hot season. In many cases the physical conditions of the soil have undergone no appreciable change during centuries, so that it is impossible to attribute so enormous an augmentation of malaria to an increase in its annual production, itself increased by a progressive alteration of the chemical composition of the soil. But if, on the contrary, it be admitted that malaria is caused by a living organism whose successive generations accumulate in the soil, the interpretation of this fact becomes very simple.

There are, finally, _peculiarities in the local charging of the atmosphere with malaria_ which can be explained only in this manner. If the malarial miasm were composed of gaseous bodies emanating from the soil, or rather of chemical ferments formed beneath the ground and raised into the air by gases or watery vapor, the charging of the atmosphere with the specific poison ought to arrive at its maximum during the hottest part of the day, when the ground is heated the most by the sun's rays, and when the evaporation of water and all chemical actions attain their maximum intensity. But this is very different from what actually occurs. The local charging of the atmosphere is always less strong during the meridian hours than at the beginning and the end of the day, that is to say, after the rising, and especially after the setting, of the sun. Now it is precisely at these hours that the difference between the temperature of the lower layers of the atmosphere and that of the surface of the ground is the greatest, and that the ascending currents of air starting from the ground are the strongest. If malaria consists of solid particles contained in the soil, one may readily understand how their elevation _en masse_ into the atmosphere should take place especially at these two periods of the day.

All these facts, which can be easily verified if the subject of malaria be studied on the spot and without any preconceived notions, explain the tendency which has always been manifested to attribute this specific poisoning of the air to a living organism which is multiplied in the soil; and they also explain the ardor with which hygienists have applied themselves to the production of the scientific proof.

Unfortunately the investigations undertaken for this end have for a long time been fruitless, for the preconceived paludal theory has led investigators to occupy themselves exclusively with the inferior organisms inhabiting marshes. Among these organisms they studied especially the _hyphomycetes,_ which had already acquired so great an importance in dermatology; and their entire attention was concentrated upon the aquatic algae, without even taking the precaution to determine whether the varieties which they thought to be malarial were found in all malarious swamps, or whether they were capable of living within the human organism. It has thus happened that each observer has indicated as the cause of malaria a different variety of alga, whichever he found to be most abundant in the swampy ground that he had to examine. Thus Salisbury has indicated the _palmella gemiasma,_ which is found with us in places perfectly free from malaria, while it is often wanting in malarious marshes in the center of Italy; Balestra, a species of alga which is as yet indeterminate; Bargellini, the _palmogloea micrococca;_ Safford and Bartlett, the _hydrogastrum granulatum;_ and Archer, the _chitonoblastus oeruginosus_. There is not a single one of these species the parasitic nature of which has been demonstrated; and as regards the two last named varieties, it can be positively denied that they are capable of producing a general infection, for the diameter of their spores and filaments is greater than that of the capillary blood vessels.