cells through which their own peculiar functions are performed, cells which differentiate any given tissue from any other tissues, cells which are comparatively highly organized; and second, cells which form the framework and bind together, as it were, the first type of essential, functionating cells. A discussion of the first type is not to our present purpose. It is more particularly of the second type that we wish to speak in connection with inflammation.

For

This second type of cells, supporting and connecting organic cells of the most varied nature, is repeated and duplicated in the most diverse structures throughout the body. To it belong what we call all cells of the connective tissue type, of which there are at least three kinds. So far as we know connective tissue cells are not transported from point to point in the body like cells that are included in the blood and lymph, nor do they migrate from point to point outside the vessels like certain other cells. They are also incapable of independent or automatic movement. these reasons they are in general called fixed tissue cells in contradistinction to those cells that are carried around or provide their own means of locomotion, which are therefore called wandering cells. These fixed tissue cells occur everywhere; in skin, in mucous membrane, in subcutaneous and submucous tissue, in bone, brain, liver and lungs, in the inner lining membrane of blood vessels and all channels and ducts of the body. And everywhere they "act" the same. They are the basic framework on which the bricks, the tiles, the mosaics, are strung.

As the exudation of an inflammatory process goes on, there soon comes a time when unwonted changes in these fixed tissue cells of the part concerned begin to occur. These cells begin to divide and multiply, and, from preexisting cells, "daughter-cells" are given off. In other words, under the influence of the stimulus, the irritation at hand, they take on unusual powers of reproduction, of proliferation, as we term the particular process. The new cells, at first round and globular, soon change in shape. They become spindle-shaped-lengthened and flattened; and soon throw out fine fibrils-thin thread-like processes. They accumulate more and more and become packed in more and more closely. Meanwhile the fibrils interlace and the cells keep shrinking; and at the same time the products that have resulted from the exudation of serum, leucocytes and red blood cells disappear. And after a while we find that redness has disappeared, swelling is gone, pain is a thing of the past, and the gap made by the cut is filled in with a firm "concrete," as it were, of connective tissue that unlike normal tissue is bloodless, and is represented by a depressed, white line, the scar.

We have been at some length and no little pains to lay before the reader in the rough the elementary features of inflammation, a common tissue reaction to irritation, because

But

we feel that without some comprehension of its mechanism an adequate understanding_of what is to follow would be impossible. even more than this, we are desirous of emphasizing once more that no matter what may or may not be the immediate or ultimate outcome of such a reaction, so far as the function or life of the affected individual is concerned, this particular type of reaction to irritation is in essence conservative and protective. Inflammations may be so intense and so extensive as thoroughly to destroy tissue and to snuff out life. But when this happens it is because, under the circumstances, the reaction, potentially inherent in the tissues, was more than the tissues or the individual could endure. Under the circumstances, too, the irritant was intense. The tissues "ran true to form." If in this connection we may speak of a "purpose," this purpose was to ward off the irritant and to limit its effect. And this fact will always remain even though the ultimate result is calamitous. And, in such an event, we deal once more with the common experience of an acme of resistance resulting in the exhaustion and annihilation of the defender. In civil life we do not a priori look upon the fact of defeat as creating a compelling presumption that no resistance was offered to the foe. In "scientific" medicine we have been all too prone to take this point of view.

What now happens when the tissues are called upon to react to other forms of irritation?

It is not an uncommon circumstance for foreign substances to gain access to the body. This event may occur when materials of various kinds are carried into the tissues while these are being wounded, as happens when bits of dirt are ground into a lacerated wound or particles of clothing follow the track of a bullet-wound. There are also a large number of substances that may gain the interior of the body and be deposited among its cells without the intervention of a gross wound. The best examples of these substances are particles of dust or smoke-pigment which make up so large a part of the atmospheric air and which are breathed in and come to rest in the tissues of the lung and the tributary lymph nodes; and invisible living particles, such as bacteria, which may be inhaled by the nose or ingested by the mouth and from these two organs proceed to deeper-seated tissues.

If a foreign substance is of such a nature that it is easily soluble in the fluids of the body it is soon taken up and absorbed by these, and no local reaction results beyond a slight and transitory inflammation that would be the result of the puncture-wound if the material were injected. Such a series of events would follow the injection under the skin of small amounts of a common salt, or sugar, solution.

But if the foreign particles are such that the fluids of the body cannot readily dissolve them, the tissues treat them in an entirely different

manner. Such particles are so dissimilar to the normal elementary constituents of tissues that they cannot as such be incorporated within the latter. They are also so resistant to the solvent and digesting powers of body fluids that they cannot readily be absorbed or broken down into simpler products. The tendency, therefore, is for them to retain for a time at least their native constitution; and once having got into the tissues they act as irritants exerting a stimulating action of a comparatively mild degree over a considerable period of time.

For fifty years the reaction of tissues to irritants of this kind-to non-living foreign particles, such as hairs, strands of cotton, silk or wool, grains of sand, or of pigments such as India ink has been very carefully studied, and from these investigations much has been learned that helps to elucidate the nature and mechanism of tissue reactions to more highly organized foreign particles, such as tubercle bacilli. Before describing the latter, therefore, we may profitably consider the more common details of the response to inert foreign matter.

As an example of this type of reaction we may cite the observations made by Kostenitch and Wolkow of the Pasteur Institute (1892). These workers injected a suspension of particles of India ink into the anterior chamber of rabbits' eyes. Soon after the particles were deposited in the tissue, leucocytes of a certain kind (polymorphonuclear leucocytes) began to accumulate around the individual particles to the extent that these latter became englobed or encapsulated, as it were, in a sphere of leucocytes. But this type of leucocytic reaction did not last long. It soon reached its height, when the leucocytes began to become fewer and fewer until they almost entirely disappeared. Meanwhile the fixed tissue cellsthose of the connective tissue type-began to show signs of being stimulated. They underwent division and multiplication, and thus proliferating they heaped up until they formed a globular wall around the particles and thus localized the latter and shut them off from the surrounding tissue. After a while leucocytic reaction of a second type (lymphocytes) became noticeable; and these lymphocytes formed a sphere around the globule of fixed tissue cells while a few of them found their way into the new-formed mass of living cells. As a result of the irritation of the pigment granules and the tissue reaction to the irritation, there thus came into being a tiny nodule of tissue that enclosed within its center the foreign particles that were irritating to healthy tissue. Moreover, it prevented these particles from being conveyed further into the interior of the body and rendered them perfectly innocuous to the generality of tissues. Such little nodules are the common result of the introduction of minute foreign bodies into tissues.

When Kostenitch and Wolkow varied the experiment and, instead of injecting an India ink suspension into rabbits' eyes, inoculated an emulsion of living tubercle bacilli, a reac

tion occurred that in every essential was up to a certain point identical with what they had observed in response to the pigment. So far as the formation of the tubercle was concerned, whatever differences appeared between the reactions to the two substances were differences of degree and intensity in one or another of the various phases of the reaction. In both instances the structures that arose were fundamentally the same-little nodules, or tubercles, as they are called. And the tissue reaction to an inert irritant like a granule of pigment is so similar to that which occurs in response to a living irritant like the tubercle bacillus that the product of the former has always been designated as a foreign body tubercle, taking the name tubercle from the product of the tissues that react to real tubercle bacilli, which it so closely resembles.

There can hardly be any doubt as to what this type of reaction means. Stimulated in the one case by an insoluble irritant, the foreign body, India ink, the tissues proliferate and cells exude; and the end result is a formation -a tubercle that encapsulates the irritating particle and prevents further irritation and possible damage of other tissues. And up to the same point the case with the reaction to the tubercle bacillus is identical. The tissues treat it as a similar irritating foreign body. The tubercle bacillus is made up of a relatively large proportion of fats and waxes, or perhaps, more exactly, of higher alcohols and lipoid substances. These are materials that are soluble only with great difficulty in the body; and being thus less open to attack they act as foreign particles just as do the granules of pigment and the tissues treat them as such. The tissues invest them with a wall of newformed living tissue and seek to close them in and restrict their fields of action.

In each instance the reaction, a response to irritation, is in the fullest sense of the term a protective reaction. It is as purely resistance, at least an effort at resistance, as anything we comprehend under the term. When the reaction occurs in response to inert and non-living foreign particles like the India ink that we have just been considering, the effort at resistance usually suffices and is completely competent. The particles are usually permanently hemmed in once tubercle is established; or, if transported further, reach other parts in smaller and smaller amounts with the consequent exercise of less and less irritation. But when the reaction is to tubercle bacilli the effort at resistance does not always eventuate so satisfactorily. A reaction to tubercle bacili is one to living foreign particles which are endowed with the capacity of multiplying and maintaining themselves in animal tissues, and which, so long as they remain alive, may under certain conditions be conveyed to remote parts of the body there again to increase and exert their effect. Again, because they are alive, tubercle bacilli, in a way that is still obscure to us, bring about a necrotizing or killing effect on tissue, particularly of the tissue of the tubercle itself.

They may thus establish conditions that favor both their rapid multiplication and their dissemination from tubercles where they were once encysted and held at bay.

Nevertheless, even so far as living tubercle bacilli are concerned, this protective reaction, this effort of resistance to first infection, is often completely adequate. There is no doubt that an initial infection with small numbers of bacilli not infrequently results in tubercle that perfectly hems in the bacilli which then gradually die out in the interior of the nodule. And even when initial dosage is larger the character of the process is such that it tends to delay florid multiplication and widespread dissemination of the bacilli, and thus gives the tissues and the body a chance to summon its other defensive forces and be ready to meet renewed and augmented onslaughts of the foe.

We would, therefore, strongly press the point that every animal has a certain native resistance to first infection by tubercle bacilli. This resistance varies but no animal species is without it; and some, like man, possess it to

a high degree. This resistance is at bottom dependent upon a reaction to irritation, a true protective reaction, which expresses itself in and through the formation of tubercle in response to irritation brought to bear on tissues by a living foreign particle of high chemical stability, the tubercle bacillus. This is the lesson that a hurried consideration of the matter of tissue reactions to irritation teaches us. Yet this is by no means all that there is to resistance to tuberculous infection. It is only a small part of it and it remains for us to examine whether, in response to the localization of tubercle bacilli, the tissues react differently than in the manner we have just described; and, if so, under what conditions other types of reaction occur and what their significance as concerns resistance may be.

(Some Phases of Resistance to be continued in the September number under the title, "The Reaction of the Tissues of the Tuberculous Animal to Reinfection and to the Products of the Tubercle Bacillus.")

a fighting cock and you find that your batteries are fully charged all day. Now, isn't it worth the effort? It surely is.

Of course, we all know now that complete rest in the open air, together with good nourishing food and the elimination of all sorts of worry, are the fundamentals in the cure of to-day and hardly need many further emphasis, but there is one thing that we don't know and that should be drummed into our heads every day until it will be impossible for us to forget it, and that is F-A-I-T-H. I have heard the expression so many times recently, "It's no use; once a lunger, always one,' You would be surprised to know how many slightly involved fellows have passed to the great beyond in the past twelve years, men whom I have known personally and whose

lives I have studied from the start of their trouble; and in practically every case the sole difficulty was a lack of faith. They said in their hearts, "It can't be did." Whoever says he "can't" CAN'T, and that is all there is to it. You must believe in yourself and the treatment you are taking, and the balance is easy. Did you ever stop to think about it? This is the main reason that nobody got well through the centuries up to thirty-five or forty years ago. On the other hand, I have known personally so very many more of the other class who were full of faith, got well and stayed well. Among the latter I have known many who were very much more involved and who had reason to despair, and yet came out with flying colors, all simply because they would not be whipped.

TO THE EDITOR:

1. Kindly explain the institutional difference between sanatoria, sanatorium, sanitarium?

2. December last Dr. Tweddle, of New York, read before members of the Yale Club (New York) a pamphiet on the treatment of tuberculosis by means of sulphur dioxide.

This article was published in the Medical Journal of December 22d. Can you furnish the name of the publisher or some one from whom I can obtain a copy of this journal? C. A. S.

1. "Sanitarium" designates a healthy place to live in, not necessarily for persons definitely ill, but more as a prophylactic measure for those whose health is not vigorous.

"Sanatorium" designates a similar place, but more especially as a resort for invalids and for treatment of disease.

"Sanatoria" is the plural of "Sanatorium."

2. We have not reviewed the article mentioned, and from your reference do not recognize where it appeared.

TO THE EDITOR:

Please let me have your opinion and if possible any statistical information concerning the Bonine Serum Treatment, now being administered at the German Dispensary at 42d St. and 9th Ave. I have various professional opinions concerning this treatment and would thank you for anything definite relative to same. R. B. N. We do not have any direct information concerning the Bonine Treatment, and would advise that you write directly to the hospital you mention for the information. At any rate, the treatment is not in use by the leading specialists throughout the country.

TO THE EDITOR:

Have you examined a copy of the lessons on correct eating put out by the "Corrective Eating Society"? If so, what is your opinion and do you think them good to follow where one has had a tubercular infection of the stomach, but who can eat anything now? H. D. H.

Your inquiry addressed to the Question Box has been referred to me as editor of that department of the JOURNAL.

We have not investigated the Corrective Eating Society and cannot give any detailed information or opinion about their activities. However, on general principles, we can advise you, if you have any digestive disturbances, to consult a reputable physician who has made a specialty of diagnosing and treating such conditions, and if your trouble is definitely tuberculosis of the gastro-intestinal tract to endeavor to secure the services of a physician who is experienced in the treatment of tuberculosis as a whole as well.

Any further information in our possession will be gladly given if desired.

TO THE EDITOR:

1. What are the arguments in favor of a high caloric diet of food over that of a wellbalanced ration in the treatment of tuberculosis?

2. Is water in which pine tar has been placed of any benefit in the treatment of tuberculosis?

3. Do you consider that a high altitude has any advantages over a low altitude for persons whose hearts can stand a higher altitude and whose general condition is good?

4. Would the occasional expectoration of pink sputum be an impediment in going to a higher altitude?

5. Is a warm dry climate (altitude high or low) preferable to a high altitude in temperate atmosphere? E. G. R.

1. In order to be of value, food must be not only well balanced as regards protein, carbohydrates, fats, mineral salts, etc., but must also possess principles which are known as vitamines. A diet of high caloric value but not well balanced will produce digestive and nutritional disturbances.

2. No.

3. As a general rule, no. However, there is a certain percentage of tuberculous patients who must go to higher altitudes for treatment. 4. No.

5. This depends very largely upon the individual, his age and disposition, and the extent and character of his disease.

TO THE EDITOR:

I am a regular physican and surgeon, 58 years old and am under treatment of firstclass specialist. I am being cured. In fact, I am now at work practising medicine. I am concerned about my family of wife and three daughters. (Two daughters have husbands and total of five children.) My wife and one daughter (of age 24) live in house with me. I try to be careful. Sputum cups are burnt regularly and frame wiped with green soap, and kept in sleeping-house. Use only paper napkins and burn. Change suits twice a week and have one suit ALWAYS hanging to "AIR or SUN." Linen in "my" bag and "my" bag and linen both are boiled in being laundered. Hang night clothes in sun or air in sleepinghouse daily. Do ALL this myself. hands and face often and always before eating. Towels are "mine" and I hang them in air or sun. Knife, pencil, eating utensils as dishes and knife and fork are boiled afterward. No kissing of members of family since diagnosis. I do write letters and notes to family and others. I have read in J. O. L. that such habits as I have outlined are not likely to infect other people with the disease. My family is precious to me and I want to protect them and I also wish to convince them of their safety-if my attitude in above statements is correct.

Wash

E. V. H.

We agree with you that the practice of living as you have outlined will almost surely prevent infection by you of any in your family, and we see no occasion for worry on that score from now on. It is possible, however, that infection might have occurred before the diagnosis was made, and, as you probably know, a very large proportion of the general population is infected with the tubercle bacillus before the age of 18, though this does not mean that "clinical tuberculosis" necessarily follows.

TO THE EDITOR:

Where lung tissue is diseased would rubbing cocoa butter, or similar food, into the chest be beneficial, or would it feed the disease? L. A.

Some people have tried rubbing in various fats in order to improve nutrition or to gain in weight, though with no demonstrable effect upon the lungs. If the patient himself does the rubbing, the exertion entailed may prove harmful.