^^^y^w^ , ; Uv" v W Wwv^ ^wimti&®$® |B ^V^W^Vwy yvw^w^^ww»> .**&$«$& @iS»y ^yyuw*/ ^LIBRARY OF CONGRESS.? [SMITHSONIAN DEPOSIT.] .TJjb- | UNITED STATES OF AMERICA. J fe^wyvvji v - /w^wyu^/^g ^^*vwv; wwvvvV'V 1 wwwggggg S^WP^HiWffi mM& * i&i^^ ViMA/yv' mmfim$ wmmmmmim *ym*&W^^ ^gWgWYV J V 'WWW^ ■: ^ ; 'W "^v^^ w vw, w^^toSv^^ ■ ^ .^ . w yA> w vjggw^ /gwww vv . "w^aw )\ju*\jy?w- mmm v ^g^W^Wv w ^ W ^ V ^ WWW WW, VU£$ 'K/uVUM^^^W^ #» l/Vv ,'»'W»\ : uw ^uuu vw ! ^^u^^wwvu^w^^wyywuvg vvv^yg Wwu^VWW^V^ v ^ W^AM©«&v WUu, a AW gl^ :wysy 'vyvyvww'C^Vi j^V w VOv^UU^ *r*m VH^yVV THE ORIGIN AND PROPAGATION OF DISEASE. AN ANNIVERSARY DISCOURSE, DELIVERED BEFORE THE NEW YORK ACADEMY OF MEDICINE, NOVEMBER 20, 1873. gjg JOHN C. DALTON, M. D., PROFESSOR OF PHYSIOLOGY IN THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK. [PUBLISHED BY ORDER OP THE ACADEMY.] NEW YOEK: D. APPLETON ANT) COMPANY, 549 & 551 BROADWAY. 1874. \ ^ OFFICERS AND TIME OF SERVICE President. AUSTIN FLINT, Senior, M. D., 1873-'75. Vice-Presidents. WILLIAM C. ROBERTS, M. D., 1873-'74. SAMUEL S. PURPLE, M.D., 1872-'75. SAMUEL T. HUBBARD, M.D., 1873-'76. Recording Secretary. WILLIAM T. WHITE, M. D., 1871-'74. Assistant Recording Secretary. WILLIAM H. B. POST, M. D., 187l-'74. Corresponding Secretary. JOHN G. ADAMS, M. D., 187l-'74. Treasurer. JAMES O. POND, M. D., 187l-'74. Librarian. JOHN H. HINTON, M. D. Trustees. JAMES L. BANKS, M. D., 1869-'74. JAMES ANDERSON, M.D., 1870-'75. ALFRED UNDERHILL, 1871-'76. ISAAC E. TAYLOR, M. D., 1872-'77. EDMUND R. PEASLEE, M. D., 187 3-' 7 8. Publication Committee. EDMUND R. PEASLEE, M. D. SAMUEL S. PURPLE, M. D. WILLIAM T. WHITE, M.D. ANNIVERSARY DISCOURSE. Mr. President and Fellows of the Kew York Academy of Medicine: The anniversary meeting of the Academy of Medicine may be regarded as a sort of annual conference, in which one of its members is deputed to offer to the Academy a short address upon some topic of general professional interest, and more or less appropriate to the time. Perhaps we can hardly employ the occasion to-night in a more suitable way than by endeavoring to see what, on the whole, is the direction in which medical thought is now most active ; to cast the pro- fessional horoscope, so to speak, for the present, and to antici- pate, as nearly as may be, what we are to expect from it in the immediate future. Not that we should be willing to claim the gift of prophecy, or to place too much confidence in delusive flights of the ima- gination. Medicine is essentially a skeptical science, and very properly regards with disapproval any thing which claims her attention without offering, at the same time, unmistakable guarantees of respectability. But there may be a kind of an- ticipation which is really a scientific one. "Within the past two or three years we have seen our own Meteorological Bureau triumph over what was proverbially the most difficult of all popular puzzles, aud foretell the weather of each day with a certainty which has excited our surprise and admiration. With 6 telegraph-lines from all over the continent converging to the central office at Washington, the chief of the Bureau can trace, from hour to hour, the progress of a meteorological change, moving, with uniform or accelerated speed, from St. Paul to Milwaukee, from Milwaukee to Detroit, from Detroit to Buf- falo ; and he knows that within a given period it will reach New York, with almost as much certainty as though he stood on the top of a watch-tower and saw it coming. Within such' limits as these it may perhaps be allowable sometimes to in- dulge in surmises, even in the strictest and most exacting of the natural sciences. Is there any thing in the aspect and condition of any part of medicine to-day that looks like a change in the scientific barometer ? Can we see such a tendency in the medical mind, at present, as would suggest what may fairly be called a new movement — in which successive ideas and discoveries are not only accumulating as heretofore, but in which they also seem to be taking, or about to take, a new interpretation ; so as to give expression, in definite terms, to a doctrine which has here- tofore had only a vague and uncertain existence ? If there be any one direction in which progress is now so marked as to constitute a dominant feature of the present state of medicine, and to embrace a practically new medical idea, I should say it was that of the origin and propagation of disease by independent organic germs. Perhaps it would be wrong to say that this doctrine is even yet distinctly formu- lated. It is certainly far from being definitely established as a general truth. Some very wild and reckless statements have been made in regard to it, by observers possessed of more zeal than knowledge ; and some elaborate but baseless theories re- lating to the specific development and transformation of organic germs have been tried at the bar of scientific investigation, and, being convicted of incompetency, have suffered, accordingly, the just penalty of extermination. Perhaps the doctrine itself will also be finally abandoned. It may be that the evidence in its favor, which is yet only partial, will hereafter lose its special significance ; and the appearances which now seem to sustain it may come to be naturally explained in some other way. Still, there can be no doubt that the idea is at present entertained, and that it is by no means confined to the minds of careless or irresponsible theorizers. So far, it exists in the form rather of a scientific instinct than of a positive belief; and its gray light hangs about the edge of the medical horizon like the coming dawn of a new period. Isow, can this instinct of the medical mind be justified in any way ? Are there any facts and discoveries, already estab- lished beyond the possibility of doubt, which have naturally led it in this direction, and which point, like the telegraphic reports of successive meteorological stations, to a continuous and definite movement of scientific pathology ? I think it really began many years ago, in the early inves- tigation of parasitic diseases. Perhaps we can hardly include under this designation the effects produced by ordinary intes- tinal worms, like taenia or ascaris, because the animal and para- sitic nature of these worms was perfectly palpable, and could not be mistaken by any one. l&ut^scdbies was on a different footing. It was a contagious, eruptive affection, capable of spreading over a large portion of the body, and of giving the patient great discomfort ; and, when it was found to be due simply to the presence and propagation of a parasitic insect, the discovery was a great achievement, and for the first time made it possible to have a distinct and rational comprehension of the origin of the disease, as well as of its propagation and means of cure. A remarkable circumstance in the history of our knowledge in regard to Sarcoptes scabiei is, that its dis- covery in the present century was in fact a rediscovery of something which had been known centuries before and long forgotten ; or, at least, the method of finding the insect having been lost, the most eminent dermatologists of forty years ago had never seen it, and were really in doubt as to its existence. However, this uncertainty was terminated in 1834, by the Corsican student Eenucci, and the study of its structure and development was afterward accomplished by Raspail and Bourguignon ; so that our knowledge, both of the disease and its parasite, was then placed upon a permanent footing. Perhaps the most suggestive part of this discovery related to the reproduction of the parasite, the manner in which the female lays her eggs in galleries excavated in the skin, and the time required for the hatching and dispersion of the young, because this showed a direct connection between the local spread of the disease and the increase, by ordinary sexual gen- eration, of the young brood of the parasite. However, there was nothing very remarkable in the mode of this generation. The eggs of the female were deposited and hatched in the usual way, and the young sarcoptes came to resemble their parents after a very short and regular period of development. But ten or fifteen years later a discovery was made with regard to some of the internal parasites which had a charac- ter of unexpected peculiarity : that was, the specific identity of two parasites formerly supposed to be distinct, namely, cysti- cercus and trenia. These two worms — so unlike in their size, their general configuration, and even in the species of animal which they inhabit — were shown \>y the researches of Siebold and Kuchenmeister to be only different stages of growth of the same creature — one the encysted and quiescent, the other the intestinal and reproductive form. The well-known experi. ments carried on in this investigation showed furthermore the regular and natural conversion of these two forms into each other ; and thus we came fully to understand that the exist- ence of tape-worm in man was owing to his having eaten measly pork containing cysticercus, and that the pig became contaminated with cysticercus by devouring the eggs or the egg-bearing articulations of tasnia solium. The knowledge of the alternation of generations and of the migration of para- sites from one habitat to another at different periods of their development became in this way connected with the pathology and mode of propagation of certain well-known and perfectly distinct morbid affections. But so far, perhaps, these morbid affections hardly deserved the name of diseases. They were simply local disorders, due to the presence of a parasitic intruder in the substance of the skin or in the cavity of the intestinal canal. It was another 9 thing, to learn, some years later, that a microscopic parasite might diffuse itself generally throughout the system, and thus give rise to a rapid and fatal train of symptoms hardly dis- tinguishable from those of any febrile constitutional disease. No doubt cases of infection by Trichina spiralis have always occurred, as frequently as they do now. But previous to the year 1850 the milder ones in all probability were supposed to be rheumatic in their origin, while the fatal cases passed for fevers of a typhoid character. There were even epidemics of the trichinous affection, as there are of typhoid fever and in- fluenza ; and, when the true character of the disease became known, it was perfectly evident how these epidemics origi- nated and exactly how far they might extend. Each one was commenced by the slaughter and preparation for food of a trichinous pig ; and the patients affected were precisely those who had introduced into their systems ever so small a portion of the infectious food. In this instance, also, there was found to be an unexpected relation between two different forms of the same parasite. Trichina spiralis had been known since 1830 : but it had yet been seen only in its quiescent, encysted form, embedded in the muscular tissue, without movement or reproduction. Con- sequently, though we were familiar with the worm itself, we knew nothing of the disease produced by it. Its new growth and active reproduction in the intestinal canal, the swarming emigration of its innumerable progeny, and the constitutional symptoms which followed, were a new revelation, and showed that the whole system, as well as a particular organ or tissue, might suffer from the effects of parasitic contamination. In all the affections which have now been enumerated, the parasite is one of an animal nature, with regular generative apparatus and active sexual reproduction. But the last thirty years have seen a very remarkable advance also in our knowl- edge of the vegetable parasites. This has naturally coincided with a similar activity among scientific botanists in the study of the simpler forms of vegetation, the cryptogam ic plants in general, and particularly of the microscopic fungi and algas. 10 A. little over half a century ago the species of flowering plants described by botanists were much more numerous than the cryptogams ; but now the proportions of the two classes are reversed. In 1818, according to Mr. Cooke, 1 an eminent Brit- ish botanist, " less than eighty of the more minute species of fungi, but few of which deserved the name of microscopic, were supposed to contain all then known of these wonderful organisms. Since that period microscopes have become very different instruments ; and one result has been the increase of the 564 species of British fungi to 2,479. By far the greater number of the species thus added depend for their specific characters upon microscopical examination. At the present time the number of British species of flowering plants scarcely exceeds three-fourths of the number of fungi alone, not to mention ferns, mosses, alga?, and lichens." A large proportion of these microscopic plants are para- sitic upon other organisms ; and for the earliest study of them, as connected with disease in the human subject, we are indebted to the dermatologists. The first discovery of parasitic vegetation in cutaneous affections was by Schonlein, in 1839, 2 who found in the crust of favus cryptogamic vegetable filaments ramifying in the diseased growth. In 1841 Gruby made a similar observa- tion, 3 and described accurately both the mycelium filaments and the spores. He asserted them to be always present in cases of favus, and declared that the malady itself was essentially " nothing but a vegetation." The parasite thus described proved to be the same with that previously seen by Schonlein, and it was at last definitely known by the name of Achorion Schonleinii. Gruby continued his examinations, and in 1844 discovered a microscopic vegetation growing upon the skin, in a case of 1 "Introduction to the Study of Microscopic Fungi," London, 1870, p. 45. 2 Miiller's Arcliiv for 1839 ; cited in Robin," Vggetaux Parasites," Paris, 1853, p. 477. 3 " Coraptes Rendus de rAcad&nie des Sciences," 1841, tome xiii., pp. 72, 309. 11 porrigo decalvans ; * and the same parasite, the Trichophyton tonsurans, has since been recognized as a constant accompani- ment of tinea sycosis and tinea circinnata. Finally, Microsporon furftir was discovered by Eichstedt, in 1846, 2 as a parasitic vegetation in tinea versicolor; so that within ssven or eight years three distinct microscopic fungi were discovered and recognized as occurring in diseased con- ditions of the human skin. ISTow, the first question which naturally came up in rela- tion to the discovery was this : Is the microscopic fungus the cause of the disease, or is the disease the cause of the fungus ? Either of these two suppositions might be the true one. In the first place, the fungus, by its accidental presence and growth in the skin, might excite all the irritation and morbid discharges characteristic of the malady. On the other hand, its presence might be altogether secondary, and a result of the morbid action instead of its cause. Every vegetable requires a soil suited to its growth. The fungus-germs might be in- capable of fastening themselves upon the healthy skin, but might readily flourish in the decomposing mixture of inflam- matory exudations. This question, in the earlier stages of the investigation, presented a real difficulty. Henle, in 1840, believed that Achorion Schonleinii was merely an incidental formation in the crust of favus, while Remak and others re- garded it as the cause and essential element of the disease. Now, how was this difficulty to be settled ? If tinea ton- surans is always accompanied by trichophyton, and if tricho- phyton is never found upon the skin, except in some form of tinea, how can we tell which of these two is the cause and which the consequence of the other? The test of this is twofold : 1. Inoculation of the parasite and reproduction of the disease ; 2. Destruction of the parasite and cure of the disease, Both of these tests have been successfully carried out. The inoculation of Achorion Schonleinii was accomplished by 1 " Oomptes Eendus de l'Acad became ill, but finally recovered. In cases of septicaemia, therefore, the bacteria really mul- tiply in the circulation during life ; and the small quantity of infectious blood necessary to produce the disease is explained by their singular activity of reproduction. These experiments certainly bring the study of morbid con- tagion into very close relationship with that of putrefaction and fermentation ; and there is no doubt that the analogies between them become more distinct and suggestive at every step of the investigation. It only remains to show that the same results will apply to diseases of more regular type and more familiar occurrence. If we were to choose any single morbid affection as a fair representative of the whole class of contagious disorders, I suppose small-pox would be the one selected. Its virulence, the certainty of its communication, the abundance of infec- tious matter generated, the regularity of its symptoms, and the definite periods of its incubation and development, all make it, so to speak, a kind of exponent of the essential qualities of infectious disease. Beside this, its singular relations to vaccine give it a peculiar interest ; and the vaccine affection also, though milder in its symptoms, is hardly less marked as a contagion than small-pox itself. Conclusions derived from ex- periments with either must be of great value in regard to the study of contagion as a whole. The first definite experiments in regard to the contagion of vaccine we owe, I think, to Chauveau. 1 He endeavored to as- certain whether the contagious principle of vaccine lymph were in its liquid or in its solid portions. For this purpose he treated vaccine lymph by the process of diffusion. The result showed that the contagious property of the lymph does not reside in its liquid part, but in its solid corpuscles and granu- lations. The liquid withdrawn by diffusion, though always found to contain abundance of albuminous matter in solution, 1 "Comptes Eendus de 1'AcadGmie des Sciences," 1808, tome lxvi., p. 289. 2S failed when used for vaccination ; while that containing the solid granules possessed its normal activity and succeeded as fully as the fresh lymph. The results of these diffusion ex- periments were confirmed by those of Dr. Burdon-Sanderson, 1 performed subsequently. Chauveau also adopted a second plan for investigating the same point, namely, that by dilution. The significance of this test depends on the following consideration : If the real vaccine virus be a fluid, it is of course uniformly distributed through all parts of the lymph ; and, if this lymph be diluted to any extent, the fluid virus will still be equally disseminated throughout the whole. When the dilution becomes so great as to extinguish the activity of the virus, this activity ought to diminish and disappear at the same time uniformly through all parts of the liquid. On the other hand, if the contagious principle reside in the solid particles, each one of which is capable of reproducing its kind, these particles will only be separated from each other by the dilution, and made less likely to be taken up in the drop used for vaccination. But, if one of them should be so taken up, it would still produce its full effect. In this case, the number of successful vaccinations would diminish in proportion to the dilution, and the number of failures would increase. But every vaccination which failed would fail completely, and every one which succeeded would produce a normal result. Chauveau's experiments showed that the latter supposition was correct. Yaccine lymph might be diluted with from two to eighteen times its weight of water without sensibly losing in efficacy ; and in one case the experimenter obtained a single pustule from a number of vaccinations made with lymph di- luted to y^-q-. He obtained, however, the most remarkable results with the lymph of sheep-pox, upon which he experi- mented largely. 2 He inoculated the same animal, by twenty- one punctures, with pock-lymph diluted to jfo ; and of these 1 "Twelfth Eeport of the Medical Officer of the Privy Council," Lon- don, 1870, pp. 233, 235. s "Comptes Eendus," 1868, tome Ixvii., p. 749. 29 twenty-one inoculations eight failed, while thirteen gave origin to full-sized pustules. He then diluted the pock-lymph at once to ttt,^T¥? an d- "with t n ^ s diluted lymph, out of twenty inocu- lations he obtained only a single pustule, but that pustule pre- sented its normal features, and went through the usual stages of development. The active properties of the lymph of vaccine and variola, therefore, do not reside in its liquid ingredients, but in its solid corpuscles. These corpuscles, which were already observed by Chauveau and Burdon-Sanderson, have been recently exam- ined and described with great care by Dr. Colin. 1 This ob- server adopted every precaution against the introduction of foreign elements into the lymph. Some children with healthy vaccine vesicles were brought to the Botanical Institute, the vesicles opened with a new, unused lancet, the lymph taken up by aspiration in a recently-heated capillary glass tube, dropped upon a microscope-slide, and fitted with a glass cover, both the slide and cover having just been thoroughly cleansed with ammonia and boiling water. The edges of the cover were then lacquered down, to exclude the air, and the lymph- corpuscles examined at successive intervals of time. According to Dr. Cohn's observations, these corpuscles are single cells of a spherical form, not more than -g-^To °f an mcn in diameter. They belong to the genus Micrococcus, and those of the vaccine lymph are designated by the name of Micrococcus vaccinae. They increase in numbers if kept at the temperature of the living body, forming chains and groups of associated articulations. Dr. Cohn finds similar bodies in the fluid of small-pox vesicles, identical in size and appear- ance with those of the vaccine lymph. " We must, therefore," he says, " for the present regard the pock-lymph corpuscles as living and independent organisms, belonging to the smallest and simplest of all living things, which multiply, without formation of mycelium, by cell-division alone, and perhaps also by the production of resting spores." 1 " Organisraen in der Pockcnlympbe." Archiv far pathologische Ana- tomic und Physiologies 1872, pp. 55, 229. 30 Finally, another kind of micrococcus lias been described by Dr. Oertel, 1 of Vienna, and by Prof. Ebert," of Zurich, as constantly present in cases of diphtheria ; and both observers have found that its inoculation in different parts of the body in healthy animals produces a diphtheritic malady, having its starting-point at the place of inoculation. The contributions to medical literature on this subject have increased of late with unusual rapidity. Since the beginning of 1870 more than two hundred distinct publications have made their appearance, either in the medical journals, or as separate volumes, on septicaemia and diphtheria, on micrococ- cus and bacteria, the ferment-corpuscles, fermentation and putrefaction, their relation to contagion and infection, and kindred topics. Many of these essays are extremely impor- tant, others of more or less doubtful value. I have not at- tempted to notice them all, but only those which seem to have really established some new facts relating to the origin and propagation of disease. Should the discoveries of the next ten years continue to lead in the direction now indicated, it will illustrate more fully than ever the intimate relation which exists between all the branches of medicine and natural science ; for it will show how large a part of human pathology is connected with the general physiology of vegetative life. 1 " Deutsches Archiv fur klinische Medicin," 1871, B. viii., p. 242. 2 " Zur Kentnis3 der bacteritischea Mykosen," Leipzig, 1872. 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