Discovered! "Ahem! Ahem!" coughed the patient Green, "Got the worst cold you ever seen, Caught it last June, and ain't it funnyCan't get rid of it for love or money." "Sure," said the Irishman, thru mirth-made tears, "I've had a cold like that for the past tin years." NOT: "Ask Mr. Foster!" Ask any T. B., anywhere, anytime, about anything, and should you misplace your encyclopedia-!! The nurse was new, good-looking and very, very flirtatious. The patient—well, he was known as the Romeo of the San. The nurse knew of the patient's "rep", and the patient knew of the nurse's; in fact the patient had begged the nurse innumerable times for-yes, we might as well tell it a kiss; and, we might add, she had promised him one for that very morning. (Shocking, isn't it?) Quite naturally Romeo was on the qui vive when nursey smilingly entered his room. "Now, little boy," chirped the beauty, "close your eyes and prepare to receive something you have asked for many, many times." Romeo knowingly grinned, closed his eyes and expectantly pursed his lips. The next second those warm, "O Lord, deliver us from the profes- pulsing lips felt the contact of a-cold sional sympathizer." The oft-repeated bromide the T. B. is forced to endure: "You're looking so well; one wouldn't think there was a thing the matter with you," reminds us of the two New Mexico doughboys when they woke up one morning and saw the ocean for the first time. "Gee!" said one, "I haven't seen so much water in all my life." To which his buddy replied: "Yeah! and just think, we're only seeing what's on top!" Are you trying Harder to do More than you ever Dreamed you Could do? What in the world do you imagine that French nurse meant when she complained of the T. B. that he had "shot his eye at her"? Surely it couldn't be that the rascal had winked at the "Weewee." glass tube, and the very next second he heard a suppressed feminine giggle as a door softly closed. Moral: She served him right, that's a nurse's business. And besides she may have a Romeo of her own, and in the event of fistic reprisals what chance has a T. B.? He can't fight, he can't run and some of 'em can't even talk. So many claims, so many creeds, So many hopes that lure and lure, When just the art of getting cured Is all the T. B. needs. Lungerdom's Ace of Aces: Gunemeyer, the French T. B.-aviator. He Fought the Fight and Died the Death of a Hero of Heroes. A great many folks have found it true that fighting T. B. is much like taking a post-graduate course in the University of Life. PROPHYLAXIS IN TUBERCULOSIS By EDWARD HORACE CLEVELAND, A.M., M.D., Dr. Wm. A. White's suggestive remark on the subject of inheritance in psychosis may well be applied to the familiar liability of weak physical constitutions to yield to the onset of tuberculous disease. Dr. White says, "Every individual born into the world has, if it could be determined, a definite potentiality of development. The force of the impetus which starts it on its path is sufficient to carry it a certain definite distance. The predetermined goal in each case will be reached if no accident intervenes to prevent. In many subjects of this disease the original impetus has been weak, only sufficient to carry them a short way, and when its force is spent development stops, and the retrograde process is hastened or perhaps immediately initiated by some special physical or mental stress occurring at the critical point of puberty and adolescent evolution." A distinguished professor in one of our medical colleges stated, in a lecture on preventive medicine, that whenever in general practice he furnished his patients with carefully considered rules for health, adapted to each individual, advising them what to do and what to avoid in order to maintain health, writing it all out for the sake of greater certainty, his patients would respond to his kindness somewhat as follows: "Well, doctor, we appreciate your thoughtfulness, and have no doubt it is intended for our good, but really to go right on doing as we always have done, that is not our idea at all. In fact, we expect eating and drinking whatever we like and taking all sorts of risks the same as before. Then, when we happen to be ill, we will send for you and expect you to come and look after us till we are well again." Notwithstanding this widely prevalent attitude of mind, it may be of use to offer certain practical suggestions, in the line of prophylaxis, for the benefit of those who have highly resolved that for themselves and their children they prefer health to illness, ability to disability, the home to the sanatorium, and freedom from tuberculous disease to the possibility of finding themselves some day in the relentless grasp of a cruel and implacable foe. It should be clearly understood that in many, if not in most cases, the development of tuberculosis is personally invited by lack of care and by poor management in the ordering of one's life. Given a physical inheritance that is subnormal, or at best below the average, and the practically universal opportunity for infection in the period of childhood, the wonder is that so many of us escape the manifestation of tuberculosis in adolescent or maturer years. Conditions, in brief what we call environment, in connection with inherited weakness, will always be the key to this problem. If it were possible to get hold of the children who are not constitutionally robust, and give them the benefit of the out-door life for a sustained period of months or years, something definite might be done toward lowering the mortality due to tuberculosis. It is among the younger patients that so-called arrested cases most frequently occur. With continuous care and good management in the ordering of life, such cases may avoid active recurrence of the disease, while older persons must commonly be content with signs of restored health and general improvement, which may prove permanent under favorable conditions. Prophylaxis in tuberculosis should begin as early as possible, and have due regard to the following important particulars: Fresh Air: Never be without it, day or night, if you can help it. Oxygen without food is better for you than food without oxygen. Fasten your windows open, at the top, if only a couple of inches, so that nobody can shut them. Some folks have a mania for closing windows, shutting blinds, pulling down shades, and drawing curtains. Keep the air in your rooms moving. Dead air is devitalizing. Let in God's sunshine. Live in the sunshine. Air that has already been breathed, only once even, is deadly poison. Think of the helpless babes and children who are trying to sustain life and grow strong on stale air! It cannot be done. Humans who are out-of-doors as many hours out of the twenty-four as possible, have the highest resistance to contagion or infection. Houses are for shelter when needed, not for life-long imprisonment. Mothers who stay indoors all week cannot hope to have vigorous offspring. The blood is the life, and fresh air, air in motion, clean air, is essential to the purifying of the blood. Get up and go outdoors. Diet: Eat a good sensible breakfast every day, whether you happen to feel like it or not. For aught you know, it may be the last meal you will ever eat. Physical and mental exertion without adequate material foundation, if habitual, paves the way for physical deterioration. There is no exception to this rule. Drink plenty of cool water, not iced, at meals and also between meals. Water in abundance makes elimination of waste material, which will otherwise poison the system, natural and easy. Use very little coffee or tea or cocoa, and absolutely no beer, ale, stout, wine, whisky or other liquors. These interfere, positively and seriously, with elimination and with nutrition, and tend to wear out the kidneys and liver and other organs, leaving poison in the system from top to toe, as gout and apoplexy abundantly prove. See to it that whatever goes down your throat is constructive, and not destructive, for we dig our graves with our teeth, and some of us by crooking our elbow. What we call consumption is in reality starvation. Habits: Be sure you get proper bowel action daily. Use mild cathartics only, and only when necessary, preferring these to enemas, which are to be reserved for special occasions. Take a full bath, warm at night, or cool in the morning, with a good rub-down, avoiding extremes of temperature. Contrive to walk three or four miles daily, or have equivalent bodily exercise in the open air. Let there be as little home-work as possible for children who have to sit in crowded school-rooms five hours a day. The shortening of schoolhours, and a let-up in school requirements, will help to decrease tuberculosis. Every boy and girl should have an intelligent method of bodily muscle-training, devised to suit individual physique and convenience, and should stick to such a system for ten or fifteen years at a stretch, if they hope to be active and vigorous in later life. Make it a religious duty to retire for rest at a reasonable hour. No midnight oil, and no dancing till the wee sma' hours, for our boys and girls. Regularity and strictness in this regard will pay big dividends in nerveforce and mental capacity by and by, for late hours and irregular rest, and lack of regularity in eating one's customary three substantial meals per day, simply prepare the way for tuberculosis by reducing vitality. A majority of patients in our sanatoriums will testify to the truth of this statement. Occupation: Have some good work to do every day, and do it. Thousands of people who die of tuberculosis die of mental and physical indolence. They have never been active enough in mind or body to keep themselves in good condition. We must really be alive in order to go on living, and it is a pity so many fail to learn this until their days are practically numbered. If you have a weak constitution, try to develop it without over-taxing it. If you have a robust physique, do not imagine you can stand all sorts of exposure and fatigue and abuse of your strength, for the limit is apt to be reached long before you expect it, and then it will be too late. You or your children will surely pay for it. Sociability: Cultivate cheerful ideas and associate as much as possible with hopeful and pleasant people. Nobody ought to be obliged to ruin his health and spirits trying to get. along with crabbed and disagreeable companions. Such specimens should be grouped and labeled, for the warning of passers-by, and be made to enjoy each other's society as best they can. Morality: Recognize the just claims of the Almighty upon your time and strength and means. Don't be ashamed to pray every day for judgment and guidance, and don't be too timid to invest something worth while in the kind of bonds that mature in the endless future, and pay excellent interest as you go along. Don't fancy you can ignore and do violence to the Ten Commandments and go scot free. Too many have tried this. And they all have found out in the long run that these are the great original laws of health, without due observance of which there is no such thing as a sound mind in a sound body. And be sure that if you offer your Creator anything short of the best mind and body for His purposes that you can muster, you will be withholding from Him a part of what is due and will be cheating yourself into the bargain. Say to yourself every morning, "How can I best regulate myself and my efforts this day, so as to be as ready as possible to ward off every kind of infection in general, and that of tuberculosis in particular?" Intelligence and persistency and obedience to conscience will succeed. It may be helpful to add that the same constant observance of health-principles that is necessary for the prevention of disease, will prove of utmost value in checking or controlling disease, especially lung disease, after it has become established. Although pathological conditions may be so firmly fixed as not to be permanently removable, they can at least in all ordinary cases receive temporary relief through the common-sense mode of living already outlined, and in tuberculosis we cannot look for satisfactory relief by any other method. Change of climate has been found to be of very little help in such cases. Experts now agree that pulmonary patients thrive better, as a rule, in their native surroundings than they are likely to do elsewhere. People born without the bump of caution carry this handicap with them everywhere they go. Indeed, this lack of practical judgment, a certain inability to learn discretion from the hard lessons of experience, seems to be generally characteristic of this class of patients. The psychological effects of home-sickness is such an important factor in their problem, in many cases, that greater progress and improvement may be expected, the nearer the patients are to their home and friends and to the geographical location with which they have been long familiar. When one contemplates the startling fact that one-tenth of all the people of any given region are ill at all times, and of this onetenth twenty-five per cent. are known to be consumptive, the importance of serious and sustained and systematic effort toward prevention is apparent. Probably one-half of all the sickness in the world is preventable. Some authorities say three- fourths of it is preventable. It has been carefully estimated that fifteen years of active usefulness could be added to the average duration of life by an intelligent application of the science of preventing disease. More than half of this additional life would come from the prevention of tuberculosis, typhoid fever, and five other diseases, the prevention of which woud be accomplished by three things chiefly, pure air, pure water, and pure foods, coupled with hygienic habits of living. Fifteen more years of active life for every citizen would mean an enormous increase in the strength and happiness of the (Concluded on Page 342) ESSAYS ON TUBERCULOSIS XX. Some Phases of Resistance. Part IV: Immunity: Its General Types By ALLEN K. KRAUSE, M.D. Even though there were no special branch of knowledge devoted to the study of disease there are certain facts of resistance to infections which are so plain and prominent that the most casual observer would soon have to invent terms to characterize them. Every child learns that if it has once had measles it can ever afterwards come in contact with measles with impunity. For it measles is no longer "catching." It learns the same lesson from chicken pox and whooping cough and scarlet fever; and thus becomes familiar with one of the great laws that govern the spread of many infectious diseases, namely, that they do not strike down individuals who have once had them. The causes of this peculiar and striking exemption from the normal consequences of contact with such diseases are thoroughly mysterious. With more or less reason, yet perhaps more in ignorance than with any knowledge, much has been made of certain habits and constitutional factors as being determining influences in the acquirement of infections, provided contact has been established. We hear continually that bodily weakness, undernourishment, loss of nervous stability, and vicious or abnormal habits of living, sleeping and eating, lay us more open to infections; or, as is commonly told us, these lower our resistance. I have no doubt that they do tend to weaken our defense against the germs of disease once infection has taken place and its results have become apparent. But, as concerns a number of acute infections at least, there is ample evidence that these take place irrespective of the general condition of the body at the time of infection. So far as "taking" measles is concerned, it matters little at the time of exposure whether the child is plump or scrawny, full blooded or anaemic, strong or flabby, stolid or fidgety, or whether it is manifestly in or out of health. Given the proper first contact, the children who will not take measles are so few that we can say that every child will contract the disease. But of children who have once had measles, the child who, under any circumstances, will again contract it is so exceptional, that we may say that none will fall ill with it. Then, the child in the poorest physical condition has apparently just as good a defense against infection as one in the very best of health. Moreover, this resistance to infection is specific, that is, it is a resistance of one who has had measles to measles only, of one who has had whooping cough to whooping cough only, of one who has had chicken pox to chicken pox only. Plain facts, such as these-facts which are common knowledge-compel the conclusion that there is an aspect of resistance which is entirely independent of transitory bodily habit or constitution of the individual. An infection comes upon a susceptible individual and goes. It goes completely; but leaves a very different individual so far as the particular infection is concerned. Toward it the individual has now acquired an entirely new quality of resistance and has become completely refractory. What this latter quality consists of we do not know, nevertheless the phenomenon is very real. From this phenomenon there originated our ideas of specific immunity. The term, immunity, so far as it is applied to infections, was first used to designate this acquired resistance to infections. Its scope was then widened to include a resistance that might exist among all the members of a race or an animal species to a given infection. Latterly it has in some hands taken on a broader and broader meaning, until we sometimes find it being used almost synonymously with resistance. There is little doubt that this tendency will breed confusion rather than clarity of ideas. Resistance should be the broader and more inclusive term. Under it we should comprehend all defensive mechanisms of whatever character these may be-whether physical, chemical, thermal, specific or non-specific-which the body employs to combat micro-örganisms and their products. It would include immunity, which we should use only when we deal with bodily effects which are specific in the sense that they are elicited by particular micro-örganisms and only in response to these or related micro örganisms. The tubercle, for instance, is a defensive structure, a mechanism of resistance, but in the present state of our knowledge we must look upon it as a non-specific weapon of defense, which acts in a mechanical way by creating a barrier, walling in the bacilli and thus limiting the activities of the latter. As an anatomic structure it is nonspecific because in essence it is merely the tissue reaction to a foreign body. On the other hand the resistance to smallpox infection conferred by the virus of cowpox is a specific resistance and is immunity in the strictest sense of the term. The virus of cowpox is a modified form of that of smallpox; and the resultant resistance can be produced only by one or the other and protects against only the one or the other. Now it has always been plain that there is such a thing as an immunity to measles, or to smallpox, or to yellow fever, as well as to a large number of other infections. This immunity was manifested in the way that we have already considered in the fact that one attack protected against subsequent exposure to the same disease; and it was this idea of immunity that gradually took hold of our point of view until it had usurped the field so far as any concepts of resistance were concerned. We fell into the loose and easy habit of saying that if there were no evidence of this immunity from second or repeated attacks of the same infection then there was no element of resistance connected with it. Later we found upon closer scrutiny that immunity need not be total or complete as is usually the case with measles. It might also be partial; that is to say, if successive attacks of the same infection are suffered, the second may be much less severe than the first because of a certain degree of protection that the latter conferred. There arose therefore also the idea of a partial or relative resistance. But the idea that there might be resisting or protective processes at work, while at the same time there were no evidences of a less severe infection than usual was not entertained, at least, not until recently. It is therefore not hard to appreciate why, not so very long ago, there was a very definite and general opinion that no element of immunity or resistance entered into tuberculosis infection. In the first place, it was universally believed that only the sick were infected; until recently no one knew and hardly any one thought that most healthy people have tubercle bacilli in themselves and in some way or other are holding them in check. Yet this and we have repeated it often-is true. And being true, it can mean only one thing, namely, that there is some resisting force or forces keeping the bacilli in check. We have already discussed how one force-the tubercle itself can work towards this end. In the second place, because formerly tuberculosis was diagnosed as such only in its latest stages and because practically every advanced case died, it was hard to comprehend that the body was putting up any defense against the disease. Finally, although it was a common observation that many of these advanced consumptives had periods of improvement, and now and then even complete relief, it was just as common to find that these same patients suffered relapses,second, or third or many repeated attacks-until one eventuated in death. This led to the idea that, if consumption of the lungs did anything, it did not protect against subsequent attacks, but on the contrary, only made the patient less resistant or immune than normal and laid him more open to future illness of a like nature. Just so long as consumption and tuberculosis were observed and studied only on the human patient these views held sway with scarcely a criticism or objection aimed against them.* They would undoubtedly obtain today had we not resorted to animal experimentation to learn more about tuberculosis and had we then not confirmed what we thus learned by comparing it with what the human patient discloses. Animal experimentation can furnish no better argument for its practice than the results of the study of this single phase of tuberculosis; for it is undeniable that the complexities and confusing features of the situation are such that continued and more intensified study of the patient alone would have served only to lead us further from the truth. The full force of this we shall see later. Let us remember meanwhile that one of the only two conceivable hopes of intentionally preventing tuberculosis that we can imagine lies in the invention of a successful method of artificial immunization. An enormous amount of research and animal experimentation have been directed toward this end; yet the goal has not been reached-we are still without a practicable method of successfully See observation by Marfan, May, 1919, number, p. 151. preventing and protecting against tuberculosis. Nevertheless these studies have given us a surprising amount of information concerning the presence or absence of defensive processes against which the tubercle bacillus operates. In this essay I mean to review some of the more important work that has aimed specifically to protect animals against tuberculous infection. I consider this method of inquiry to promise most in helping us to an intelligent opinion concerning several particulars of tuberculosis immunity about which it is highly desirable and necessary that we know something. Though we may not attempt a solution in the following sequence, these particulars may be phrased by a series of questions: Is there such a thing as an immunity to tuberculosis? If so, is the immunity a partial or complete one?-under what conditions is it established and under what conditions does it continue to exist?-and is it possible to come to any explanation of its nature or mechanism? With these points settled one way or the other, we may then proceed to a rational discussion of the influence of early infection on the later career of the human individual. In this quest for information I would have it clearly understood that I am concerned with only one type of immunity, and this is an immunity or specific protection against the implantation and subsequent development of tubercle bacilli in animal tissues,-in other words, against infection and the furher spread of micro-organisms. My concept of immunity will not include such matters as whether the bacilli contain or elborate substances which have a harmful effect upon the body (toxins) and whether the body does or does not protect itself against these; to discuss them satisfactorily here would only confuse the issue. Preliminary to this review of the efforts that have been made to attain what we may call tuberculo-immunity, and in order to contribute to a clearer understanding of their purpose, their scope and their results, I desire to summarize briefly the general types of immunity which we recognize as being in existence or as being attainable. THE GENERAL TYPES OF IMMUNITY. In its broadest sense there are only two types of immunity to infections. These are (1) natural or native immunity, and (2) acquired immunity. Natural or Native Immunity. It must be perfectly evident to everyone that the different species of animals vary greatly in their susceptibility to infections. The pig, the cow, the dog, the horse, in fact, every lower animal, can drink with impunity a polluted water which would bring on typhoid fever in man. The disease is limited strictly to man and there is no known way in which we can make these animals contract it. Anthrax has a wider range, and is infectious for several species of domestic animals as well as for man. Chicken cholera is very contagious for fowls, but never affects mammals. Hog cholera which is such a frightful plague is limited to swine. Bubonic plague spreads from man to man and from animals to man, as well as among several species of both domestic and wild animals. The closest association with man will not bring about in animals such highly infectious diseases as chicken pox, measles and influenza. In fact, |