It is self-evident that the intoxication of tuberculosis is brought about by some one or more substances which originate in the foci of infection. But it is by no means plain as to what focal element produces the material which harms the body.

If resolved into their elements, foci of tubercle will appear as comparatively complex structures. While they are developing they of course contain tubercle bacilli, germs which are living and possessed of every normal biological function as well as germs in several stages of disintegration and decay. They also contain body cells, some of which are the descendants of new cells elaborated by the body while others have entered the foci from the circulation and elsewhere. Like the bacteria, these component cells of tuberculous processes will also exist in several states. Many will be living and performing their fundamental functions; others may have only recently been struck by death; while still others, dead some time, may be going through the various stages of necrosis and dissolution, and in these processes have their original chemical constitution converted into more and more remote elements.

It was once natural and thoroughly logical to assume that the poison of tuberculosis resided in the bacilli which produced the disease. The tubercle bacillus was a child of less than ten years of age in the bacteriological family when we began to learn that certain germs of disease gave off poisons of far greater potency than strychnine or atropine or the venom of the cobra. The intoxicating power of diphtheria and tetanus toxin is little short of astounding. And when,

thirty years ago, we had separated these poisons from their bacteria and had tested their strength on animals, it was only logical, we repeat, to predict that all germs of disease would in time yield to us their toxin and to ascribe meanwhile the constitutional symptoms of every infectious disease to its bacterial poison.

But, as regards tuberculosis, a vast amount of scientific study since then has confuted logic. Intoxication of every tuberculosis patient goes on now, just as it always has done, and hundreds of able workers have turned to the germ for its poison, but the latter remains undiscovered. What is more significant, practically all careful study would indicate that there is no such thing as a specific bacterial toxin of the tubercle bacillus. A few have been described and put out-by Weyl, by Auclair, by Landmann, and by others-but in no particular does any one satisfy our conception or requirements of what a specific bacterial poison should be.

In previous essays, in the course of our long account of hypersensitiveness and immunity, we told of certain phenomena which may have a bearing on intoxication. It will be remembered that living tubercle bacilli do not bring about the slightest illness of

an animal after their first inoculation, until several weeks have elapsed and infection has settled upon the tissues. But the case is entirely different if the bacilli are applied to an animal which is already infected. Then symptoms, constitutional symptoms, severe and profound if reinfection is large enough, come on almost at once, that is, within a few hours after the new infection. In other words, tubercle bacilli poison the tuberculous animal but exert no similar action on a healthy animal.

From this circumstance and from other phenomena of the hypersensitive state which are to be observed, we come to the conclusion that an animal body, made sensitive by preliminary infection, has the power to destroy reinfecting bacilli and to break up or degrade the chemical constituents of the germs into substances which are poisonous for the body. It is now known that this sequence of events is one which is not peculiar to infection with tubercle bacilli. It has been well determined that the animal body reacts in an essentially identical way to first and subsequent injections of many, perhaps all, substances which contain protein or are of a protein nature. It is understood also that several degradation fractions of protein are intoxicating; and that no matter from which original protein they may be derived they exert similar intoxicating effects on the animal body.

If, therefore, tubercle bacilli poison the body in the manner described, they do this by and through what is at bottom a nonspecific substance, a split product of their protein which is more or less common to many other proteins. And such a substance is a very different entity from specific bacterial toxins like those which are elaborated by several germs, of which tetanus and diphtheria bacilli are types.

We have reason for believing, therefore, that tubercle bacilli undergoing disintegration, can give rise to constitutional symptoms which are the expressions of an intoxication by certain nonspecific substances obtainable from the germs of disease. But there are other features of tuberculous intoxication which would lead one to think that other elements are concerned in it.

The cells of tuberculous processes, apart from bacteria, are elements which are also continually passing through changes which bring about dissolution and degradation of their chemical constituents. They, also, are in large part of a protein nature and, when broken up, give rise to the split products of protein. In most tuberculous processes, the split products of tubercle cellular protein would be formed in much larger amounts than would the split products of bacillary protein. And, theoretically, in similar amounts, cellular materials should be just as intoxicating as bacterial substances.

The results of experimentation would seem to place this likelihood beyond the shadow ground of theory. It can be shown

that the pressed out juice of tubercles or even of normal tissues is intoxicating for the same species of animals from which the tissues were obtained. All of us can be apparently poisoned by our own tissues, if enough material from them, in the proper physical state can be absorbed rapidly enough in a given time. It is common clinical experience that we are thus poisoned and respond with constitutional symptoms when, for instance, we have suffered severe burns or comminuted fractures of bones or extensive surgical operations. At times like these, even though no infection enters into the case, we may exhibit malaise and fever and elevated pulse and other constitutional symptoms because the products of much destroyed tissue have gained access to the circulation and under these conditions tissue is poisonous.

We have pointed out several times in these essays that the absorption of focal materials is dependent quantitatively in part on the structure of the tuberculous formation and on the physiological activity of the involved part; that comparatively poorly invested tubercle and increased circulation in an organ make for greater absorption while competent peripheral scarring of tubercle and functional quiescence of organ promote nonabsorption. Bearing this in mind, we may now go one step further and venture that absorption from foci and consequent intoxication and constitutional symptoms will run parallel with disintegrating tissue processes which may at any time be going on in the interior of foci.

We recognize this circumstance clinically

Ju

when we associate the appearance or increase of constitutional symptoms with what we loosely call "softening" of tubercles or speak of a "drying" or "fibrosis" of the process accompanying improvement in the general condition of the patient. When tubercles are "softening" their cel lular components are dying and undergoing necrosis and disintegration and the chemical constituents of these are being broken up into those bodies which are poisonous; and, if absorption in sufficient amounts is possible, the result is intoxication and constitutional symptoms. As processes of dissolution come to an end, there is less and less focal material of poisonous character, and intoxication diminishes or ceases. Meanwhile, the very fact that death and destruction of tissue are going on more slowly carries with it the necessary corollary that fibrosis and scarring are taking their place, and that the mechanical barriers to absorption are at the same time becoming better perfected.

By way of recapitulation we would say, therefore, that the constitutional symptoms of tuberculosis result from intoxication, that they do not differ in kind from those of many other infections, that there is not the least scientific evidence that the intoxication is brought about by specific bacterial poisons (toxins), that, as the case stands at present, both bacilli and tubercle cell products in their disintegration release the intoxicating substances, which in both instances are nonspecific, and that more of the intoxication is to be attributed to cellular than to bacillary elements.

JUST what is a Combakker? In the spring of 1885 a young Norwegian in Minneapolis, dying, as he believed, of tuberculosis, appealed to friends to furnish him with enough money so that he might return to his homeland and be buried in Norway. One year ago as an author, this man, Knut Hamsun, was awarded the Nobel prize for literature. That is a Combakker!

One

To sketch the movements of this fisherman, cobbler, coal heaver, farm hand, store clerk, preacher, journalist, street-car conductor, lecturer, author and what not, is not easy. wonders if he himself could give a clear outline of his many ups and downs and weary wanderings. Born August 4, 1860, at Lom, in Gudrandadl, Norway, about 100 miles north of Christiania, of peasant parents, he was taken at the age of four to the Lofoten Islands. He seems not to have liked the life of the fisher folk and was apprenticed to a shoemaker when

he was somewhat older. At seventeen he produced a long story in verse form called "Bjorger." It was the story of a poor farm boy left an orphan. Thus early he began to follow his real bent as opportunity offered. Also as the story represented his view of his own early life it indicated the trend his later writings were to take. He published the booklet but it brought no recognition.

Next we hear that he had made the acquaintance of the great Norwegian author, Björnstjerne-Björnson, who suggested to him that there might be a field writing poetry for the Norwegians in America, since he estimated there were perhaps a third more of them in the states of Wisconsin, Iowa, Minnesota and the Dakotas, than there were in Norway itself. Armed with a letter to Professor Rasmus B. Anderson, professor of Scandinavian languages at the University of Wisconsin (and later United States minister to Denmark),

Cough

Most patients think that cough is a necessary and valuable factor in tuberculosis, and that it is beneficial to bring up the material which is poisoning them. At first thought such reasoning seems rational, but when the act is analyzed its danger is disclosed. If talking raises the lung pressure, then coughing brings it almost to the bursting point (and sometimes it does burst, causing pneumothorax). Patients will often work for hours and become completely exhausted, in an effort to relieve a slight tickling in the throat. It needs no long description to convince one of the serious damage this does to the tender healing parts, and by forcing infection to other parts of the lung. Undoubtedly it may be beneficial to some extent to bring up the pus and broken down material, but it is also destructive to the process of repair. If left alone and the desire to cough resisted, this material will frequently come up to where it may be expelled by simply clearing the throat. It is truly remarkable how many useless coughs may be prevented by constant practice in this respect. One does not scratch himself every time he itches, neither should he plunge into a fit of coughing on all occasions of tickling in the throat. It is of course foolish to say that all coughing can be eliminated, for there are those with large quantities of secretion who cannot prevent coughing, however hard they try. Old cavities will fill at night and no power on earth can prevent the morning "cleanout." There are few, however, who cannot greatly reduce this performance to the minimum and some are able to eliminate it entirely. No great harm is done by not bringing up the sputum. The little that is expectorated represents only a small fraction of what actually exists, most of which nature takes care of in her own efficient way. The slight good done is far outweighed by the very positive damage caused by the act.

There are no medicines known that will do more than give temporary relief from cough, and since their constant use is attended with certain unpleasant effects it is well to use them no more than actually

needed to give rest and relief from distressing cough. Simple remedies, such as sips of water, milk, syrup, or the sucking of a small bit of hard candy, often prove helpful. Fidgeting and turning in bed, and in fact any exertion may tend to produce more coughing. Cavity cases must learn to turn over very slowly on account of precipitating attacks, by bringing the secretion suddenly into contact with the dry walls of the cavity. Smoking undoubtedly tends to keep up slight coughing and is best avoided.

Occasionally one sees patients with considerable active tuberculosis who never cough or expectorate. Coughing should therefore be looked upon as being the result of an associated bronchitis, which in reality is a complication rather than a part of tuberculous infections. Efforts directed toward the relief of this condition will accomplish much.

Fever

This symptom is due to the absorption of poisons (toxins) from the diseased area and is certain evidence of active disease. Its presence is an absolute indication for remaining in bed, at complete rest, continuously, until the temperature is normal all day long for many days. Bed-rest is the most valuable treatment for this symptom, and the more complete the rest the better the results. Exercise tends to increase the poison and spread it, thus endangering healthy tissue and increasing the fever. A temperature of 99 is sufficient to demand staying in bed even though it does not occur every day. It is also well to remember that elevations (unlike the pulse) do not always occur on the day following some indulgence, but may be delayed two or three days, especially in the more chronic cases. There are many variations from the usual fever curve, but the most frequent one is that of a subnormal temperature in the mornings with elevations above normal in the afternoon and evening. The subnormal state is looked upon as being evidence that the reactive powers are low, and often exists long after the evening temperature has returned to normal.

Not every elevation of temperature in the

tuberculous is due to this disease, slight elevations often occurring from acute nasal infections, sore throats, indigestion, abscessed teeth, etc. One should not be too hasty, however, in assigning these as causes. The "alibit habit" is easy to acquire and often even the physician finds himself helping to delude the patient by assigning other causes for his symptoms, in the false belief that to know the truth will discourage him. This, we feel, is wrong, for real fortitude of the highest sort is needed by the tuberculous patient and nothing aids more in giving this than a frank discussion of the facts. It is a long hard fight and one never ceases to marvel at the wonderful fortitude and determination of most patients, especially those who fully comprehend what is necessary. No man will ever be called upon to make a sterner fight or to try his sould more than the man who sets about in earnest to defeat this disease, and fortunately the outlook is good for those who will make the sacrifice. Failure to do this we believe to be due to ignorance of the principles involved more often than to lack of good intention.

These

When a patient is found to be entirely free of fever all day long for several days, it can be assumed that the disease is getting under control. One should not get up immediately, however. No harm is done in sitting beside the bed for a short time while it is being made. If no return of the fever or elevation of the pulse occurs this time may be very cautiously increased a little each day. If a good reclining chair be used (straight and rocking chairs are very tiresome) this sitting up may be worked up to, say, an hour, morning and afternoon, but more should not be attempted until all signs of active disease have disappeared, except in the very old chronic cases. are usually able to take more exercise without injury than the early acute type. Stopping the fever is simply one favorable point gained. The sputum, weight, general condition and strength, all have to be considered in measuring the return to health. As long as signs of active disease are shown by physical examination the proper place is in bed, and the little relief afforded by sitting up for short periods after the fever has subsided will make it possible to rest better afterwards. Too much emphasis cannot be placed on the fact that simply staying in bed is not necessarily resting. Tossing, turning, reading, sewing, fidgeting, etc., are simply bad forms of exercise. One must learn to relax to the fullest and to lie in a half-sleep or dorman condition if he would accomplish the best results.

There are many things, almost too numerous to mention, which will cause an elevation of the temperature. A game of cards or chess, an argument, worry or excitement of any kind are all potent causes, and should be avoided until improvement is such that considerable exercise fails to

produce a reaction. Many patients think they cannot avoid worry, and possibly there are times when they may not, but in the great majority of instances it is pure selfindulgence.

Pulse

An increase in the pulse rate is one of the earliest signs of tuberculosis and usually the last to return to normal as recovery takes place. It is therefore a more delicate indicator, than the temperature, of what is actually happening. A more or less arbitrary rule has been stated to the effect that a pulse of 90 or above demands bed rest. This is not an extreme mark and is probably the nearest correct line to draw. It is certainly wise to stay in bed for such a pulse, unless the rapidity can be proven due to some simple factor. When one first be

gins to exercise, after long rest, the pulse is very unstable and responds to the slightest exertion, a very good proof that the change must be extremely gradual. Learn to do everything slowly, without haste or excitement, and usually the pulse will act in accord. In this way both the lung and circulation will be saved at a time when they are in poor condition to stand strains.

Rest

When a knee becomes tuberculous the first and practically only treatment consists in putting it into a plaster cast, for the purpose of stopping all movement. The result is usually a cure, and if the lung could be so treated there is reason to believe that as good results might be attained. Rest to the lung can only be a relative rest after all, depending upon rest to the entire body and mind. Relaxation must be practised until one can lie in bed for hours without moving. Not in a strained position, but with all muscles completely relaxed as when asleep. This not only protects the healing lung but saves the energy so it can be expended in the proper direction-that of fighting the disease. Many patients complain that going to bed makes them weak, but in reality it simply demonstrates how weak they are. Being put to bed could not possibly weaken any one and, if after being at rest a few days weakness is noted. it is the best possible proof that one should remain in bed. One can stay up and be about for a long time on his reserve strength (on his nerve) so that when he once gives up, the feeling of weakness is very pronounced.

It frequently happens that as soon as one finally gets in bed, neighbor and friends will, in their desire to make his lot. easier, begin devising forms of amusement and entertainment for his entire waking hours. Reading, writing, knitting, basket making, painting, and even typing are suggested. To do any of these things at first will materially defeat the treatment. Even the visitors must be limited to the min