Miss Bureau had become an inmate of almost every bedroom in the land. This would not do. It were painful to think, that they of the finer clay should be compelled to functionate with the same implements the lower strata use, and so again they sallied forth to “gay Parce" and brought home Madam Dresser to adorn their sleeping chambers, to give them a tone which the commons could not possess.

But here trouble began. For Madam Dresser was far from satisfied with being obliged to perform such various tasks, others should be employed to assist her. Her Lords and Ladies (of the soap, or corn-plaster, or chewing-gum blooded aristocracy) were now fairly swimming in clothes, and Madam Dresser was overwhelmed in trying to meet their demands in affording readily accessible drawing chests for all their "glad rags."

So down she sat one day and putting on her thinking cap, cogitated, and from the travail gave birth to the bolshevikical germ “servanttrouble" which we all know so well to-day. She forthwith demanded that her poor but honest relation from sunny France be summoned to assist her.

This relation was well adapted for this undertaking. For was not she a picker of rags, of odds and ends, in very truth a rag picker, and would it not be the simplest thing in the world to teach her how to hold these rags, as had the chest of former days held the honest garb of our forefathers? In fact she was accomplished in the necessary feat of affording storage room for the rags she had been gathering all her days.

She was the very one to help, so over the pond she came, Mademoiselle Chiffonier, to assist Madam Dresser and hold our glad rags, our flimsy stuffs, yes even the youthful garments we see at the present times adoring our gentle sex. And should you doubt this lincage, you need but consult your Almanac de Gotha, issued in this land of ours by the Websters of Massachussetts fame, although now certain similar print may be found most everywhere under such fanciful name as Dictionary.

By this time our modest folk had become so pleased with their physiognomies, it became also necessary to equip Mademoiselle with a mirror, so not a moment of pleasure need be lost, even while dressing, in observing and admiring the different types of beauty which we severally possess.

But there is one exception and trust the man for getting the practical out of it, for quickly he saw that Mademoiselle was, even as the High Boy, of suitable height to hold his shaving-glass, so up he rose and demanded his own and forthwith took that smaller but serviceable mirror for his particular use. Our demands were developing too, even as High Boys, Bureaus, and Dressers, Madame now no longer satisfied with a small mirror must have in her service only those

Our

and

Dressers who have developed large bevelled reflectors of the human form.

And in these present days her mirror tendencies are receiving another "slant." For Madam Dresser has still further divided her tasks and I hear has imported a second relative, a Mademoiselle Toilet-Table, if I have the name right, who they tell me has wing like mirrors attached to her usual reflecting head piece, thus enabling Madame to observe her classic profile without even laboring to turn her own head.

It needs but another step of Father Darwin to perfect this genus, to place it beyond the action of even his own-made rules. Could he now in some mysterious manner grow but still another mirror-fin, so placed that Madame could readily sit and gaze in rapture upon the beauties of her backhead, she might be that engrossed that the original mirror would be atrophied and ere she were aware form a habit of not even wishing to see her own mirrored countenance. Which I think in some cases might be considered good judg

ment.

Once I dreamed, that I of all, was most accursed by my fellow men. For in a moment of abstraction, I designed a mirror of unique construction. Into its reflective substance I had compounded the essence of meditation, and between its every molecule secreted an atom of comprehension, so that he who used my mirror could see, as lightning flashes in the darkest night a glimpse of the hidden things, his very soul itself, stripped of it's earthly trappings, it's smugly fitting glozing self complacence, could see it standing there naked, even as it is befouled by man-made soot, could see it in all it's warped, shrunken or bloated lines, it's very self, just as it is, and not as Iman would bedeck it with his powder puffs of vanity and self-conceit.

But not entirely cursed. For here and there, cleansed by the Living Force, were some thankful for this mirror. It's proper use cheered their hearts, for it told them the true story of their healthy-developing and growing beauty, the inevitable and indestructible results of that nourishment obtained through a correspondence, even if but feeble, with a perfect environment, their LIVING GOD.

Man's mirrors, from pocket glass to cheval, remain the usual pattern, for the other type is far from being popular. Man still prefers to see the shell rather than the inner self.

And this is in a manner wise. For is this shell not a temple, and should not each of us, his own High Priest seek to keep it in the best of order, making the most we can of it, but employing first for decoration the living things of the spirit rather than the dead ones of earth? Do not the lines of the countenance show the very turnings of the soul? Should we not daily seek to improve these lines, to beautify this shell, by first beautifying the inner man the self?

(Continued on page 22)

The question of how human infection with tuberculosis comes about is passionately discussed in scientific periodicals, at the meetings of scientific societies and on many other occasions. The vehemence of these discussions may be partly explained by the great practical importance of the problem; for upon its solution there largely depends the direction of the hygienic measures that we would take in combating this plague. It is a burning question demanding an answer, for, in spite of the undeniable diminution of tuberculosis mortality in most civilized countries during the last two decades, tuberculosis is still that disease which, next to infant mortality for which one single cause can hardly be responsibile, demands the most victims. Just as we spoke of a smallpox situation a little over a hundred years ago, so to-day with equal right we can and must speak of a tuberculosis situation.

Behind all the heat of controversy regarding tuberculous infection there lies something else concealed, and this is the uncertainty of the answer to the question. We have had similar lively disputes concerning other diseases. I remember how malaria and yellow fever were once attributed to the atmosphere, then to drinking water, and then to the direct contact of man with man,--when at one stroke, the real explanation took a totally different direction. Is it something like this with tuberculosis? Is it possible that here too we have not yet hit upon the resolving formula? I do not consider this by any means impossible, or even improbable. It is more likely that the lively discussions concerning the methods of tuberculous infection have been thus far a quarrel about the Kaiser's beard. It is presumable that no single mode of infection that has been brought forward suffices of itself to explain the whole question of tuberculous infection. Perhaps everyone who looks upon a single mode of infection or a single source as the one and only cause falls into error,

At a matter of fact, the whole question may be such that none of the well-known advocates of one or another method of infection can consider his own opinion as applicable to all cases of tuberculosis without exception. If this is so then at bottom the whole controversy turns only upon the estimation of the relative frequency with which the one or several methods of tuberculous infection come into play. Yet we owe not a little to those men who have treated the infection problem in too one-sided a manner. We can be only thankful to them for their one-sidedness. For it is grounded in human nature that only a sharp visualization of a problem, only a consciously one-sided answer, can elicit an ardent response whether this be in agreement or in contradiction; and it therefore happens that scientific problems of practical importance are viewed and attacked from many different angles. Therefore, every man, who, with grounded evidence has one-sidedly pleaded for one given method of tuberculous infection, has performed a service in advancing our conception of this infection.-Paul H. Roemer, 1914.

well

Less than five years ago Paul Roemer wrote a notably well-balanced monograph on "The Avenues of Infection of Tuberculosis" (Die Ansteckungswege der Tuberkulose) which he opened with the words quoted above. They held good then and they hold good now; yet a reader of tuberculosis literature or an habitué of tuberculosis conferences is now and again led to believe that their range of appreciation has been somewhat limited. The matter of infection is not an unpopular medium for the relief of pent-up opinion in the breasts of the knights and squires and fair Dulcineas of the anti-tuberculosis army. And it is not remarkable to have our meetings punctuated

with lively tilts and real tourneys, in which one set of lances advances with Cornet's dust or Flügge's droplets on an equally formidable and vociferous band equipped cap-a-pie with Calmette's and Behring's cow's-milk dogmata. Victory usually goes to the side that has opened the meeting with the greater number of adherents in the gallery. Opinions change by force of argument about as often as they do at the ordinary political meeting where Republicans foregather to grow excited over the handing out of the good old doctrine of governmental protection of industry or where Democrats lose themselves entranced in the nebulae of Jeffersonian statecraft. And one is sometimes led to believe that just as most men (and women) are born either Republicans or Democrats, SO most tubercle - bacilliscotchers enter upon their higher life with an irresistible inclination to either the lungs or the bowels as the point of departure for all the misery that the tubercle bacillus is about to initiate in the animal body! The lung-adherent will hear nothing of bowels; while to him who cherishes his bowels, the lungs are anathema. Meanwhile, tuberculosis flourishes apace.

Libraries have been written to show how manifest pulmonary tuberculosis is the direct and legitimate offspring of bacilli that have been inhaled through the nose with the inspired air and that have gone straight to the finer terminal issues of the lungs, there to set up disease. This, say the inhalation doctrinaires, initiates consumption of the lungs. The germs must be conveyed into the body in one of two ways,--clinging to Cornet's dust or to Flügge's droplets. In the former case, infection is indirect and brought about by the intervention of something that may be dissociated from its source for a variable length of time. In the latter, infection is a matter of contact of man with man, and is set up by the sneeze or cough or similar effort that conveys bacilli from sick to well. Flügge will grant but slight importance to infection by dust, for dust infections must of necessity originate from dried and pulverized sputum and the drying and pulverization of sputum would necessitate the operation of factors that would kill or so weaken the germs that they would lose their power of developing in fresh soil. The Cornet school, on the other hand, denies that moist, globular, droplets are capable of being inhaled deep down into the lungs and maintains that even though the consumptive coughs out a spray of germ-laden droplets, these cannot directly initiate consumption because the droplets cannot be conveyed to the innermost recesses of the lungs where manifest pulmonary tuberculosis usually begins.

However, both Flügge and Cornet would agree that coarse fresh sputum projected directly upon the ground or upon the floor would be relatively harmless so far as its capacity for immediate mischief is concerned. If you are a dust adherent and if with Cornet you start from the point of view that tuberculous infection must be inhaled then you must disregard the importance of all moist sputum as a medium of infection: for you cannot make the disgusting, smeary and slimy gobs that spot our sidewalks fit your case. This sticky stuff is manifestly fixed and "put," so long as it is heavy and sticky and does not come into contact with your shoe or skirt. In this condition it cannot on the wings of the wind fly up into your face, and thus to nostrils; and if you happen to brush some of it off on your hands as you remove your shoes, again you would not introduce it into your body by inhaling it. Therefore, as a follower of Cornet, you deny the importance of out-of-doors infection, for starting with the idea that you must inhale tuberculosis, you can't produce the real, living infectious material out-of-doors except on relatively exceptional occasions.

If you are all for Flügge, you are again an inhalationist, but you have much less to worry about than if you took your cue from Cornet. To avoid consumption, all you have to do is to keep outside the range of coughs and sneezes. Smeared sidewalks need not upset you, nor should you worry though obscured in a fog of whirling dust. If Flügge is right then so far as tuberculous infection is concerned we have wasted a tremendous lot of time in trying to keep our streets and dwellings passably free from the expectoration of tuberculous man. Even though Cornet is right, we have wasted a good deal of time, for, according to both, fresh sputum,-the real thing, teeming with germs, live and vigorous, just fresh from the tuberculous focus,-that is delivered to the ground is in practice a noninfectious thing because it cannot fit in with the conditions of inhalation infection. And why can it not? Because this infection must be inhaled and coarse sputum cannot be breathed in.

To my mind, there cannot be a more striking example of the absurdities into which a slavish application of what is sometimes loosely called the "scientific method" of investigating phenomena can lead the "scientist." There can be no doubt that both Cornet and Flügge, before starting upon their tours of observation, believed in, or had a strong inclination to, the inhalation theory of infection. And with this bias very strong upon them they had of necessity to bend everything they saw to fit their point of view. This might be all very well, but the trouble is that they had to refuse or neglect to see many other things.

It is rather remarkable that so many of us never stop to think that, living in an atmosphere of continually variable quality and constitution, we take air, and all that this contains, into our bodies in other ways than by way of

the nostrils and thence directly down deep into the lungs. In this everyday life of ours a not inconsiderable part of our time is spent in such more or less necessary actions as eating and talking and laughing; and in performing these acts our mouths open. When we exercise hard or in the expression of numerous emotions automatically we open our mouths. In sleep the lips are parted, to some extent at least, as often as they are tightly closed. Indeed, I do not think it an exaggeration to state that we live with mouth partly open almost as many minutes as it is completely shut.

If then a man, unconsciously or otherwise, is in an atmosphere of bacilli, whether these are floating about on dust or droplets, why, in the very nature of things, should he gather these bacilli to himself only by way of the nostrils? The nostrils and the mouth are in juxtaposition. The bacterial content therefore of the air that comes to the mouth must be considered identical with that which comes in contact with the nose. The area of the opening of the mouth is in most people many times that of the nostrils. More micro-örganisms would therefore undoubtedly attach themselves to and enter the mouth than the nose. And if the mouth were closed the germs would settle on the lips to be taken into the mouth with the next licking of the lips by the tongue. Once inside the mouth, the bacilli would not meet with the physical obstructions-the hairs, tortuous passages, etc.,-that guard the entrance to the throat by way of the nose. The opportunities for getting directly into tissues and settling down and beginning to make a nest for themselves are immeasurably greater than if they entered by the nose.

Even though the bacilli came in by inhalation by way of the nose- -and had passed the nose many would be caught on the moist surfaces of the throat, and some would be there carried into the tissues and be in a position, to start infection-infection not in the lungs remember, but much higher up.

We see, therefore, that even though we were to accept Cornet's and Flügge's media of infection, we need not go all the way and inevitably conclude that bacilli must be inhaled down deep into the lungs because they enter the body in breathable material. Common sense at once tells us that as often as not this breathable material must enter the mouth, and that once having thus gained entrance, if it sets up infection it does so, not by inhalation but by ingestion, for it then really enters the body by way of the alimentary canal.

Just as Flügge's and Cornet's doctrines undoubtedly had their birth in a strong inclination to the inhalation theory, so their ideas of inhalation as being the main or only method of tuberculous infection must have originated in the fact that after childhood at least, most manifest tuberculosis appears first in the lungs. Twenty and thirty years ago, when Flügge and Cornet wrote, this was but the natural development of an idea. But if

we have learned anything about tuberculosis since 1900, it is the transcendently important fact that manifest tuberculous disease does not have to arise in the spot where infection took place. Of itself, the mere location of the first eloquent expression of tuberculosis in the adult human body, need teach us nothing as regards the point of entrance of the germ and its subsequent migration. And we are to-day almost certain that in a vast number of cases the human being falls ill with tuberculosis located at a place that is more or less remote from the real portal of entry of the bacillus. This is not the place to take up the matter of transmission of the tubercle bacillus from remote, quiescent foci to the lungs, and for the present we shall postpone its discussion.

If libraries have been written about tuberculous infection by inhalation, hardly less ink has spent on infection by feeding and ingestion. But with the rarest exceptions the point of view of the advocates of ingestion has always been the same, has always been limited to a comparatively narrow idea of the possibilities. For practically every investigator infection by ingestion, no matter what the medium, has meant only invasion of the body by tubercle bacilli after these have been swallowed. The germs, following this idea, then gained entrance to the tissues by passing through the mucous membrane of the intestines, and from this point set out on their subsequent course, to reach the lungs in time and there set up the first manifest disease. Infection-first infection-from higher up in the digestive tract cuts but a slight figure in the literature and in various discussions of the problem. This is very likely the case because again we have inherited the point of view of two or three decades ago, when aware that manifest disease of the appendages of the upper part of the digestive tract was comparatively infrequent in the human adult, when impressed by the enormous preponderance of pulmonary disease, and when unwittingly thinking of infection and manifest disease as more or less coincident or simultaneous occurrences, we paid but scant attention to what might be going on near a major portal of entry like the mouth and centered all our studies and observations on the place of visible development of tuberculosis.

And this was before we realized, as we do to-day, the almost complete universality of tuberculous infection. It was before we sensed so clearly the likelihood that adult disease was a later development of childhood infection. It was at a time when we had no idea that so many children harbor tubercle bacilli and, therefore, have tuberculous changes in their tissues, whether or not these force themselves into the realm of consciousness. It was when we did not consider a child tuberculous unless it had visible, enlarged and inflamed lymphatic nodes in the neck, or developed a limp or a crooked back, or fell ill with peritonitis or lung trouble. But in the last ten years we have learned that compared to the poor little

unfortunates who suffer in these ways, the number of perfectly well and healthy children, who react to infection tests and who are there-fore infected with tubercle bacilli, is legion. Many studies have been made on children who during life have never shown a symptom of tuberculosis but who have died of diphtheria, or acute pneumonia, or of many other nontuberculous diseases that are incident to childhood. Though such pathological investigations have usually been anything but complete, though in most cases they have been concentrated on the lungs and intestines and their tributary lymph nodes, and have failed to examine carefully the tissues that are more closely associated with portals of entry; nevertheless the net amount of visible tubercle that has been discovered in children who were never ill from tuberculosis is little short of amazing.

Depending on their individual point of view and also upon the thoroughness of their work, various performers of autopsies on children have interpreted their findings very differently, and so far as portals of entry are concerned have not always been in agreement. Ghon has written a book on "The Primary Lung Focus of Tuberculosis in Children." In the study of many cadavers he writes that if there was a visible focus of tubercle in the lung there was always visible tubercle in the tracheo-bronchial lympathic nodes that drain the lung, that these nodes never showed tubercle unless there was also tubercle in the lung, and that therefore any tubercle that was in the nodes must have originated from bacilli that came to them from the lung where they had already previously set up structural change. Ghon, it must be remembered, is writing about the first focus in the lung which by no means need be the first focus in the body, which as regards the methods of dissemination of bacilli and their entrance into our bodies is all that concerns us. And Ghon goes considerably beyond his title and the facts at his command when he takes another step and would make his first pulmonary foci the first body foci. If this were the proper place, one might bring up in detail many criticisms of his methods of approach and of reasoning. We might quarrel with his criteria in determining the relative ages of foci, which is really the all-important matter in his study and upon which the validity of his conclusions depends. We might also object to the reasoning that always for him makes tonsillar disease or infection an event that is secondary to what first occurred in the lungs. We might also push fairly hard the few exceptional observations that he cites near the end of his book that would belie his general argument.

Harbitz with a large material at hand in Christiania worked a little differently. He very carefully investigated the organs and tissues of children who had died of non-tuberculous diseases. He found much concealed tuberculosis of the lungs and tracheo-bron

chial nodes that had been unsuspected during life. But when he examined the structures that lie higher up than the lungs and that intervene between the lungs and the mouth and nose, he found more and more evidences of tuberculous infection the higher he went. And he also found that the younger the child the more likely it was to have tuberculous infection limited to the structures of the neck and to the exclusion of tubercle in the lungs. It was more usual for the older children to show tubercle in several places-in the neck as well as in the lungs. In other words, Harbitz's studies made it appear that in the younger children, in those at an age that would, theoretically at least, have them come to autopsy a relatively short time after infection, the infection was more likely to be found high up, near a portal of entry, than in the lungs or in both.

We may study in other ways what happens in the immediate neighborhood of the mouth and throat. We can investigate tissues removed from the living human being and come to some conclusion as regards the relative frequency of infection and the site of this infection. In this connection the work of Crowe, of the Johns Hopkins Hospital that was published less than two years ago, is of more than passing signifirande. During a period of five years as head of the laryngological department of this hospital, Crowe and his assistants removed the tonsils from approximately 1,000 people, most of whom were children. Before operation none of these patients had ever shown noticeable signs or symptoms of tuberculous disease. Crowe examined these tonsils for evidences of tuberculosis, and found that, even though his methods of detection were comparatively crude and insufficient, no less than five per cent. of these clinically nontuberculous people had specific tubercle in their tonsils.

Now this five per cent. represented an absolute minimum of concealed tonsillar infection. Crowe did not look for tubercle by examining serial sections that would include every bit of all these tonsils; and, there can be no doubt that, if such a procedure had been feasible, he would have found a good deal more than five per cent. of infection.

Manifest tonsillar tuberculosis, tuberculosis of a tonsil that causes symptoms, is an excessively rare occurrence in medicine. Primary manifest tuberculosis is still rarer. Yet here we have undoubted evidence that at least five per cent., and probably many more, of all people who come to a city hospital dispensary harbor tuberculous infection in their tonsils. Tonsillar infection therefore must be quite common. But until we remove tonsils and subject these to microscopic examination, it is practically impossible to detect mere tonsillar infection. The significant thing is that here we have infection without manifest diseaseinfection too that very rarely goes on to manifest disease in the tonsil-infection too that in all of Crowe's cases had up to the time

of operation not yet taken the journey that we call clinical tuberculosis.

It is again absolutely certain that all these tonsils of Crowe's cases represented primary infections, that they were set up by bacilli that entered the body by the mouth or nose, and that here we are dealing with neither an inhalation or an ingestion infection in the accepted sense of the terms. Infection here did not take place after the swallowing or the deep breathing of bacilli.

Now Crowe's work brought forward nothing new. It did not originate a single idea, other men had found living tubercle bacilli and anatomic tubercle in tonsils before Crowe. But it gave tremendous point and support to what men like Aufrecht and Weleminsky and Weichselbaum had been maintaining for years. As far back as 1900 Aufrecht looked upon the tonsil as being the chief portal of entry of the tubercle bacillus, even so far as pulmonary tuberculosis is concerned, though there can be no doubt that his idea of how the bacillus travels from tonsil to lung is far from correct. Weleminsky's views were much weakened by his thoroughly erroneous conception of the anatomy of the lymphatic system, which he made responsible for the transit of the germ from remote places to the tracheo-bronchial nodes, a direct journey that the well-authenticated work of Beitzke, of Most, of Hashiba, and others, has shown to be absolutely impossible.

In 1907 Weichselbaum went over all the facts for and against inhalation and ingestion infection, and was then willing to put himself on record as follows:

"Deglutition (ingestion) tuberculosis, occurring in man and especially in children, is a much more frequent occurrence than most investigators until recently would have believed. But in this method of infection, the entrance of tubercle bacilli does not necessarily have to take place merely from the stomach and intestines. It occurs also from the mouth, the nose and the throat, and indifferently from all these places. It is immaterial whether the bacilli enter the mouth, the nose and the throat with the food or other ingesta, or with the atmospheric air, or in any other way. Manifest tuberculous processes need not arise at once in the mucous membranes or in the regionary lymph nodes. The action of the bacilli can express itself in the production of so-called lymphoid tuberculosis that can last for a long time, and which can finally altogether disappear or lead to renewed infection. Yet this renewed infection need not lead to manifest changes whether it takes place at the portal of entry, or in the lungs or bronchial lymph nodes, or in other organs."

Were we not familiar with the human being's passion to embrace with ecstasy dogma that is based on columns of meticulously noted observations, whether "scientific" or otherwise, it would be almost inexplicable to us why practically every general work on tuberculosis or on tuberculous infection lum