Thus the farmer's life from year's end to year's end is in most intimate association with bacteria. Upon them he depends to insure the continued fertility of his soil and the constant continued production of good crops. Upon them he depends to turn into plant food all the organic refuse from his house or from his barn. Upon them he depends to replenish his stock of nitrogen. It is these organisms which furnish his dairy with its butter flavours and with the taste of its cheese. But, on the other hand, against them he must be constantly alert. All his food products must be protected from their ravages. A successful farmer's life, then, largely resolves itself into a skilful management of bacterial activity. To aid them in destroying or decomposing everything which he does not desire to preserve, and to prevent their destroying the organic material which he wishes to keep for future use, is the object of a considerable portion of farm labour; and the most successful farmer to-day, and we believe the most successful farmer of the future, is the one who most intelligently and skilfully manipulates these gigantic forces furnished him by the growth of his microscopical allies.
RELATION OF BACTERIA TO COAL. Another one of Nature's processes in which bacteria have played an important part is in the formation of coal. It is unnecessary to emphasize the importance of coal in modern civilization. Aside from its use as fuel, upon which civilization is dependent, coal is a source of an endless variety of valuable products. It is the source of our illuminating gas, and ammonia is one of the products of the gas manufacture. From the coal also comes coal tar, the material from which such a long series of valuable materials, as aniline colours, carbolic acid, etc, is derived. The list of products which we owe to coal is very long, and the value of this material is hardly to be overrated. In the preparation of these ingredients from coal bacteria do not play any part. Most of them are derived by means of distillation. But when asked for the agents which have given us the coal of the coal beds, we shall find that here, too, we owe a great debt to bacteria.
Coal, as is well known, has come from the accumulation of the luxuriant vegetable growth of the past geological ages. It has therefore been directly furnished us by the vegetation of the green plants of the past, and, in general, it represents so much carbonic dioxide which these plants have extracted from the atmosphere. But while the green plants have been the active agents in producing this assimilation, bacteria have played an important part in coal manufacture in two different directions. The first appears to be in furnishing these plants with nitrogen. Without a store of fixed nitrogen in the soil these carboniferous plants could not have grown. This matter has already been considered. We have no very absolute knowledge as to the agency of bacteria in furnishing nitrogen for this vegetation in past ages, but there is every reason to believe that in the past, as in the present, the chief source of organic nitrogen has been from the atmosphere and derived from the atmosphere through the agency of bacteria. In the absence of any other known factor we may be pretty safe in the assumption that bacteria played an important part in this nitrogen fixation, and that bacteria must therefore be regarded as the agents which have furnished us the nitrogen stored in the coal.
But in a later stage of coal formation bacteria have contributed more directly to the formation of coal. Coal is not simply accumulated vegetation. The coal of our coal beds is very different in its chemical composition from the wood of the trees. It contains a much higher percentage of carbon and a lower percentage of hydrogen and oxygen than ordinary vegetable substances. The conversion of the vegetation of the carboniferous ages into coal was accompanied by a gradual loss of hydrogen and a consequent increase in the percentage of carbon. It is this change that has added to the density of the substance and makes the greater value of coal as fuel. There is little doubt now as to the method by which this woody material of the past has been converted into coal. The same process appears to be going on in a similar manner to-day in the peat beds of various northern countries. The fallen vegetation, trees, trunks, branches, and leaves, accumulate in masses, and, when the conditions of moisture and temperature are right, begin to undergo a fermentation. Ordinarily this action of bacteria, as already noticed, produces an almost complete though slow oxidation of the carbon, and results in the total decay of the vegetable matter. But if the vegetable mass be covered by water and mud under proper conditions of moisture and temperature, a different kind of fermentation arises which does not produce such complete decay. The covering of water prevents the access of oxygen to the fermenting mass, an oxidation of the carbon is largely prevented, and the vegetable matter slowly changes its character. Under the influence of this slow fermentation, aided, probably by pressure, the mass becomes more and more solid and condensed, its woody character becomes less and less distinct, and there is a gradual loss of the hydrogen and the oxygen. Doubtless there is a loss of carbon also, for there is an evolution of marsh gas which contains carbon. But, in this slow fermentation taking place under the water in peat bogs and marshes the carbon loss is relatively small; the woody material does not become completely oxidized, as it does in free operations of decay. The loss of hydrogen and oxygen from the mass is greater than that of carbon, and the percentage of carbon therefore increases. This is not the ordinary kind of fermentation that goes on in vegetable accumulations. It requires special conditions and possibly special kinds of fermenting organisms. Peat is not formed in all climates. In warm regions, or where the woody matter is freely exposed to the air, the fermentation of vegetable matter is more complete, and it is entirely destroyed by oxidation. It is only in colder regions and when covered with water that the destruction of the organic matter stops short of decay. But such incomplete fermentation is still going on in many parts of the world, and by its means vegetable accumulations are being converted into peat.
This formation of peat appears to be a first step in the formation of denser coal. By a continuation of the same processes the mass becomes still more dense and solid. As we pass from the top to the bottom of such an accumulation of peat, we find it becoming denser and denser, and at the bottom it is commonly of a hard consistence, brownish in colour, and with only slight traces of the original woody structure. Such material is called lignite. It contains a higher percentage of carbon than peat, but a lower percentage than coal, and is plainly a step in coal formation. But the process goes on, the hydrogen and oxygen loss continuing until there is finally produced true coal.
If this is the correct understanding of the formation of coal, we see that we have plainly a process in which bacterial life has had a large and important share. We are, of course, densely ignorant of the exact processes going on. We know nothing positively as to the kind of microorganisms which produce this slow, peculiar fermentation. As yet, the fermentation going on in the formation of the peat has not been studied by the bacteriologists, and we do not know from direct experiment that it is a matter of bacterial action. It has been commonly regarded as simply a slow chemical change, but its general similarity to other fermentative processes is so great that we can have little hesitation in attributing it to micro-organisms, and doubtless to some forms of plants allied to bacteria. There is no reason for doubting that bacteria existed in the geological ages with essentially the same powers as they now possess, and to some forms of bacteria which grow in the absence of oxygen can we probably attribute the slow change which has produced coal. Here, then, is another great source of wealth in Nature for which we are dependent upon bacteria. While, of course, water and pressure were very essential factors in the deposition of coal, it was a peculiar kind of fermentation occurring in the vegetation that brought about the chemical changes in it which resulted in its transformation into coal. The vegetation of the carboniferous age was dependent upon the nitrogen fixed by the bacteria, and to these organisms also do we owe the fact that this vegetation was stored for us in the rocks.
PARASITIC BACTERIA AND THEIR RELATION TO DISEASE.
Perhaps the most universally known fact in regard to bacteria is that they are the cause of disease. It is this fact that has made them objects of such wide interest. This is the side of the subject that first attracted attention, has been most studied, and in regard to which there has been the greatest accumulation of evidence. So persistently has the relation of bacteria to disease been discussed and emphasized that the majority of readers are hardly able to disassociate the two. To most people the very word bacteria is almost equivalent to disease, and the thought of swallowing microbes in drinking water or milk is decidedly repugnant and alarming. In the public mind it is only necessary to demonstrate that an article holds bacteria to throw it under condemnation.
We have already seen that bacteria are to be regarded as agents for good, and that from their fundamental relation to plant life they must be looked upon as our friends rather than as our enemies. It is true that there is another side to the story which relates to the parasitic species. These parasitic forms may do us direct or indirect injury. But the species of bacteria which are capable of doing us any injury, the pathogenic bacteria, are really very few compared to the great host of species which are harmless. A small number of species, perhaps a score or two, are pathogenic, while a much larger number, amounting to hundreds and perhaps thousands of species, are perfectly harmless. This latter class do no injury even though swallowed by man in thousands. They are not parasitic, and are unable to grow in the body of man. Their presence is entirely consistent with the most perfect health, and, indeed, there are some reasons for believing that they are sometimes directly beneficial to health. It is entirely unjust to condemn all bacteria because a few chance to produce mischief. Bacteria in general are agents for good rather than ill.
There are, however, some species which cause mankind much trouble by interfering in one way or another with the normal processes of life. These pathogenic bacteria, or disease germs, do not all act alike, but bring about injury to man in a number of different ways. We may recognise two different classes among them, which, however, we shall see are connected by intermediate types. These two classes are, first, the pathogenic bacteria, which are not strictly parasitic but live free in Nature; and, second, those which live as true parasites in the bodies of man or other animals. To understand the real relation of these two classes, we must first notice the method by which bacteria in general produce disease.
METHOD BY WHICH BACTERIA PRODUCE DISEASE.
Since it was first clearly recognised that certain species of bacteria have the power of producing disease, the question as to how they do so has ever been a prominent one Even if they do grow in the body, why should their presence give rise to the symptoms characterizing disease? Various answers to this question have been given in the past It has been suggested that in their growth they consume the food of the body and thus exhaust it, that they produce an oxidation of the body tissues, or that they produce a reduction of these tissues, or that they mechanically interfere with the circulation None of these suggestions have proved of much value Another view was early advanced, and has stood the test of time. This claim is that the bacteria while growing in the body produce poisons, and these poisons then have a direct action on the body We have already noticed that bacteria during their growth in any medium produce a large number of biproducts of decomposition. We noticed also that among these biproducts there are some which have a poisonous nature; so poisonous are they that when inoculated into the body of an animal they may produce poisoning and death. We have only to suppose that the pathogenic bacteria, when growing as parasites in man, produce such poisons, and we have at once an explanation of the method by which they give rise to disease.
This explanation of germ disease is more than simple theory. It has been in many cases clearly demonstrated. It has been found that the bacteria which cause diphtheria, tetanus, typhoid, tuberculosis, and many other diseases, produce, even when growing in common culture media, poisons which are of a very violent nature. These poisons when inoculated into the bodies of animals give rise to much the same symptoms as the bacteria do themselves when growing as parasites in the animals. The chief difference in the results from inoculating an animal with the poison and with the living bacteria is in the rapidity of the action. When the poison is injected the poisoning symptoms are almost immediately seen, but when the living bacteria are inoculated the effect is only seen after several days or longer, not, in short, until the inoculated bacteria have had time enough to grow in the body and produce the poison in quantity. It has not by any means been shown that all pathogenic germs produce their effect in this way, but it has been proved to be the real method in quite a number of cases, and is extremely probable in others. While some bacteria perhaps produce results by a different method, we must recognise the production of poisons as at all events the common direct cause of the symptoms of disease. This explanation will enable us more clearly to understand the relation of different bacteria to disease.
PATHOGENIC GERMS WHICH ARE NOT STRICTLY PARASITIC
Recognising that bacteria may produce poisons, we readily see that it is not always necessary that they should be parasites in order to produce trouble. In their ordinary growth in Nature such bacteria will produce no trouble The poisons will be produced in decaying material but will seldom be taken into the human body. These poisons, produced in the first stages of putrefaction, are oxidized by further stages of decomposition into harmless products. But should it happen that some of these bacteria obtained a chance to grow vigorously for a while in organic products that are subsequently swallowed as man's food, it is plain that evil results might follow. If such food is swallowed by man after the bacteria have produced their poisonous bodies, it will tend to produce an immediate poisoning of his system. The effect may be sudden and severe if considerable quantity of the poisonous material is swallowed, or slight but protracted if small quantities are repeatedly consumed in food. Such instances are not uncommon. Well-known examples are cases of ice-cream poisoning, poisoning from eating cheese or from drinking milk, or in not a few instances from eating fish or meats within which bacteria have had opportunity for growth. In all these cases the poison is swallowed in quantity sufficient to give rise quickly to severe symptoms, sometimes resulting fatally, and at other times passing off as soon as the body succeeds in throwing off the poisons. In other cases still, however, the amount of poison swallowed may be very slight, too slight to produce much effect unless the same be consumed repeatedly. All such trouble may be attributed to fermented or partly decayed food. It is difficult to distinguish such instances from others produced in a slightly different way, as follows:
It may happen that the bacteria which grow in food products continue to grow in the food even after it is swallowed and has passed into the stomach or intestines. This appears particularly true of milk bacteria. Under these conditions the bacteria are not in any proper sense parasitic, since they are simply living in and feeding upon the same food which they consume outside the body, and are not feeding upon the tissues of man. The poisons which they produce will continue to be developed as long as the bacteria continue to grow, whether in a milk pail or a human stomach. If now the poisons are absorbed by the body, they may produce a mild or severe disease which will be more or less lasting, continuing perhaps as long as the same food and the same bacteria are supplied to the individual. The most important disease of this class appears to be the dreaded cholera infantum, so common among infants who feed upon cow's milk in warm weather. It is easy to understand the nature of this disease when we remember the great number of bacteria in milk, especially in hot weather, and when we remember that the delicate organism of the infant will be thrown at once into disorder by slight amounts of poison which would have no appreciable effect upon the stronger adult. We can easily understand, further, how the disease readily yields to treatment if care is taken to sterilize the milk given to the patient.
We do not know to-day the extent of the troubles which are produced by bacteria of this sort. They will, of course, be chiefly connected with our food products, and commonly, though not always, will affect the digestive functions. It is probable that many of the cases of summer diarrhoea are produced by some such cause, and if they could be traced to their source would be found to be produced by bacterial poisons swallowed with food or drink, or by similar poisons produced by bacteria growing in such food after it is swallowed by the individual. In hot weather, when bacteria are so abundant everywhere and growing so rapidly, it is impossible to avoid such dangers completely without exercising over all food a guard which would be decidedly oppressive. It is well to bear in mind, however, that the most common and most dangerous source of such poisons is milk or its products, and for this reason one should hesitate to drink milk in hot weather unless it is either quite fresh or has been boiled to destroy its bacteria.
PATHOGENIC BACTERIA WHICH ARE TRUE PARASITES.
This class of pathogenic bacteria includes those which actually invade the body and feed upon its tissues instead of living simply upon swallowed food. It is difficult, however, to draw any sharp line separating the two classes. The bacteria which cause diphtheria (Fig. 28), for instance, do not really invade the body. They grow in the throat, attached to its walls, and are confined to this external location or to the superficial tissues. This bacillus is, in short, only found in the mouth and throat, and is practically confined to the so-called false membranes. It never enters any of the tissues of the body, although attached to the mucous membrane. It grows vigorously in this membrane, and there secretes or in some way produces extremely violent poisons. These poisons are then absorbed by the body and give rise to the general symptoms of the disease. Much the same is true of the bacillus which causes tetanus or lockjaw (Fig. 29). This bacillus is commonly inoculated into the flesh of the victim by a wound made with some object which has been lying upon the earth where the bacillus lives. The bacillus grows readily after being inoculated, but it is localized at the point of the wound, without invading the tissue to any extent. It produces, however, during its growth several poisons which have been separated and studied. Among them are some of the most violent poisons of which we have any knowledge. While the bacillus grows in the tissues around the wound it secretes these poisons, which are then absorbed by the body generally. Their poisoning effects produce the violent symptoms of the disease. Of much the same nature is Asiatic cholera. This is caused by a bacillus which is able to grow rapidly in the intestines, feeding perhaps in part on the food in the intestines and perhaps in part upon the body secretions. To a slight extent also it appears to be able to invade the tissues of the body, for the bacilli are found in the walls of the intestines. But it is not a proper parasite, and the fatal disease it produces is the result of the absorption of the poisons secreted in the intestines.
It is but a step from this to the true parasites. Typhoid fever, for example, is a disease produced by bacteria which grow in the intestines, but which also invade the tissues more extensively than the cholera germs (Fig. 30). They do not invade the body generally, however, but become somewhat localized in special glands like the liver, the spleen, etc. Even here they do not appear to find a very favourable condition, for they do not grow extensively in these places. They are likely to be found in the spleen in small groups or centres, but not generally distributed through it. Wherever they grow they produce poison, which has been called typhotoxine, and it is this poison chiefly which gives rise to the fever.
Quite a considerable number of the pathogenic germs are, like the typhoid bacillus, more or less confined to special places. Instead of distributing themselves through the body after they find entrance, they are restricted to special organs. The most common example of a parasite of this sort is the tuberculosis bacillus, the cause of consumption, scrofula, white swelling, lupus, etc. (Fig. 31). Although this bacillus is very common and is able to attack almost any organ in the body, it is usually very restricted in growth. It may become localized in a small gland, a single joint, a small spot in the lungs, or in the glands of the mesentery, the other parts of the body remaining free from infection. Not infrequently the whole trouble is thus confined to such a small locality that nothing serious results. But in other instances the bacilli may after a time slowly or rapidly distribute themselves from these centres, attacking more and more of the body until perhaps fatal results follow in the end. This disease is therefore commonly of very slow progress.
Again, we have still other parasites which are not thus confined, but which, as soon as they enter the body, produce a general infection, attacking the blood and perhaps nearly all tissues simultaneously. The most typical example of this sort is anthrax or malignant pustule, a disease fortunately rare in man (Fig. 32). Here the bacilli multiply in the blood, and very soon a general and fatal infection of the whole body arises, resulting from the abundance of the bacilli everywhere. Some of the obscure diseases known as blood poisoning appear to be of the same general nature, these diseases resulting from a very general invasion of the whole body by certain pathogenic bacteria.
In general, then, we see that the so-called germ diseases result from the action upon the body of poisons produced by bacterial growth. Differences in the nature of these poisons produce differences in the character of the disease, and differences in the parasitic powers of the different species of bacteria produce wide differences in the course of the diseases and their relation to external phenomena.
WHAT DISEASES ARE DUE TO BACTERIA?
It is, of course, an extremely important matter to determine to what extent human diseases are caused by bacteria. It is not easy, nor indeed possible, to do this to-day with accuracy. It is no easy matter to prove that any particular disease is caused by bacteria. To do this it is necessary to find some particular bacterium present in all cases of the disease; to find some method of getting it to grow outside the body in culture media; to demonstrate its absence in healthy animals, or healthy human individuals if it be a human disease; and, finally, to reproduce the disease in healthy animals by inoculating them with the bacterium. All of these steps of proof present difficulties, but especially the last one. In the study of animals it is comparatively easy to reproduce a disease by inoculation. But experiments upon man are commonly impossible, and in the case of human diseases it is frequently very difficult or impossible to obtain the final test of the matter. After finding a specific bacterium associated with a disease, it is usually possible to experiment with it further upon animals only. But some human diseases do not attack animals, and in the case of diseases that may be given to animals it is frequently uncertain whether the disease produced in the animal by such inoculation is identical with the human disease in question, owing to the difference of symptoms in the different animals. As a consequence, the proof of the germ nature of different diseases varies all the way from absolute demonstration to mere suspicion. To give a complete and correct list of the diseases caused by bacteria, or to give a list of the bacteria species pathogenic to man, is therefore at present impossible.
The difficulty of giving such a list is rendered greater from the fact that we have in recent years learned that the same species of pathogenic bacterium may produce different results under different conditions. When the subject of germ disease was first studied and the connection between bacteria and disease was first demonstrated, it was thought that each particular species of pathogenic bacteria produced a single definite disease; and conversely, each germ disease was supposed to have its own definite species of bacterium as its cause. Recent study has shown, however, that this is not wholly true. It is true that some diseases do have such a definite relation to definite bacteria. The anthrax germ, for example, will always produce anthrax, no matter where or how it is inoculated into the body. So, also, in quite a number of other cases distinct specific bacteria are associated with distinct diseases. But, on the other hand, there are some pathogenic bacteria which are not so definite in their action, and produce different results in accordance with circumstances, the effect varying both with the organ attacked and with the condition of the individual. For instance, a considerable number of different types of blood poisoning, septicaemia, pyaemia, gangrene, inflammation of wounds, or formation of pus from slight skin wounds—indeed, a host of miscellaneous troubles, ranging all the way from a slight pus formation to a violent and severe blood poisoning—all appear to be caused by bacteria, and it is impossible to make out any definite species associated with the different types of these troubles. There are three common forms of so-called pus cocci, and these are found almost indiscriminately with various types of inflammatory troubles. Moreover, these species of bacteria are found with almost absolute constancy in and around the body, even in health. They are on the clothing, on the skin, in the mouth and alimentary canal. Here they exist, commonly doing no harm. They have, however, the power of doing injury if by chance they get into wounds. But their power of doing injury varies both with the condition of the individual and with variations in the bacteria themselves. If the individual is in a good condition of health these bacteria have little power of injuring him even when they do get into such wounds, while at times of feeble vitality they may do much more injury, and take the occasion of any little cut or bruise to enter under the skin and give rise to inflammation and pus. Some people will develop slight abscesses or slight inflammations whenever the skin is bruised, while with others such bruises or cuts heal at once without trouble. Both are doubtless subject to the same chance of infection, but the one resists, while the other does not. In common parlance, we say that such a tendency to abscesses indicates a bad condition of the blood—a phrase which means nothing. Further, we find that the same species of bacterium may have varying powers of producing disease at different times. Some species are universal inhabitants of the alimentary canal and are ordinarily harmless, while under other conditions of unknown character they invade the tissues and give rise to a serious and perhaps fatal disease. We may thus recognise some bacteria which may be compared to foreign invaders, while others are domestic enemies. The former, like the typhoid bacillus, always produce trouble when they succeed in entering the body and finding a foothold. The latter, like the normal intestinal bacilli, are always present but commonly harmless, only under special conditions becoming troublesome. All this shows that there are other factors in determining the course of a disease, or even the existence of a disease, than the simple presence of a peculiar species of pathogenic bacterium.
From the facts just stated it will be evident that any list of germ diseases will be rather uncertain. Still, the studies of the last twenty years or more have disclosed some definite relations of bacteria and disease, and a list of the diseases more or less definitely associated with distinct species of bacteria is of interest. Such a list, including only well-known diseases, is as follows:
Name of disease. Name of bacterium producing the disease. Anthrax (Malignant pustule). Bacillus anthracis. Cholera. Spirillum cholera: asiaticae Croupous pneumonia. Micrococcus pneumonia crouposa. Diphtheria. Bacillus diphtheria. Glanders. Bacillus mallei. Gonorrhoea. Micrococcus gonorrhaeae Influenza. Bacillus of influenza. Leprosy. Bacillus leprae. Relapsing fever. Spirillum Obermeieri. Tetanus (lockjaw). Bacillus tetani. Tuberculosis (including consumption, scrofula, etc.) Bacillus tuberculosis. Typhoid fever. Bacillus typhi abdominalis.
Various wound infections, including septicaemia, pyaemia, acute abscesses, ulcers, erysipelas, etc., are produced by a few forms of micrococci, resembling each other in many points but differing slightly. They are found almost indiscriminately in any of these wound infections, and none of them appears to have any definite relation to any special form of disease unless it be the micrococcus of erysipelas. The common pus micrococci are grouped under three species, Staphylococcus pyogenes aureus, Staphylococcus pyogenes, and Streptococcus pyogenes. These three are the most common, but others are occasionally found.
In addition to these, which may be regarded as demonstrated, the following diseases are with more or less certainty regarded as caused by distinct specific bacteria: Bronchitis, endocarditis, measles, whooping-cough, peritonitis, pneumonia, syphilis.
Still another list might be given of diseases whose general nature indicates that they are caused by bacteria, but in connection with which no distinct bacterium has yet been found. As might be expected also, a larger list of animal diseases has been demonstrated to be caused by these organisms. In addition, quite a number of species of bacteria have been found in such material as faeces, putrefying blood, etc., which have been shown by experiment to be capable of producing diseases in animals, but in regard to which we have no evidence that they ever do produce actual disease under any normal conditions. These may contribute, perhaps, to the troubles arising from poisonous foods, but can not be regarded as disease germs proper.
VARIABILITY OF PATHOGENIC POWERS.
As has already been stated, our ideas of the relation of bacteria to disease have undergone quite a change since they were first formulated, and we recognise other factors influencing disease besides the actual presence of the bacterium. These we may briefly consider under two heads, viz., variation in the bacterium, and variation in the susceptibility of the individual. The first will require only a brief consideration.
That the same species of pathogenic bacteria at different times varies in its powers to produce disease has long been known. Various conditions are known to affect thus the virulence of bacteria. The bacillus which is supposed to give rise to pneumonia loses its power to produce the disease after having been cultivated for a short time in ordinary culture media in the laboratory. This is easily understood upon the suggestion that it is a parasitic bacillus and does not thrive except under parasitic conditions. Its pathogenic powers can sometimes be restored by passing it again through some susceptible animal. One of the most violent pathogenic bacteria is that which produces anthrax, but this loses its pathogenic powers if it is cultivated for a considerable period at a high temperature. The micrococcus which causes fowl cholera loses its power if it be cultivated in common culture media, care being taken to allow several days to elapse between the successive inoculations into new culture flasks. Most pathogenic bacteria can in some way be so treated as to suffer a diminution or complete loss of their powers of producing a fatal disease. On the other hand, other conditions will cause an increase in the virulence of a pathogenic germ. The virus which produces hydrophobia is increased in violence if it is inoculated into a rabbit and subsequently taken from the rabbit for further inoculation. The fowl cholera micrococcus, which has been weakened as just mentioned, may be restored to its original violence by inoculating it into a small bird, like a sparrow, and inoculating a second bird from this. A few such inoculations will make it as active as ever. These variations doubtless exist among the species in Nature as well as in artificial cultures. The bacteria which produce the various wound infections and abscesses, etc., appear to vary under normal conditions from a type capable of producing violent and fatal blood poisoning to a type producing only a simple abscess, or even to a type that is entirely innocuous. It is this factor, doubtless, which in a large measure determines the severity of any epidemic of a bacterial contagious disease.
SUSCEPTIBILITY OF THE INDIVIDUAL.
The very great modification of our early views has affected our ideas as to the power which individuals have of resisting the invasion of pathogenic bacteria. It has from the first been understood that some individuals are more susceptible to disease than others, and in attempting to determine the significance of this fact many valuable and interesting discoveries have been made. After the exposure to the disease there follows a period of some length in which there are no discernible effects. This is followed by the onset of the disease and its development to a crisis, and, if this be passed, by a recovery. The general course of a germ disease is divided into three stages: the stage of incubation, the development of the disease, and the recovery. The susceptibility of the body to a disease may be best considered under the three heads of Invasion, Resistance, Recovery.
Means of Invasion.—In order that a germ disease should arise in an individual, it is first necessary that the special bacterium which causes the disease should get into the body. There are several channels through which bacteria can thus find entrance; these are through the mouth, through the nose, through the skin, and occasionally through excretory ducts. Those which come through the mouth come with the food or drink which we swallow; those which enter through the nose must be traced to the air; and those which enter through the skin come in most cases through contact with some infected object, such as direct contact with the body of an infected person or his clothing or some objects he has handled, etc. Occasionally, perhaps, the bacteria may get into the skin from the air, but this is certainly uncommon and confined to a few diseases. There are here two facts of the utmost importance for every one to understand: first, that the chance of disease bacteria being carried to us through the air is very slight and confined to a few diseases, such as smallpox, tuberculosis, scarlet fever; etc., and, secondly, that the uninjured skin and the uninjured mucous membrane also is almost a sure protection against the invasion of the bacteria. If the skin is whole, without bruises or cuts, bacteria can seldom, if ever, find passage through it. These two facts are of the utmost importance, since of all sources of infection we have the least power to guard against infection through the air, and since of all means 'of entrance we can guard the skin with the greatest difficulty. We can easily render food free from pathogenic bacteria by heating it. The material we drink can similarly be rendered harmless, but we can not by any known means avoid breathing air, nor is there any known method of disinfecting the air, and it is impossible for those who have anything to do with sick persons to avoid entirely having contact either with the patient or with infected clothing or utensils.
From the facts here given it will be seen that the individual's susceptibility to disease produced by parasitic bacteria will depend upon his habits of cleanliness, his care in handling infectious material, or care in cleansing the hands after such handling, upon his habit of eating food cooked or raw, and upon the condition of his skin and mucous membranes, since any kind of bruises will increase susceptibility. Slight ailments, such as colds, which inflame the mucous membrane, will decrease its resisting power and render the individual more susceptible to the entrance of any pathogenic germs should they happen to be present. Sores in the mouth or decayed teeth may in the same way be prominent factors in the individual's susceptibility. Thus quite a number of purely physical factors may contribute to an individual's susceptibility.
Resisting Power of the Body.—Even after the bacteria get into the body it is by no means certain that they will give rise to disease, for they have now a battle to fight before they can be sure of holding their own. It is now, indeed, that the actual conflict between the powers of the body and these microscopic invaders begins. After they have found entrance into the body the bacteria have arrayed against them strong resisting forces of the human organism, endeavouring to destroy and expel them. Many of them are rapidly killed, and sometimes they are all destroyed without being able to gain a foothold. In such cases, of course, no trouble results. In other cases the body fails to overcome the powers of the invaders and they eventually multiply rapidly. In this struggle the success of the invaders is not necessarily a matter of numbers. They are simply struggling to gain a position in the body, where they can feed and grow. A few individuals may be entirely sufficient to seize such a foothold, and then these by multiplying may soon become indefinitely numerous. To protect itself, therefore, the human body must destroy every individual bacterium, or at least render them all incapable of growth. Their marvellous reproductive powers give the bacteria an advantage in the battle. On the other hand, it takes time even for these rapidly multiplying beings to become sufficiently numerous to do injury. There is thus an interval after their penetration into the body when these invaders are weak in numbers. During this interval—the period of incubation—the body may organize a resistance sufficient to expel them.
We do not as yet thoroughly understand the forces which the human organism is able to array against these invading foes. Some of its methods of defence are, however, already intelligible to us, and we know enough, at all events, to give us an idea of the intensity of the conflict that is going on, and of the vigorous and powerful forces which the human organism is able to bring against its invading enemies.
In the first place, we notice that a majority of bacteria are utterly unable to grow in the human body even if they do find entrance. There are known to bacteriologists to-day many hundreds, even thousands of species, but the vast majority of these find in the human tissues conditions so hostile to their life that they are utterly unable to grow therein. Human flesh or human blood will furnish excellent food for them if the individual be dead, but living human flesh and blood in some way exerts a repressing influence upon them which is fatal to the growth of a vast majority of species. Some few species, however, are not thus destroyed by the hostile agencies of the tissues of the animal, but are capable of growing and multiplying in the living body. These alone are what constitute the pathogenic bacteria, since, of course, these are the only bacteria which can produce disease by growing in the tissues of an animal. The fact that the vast majority of bacteria can not grow in the living organism shows clearly enough that there are some conditions existing in the living tissue hostile to bacterial life. There can be little doubt, moreover, that it is these same hostile conditions, which enable the body to resist the attack of the pathogenic species in cases where resistance is successfully made.
What are the forces arrayed against these invaders? The essential nature of the battle appears to be a production of poisons and counter poisons. It appears to be an undoubted fact that the first step in repelling these bacteria is to flood them with certain poisons which check their growth. In the blood and lymph of man and other animals there are present certain products which have a direct deleterious influence upon the growth of micro-organisms. The existence of these poisons is undoubted, many an experiment having directly attested to their presence in the blood of animals. Of their nature we know very little, but of their repressing influence upon bacterial growth we are sure. They have been named alexines, and they are produced in the living tissue, although as to the method of their production we are in ignorance. By the aid of these poisons the body is able to prevent the growth of the vast majority of bacteria which get into its tissues. Ordinary micro-organisms are killed at once, for these alexines act as antiseptics, and common bacteria can no more grow in the living body than they could in a solution containing other poisons Thus the body has a perfect protection against the majority of bacteria. The great host of species which are found in water, milk, air, in our mouths or clinging to our skin, and which are almost omnipresent in Nature, are capable of growing well enough in ordinary lifeless organic foods, but just as soon as they succeed in finding entrance into living human tissue their growth is checked at once by these antiseptic agents which are poured upon them. Such bacteria are therefore not pathogenic germs, and not sources of trouble to human health.
There are, on the other hand, a few species of bacteria which may be able to retain their lodgment in the body m spite of this attempt of the individual to get rid of them. These, of course, constitute the pathogenic species, or so called "disease germs". Only such species as can overcome this first resistance can be disease germs, for they alone can retain their foothold in the body.
But how do these species overcome the poisons, which kill the other harmless bacteria? They, as well as the harmless forms, find these alexines injurious to their growth, but in some way they are able to counteract the poisons. In this general discussion of poisons we are dealing with a subject which is somewhat obscure, but apparently the pathogenic bacteria are able to overcome the alexines of the body by producing in their turn certain other products which neutralize the alexines, thus annulling their action. These pathogenic bacteria, when they get into the body, give rise at once to a group of bodies which have been named lysines. These lysines are as mysterious to us as the alexines, but they neutralize the effect of the alexines and thus overcome the resistance the body offers to bacterial growth The invaders can now multiply rapidly enough to get a lasting foothold in the body and then soon produce the abnormal symptoms which we call disease Pathogenic bacteria thus differ from the non-pathogenic bacteria primarily in this power of secreting products which can neutralize the ordinary effects of the alexines, and so overcome the body's normal resistance to their parasitic life.
Even if the bacteria do thus overcome the alexines the battle is not yet over, for the individual has another method of defence which is now brought into activity to check the growth of the invading organisms. This second method of resistance is by means of a series of active cells found in the blood, known as white blood-corpuscles (Fig. 33 a, b). They are minute bits of protoplasm present in the blood and lymph in large quantities. They are active cells, capable of locomotion and able to crawl out of the blood-vessels Not infrequently they are found to take into their bodies small objects with which they come in contact. One of their duties is thus to engulf minute irritating bodies which may be in the tissues, and to carry them away for excretion. They thus act as scavengers These corpuscles certainly have some agency in warding off the attacks of pathogenic bacteria Very commonly they collect in great numbers in the region of the body where invading bacteria are found. Such invading bacteria exist upon them a strong attraction, and the corpuscles leave the blood-vessels and sometimes form a solid phalanx completely surrounding the invading germs. Their collection at these points may make itself seen externally by the phenomenon we call inflammation.
There is no question that the corpuscles engage in conflict with the bacteria when they thus surround them. There has been not a little dispute, however, as to the method by which they carry on the conflict. It has been held by some that the corpuscles actually take the bacteria into their bodies, swallow them, as it were, and subsequently digest them (Fig. 33 c, d, e). This idea gave rise to the theory of phagocytosis, and the corpuscles were consequently named phagocytes. The study of several years has, however, made it probable that this is not the ordinary method by which the corpuscles destroy the bacteria. According to our present knowledge the method is a chemical one. These cells, when they thus collect in quantities around the invaders, appear to secrete from their own bodies certain injurious products which act upon the bacteria much as do the alexines already mentioned. These new bodies have a decidedly injurious effect upon the multiplying bacteria; they rapidly check their growth, and, acting in union with the alexines, may perhaps entirely destroy them.
After the bacteria are thus killed, the white blood-corpuscles may load themselves with their dead bodies and carry them away (Fig. 33 d, e). Sometimes they pass back into the blood stream and carry the bacteria to various parts of the body for elimination. Not infrequently the white corpuscles die in the contest, and then may accumulate in the form of pus and make their way through the skin to be discharged directly. The battle between these phagocytes and the bacteria goes on vigorously. If in the end the phagocytes prove too strong for the invaders, the bacteria are gradually all destroyed, and the attack is repelled. Under these circumstances the individual commonly knows nothing—of the matter. This conflict has taken place entirely without any consciousness on his part, and he may not even know that he has been exposed to the attack of the bacteria. In other cases the bacteria prove too strong for the phagocytes. They multiply too rapidly, and sometimes they produce secretions which actually drive the phagocytes away. Commonly, as already noticed, the corpuscles are attracted to the point of invasion, but in some cases, when a particularly deadly and vigorous species of bacteria invades the body, the secretions produced by them are so powerful as actually to drive the corpuscles away. Under these circumstances the invading hosts have a chance to multiply unimpeded, to distribute themselves over the body, and the disease rapidly follows as the result of their poisoning action on the body tissues.
It is plain, then, that the human body is not helpless in the presence of the bacteria of disease, but that it is supplied with powerful resistant forces. It must not be supposed, however, that the outline of the action of these forces just given is anything like a complete account of the matter; nor must it be inferred that the resistance is in all respects exactly as outlined. The subject has only recently been an object of investigation, and we are as yet in the dark in regard to many of the facts. The future may require us to modify to some extent even the brief outline which has been given. But while we recognise this uncertainty in the details, we may be assured of the general facts. The living body has some very efficacious resistant forces which prevent most bacteria from growing within its tissues, and which in large measure may be relied upon to drive out the true pathogenic bacteria. These resistant forces are in part associated with the productions of body poisons, and are in part associated with the active powers of special cells which have been called phagocytes. The origin of the poisons and the exact method of action of the phagocytes we may well leave to the future to explain.
These resisting powers of the body will vary with conditions. It is evident that they are natural powers, and they will doubtless vary with the general condition of vigour of the individual. Robust health, a body whose powers are strong, well nourished, and vigorous, will plainly furnish the conditions for the greatest resistance to bacterial diseases. One whose bodily activities are weakened by poor nutrition can offer less resistance. The question whether one shall suffer from a germ disease is not simply the question whether he shall be exposed, or even the question whether the bacteria shall find entrance into his body. It is equally dependent upon whether he has the bodily vigour to produce alexines in proper quantity, or to summon the phagocytes in sufficient abundance and vigour to ward off the attack. We may do much to prevent disease by sanitation, which aids in protecting the individual from attack; but we must not forget that the other half of the battle is of equal importance, and hence we must do all we can to strengthen the resisting forces of the organism.
RECOVERY FROM GERM DISEASES.
These resisting forces are not always sufficient to drive off the invaders. The organisms may retain their hold in the body for a time and eventually break down the resistance. After this they may multiply unimpeded and take entire possession of the body. As they become more numerous their poisonous products increase and begin to produce direct poisoning effects on the body. The incubation period is over and the disease comes on. The disease now runs its course. It becomes commonly more and more severe until a crisis is reached. Then, unless the poisoning is so severe that death occurs, the effects pass away and recovery takes place.
But why should not a germ disease be always fatal? If the bacteria thus take possession of the body and can grow there, why do they not always continue to multiply until they produce sufficient poison to destroy the life of the individual? Such fatal results do, of course, occur, but in by far the larger proportion of cases recovery finally takes place.
Plainly, the body must have another set of resisting forces which is concerned in the final recovery. Although weakened by the poisoning and suffering from the disease, it does not yield the battle, but somewhat slowly organizes a new attack upon the invaders. For a time the multiplying bacteria have an unimpeded course and grow rapidly; but finally their further increase is checked, their vigour impaired, and after this they diminish in numbers and are finally expelled from the body entirely. Of the nature of this new resistance but little is yet known. We notice, in the first place, that commonly after such a recovery the individual has decidedly increased resistance to the disease. This increased resistance may be very lasting, and may be so considerable as to give almost complete immunity from the disease for many years, or for life. One attack of scarlet fever gives the individual great immunity for the future. On the other hand, the resistance thus derived may be very temporary, as in the case of diphtheria. But a certain amount of resistance appears to be always acquired. This power of resisting the activities of the parasites seems to be increased during the progress of the disease, and, if it becomes sufficient, it finally drives off the bacteria before they have produced death. After this, recovery takes place. To what this newly acquired resisting power is due is by no means clear to bacteriologists, although certain factors are already known. It appears beyond question that in the case of certain diseases the cells of the body after a time produce substances which serve as antidotes to the poisons produced by the bacteria during their growth in the body-antitoxines. In the case of diphtheria, for instance, the germs growing in the throat produce poisons which are absorbed by the body and give rise to the symptoms of the disease; but after a time the body cells react, and themselves produce a counter toxic body which neutralizes the poisonous effect of the diphtheria poison. This substance has been isolated from the blood of animals that have recovered from an attack of diphtheria, and has been called diphtheria antitoxine. But even with this knowledge the recovery is not fully explained. This antitoxine neutralizes the effects of the diphtheria toxine, and then the body develops strength to drive off the bacteria which have obtained lodgment in the throat. How they accomplish this latter achievement we do not know as yet. The antitoxme developed simply neutralizes the effects of the toxine. Some other force must be at work to get rid of the bacteria, a force which can only exert itself after the poisoning effect of the poison is neutralized. In these cases, then, the recovery is due, first, to the development in the body of the natural antidotes to the toxic poisons, and, second, to some other unknown force which drives off the parasites.
These facts are certainly surprising. If one had been asked to suggest the least likely theory to explain recovery from disease, he could hardly have found one more unlikely than that the body cells developed during the disease an antidote to the poison which the disease bacteria were producing. Nevertheless, it is beyond question that such antidotes are formed during the course of the germ diseases. It has not yet been shown in all diseases, and it would be entirely too much to claim that this is the method of recovery in all cases. We may say, however, in regard to bacterial diseases in general, that after the bacteria enter the body at some weak point they have first a battle to fight with the resisting powers of the body, which appear to be partly biological and partly chemical. These resisting powers are in many cases entirely sufficient to prevent the bacteria from obtaining a foothold. If the invading host overcome the resisting powers, then they begin to multiply rapidly, and take possession of the body or some part of it. They continue to grow until either the individual dies or something occurs to check their growth. After the individual develops the renewed powers of checking their growth, recovery takes place, and the individual is then, because of these renewed powers of resistance, immune from a second attack of the disease for a variable length of time.
This, in the merest outline, represents the relation of bacterial parasites to the human body But while this is a fair general expression of the matter, it must be recognised that different diseases differ much in their relations, and no general outline will apply to all They differ in their method of attack and in the point of attack. Not only do they produce different kinds of poisons giving rise to different symptoms of poisoning; not only do they produce different results in different animals; not only do the different pathogenic species differ much in their power to develop serious disease, but the different species are very particular as to what species of animal they attack. Some of them can live as parasites in man alone; some can live as parasites upon man and the mouse and a few other animals; some can live in various animals but not in man; some appear to be able to live in the field mouse, but not in the common mouse; some live in the horse; some in birds, but not in warm-blooded mammals; while others, again, can live almost equally well in the tissues of a long list of animals. Those which can live as parasites upon man are, of course, especially related to human disease, and are of particular interest to the physician, while those which live in animals are in a similar way of interest to veterinarians.
Thus we see that parasitic bacteria show the widest variations. They differ in point of attack, in method of attack, and in the part of the body which they seize upon as a nucleus for growth. They differ in violence and in the character of the poisons they produce, as well as in their power of overcoming the resisting powers of the body. They differ at different times in their powers of producing disease. In short, they show such a large number of different methods of action that no general statements can be made which will apply universally, and no one method of guarding against them or in driving them off can be hoped to apply to any extended list of diseases.
DISEASES CAUSED BY OTHER ORGANISMS THAN BACTERIA.
Although the purpose of this work is to deal primarily with the bacterial world, it would hardly be fitting to leave the subject without some reference to diseases caused by organisms which do not belong to the group of bacteria. While most of the so-called germ diseases are caused by the bacteria which we have been studying in the previous chapters, there are some whose inciting cause is to be found among organisms belonging to other groups. Some of these are plants of a higher organization than bacteria, but others are undoubtedly microscopic animals. Their life habits are somewhat different from those of bacteria, and hence the course of the diseases is commonly different. Of the diseases thus produced by microscopic animals or by higher plants, one or two are of importance enough to deserve special mention here.
Malaria.—The most important of these diseases is malaria in its various forms, and known under various names—chills and fever, autumnal fever, etc. This disease, so common almost everywhere, has been studied by physicians and scientists for a long time, and many have been the causes assigned to it. At one time it was thought to be the result of the growth of a bacterium, and a distinct bacillus was described as producing it. It has finally been shown, however, to be caused by a microscopic organism belonging to the group of unicellular animals, and somewhat closely related to the well-known amoeba. This organism is shown in Fig. 34. The whole history of the malarial organism is not yet known. The following statements comprise the most important facts known in regard to it, and its relation to the disease in man.
Undoubtedly the malarial germ has some home outside the human body, but it is not yet very definitely known what this external home is; nor do we know from what source the human parasite is derived. It appears probable that water serves in some cases as its means of transference to man, and air in other cases. From some external source it gains access to man and finds its way into the blood. Here it attacks the red blood-corpuscles, each malarial organism making its way into a single one (Fig. 340). Here it now grows, increasing in size at the expense of the substance of the corpuscle. As it becomes larger it becomes granular, and soon shows a tendency to separate into a number of irregular masses. Finally it breaks up into many minute bodies called spores. These bodies break out of the corpuscle and for a time live a free life in the blood. After a time they make their way into other red blood-corpuscles, develop into new malarial amoeboid parasites, and repeat the growth and sporulation. This process can apparently be repeated many times without check.
These organisms are thus to be regarded as parasites of the red corpuscles. It is, of course, easy to believe that an extensive parasitism and destruction of the corpuscles would be disastrous to the health of the individual, and the severity of the disease will depend upon the extent of the parasitism. Corresponding to this life history of the organism, the disease malaria is commonly characterized by a decided intermittency, periods of chill and fever alternating with periods of intermission in which these symptoms are abated. The paroxysms of the disease, characterized by the chill, occur at the time that the spores are escaping from the blood-corpuscles and floating in the blood. After they have again found their way into a blood-corpuscle the fever diminishes, and during their growth in the corpuscle until the next sporulation the individual has a rest from the more severe symptoms.
There appears to be more than one variety of the malarial organism, the different types differing in the length of time it takes for their growth and sporulation. There is one variety, the most common one, which requires two days for its growth, thus giving rise to the paroxysm of the disease about once in forty- eight hours; another variety appears to require three days for its growth; while still another variety appears to be decidedly irregular in its period of growth and sporulation. These facts readily explain some of the variations in the disease. Certain other irregularities appear to be due to a different cause. More than one brood of parasites may be in the blood of the individual at the same time, one producing sporulation at one time and another at a different time. Such a simultaneous growth of two independent broods may plainly produce almost any kind of modification in the regularity of the disease.
The malarial organism appears to be very sensitive to quinine, a very small quantity being sufficient to kill it. Upon this point depends the value of quinine as a medicine. If the drug be present in the blood at the time when the spores are set free from the blood-corpuscle, they are rapidly killed by it before they have a chance to enter another corpuscle. During their growth in the corpuscle they are far less sensitive to quinine than when they exist in the free condition as spores, and at this time the drug has little effect.
The malarial organism is an animal, and can not be cultivated in the laboratory by any artificial method yet devised. Its whole history is therefore not known. It doubtless has some home outside the blood of animals, and very likely it may pass through other stages of a metamorphosis in the bodies of other animals. Most parasitic animals have two or more hosts upon which they live, alternating from one to the other, and that such is the case with the malarial parasite is at least probable. But as yet bacteriologists have been unable to discover anything very definite in regard to the matter. Until we can learn something in regard to its life outside the blood of man we can do little in the way of devising methods to avoid it.
Malaria differs from most germ diseases in the fact that the organisms which produce it are not eliminated from the body in any way. In most germ diseases the germs are discharged from the patient by secretions or excretions of some kind, and from these excretions may readily find their way into other individuals. The malarial organism is not discharged from the body in any way, and hence is not contagious. If the parasite does pass part of its history in some other animal than man, there must be some means by which it passes from man to its other host. It has been suggested that some of the insects which feed upon human blood may serve as the second host and become inoculated when feeding upon such blood. This has been demonstrated with startling success in regard to the mosquito (Anopheles), some investigators going so far as to say that this is the only way in which the disease can be communicated.
Several other microscopic animals occur as parasites upon man, and some of them are so definitely associated with certain diseases as to lead to the belief that they are the cause of these diseases. The only one of very common occurrence is a species known as Amaeba coli, which is found in cases of dysentery. In a certain type of dysentery this organism is so universally found that there is little doubt that it is in some very intimate way associated with the cause of the disease. Definite proof of the matter is, however, as yet wanting.
On the side of plants, we find that several plants of a higher organization than bacteria may become parasitic upon the body of man and produce various types of disease. These plants belong mostly to the same group as the moulds, and they are especially apt to attack the skin. They grow in the skin, particularly under the hair, and may send their threadlike branches into some of the subdermal tissues. This produces irritation and inflammation of the skin, resulting in trouble, and making sores difficult to heal. So long as the plant continues to grow, the sores, of course, can not be healed, and when the organisms get into the skin under the hair it is frequently difficult to destroy them. Among the diseases thus caused are ringworm, thrush, alopecia, etc.
METHODS OF COMBATING PARASITIC BACTERIA.
The chief advantage of knowing the cause of disease is that it gives us a vantage ground from which we may hope to find means of avoiding its evils. The study of medicine in the past history of the world has been almost purely empirical, with a very little of scientific basis. Great hopes are now entertained that these new facts will place this matter upon a more strictly scientific foundation. Certainly in the past twenty-five years, since bacteriology has been studied, more has been done to solve problems connected with disease than ever before. This new knowledge has been particularly directed toward means of avoiding disease. Bacteriology has thus far borne fruit largely in the line of preventive medicine, although to a certain extent also along the line of curative medicine. This chapter will be devoted to considering how the study of bacteriology has contributed directly and indirectly to our power of combating disease.
In the study of medicine in the past centuries the only aim has been to discover methods of curing disease; at the present time a large and increasing amount of study is devoted to the methods of preventing disease. Preventive medicine is a development of the last few years, and is based almost wholly upon our knowledge of bacteria. This subject is yearly becoming of more importance. Forewarned is forearmed, and it has been found that to know the cause of a disease is a long step toward avoiding it. As some of our contagious and epidemic diseases have been studied in the light of bacteriological knowledge, it has been found possible to determine not only their cause, but also how infection is brought about, and consequently how contagion may be avoided. Some of the results which have grown up so slowly as to be hardly appreciated are really great triumphs. For instance, the study of bacteriology first led us to suspect, and then demonstrated, that tuberculosis is a contagious disease, and from the time that this was thus proved there has been a slow, but, it is hoped, a sure decline in this disease. Bacteriological study has shown that the source of cholera infection in cases of raging epidemics is, in large part at least, our drinking water; and since this has been known, although cholera has twice invaded Europe, and has been widely distributed, it has not obtained any strong foothold or given rise to any serious epidemic except in a few cases where its ravages can be traced to recognised carelessness. It is very significant to compare the history of the cholera epidemics of the past few years with those of earlier dates. In the epidemics of earlier years the cholera swept ruthlessly through communities without check. In the last few years, although it has repeatedly knocked at the doors of many European cities, it has been commonly confined to isolated cases, except in a few instances where these facts concerning the relation to drinking water were ignored.
The study of preventive medicine is yet in its infancy, but it has already accomplished much. It has developed modern systems of sanitation, has guided us in the building of hospitals, given rules for the management of the sick-room which largely prevent contagion from patient to nurse; it has told us what diseases are contagious, and in what way; it has told us what sources of contagion should be suspected and guarded against, and has thus done very much to prevent the spread of disease. Its value is seen in the fact that there has been a constant decrease in the death rate since modern ideas of sanitation began to have any influence, and in the fact that our general epidemics are less severe than in former years, as well as in the fact that more people escape the diseases which were in former times almost universal.
The study of preventive medicine takes into view several factors, all connected with the method and means of contagion. They are the following:
The Source of Infectious Material.—t has been learned that for most diseases the infectious material comes from individuals suffering with the disease, and that except in a few cases, like malaria, we must always look to individuals suffering from disease for all sources of contagion. It is found that pathogenic bacteria are in all these cases eliminated from the patient in some way, either from the alimentary canal or from skin secretions or otherwise, and that any nurse with common sense can have no difficulty in determining in what way the infectious material is eliminated from her patients. When this fact is known and taken into consideration it is a comparatively easy matter to devise valuable precautions against distribution of such material. It is thus of no small importance to remember that the simple presence of bacteria in food or drink is of no significance unless these bacteria have come from some source of disease infection.
The Method of Distribution.—The bacteria must next get from the original source of the disease to the new susceptible individual. Bacteria have no independent powers of distribution unless they be immersed in liquids, and therefore their passage from individual to individual must be a passive one. They are readily transferred, however, by a number of different means, and the study of these means is aiding much in checking contagion Study along this line has shown that the means by which bacteria are carried are several. First we may notice food as a distributor. Food may become contaminated by infectious material in many ways; for example, by contact with sewage, or with polluted water, or even with eating utensils which have been used by patients. Water is also likely to be contaminated with infectious material, and is a fertile source for distributing typhoid and cholera. Milk may become contaminated in a variety of ways, and be a source of distributing the bacteria which produce typhoid fever, tuberculosis, diphtheria, scarlet fever, and a few other less common diseases. Again, infected clothing, bedding, or eating utensils may be taken from a patient and be used by another individual without proper cleansing. Direct contact, or contact with infected animals, furnishes another method. Insects sometimes carry the bacteria from person to person, and in some diseases (tuberculosis, and perhaps scarlet fever and smallpox) we must look to the air as a distributor of the infectious material. Knowledge of these facts is helping to account for multitudes of mysterious cases of infection, especially when we combine them with the known sources of contagious matter.
Means of Invasion.—Bacteriology has shown us that different species of parasitic bacteria have different means of entering the body, and that each must enter the proper place in order to get a foothold. After we learn that typhoid infectious material must enter the mouth in order to produce the disease; that tuberculosis may find entrance through the nose in breathing, while types of blood poisoning enter only through wounds or broken skin, we learn at once fundamental facts as to the proper methods of meeting these dangers. We learn that with some diseases care exercised to prevent the swallowing of infectious material is sufficient to prevent contagion, while with others this is entirely insufficient. When all these facts are understood it is almost always perfectly possible to avoid contagion; and as these facts become more and more widely known direct contagion is sure to become less frequent.
Above all, it is telling us what becomes of the pathogenic bacteria after being eliminated from the body of the patient; how they may exist for a long time still active; how they may lurk in filth or water dormant but alive, or how they may even multiply there. Preventive medicine is telling us how to destroy those thus lying in wait for a chance of infection, by discovering disinfectants and telling us especially where and when to use them. It has already taught us how to crush out certain forms of epidemics by the proper means of destroying bacteria, and is lessening the dangers from contagious diseases. In short, the study of bacteriology has brought us into a condition where we are no longer helpless in the presence of a raging epidemic. We no longer sit in helpless dismay, as did our ancestors, when an epidemic enters a community, but, knowing their causes and sources, set about at once to remove them. As a result, severe epidemics are becoming comparatively short-lived.
BACTERIA IN SURGERY.
In no line of preventive medicine has bacteriology been of so much value and so striking in its results as in surgery. Ever since surgery has been practised surgeons have had two difficulties to contend with. The first has been the shock resulting from the operation. This is dependent upon the extent of the operation, and must always be a part of a surgical operation. The second has been secondary effects following the operation. After the operation, even though it was successful, there were almost sure to arise secondary complications known as surgical fever, inflammation, blood poisoning, gangrene, etc., which frequently resulted fatally. These secondary complications were commonly much more serious than the shock of the operation, and it used to be the common occurrence for the patient to recover entirely from the shock, but yield to the fevers which followed. They appeared to be entirely unavoidable, and were indeed regarded as necessary parts of the healing of the wound. Too frequently it appeared that the greater the care taken with the patient the more likely he was to suffer from some of these troubles. The soldier who was treated on the battlefield and nursed in an improvised field hospital would frequently recover, while the soldier who had the fortune to be taken into the regular hospital, where greater care was possible, succumbed to hospital gangrene. All these facts were clearly recognised, but the surgeon, through ignorance of their cause, was helpless in the presence of these inflammatory troubles, and felt it always necessary to take them into consideration.
The demonstration that putrefaction and decay were caused by bacteria, and the early proof that the silkworm disease was produced by a micro-organism, led to the suggestion that the inflammatory diseases accompanying wounds were similarly caused. There are many striking similarities between these troubles and putrefaction, and the suggestion was an obvious one. At first, however, and for quite a number of years, it was impossible to demonstrate the theory by finding the distinct species of micro- organisms which produced the troubles. We have already seen that there are several different species of bacteria which are associated with this general class of diseases, but that no specific one has any particular relation to a definite type of inflammation. This fact made discoveries in this connection a slow matter from the microscopical standpoint. But long before this demonstration was finally reached the theory had received practical application in the form of what has developed into antiseptic or aseptic surgery.
Antiseptic surgery is based simply upon the attempt to prevent the entrance of bacteria into the surgical wound. It is assumed that if these organisms are kept from the wound the healing will take place without the secondary fevers and inflammations which occur if they do get a chance to grow in the wound. The theory met with decided opposition at first, but accumulating facts demonstrated its value, and to-day its methods have been adopted everywhere in the civilized world. As the evidence has been accumulating, surgeons have learned many important facts, foremost among which is a knowledge of the common sources from which the infection of wounds occurs. At first it was thought that the air was the great source of infection, but the air bacteria have been found to be usually harmless. It has appeared that the more common sources are the surgeon's instruments, or his hands, or the clothing or sponges which are allowed to come in contact with the wounds. It has also appeared that the bacteria which produce this class of troubles are common species, existing everywhere and universally present around the body, clinging to the clothing or skin, and always on hand to enter the wound if occasion offers. They are always present, but commonly harmless. They are not foreign invaders like the more violent pathogenic species, such as those of Asiatic cholera, but may be compared to domestic enemies at hand. It is these ever-present bacteria which the surgeon must guard against. The methods by which he does this need not detain us here. They consist essentially in bacteriological cleanliness. The operation is performed with sterilized instruments under most exacting conditions of cleanliness.
The result has been a complete revolution in surgery. As the methods have become better understood and more thoroughly adopted, the instances of secondary troubles following surgical wounds have become less and less frequent until they have practically disappeared in all simple cases. To-day the surgeon recognises that when inflammatory troubles of this sort follow simple surgical wounds it is a testimony to his carelessness. The skilful surgeon has learned that with the precautions which he is able to take to-day he has to fear only the direct effect of the shock of the wound and its subsequent direct influence; but secondary surgical fevers, blood poisoning, and surgical gangrene need not be taken into consideration at all. Indeed, the modern surgeon hardly knows what surgical gangrene is, and bacteriologists have had practically no chance to study it. Secondary infections have largely disappeared, and the surgeon is concerned simply with the effect of the wound itself, and the power of the body to withstand the shock and subsequently heal the wound.
With these secondary troubles no longer to disturb him, the surgeon has become more and more bold. Operations formerly not dreamed of are now performed without hesitation. In former years an operation which opened the abdominal cavity was not thought possible, or at least it was so nearly certain to result fatally that it was resorted to only on the last extremity; while to-day such operations are hardly regarded as serious. Even brain surgery is becoming more and more common. Possibly our surgeons are passing too far to the other extreme, and, feeling their power of performing so many operations without inconvenience or danger, they are using the knife in cases where it would be better to leave Nature to herself for her own healing. But, be this as it may, it is impossible to estimate the amount of suffering prevented and the number of lives saved by the mastery of the secondary inflammatory troubles which used to follow surgical wounds.
Preventive medicine, then, has for its object the prevention rather than the cure of disease. By showing the causes of disease and telling us where and how they are contracted, it is telling us how they may to a large extent be avoided. Unlike practical medicine, this subject is one which has a direct relation to the general public. While it may be best that the knowledge of curative methods be confined largely to the medical profession, it is eminently desirable that a knowledge of all the facts bearing upon preventive medicine should be distributed as widely as possible. One person can not satisfactorily apply his knowledge of preventive medicine, if his neighbour is ignorant of or careless of the facts. We can not hope to achieve the possibilities lying along this line until there is a very wide distribution of knowledge. Every epidemic that sweeps through our communities is a testimony to the crying need of education in regard to such simple facts as the source of infectious material, the methods of its distribution, and the means of rendering it harmless.
PREVENTION IN INOCULATION.
It has long been recognised that in most cases recovery from one attack of a contagious disease renders an individual more or less immune against a second attack. It is unusual for an individual to have the same contagious disease twice. This belief is certainly based upon fact, although the immunity thus acquired is subject to wide variations. There are some diseases in which there is little reason for thinking that any immunity is acquired, as in the case of tuberculosis, while there are others in which the immunity is very great and very lasting, as in the case of scarlet fever. Moreover, the immunity differs with individuals. While some persons appear to acquire a lasting immunity by recovery from a single attack, others will yield to a second attack very readily. But in spite of this the fact of such acquired immunity is beyond question. Apparently all infectious diseases from which a real recovery takes place are followed by a certain amount of protection from a second attack; but with some diseases the immunity is very fleeting, while with others it is more lasting. Diseases which produce a general infection of the whole system are, as a rule, more likely to give rise to a lasting immunity than those which affect only small parts. Tuberculosis, which, as already noticed, is commonly quite localized in the body, has little power of conveying immunity, while a disease like scarlet fever, which affects the whole system, conveys a more lasting protection.
Such immunity has long been known, and in the earlier years was sometimes voluntarily acquired; even to-day we find some individuals making use of the principle. It appears that a mild attack of such diseases produces immunity equally well with a severe attack, and acting upon this fact mothers have not infrequently intentionally exposed their children to certain diseases at seasons when they are mild, in order to have the disease "over with" and their children protected in the future. Even the more severe diseases have at times been thus voluntarily acquired. In China it has sometimes been the custom thus to acquire smallpox. Such methods are decidedly heroic, and of course to be heartily condemned. But the principle that a mild type of the disease conveys protection has been made use of in a more logical and defensible way.
The first instance of this principle was in vaccination against smallpox, now practised for more than a century. Cowpox is doubtless closely related to smallpox, and an attack of the former conveys a certain amount of protection against the latter. It was easy, therefore, to inoculate man with some of the infectious material from cowpox, and thus give him some protection against the more serious smallpox. This was a purely empirical discovery, and vaccination was practised long before the principle underlying it was understood, and long before the germ nature of disease was recognised. The principle was revived again, however, by Pasteur, and this time with a logical thought as to its value. While working upon anthrax among animals, he learned that here, as in other diseases, recovery, when it occurred, conveyed immunity. This led him to ask if it were not possible to devise a method of giving to animals a mild form of the disease and thus protect them from the more severe type. The problem of giving a mild type of this extraordinarily severe disease was not an easy one. It could not be done, of course, by inoculating the animals with a small number of the bacteria, for their power of multiplication would soon make them indefinitely numerous. It was necessary in some way to diminish their violence. Pasteur succeeded in doing this by causing them to grow in culture fluids for a time at a high temperature. This treatment diminished their violence so much that they could be inoculated into cattle, where they produced only the mildest type of indisposition, from which the animals speedily recovered. But even this mild type of the disease was triumphantly demonstrated to protect the animals from the most severe form of anthrax. The discovery was naturally hailed as a most remarkable one, and one which promised great things in the future. If it was thus possible, by direct laboratory methods, to find a means of inoculating against a serious disease like anthrax, why could not the same principle be applied to human diseases? The enthusiasts began at once to look forward to a time when all diseases should be thus conquered.
But the principle has not borne the fruit at first expected. There is little doubt that it might be applied to quite a number of human diseases if a serious attempt should be made. But several objections arise against its wide application. In the first place, the inoculation thus necessary is really a serious matter. Even vaccination, as is well known, sometimes, through faulty methods, results fatally, and it is a very serious thing to experiment upon human beings with anything so powerful for ill as pathogenic bacteria. The seriousness of the disease smallpox, its extraordinary contagiousness, and the comparatively mild results of vaccination, have made us willing to undergo vaccination at times of epidemics to avoid the somewhat great probability of taking the disease. But mankind is unwilling to undergo such an operation, even though mild, for the purpose of avoiding other less severe diseases, or diseases which are less likely to be taken. We are unwilling to be inoculated against mild diseases, or against the more severe ones which are uncommon. For instance, a method has been devised for rendering animals immune against lockjaw, which would probably apply equally well to man. But mankind in general will never adopt it, since the danger from lockjaw is so small. Inoculation must then be reserved for diseases which are so severe and so common, or which occur in periodical epidemics of so great severity, as to make people in general willing to submit to inoculation as a protection. A further objection arises from the fact that the immunity acquired is not necessarily lasting. The cattle inoculated against anthrax retain their protective powers for only a few months. How long similar immunity might be retained in other cases we can not say, but plainly this fact would effectually prevent this method of protecting mankind from being used except in special cases. It is out of the question to think of constant and repeated inoculations against various diseases.
As a result, the principle of inoculation as an aid in preventive medicine has not proved of very much value. The only other human disease in which it has been attempted seriously is Asiatic cholera. This disease in times of epidemics is so severe and the chance of infection is so great as to justify such inoculation. Several bacteriologists have in the last few years been trying to discover a harmless method of inoculating against this disease. Apparently they have succeeded, for experiments in India, the home of the cholera, have been as successful as could be anticipated. Bacteriological science has now in its possession a means of inoculation against cholera which is perhaps as efficacious as vaccination is against smallpox. Whether it will ever be used to any extent is doubtful, since, as already pointed out, we are in a position to avoid cholera epidemics by other means. If we can protect our communities by guarding the water supply, it is not likely that the method of inoculation will ever be widely used.
Another instance of the application of preventive inoculation has been made, but one based upon a different principle. Hydrophobia is certainly one of the most horrible of diseases, although comparatively rare. Its rarity would effectually prevent mankind from submitting to a general inoculation against it, but its severity would make one who had been exposed to it by the bite of a rabid animal ready to submit to almost any treatment that promised to ward off the disease. In the attempt to discover a means of inoculating against this disease it was necessary, therefore, to find a method that could be applied after the time of exposure—i.e., after the individual had been bitten by the rabid animal. Fortunately, the disease has a long period of incubation, and one that has proved long enough for the purpose. A method of inoculation against this disease has been devised by Pasteur, which can be applied after the individual has been bitten by the rabid animal. Apparently, however, this preventive inoculation is dependent upon a different principle from vaccination or inoculation against anthrax. It does not appear to give rise to a mild form of the disease, thus protecting the individual, but rather to an acquired tolerance of the chemical poisons produced by the disease. It is a well-known physiological fact that the body can become accustomed to tolerate poisons if inured to them by successively larger and larger doses. It is by this power, apparently, that the inoculation against hydrophobia produces its effect. Material containing the hydrophobia poison (taken from the spinal cord of a rabbit dead with the disease) is injected into the individual after he has been bitten by a rabid animal. The poisonous material in the first injection is very weak, but is followed later by a more powerful inoculation. The result is that after a short time the individual has acquired the power of resisting the hydrophobia poisons. Before the incubation period of the original infectious matter from the bite of the rabid animal has passed, the inoculated individual has so thoroughly acquired a tolerance of the poison that he successfully resists the attack of the infection. This method of inoculation thus neutralizes the effects of the disease by anticipating them.