THE ENCYCLOPEDIA AMERICANA 120 
TUBE WELL - TUBERCULOSIS 
TUBE WELL, or DRIVEN WELL, a 
device for obtaining water from the soil, con- 
sisting of an iron pipe of small diameter, 
pointed at the lower end, and driven vertically 
down into the earth usually by means similar 
to those used in driving oil wells, until it 
pierces a water-bearing stratum. The tube is 
provided with a number of lateral perforations 
near its lower end, through which the water 
can enter it. In some cases the water exists in 
the soil under a pressure sufficient to cause it to 
flow up through the tube and out at the top; 
but more commonly a pump must be applied at 
the upper end, to draw the water up to the sur- 
face. When the well is to be driven to a depth 
greater than one length of pipe, the tubing is 
usually constructed in sections, which are united 
by means of screw connections; new sections 
being added at the upper end as the sinking of 
the well proceeds. 
TUBER, a shortened, thickened, fleshy, sub- 
terranean stem in which the leaves appear as 
scales with axillary dormant buds, collectively 
called aeyes)) in the potato, and Terusalem arti- 
choke, which are good examples. Internally 
they contain starch as a principal component. 
Tneir office is to act as reservoirs of food and 
to propagate the species when favorable condi- 
tions present. Plants which bear tubers are all 
perennials. 
TUBERACE2E. See Fungi. 
TUBERCULIN, a culture used to test for 
the presence of the disease tuberculosis in cat- 
tle. Prepared as follows: The attenuated cul- 
tures of tubercle bacilli or germs are allowed 
to grow in broth containing glycerine. After 
growing for several weeks, the bacilli produce 
certain toxic or poisonous substances which are 
soluble in and hence dissolved in the broth. 
The toxic solution is filtered from the bacilli 
and becomes the solution tuberculin. The 
process of manufacture has been subject to 
much variation. When injected in small quan- 
tity into a healthy animal it produces no effect, 
but if the animal has the disease tuberculosis 
it causes a decided rise in bodily temperature 
and hence can be used as a test for that dis- 
ease. It was originally introduced by Profes- 
sor Koch of Berlin, and hailed as a cure for 
consumption, on the principle of vaccination 
for hydrophobia. It proved ineffective, but is 
bv some deemed useful as a test. Consult 
Cochrane and Sprawson, (Guide to the Use of 
Tuberculin5 (1915). 
TUBERCULOSIS, an infectious, com- 
municable disease caused by the bacillus 
of tuberculosis. The bacillus induces the 
formation of little nodules called tubercles. 
These tubercles may grow in size through 
the continued action of the organisms; they 
may soften, break down and be expelled, 
leaving behind an ulcer or a cavity; they may 
become hard by a process of sclerosis; or they 
may calcify. In addition to the local mani- 
festations the disease produces general symp- 
toms like elevation of the body temperature, 
increased pulse-rate and loss of weight. It is 
popularly known under a variety of other names 
as consumption, phthisis, decline, debility, hectic 
fever and when localized in a special part or 
tissue, as Pott's disease or hunchback, scrofula, 
hip-joint disease, white swelling (tuberculosis 
of elbow) and lupus (tuberculosis of skin). 
Contrary to prevalent lay opinion, when prop- 
erly treated, it is a very curable affection. 
Distribution of the Disease, Geographical. 
- Tuberculosis is the most universal of all dis- 
eases. It is found in every part of the world, 
and has been known from the beginning of his- 
tory. It was accurately described by Hippoc- 
rates (460 b.c.), and by Galen (200 a.d.). It 
is most prevalent, however, in large cities and 
especially in overcrowded districts. 
Distribution According to Race.- No race 
is exempt, but some races appear less resistant 
than others. Indians, when brought into civili- 
zation, prove especially susceptible. Among the 
other races in this country the negroes seem to 
be the most susceptible with next in order the 
Irish, while Jews stand at the end of the list. 
In the general mortality about one-tenth and 
in the mortality between the ages of 15 and 60 
about one-fourth of all deaths are due to it. 
The number of clinical cases in a community is 
about 10 times the number of deaths in a year 
(Rosenau). Eighty per cent of these manifest 
it in the lungs. 
Distribution Among Animals.- Most ani- 
mals are more or less susceptible. Among 
domestic animals it is found most frequently 
in cattle and swine, though sheep and horses are 
not exempt. Dogs and cats manifest it rarely. 
It is also found in birds (fowl) and fish. 
Wild animals in their native haunts seem less 
susceptible, yet in domestication it is the most 
common cause of death. Rabbits, guinea-pigs, 
rats and mice may acquire it. Guinea-pigs are 
especially susceptible to experimental inocula- 
tion and are, therefore, commonly used for this 
purpose. Though frequent in adult cattle, it is 
infrequent in calves (Nocard), showing that 
direct heredity plays no part. 
Etiology (Causation).- The actual cause 
of the disease is the tubercle-bacillus described 
by Robert Koch in 1882. This is a minute 
vegetable non-motile organism in the shape of 
a rod or lead-pencil, measuring about three 
microns. of an inch) in length, and about 
four to six times longer than broad. It is visible 
only under the higher powers of the microscope, 
a oil-immersion lens being usually used to 
study it. Its principal characteristic is its be- 
havior toward aniline dyes. It requires, the 
strongest dyes to stain it, but when stained it 
holds the dye so tenaciously that exposure even 
to strong mineral acids for a reasonable time 
fails to decolorize it. This characteristic fur- 
nishes the most ready means for its recognition. 
It is quite parasitic in nature, growing on but 
few artificial media, namely, blood-serum, 
glycerine-agar, bouillon or potato, best on the 
first. It grows only at the body temperature 
(37° C.). It is slow in growth, and becomes 
apparent only from 5 to 14 days after inocula- 
tion of the medium. Exposure moist to a tem- 
perature of 60° C. for 15 minutes, or boiling, 
kills it, though freezing has no effect on it. It 
is killed by direct sunlight within a variable 
period of time (from 15 minutes on), depend- 
ing on the season and the character of the 
medium containing the organism; by diffuse 
sunlight near a window in a week or two. In 
growing (either parasitically or without the 
body) the organism elaborates a chemical 
product highly poisonous to most animals. It TUBERCULOSIS 
121 
is this poison circulating in the blood which 
produces the general symptoms of the disease, 
such as fever, increased heartbeat, emaciation, 
etc. Tubercle-bacilli found in different animals 
differ in their characteristics. The human, 
bovine, avian and fish varieties have been dif- 
ferentiated. One of the principal points to be 
noted is the slow propagation of the organisms 
with the consequent slow development of the 
disease. The actual infection usually precedes 
the manifestation of the disease by scarcely 
ever less than two and frequently as many as 
20 years. 
Predisposing Causes.- Though the bacillus 
of tuberculosis is the actual cause of the disease 
whenever it occurs, other factors require con- 
sideration. As wheat will not grow on every 
soil, so the tubercle-bacillus will not grow in 
every individual. In fact it would appear that 
the majority of human beings are quite insus- 
ceptible, and that as a rule an overwhelming 
dose of the organisms repeated frequently for 
some time is necessary to overcome the resist- 
ance. All the conditions necessary to produce 
susceptibility are unknown, yet it is empirically 
true (and could be with reason supposed) that 
any circumstance which tends to lower the gen- 
eral vital resistance decreases the resistance to 
tuberculosis. Therefore, defective and insuffi- 
cient food, over-work, worry, chronic alcohol- 
ism, surroundings like a damp, dark, over- 
crowded dwelling, persistent irritation of a 
somewhat naturally susceptible part of the body, 
as irritation of the lungs by the constant in- 
halation of dust (mine-workers, stone-cutters, 
etc.), previous severe disease like typhoid fever, 
etc., all tend to increase the susceptibility. 
It was thought in the past that the most 
common cause active in the production of sus- 
ceptibility was heredity, because the disease 
manifests itself more commonly in the children 
of the tuberculous than of the non-tuberculous. 
Recognizing the communicability of the disease, 
however, the closeness of the contact after birth 
easily accounts for this, without it proving them 
more susceptible. In fact, a strong argument 
can be deduced to the contrary, namely, that 
the children of tuberculous parents are less sus- 
ceptible. Granting the communicability, it is 
not a surprise that children who are kissed and 
fondled for years by tuberculous mothers con- 
tract it, but it is a surprise if any escape; and 
if they were more susceptible we would expect 
them to contract it in such a virulent form that 
no child of a tuberculous mother would ever 
reach adult age. The fact is, however, that the 
majority of children of tuberculous parents 
never manifest the disease and the ones who do 
usually manifest it in a very chronic fashion 
and only after the age of 15. In other words, 
though these children live in an atmosphere 
impregnated with the germs, the majority fail 
to contract it and the remainder resist it for 
years. 
Flick's paper on tuberculosis as a house- 
disease goes to prove its communicability. He 
investigated all the houses of the largest, oldest 
and most thickly populated ward in Philadel- 
phia, and found that the deaths from tuber- 
culosis in that ward were disproportionately 
large in certain houses. In short, he demon- 
strated case after case of apparently healthy 
families moving into a house previously oc- 
cupied by a tuberculous person with the result 
that one or more members died of the disease. 
Modes of Infection.- There are four pos- 
sible modes of infection, namely, inoculation, 
heredity, inhalation and ingestion. 
Inoculation.- Villemin's work, supple- 
mented by that of Cohnheim and Salamonson, 
absolutely established the fact that the disease 
was inoculable. Inoculation is, however, quite 
rare as a method of general infection in human 
beings, and its occurrence is practically limited 
to special occupations. Inoculation with the 
production of a strictly limited local lesion is 
reasonably common on the hands of physicians 
who do anatomical or post-mortem work (the 
post-mortem wart, the Zeic/teH-tubercle of the 
Germans), of butchers, tanners, etc. Local 
tubercles have also been produced bv piercing 
the ears for earrings, by tattooing and by 
washing the clothes of a tuberculous patient. 
Both local and generalized tuberculosis have 
been reported as a result of the rite of cir- 
cumcision, the last step in which is the sucking 
of the wound. 
Heredity.- Up to the time of Villemin this 
was the generally accepted mode of acquiring 
the disease, though here and there down the 
centuries from the time of Galen some one has 
stood out against it in favor of contagion. 
Hereditary transmission has been experi- 
mentally proven on the lower animals (Gart- 
ner), and occasionally demonstrated in human 
beings by the finding of tuberculous lesions 
in the foetus. These proofs occur so rarely, 
however, that the ordinary view of practically 
all cases being examples of contagion, is fully 
warranted. 
Inhalation.-The common belief at the pres- 
ent day is that the majority of cases of tubercu- 
losis are the result of inhalation of the germs. 
The contagiousness of the disease being proven, 
and the infectious bacilli being found in the 
matter given off from a tuberculous ulcer 
(therefore, in the sputum in tuberculosis of the 
lungs), it is readily understood how people liv- 
ing with a consumptive may be more or less 
constantly inhaling the contagion. Nuttall's 
estimate of the number of bacilli thrown off 
in the expectoration daily could only make one 
wonder how anybody escapes the disease, were 
it not that they are so easily and quickly devital- 
ized. In a case where the patient expectorated 
about four ounces daily, Nuttall estimated the 
number of bacilli to be from one and a half 
to four billions in the 24 hours. Experiments 
on animals with the dust of rooms occupied by 
tuberculous patients have usually proven posi- 
tive (Cornet). The arguments for inhalation 
as the most common mode of infection are: (1) 
the very great frequency of tuberculosis of the 
lungs; (2) the frequency with which all per- 
sons are exposed to this form of contagion. 
Ingestion.- For years it was thought that 
tuberculosis of the lungs was the result of in- 
halation of the germs, and abdominal tuber- 
culosis the result of ingestion with food or 
otherwise. The argument favoring this view 
appeared plain; namely, that primary mesenteric 
gland tuberculosis is almost limited to children, 
especially the bottle-fed. Living as they do en- 
tirely on cows' milk, and considering the sus- 
ceptibility of horned cattle to tuberculosis, the 
inference seemed so justified that scarcely any 122 
TUBERCULOSIS 
exception was taken to it. In addition, adults 
who live as a rule on cooked food scarcely ever 
show mesenteric gland tuberculosis as a primary 
infection, but practically always tuberculosis of 
the lungs, which would readily seem to be the 
result of contact with the disease in their occu- 
pation, sleeping-rooms, etc. This plain view 
of the matter has, however, undergone a change. 
The majority of clinicians and pathologists of 
our day believe that children manifest the 
mesenteric form more frequently simply be- 
cause these glands are more susceptible at that 
age, and adults the pulmonary form for an 
analogous reason. For several years at the 
end of the 19th century considerable was writ- 
ten to prove that practically all cases of tuber- 
culosis were the result of ingestion of the 
germs. It was contended that even in tuber- 
culosis of the lungs the germs entered through 
the digestive tract, passed into the chyle-vessels 
with the fat, were carried through the thoracic 
duct to the heart and took up lodging in the 
lung on account of its non-resistive power. 
The experiments about this time demonstrating 
the infectivity of cows' milk became so numer- 
ous (Gerlach, Bang, Bollinger, Ernst) that 
the question of the digestive tract as a probably 
common route (if not actually the most com- 
mon) seemed practically settled. At the British 
congress on tuberculosis in 1901, however, 
Koch threw a shell which scattered scientific 
physicians and left them in two hostile camps. 
Coming from any one else the opinion (for it 
was scarcely more than an opinion, being based 
on a small number of experiments) would have 
been scoffed at, but coming with Koch's au- 
thority it could not fail to arouse interest and 
even advocates. Koch affirmed that the differ- 
ence between the bovine tubercle-bacillus (that 
is, the bacillus causing disease in cattle) and 
the human tubercle-bacillus was such that one 
was not contagious to the other species, or was 
so slightly contagious that the number of cases 
of tuberculosis thus produced might be left 
out of consideration without impairing statis- 
tics. During the past 18 years the efforts to 
disprove Koch's statement have been numerous, 
but the question is not yet absolutely settled. 
Our investigations are conclusive enough, how- 
ever, to lead us to believe that about 5 per cent 
of the cases in human beings are due to the 
bovine bacillus. Practically all of these are in 
the lymphatic glands of children, or in other 
extra pulmonary locations; the number in the 
lungs of adults is negligible. 
Primary and Secondary Infection.- The 
belief is gradually gaining ground that the 
ordinary manifest tuberculosis of the lungs is 
a result not of primary but of secondary in- 
fection. Inoculation experiments on animals 
have always shown primary inoculation to pro- 
duce tuberculosis of the nearest lymphatic 
glands with no lesion at the site of inoculation, 
and secondary inoculation to produce no lesion 
of the lymphatic glands with definite tubercu- 
losis at the site of inoculation. It would ap- 
pear, therefore, that pulmonary tuberculosis is 
the result of secondary rather than primary in- 
fection and occurs in one of the following 
ways: The individual ingests tubercle bacilli, 
which pass through the intestinal wall without 
producing a lesion, but cause tuberculosis of 
the mesenteric, and later the bronchial glands. 
The disease of the bronchial glands produces 
stasis of the lymphatic circulation in the lung, 
with a consequent retrograde flow of lymph, 
which carries the tubercle bacilli from the 
glands to the lung tissue. Or after the 
lymphatic glands have become involved an en- 
tirely new infection by inhalation or ingestion 
produces the pulmonary manifestation. A num- 
ber of investigators (prominent among them 
Bushnell) believe that the primary infection 
practically always occurs in childhood and that 
adult infection is extremely rare. 
Pathology.- When the tubercle bacilli are 
deposited in a tissue they proceed to multiply. 
Like other plants in growth, they take from 
their surroundings the chemical elements neces- 
sary. The living cells from which this material 
is taken die. In addition, the growing bacilli 
throw off waste products containing a poison 
(toxin) which kills other cells. We soon, 
therefore, have the tubercle bacilli in a mass of 
dead debris. A reaction now occurs on the 
part of the healthy tissue to prevent extension 
- the cells of the part multiply, and white blood 
cells wander in from the blood for the pur- 
pose of consuming the organisms. It is this 
mass of bacilli, debris and new cells which 
constitutes the tubercle described first by 
Baillie in 1794, and which is the specific lesion 
of the disease no matter in what organ it 
occurs. The debris looks like a soft cheese, 
and is called caseous material or caseation. 
The new cells are called epithelioid. Usually a 
tubercle also shows what we call a giant cell, 
a cell three to eight times larger than the 
epithelioid. 
The question of the cure of the tubercle 
seems to depend on whether the epithelioid 
cells or the tubercle-bacilli obtain the upper 
hand. If the epithelioid cells are manufactured 
more rapidly than the tubercle-bacilli destroy 
them they form a dense wall about the tubercle- 
bacilli, elongate, become fully formed fibrous 
connective-tissue cells, thus shutting the bacilli 
up in a capsule, and the bacilli die, while the 
caseous material calcifies or is absorbed and re- 
placed by scar-tissue or fibrous tissue. When 
the amount of fibrous tissue in the lung is large 
we speak of fibrosis of the lung. If, however, 
the bacilli are victorious the tubercle may grow 
larger and, coming in contact with other tuber- 
cles, form what is known as a conglomerate 
tubercle, and so continue until even a whole 
organ is involved. Again, the caseation may 
advance so rapidly, especially in the lung, that 
there is never any sharp demarcation between 
healthy and diseased tissue. This is generally 
called diffuse tuberculosis, and in the lungs is 
known as caseous or tuberculous pneumonia. 
Finally, as the tubercle advances, other 
micro-organisms (particularly streptococci or 
staphylococci) may gain entrance to the caseous 
material and break it up. If now the tubercle, 
in growing, reaches a surface its liquid con- 
tents may be expelled, leaving behind an ulcer 
or a cavity. This happens most frequently in 
the lungs, and the resultant cavity may be of 
any size from a pea to that of a whole lobe of 
the lung. 
The cavity is usually within the lung, or if 
at the margin, is limited by the pleura, which 
thickens about it. Sometimes, however, it 
breaks through the pleura, allowing pus into the TUBERCULOSIS 
123 
pleural cavity, which is called pyothorax or 
empyema; occasionally both pus and air are ad- 
mitted producing pyopneumothorax. 
When newly formed, tubercles appear to the 
naked eye as grayish-white or yellowish-white 
specks about the size of a millet seed, hence the 
name miliary tubercle. When two or more of 
these fuse, it is called a conglomerate tubercle. 
Usually the disease, especially in the lungs, pro- 
gresses by a small number of tubercles localized 
in one area running together to form con- 
glomerate tubercles and these again to form a 
larger mass which we call tuberculous infiltra- 
tion. Sometimes in non-resisting cases miliary 
tubercles develop rapidly all through the lung 
and rarely in many other organs and the indi- 
vidual dies before they become conglomerate. 
This condition is described as miliary tuber- 
culosis. In growth tubercles destroy the tissue 
which they replace and even when cure results, 
they only change to masses of scar tissue; the 
original tissue never returns. 
Lymph-Gland Tuberculosis.- Children are 
most frequently the victims, and the bronchial, 
cervical and mesenteric are the glands of predi- 
lection. Tuberculosis of the cervical lymph- 
glands is popularly called scrofula. It is treated 
in a similar way to chronic tuberculosis of the 
lungs by rest, fresh air and nourishment, or 
by the X-ray, which appears to be frequently 
successful. When the glands break down, 
surgical interference is usually necessary. 
Bone Tuberculosis.- This is likewise most 
common in children. It may be limited to the 
medulla or periosteum, and spread from either 
to the cortical portion, producing necrosis 
(tuberculous caries). It is most frequent at the 
joints, especially the hip and the intervertebral. 
Tuberculosis of the vertebral column is popu- 
larly called Pott's disease, or hunchback. It 
is usually associated with lumbar or psoas 
abscess. When localized to the vertebrae, cures 
are frequent. The treatment of Pott's disease 
and other joint tuberculous disease, like hip- 
joint disease, is similar to that of chronic tuber- 
culosis of the lungs. 
Intestinal Tuberculosis.- The intestines 
show either a miliary variety (the tubercle 
lying either beneath the mucous membrane or 
the peritoneum) or a chronic ulceration. Both 
forms are usually secondary to tuberculosis 
elsewhere. Miliary tuberculosis and tubercu- 
lous ulcers of the appendix are not uncommon, 
particularly in advanced tuberculosis of the 
lungs. 
Laryngeal Tuberculosis.-'This is mani- 
fested commonly by adults as a complication of 
advanced tuberculosis of the lungs. Its bad 
reputation, as far as cure is concerned, comes 
from the fact that it usually occurs only when 
the tuberculosis of the lungs is so advanced 
that the individual is incurable on account of 
the lung condition. When it occurs early in the 
case or as a primary affection, it is just as 
curable as tuberculosis elsewhere. The amount 
of hoarseness or pain does not indicate the 
seriousness of the condition. A small 
insignificant closed tubercle between the vocal 
cords may produce marked hoarseness; a small 
ulcer on the epiglottis may produce great pain; 
a large, much more serious ulcer when situated 
elsewhere may produce neither hoarseness nor 
pain. 
The organs most commonly affected in 
adults are the lungs; in children, the lymph- 
glands, bones and joints. The other organs are 
affected much less frequently, and in about the 
following order: Intestines, peritoneum, kid- 
neys, meninges, brain, spleen, liver, generative 
organs, pericardium, heart. Tuberculosis of 
the skin comes under the head of lupus (q.v.). 
Symptoms and Prognosis of Tuberculosis 
of the Lungs.- It is necessary to differentiate 
three varieties, acute miliary tuberculosis, acute 
tuberculous pneumonia and chronic tubercu- 
losis. 
Acute Miliary Tuberculosis of the Lungs. 
-This may begin as a primary or be secondary to 
an acute or chronic affection elsewhere. It is 
most common as a termination of a chronic 
affection of the lungs. It comes on rather 
rapidly, like the ordinary acute infectious dis- 
eases, and is sometimes distinguished from 
them (especially typhoid fever) with difficulty. 
There is a loss of appetite, loss of flesh and 
strength, fever (102° to 104° F.), accelerated 
pulse, hurried respirations, a brown fissured 
tongue, delirium, then stupor and death. The 
duration is from two to four weeks. The prog- 
nosis is always grave, though no case of tuber- 
culosis is ever so grave that treatment is surely 
in vain. 
Acute Tuberculous Pneumonia.- This is 
practically always secondary to a chronic tuber- 
culosis of the lungs. It begins, like lobar 
(ordinary) pneumonia, with a chill, high fever, 
rapid pulse, shortness of breath, hemorrhagic 
sputum, flushed face, and the physical signs of 
consolidation of parts of the lung. Instead of 
ending by crisis about the ninth day, like lobar 
pneumonia, it continues to a fatal termination; 
or the acute symptoms gradually subside, the 
diseased area becomes fibrous, and the patient 
gradually gets well, or approximately so, with 
a loss of lung-tissue equal to the involvement, 
which is sometimes an entire lung. The 
diagnosis is made by the ordinary _ signs of 
pneumonia and the tubercleJbacilli in the 
sputum. The prognosis is very unfavorable; 
rarely, however, a case recovers sufficiently to 
lead a useful life for a number of years. The 
treatment is that of chronic tuberculosis. 
Chronic Tuberculosis of the Lungs.- This 
is what is ordinarily understood by consumption, 
or tuberculosis of the lungs without qualifi- 
cation. Its symptoms vary with the progress 
of the disease, and the susceptibility of the in- 
dividual to the poison (toxin) excreted by the 
bacillus. The onset is usually insidious, and the 
disease frequently progresses for 5 to 20 
years before the patient recognizes it. The 
symptoms are often brought out by a <(cold® 
from which the patient seemingly does not re- 
cover. Many, therefore, attribute their disease 
to such a The first noticeable symptom 
is sometimes a hemorrhage or a pleurisy; again, 
a progressive loss in weight or a slight dry 
cough, becoming gradually worse. The most 
important very early symptoms are usually 
slight fever, especially toward evening (which 
may or may not be accompanied by a chill), 
hectic flush, acceleration of the pulse-rate, 
cough, expectoration, loss in weight, progressive 
pallor of the skin, night-sweats, indigestion or 
loss of appetite, vague general pains, and sore- 
ness localized in the chest. The one positive 124 
TUBERCULOSIS 
sign of tuberculosis at this stage is the finding 
of tubercle-bacilli in the sputum. If every 
lesion were open, that is, in communication with 
a bronchus, there would be tubercle-bacilli in 
the sputum from the earliest stages, and the 
diagnosis would be easy; but many lesions are 
closed, that is, completely encapsulated, and, 
therefore, show no bacilli in the sputum. Hence 
the physician must rely on other signs brought 
out by careful inspection, palpation, percussion 
and auscultation of the chest and X-ray ex- 
amination. 
As the disease advances, all the foregoing 
symptoms are intensified. The pulse-rate be- 
comes more rapid, so that it is evident to the 
patient in palpitation or shortness of breath, the 
temperature rises to 102 or more, the loss of 
weight becomes excessive, frequently reaching 
one-fourth, sometimes one-third and rarely one- 
half of the usual weight, the pallor becomes 
marked, the appetite is completely lost, cough 
may become almost continuous day and night 
and of a most racking character, expectoration 
increases, the feet usually swell and the picture 
presented is known to everybody. The patient 
is extremely emaciated, the chest is quite flat, 
the depressions above and below the clavicles are 
marked and the scapulae stand out prominently 
on the back. Hemorrhage may or may not 
occur. As a rule there is little or no pain. 
The lungs themselves possess no sensitive 
nerves, and it is only the associated pleurisy 
which occurs at intervals that produces this 
symptom. Examination by the physician now 
reveals the signs of extensive solidification. 
This may extend over one whole lung or over 
the greater part of both. It may or may not 
be associated with cavities. 
Chronic tuberculosis of the lungs, when diag- 
nosed sufficiently early, and when the personal 
resistance is good, is a very curable affection. 
This is proven by the number of cured lesions 
found at autopsy. It is very conservative to 
say that 50 per cent of all bodies coming to the 
autopsy table past the age ©f 35 (death having 
been the result of some other disease than 
tuberculosis of the lungs), show a healed lesion 
of tuberculosis of the lungs. The present post- 
mortem and clinical records demonstrate that 
75 per cent of cases recover. Moreover, these 
post-mortem records are absolute; there is no 
practical question of diagnostic error. In addi- 
tion, many cases with a lessened resistance can 
be so improved under judicious treatment that 
their lives are prolonged in comfort for 10, 20, 
even 30 years. For the encouragement of those 
afflicted, it might be stated that according to 
Jacobson the following appear to have suffered 
from tuberculosis: Cicero, Milton, Samuel But- 
ler, Pope, Shelley, Hood, Keats, Elizabeth Bar- 
rett Browning, Francis Thompson, Goethe, 
Schiller, Moliere, Richelieu, Merimee, Thoreau, 
Calvin, Descartes, Locke, Kant, Spinoza, 
Mozart, Chopin, Paganini, Beaumont, Samuel 
Johnson, Sterne, DeQuincey, Scott, Jane Austen, 
Charlotte and Emily Bronte, Stevenson, Bal- 
zac, Voltaire, Rousseau, Washington Irving, 
Hawthorne, Gibbon, Kingsley, Ruskin, Emer- 
son, Cardinal Manning, Raphael, Watteau, 
Bastien LePage, Marie Bashkirtseff, Cecil 
Rhodes and Laennec, as well as a large num- 
ber of present-day physicians, who after de- 
veloping the disease became tuberculosis experts, 
like Edward L. Trudeau, Lawrence F. Flick, 
H. R. M. Landis, Lawrason Brown, A. M. 
Forster, James Price, Estes Nichols and E. 
S. Bullock. 
Diagnosis.- Only rarely is the diagnosis 
difficult. The comparison of the autopsy find- 
ings with the clinical diagnosis at the Henry 
Phipps Institute showed the physical signs of 
Laennec to be practically perfect. In addition, 
we have as aids the examination of the sputum, 
the X-ray and the tuberculin test. Of these the 
physical signs elicited by an expert are the most 
positive. The sputum may fail to show tubercle 
bacilli on account of the lesion being closed. 
The tuberculin test is practically absolute, 
though it does not tell us in what part of the 
body the tuberculosis is. It is very useful in the 
diagnosis of tuberculosis in cattle because we 
only wish to learn the fact of its existence and 
are not concerned about its location; but not 
so useful in human beings in whom we usually 
wish to learn the nature of a lesion in a particu- 
lar place. The X-ray in advanced tuberculosis 
is about as accurate as physical signs, but in 
early lesions it frequently fails. It is likely 
that time will make the X-ray more accurate. 
Treatment of Chronic Tuberculosis of the 
Lungs.- There is no known specific for the 
disease. Koch's tuberculin is used by the 
minority of physicians and by them only in 
selected cases. There are at present more than 
25 different tuberculins (emulsions and sera) 
on the market, and almost every discoverer 
claims his is the only one beneficial. The most 
that can be said with certainty in regard to 
the treatment with any of them is that in ex- 
pert hands in small doses they do no harm. 
In the hands of inexperience their employment 
is fraught with danger. Whether tuberculin 
is used or not, the most careful hygienic regime 
must be instituted. The disease progresses on 
account of a lack of resistance in the patient; 
the object, therefore, is to increase the resisting 
power. This is accomplished by rest, fresh air 
and good nourishment. If the disease is active, 
that is associated with fever, rapid pulse or 
rapid emaciation, or other serious symptoms, 
rest in bed is necessary. The patient should 
remain in bed until the temperature is below 
99.6, the pulse below 100, serious symptoms in 
abeyance and gain in weight is evident. An 
early favorable case usually requires from two 
to six weeks rest in bed; advanced cases cor- 
respondingly longer. Even when ready to be 
up all day he should lead a regular life, retiring 
at a proper hour (before 10 p.m. if an adult), 
in order to get sufficient rest. He should have 
nine hours' sleep, must sleep alone and, when 
possible, in a room alone. The best situation 
for the room is on the southwest corner of 
the house. The windows of the sleeping-room 
should be kept wide open, no matter what the 
weather. In summer all the windows in the 
room, and in winter, when the air diffuses much 
more readily, one window at least, should be 
wide open. The idea is to make every inhala- 
tion one of fresh air. During the day the 
patient must spend as much time as possible out 
of doors, yet in summer he must not be in the 
sun. When the weather is cold he should be 
comfortably wrapped. It is better to multiply 
the coverings which are readily removed than 
underclothes. Patients suspecting lung trouble TUBERCULOSIS 
125 
frequently come to the physician wearing a 
chest protector, two or even three undershirts 
and other clothes. This is not only unnecessary, 
but probably harmful. The regulation clothes 
of the kind most comfortable to the patient 
meet all requirements. 
Diet.- Nourishment is most important. If 
a patient is run down, and he usually is, it is 
absolutely necessary to build him up. This can 
be accomplished only by a proper amount of 
food. Some physicians of repute in tuberculosis 
advise a general mixed diet with the addition 
of two to four pints of milk daily. Some push 
the nourishment; others, like Bushnell, insist 
that it should not be forced. In regard to 
nutritive value foodstuffs stand in the following 
order: Milk, eggs, meat, vegetables, cereals. 
Contrary to popular opinion potatoes never 
made anyone fat. An ordinary good diet would 
be: Breakfast, 7:30 a.m., fruit, two boiled 
eggs, bread and butter and two glasses of milk; 
lunch, 9:45 a.m., one glass of milk; dinner, 
12:30 p.m., soup, meat (preferably rare roast 
beef or beefsteak), three kinds of vegetables 
and a simple dessert, like ice cream or rice pud- 
ding; lunch, 3:30 pm., one glass of milk; sup- 
per, 6 p.m., meat or eggs, potatoes or other 
vegetable, bread and butter and two glasses of 
milk. The diet found most generally suitable 
to the great majority of patients at the Sana- 
torium for Consumptives at White Haven, Pa., 
is as follows: Breakfast, 7:30 a.m., one and 
one-half pints of milk, with two raw eggs (the 
eggs may be broken up in the milk or taken 
whole) and fruit; lunch, 10 a.m., one pint of 
milk and one raw egg; dinner, 12:30 p.m., soup, 
meat, three or four kinds of vegetables and 
pudding or ice cream; lunch, 3:30 P.M., one 
pint of milk and one raw egg; supper, 6 P.M., 
one and one-half pints of milk, two raw eggs 
and fruit; lunch, 8 p.m. (just before retiring), 
one-half to one pint of milk. Alcohol (whisky, 
brandy, wine, etc.), which was at one time much 
lauded, especially by the laity, is now avoided 
by experts. 
Climate.- Up to recently considerable de- 
pendence was placed on climate. Patients who 
could afford it were advised to betake them- 
selves to the Southwest, and not infrequently 
those who could not afford it were told to 
"beat their way?' It is still generally believed 
that a dry climate is more suitable for the cure 
of the majority of patients; yet no matter what 
the climate, the patient must carry out the fore- 
going or a similar line of treatment. It is to be 
remembered that tuberculosis is a disease of all 
climes and altitudes; that cases develop in 
Colorado and New Mexico as well as in Can- 
ada, and that cases have been and are being 
cured in all parts of the world. Some writers, 
among them many eminent in the specialty of 
tuberculosis, absolutelv deny any influence to 
climate. This, however, may be affirmed with 
certainty: that if the removal to another cli- 
mate entails, or is likely to entail, the least hard- 
ship or privation, it is better for the patient to 
remain at home. Moreover, if the patient is 
sent away he must be referred to another 
physician, or to a sanatorium, where he will 
have a physician's care. To send him away to 
meet his difficulties and emergencies by him- 
self is an acknowledgment on the part of the 
physician that he does not know how to treat 
tuberculosis. Tuberculosis is, at least, as seri- 
ous a disease as typhoid fever and requires 
analogous attention to detail. To send a tuber- 
culous patient to a farmhouse or hotel in the 
country away from medical supervision is simi- 
lar to instructing the family of a typhoid 
patient in the regime to be followed without 
returning to learn if the directions are carried 
out properly, or if new complications have 
taken place. In addition, in the hotel or board- 
ing-house the patient is afraid to follow the 
regime too strictly, fearing that others will 
recognize his complaint, and he will be asked to 
leave. Moreover, to send a patient to a farm- 
house where his disease is known has no fur- 
ther advantage. In this case the people have 
usually had tuberculous patients previously and 
have some ideas relative to the disease. These 
ideas are frequently wrong, yet wishing the 
patient well, they endeavor to instruct him. 
Any sick individual is more or less at the mercy 
of the well people about him; if they insist on 
certain things he has not the will-power to 
resist. He is, therefore, being treated by lay 
people not a physician. 
Sanatoriums.-New sanatoriums for the 
treatment of tuberculosis are springing up al- 
most every month. They are opening their 
doors as a result of private enterprise or bene- 
faction or of a municipal crusade against the 
disease. They serve a three-fold purpose: (1) 
they gather in consumptives from large centres 
of population, and so prevent them from acting 
as a focus of contagion; (2) they instruct the 
patient how to take care of himself so that he 
is not a menace to others even when he returns 
home; (3) they demand a discipline which, if 
followed out, will in a favorable case cure. 
As a rule patients do better in sanatoriums than 
at home. There are a number of satisfactory 
sanatoriums throughout the United States, es- 
pecially in the Northeast and Southwest 
quadrants. 
Prevention in Cases of Chronic Tuber- 
culosis of the Lungs.- The contagion is con- 
tained in the matter given off from a tuber- 
culous sore. Therefore, in a case of tubercu- 
losis of the lungs it is only necessary to destroy 
the sputum to prevent contagion to others. The 
patient should expectorate only into receptacles 
where the sputum can be properly handled with- 
out coming in contact with other things. He 
should never expectorate into rags or hand- 
kerchiefs, but should limit himself to spit-cup 
and paper napkins. The spit-cup should be 
made of paper so that it may be burned, or if 
of china should contain an antiseptic or ger- 
micide. Ordinary lye will suffice. The cup 
should be boiled daily. When coughing, the 
patient should hold a paper napkin before his 
mouth. There should be no question of any- 
one sleeping with the patient. Children are 
especially susceptible; hence, when the parents 
are tuberculous, extra care must be exercised. 
The sick room should be uncarpeted, have no 
curtains or hangings and contain only the bed, 
a table, washstand and the necessary two or 
three chairs. Window shades are permissible. 
The room should be as open to the sunlight as 
possible in order to keep up constant disin- 
fection. The patient, however, should not be 
in the sun. The eating utensils (knives, forks, 
spoons, cups, saucers, plates and glasses) should 126 
TUBERCULOSIS 
be separate and should be boiled after use. 
Food of any kind left over should be burned; 
it must not be given to others, or even to the 
domestic animals, the cow, dog, pig or cat. The 
patient's soiled clothes should be handled as 
little as possible. When a change of clothes, 
sheets, pillow-cases, wearing apparel takes place, 
the soiled pieces should be rolled up in a clean 
sheet and boiled without unrolling. They may 
then be washed in the usual manner. If the 
patient is walking about the house, every room 
that he occupies should be as open as possible. 
He should not be allowed to make the dining- 
room or the kitchen his living-room. Nobody 
should leave the patient's room without washing 
the hands immediately. Children should not be 
allowed in the sick-room. If the patient dies, 
the bed and furniture should be taken outside 
and washed. Bureau drawers should be 
scrubbed. The mattress should be sent to a 
steam-cleaning establishment, or at least the 
stains on it washed with soap and water. Fol- 
lowing this the mattress and furniture should 
be exposed to the sunlight for at least three or 
four days. The floor and woodwork of the 
room should be scrubbed and the room opened 
as much as possible to the air and sunlight for a 
week. A good working rule for all infectious 
diseases is that everything which has come in 
contact with the patient should be burned or 
boiled; if neither is feasible, it should be thor- 
oughly scrubbed and exposed to the sunlight. 
Campaign against Tuberculosis.- This is 
one of the most important public health issues 
of the day, and through it we expect the eradi- 
cation of the disease. During the last 40 years 
the death rate of tuberculosis has fallen 50 per 
cent, due, at least, partly to the public health 
efforts against it. The prospect is sufficiently 
bright that every State, municipality and indi- 
vidual should be interested. Every municipality 
should have hospitals for early and advanced 
cases, dispensaries for the treatment of the 
poor, an anti-tuberculosis society for the edu- 
cation of the public and open-air schools for 
tuberculous children. Anti-spitting laws should 
be made and enforced. Tuberculosis should be 
on the list of notifiable diseases. Tuberculosis 
in cattle should be under administrative control. 
The individual -can aid by voluntary work in 
connection with a hospital or dispensary, by 
membership in the anti-tuberculosis society or 
by donation of funds for the work. 
Bibliography.- For scientific treatment of 
the subject, the following writings may be con- 
sulted: Laennec, 'Diseases of the Chest' 
(1823) ; Walshe, 'Diseases of the Lungs' 
(I860) ; Koch, 'Die 2Etiologie der Tuberkulose' 
(in 'Berliner Klinische Wochenschrift,' No. 15, 
1882) ; and 'Weitere Mittheilungen uber der 
Tuberkulose' (in 'Deutsche Mcdizinische Wo- 
chenschrift,' 1891) ; and 'Uefber bakteriologische 
Forschung' ('Verhandlungen des X. Interna- 
tionalen Medizinischen Congress,' Berlin, 4 
Aug. 1890) ; and 'Relation of Human and Bo- 
vine Tuberculosis' (in 'Sixth International 
Congress on Tuberculosis,' Vol. IV, p. 645, 
1908) ; Smith, 'A Comparative Study of Bovine 
Tubercle Bacilli and of Human Bacilli from 
Sputum' (in Journal of Experimental Medi- 
cine, 1898, III, p. 451); Cornet, 'Verbreitung 
der Tuberkelbacillen ausserhalb des Korpers' 
(in 'Zeitschrift fur Hygiene,' 1888, Vol. V) ; 
Flick, 'A Review of the Cases of Tuberculosis 
which Terminated in Death in the Fifth Ward 
of Philadelphia, during the Year 1888) (in 
Proceedings of the County Medical Association, 
May 1889) ; Trudeau, 'The Therapeutic Use of 
Tuberculin Combined with Sanatorium Treat- 
ment of Tuberculosis* (in Transactions of the 
Second Annual Meeting of the National Asso- 
ciation for the Study and Prevention of Tuber- 
culosis, 1906) ; Hamman and Wolman, 'Tuber- 
culin in Diagnosis and Treatment* (1912) ; 
Norris and Landis, 'Diseases of the Chest* 
(1917) ; Fishberg, 'Pulmonary Tuberculosis* 
(1916) ; Lord, 'Diseases of the Bronchi, Lungs 
and Pleura* (1915) ; Pottenger, 'Clinical Tu- 
berculosis* (1917) ; Brown, 'Symptoms, Diag- 
nosis, Prophylaxis and Treatment of Tuber- 
culosis* (in 'Osier's Modern Medicine,* 1913) ; 
Bushnell, 'Manifest Pulmonary Tuberculosis 
(in Military Surgeon, April 1918) ; Barjon, 
'Radio-Diagnosis of Pleuro-Pulmonary Affec- 
tions* (tr. by Honeii, 1918) ; Dunham, 'Manual 
of the Roentgenological Examination of the 
Chest* (in American Review of Tuberculosis, 
November 1918) ; Walsh, 'Tuberculosis Work 
in Europe* (in Bulletin Johns Hopkins Hos- 
pital, 1906), and 'Folly of Sending Tuberculous 
Patients away from Medical Supervision* (in 
Journal of the American Medical Association, 
3 June 1911), and 'Pregnancy in Cases of Tu- 
berculosis of the Lungs* (in American Journal 
of Obstetrics, LXXVII, 1918) ; Walsh, Wood 
and Thompson, 'X-ray Study of Advanced 
Tuberculosis of the Lungs with Autopsies - 
The Degrees of Density of General Hospital 
No. 17* (in Transactions National Tuberculosis 
Association, 1919) ; Crowell, 'Tuberculosis Dis- 
pensary Method and Procedure* (1916) ; 'Tu- 
berculosis Directory of Institutions and Asso- 
ciations in the United States* (published by 
the National Tuberculosis Association). 
In general it may be stated that the more 
the patient learns about tuberculosis the more 
he will understand the reasons for the direc- 
tions of the physician and the more likely he 
is to carry them out. Every patient who can 
afford it, therefore, should join the National 
Tuberculosis Association (381 Fourth avenue, 
New York City), in order to receive the litera- 
ture accompanying membership. In addition 
the following popular works are recommended: 
Flick, 'Crusade against Tuberculosis. Consump- 
tion a Curable and Preventable Disease. What 
a Layman should Know about it* (1903); 
Knopf, 'Pulmonary Tuberculosis: Its Modern 
Prophylaxis and the Treatment in Special In- 
stitutions and at Home* (1899) ; Brown, 'Rules 
for Recovery from Pulmonary Tuberculosis* 
(1916); Krause, 'Essays on Tuberculosis* (in 
Journal of the Outdoor Life, 1918-19); Carring- 
ton, 'Fresh Air and How to Use It* (1912), 
and 'Living and Sleeping in the Open Air* 
(1912) ; Minor, 'Hints and Helps for Tu- 
berculous Patients*; Walsh, 'Onset of Tubercu- 
losis* (in Journal of the Outdoor Life, August 
1908), and 'Occupations for the Arrested Tu- 
berculous* (in Spunk, August 1919) ; National 
Tuberculosis Association Standard Pamphlet, 
'What you should know about Consumption* 
(1916); Otis, 'Tuberculosis, Its Cause, Cure and 
Prevention* (1918) ; King, 'The Battle with 
Tuberculosis and How to Win it* (1917) ; 
French, 'Home Care of Consumptives* (1916) ; TUBERCULOSIS - TUBUAI 
127 
Galbrcath, (T. B. Playing the Lone Game of 
Consumption5 (1915) ; Hawes, <Consumption, 
What it is and what to do about it5 (1916) ; 
(Nostrums and Quackery5 (published by the 
American Medical Association Press, 1912). 
Joseph Walsh, A.M., M.D., 
Medical Director, White Haven Sanatorium for 
Tuberculosis; formerly Commanding Officer, 
United States Army General 17 
(for Tuberculosis). } 
TUBERCULOSIS, in cattle. See Rinder- 
pest. 3 
TUBEROSE, tu'be-rds or tulfro-z, an am- 
aryllidaceous garden-flower (Polianthes tube- 
rosa). The funnel-shaped perianth, an incurved 
tube, with somewhat rose-like lobes, often 
doubled in cultivation, has caused a misunder- 
standing as to the name, which properly refers 
to tuberous roots, but is generally pronounced 
as if it were "tube-rose.55 The flowers are 
creamy-white, waxen and brittle in texture, do 
not fade quickly, and are extremely fragrant, 
especially toward night. They are borne in a 
raceme at the top of a slender stem, from two 
to three feet tall. This stalk springs from a 
tuft of linear leaves, and is sheathed with the 
bases of others. The tube-rose is raised from 
bulbs, which are not hardy in the northern, but 
are grown for the trade very successfully in 
the southern, United States. 
TUBES, Metal. See Pipe, Manufacture 
of. 
TUBES, Pneumatic. See Pneumatic 
Tubes. 
TUBES OF FORCE, imaginary tubular 
spaces in a field of force, and especially in a 
field of electric or magnetic force, whose 
bounding surfaces may be regarded as made up 
of lines of force. At any point in the surface 
of such a tube, the resultant force has a direc- 
tion that is tangent to the tube. The concep- 
tion is due to Faraday, and is very useful in 
forming a mental image of the physical state 
of a field of force. A tube of force cannot 
have a free end in any finite region of space. 
The tube must either return into itself, or pass 
off to an infinite distance, or terminate upon a 
mass of matter. The total number of lines of 
force included within a given tube of force is 
constant throughout the entire length of the 
tube; and hence it follows that the total force 
at all sections of the tube is the same; the in- 
tensity of a force varying inversely as the 
cross-section of the tube. In the case of an 
isolated electrified sphere, the tubes of electric 
force are radial cones, which converge, in ex- 
ternal space, toward the centre of the sphere, 
but which terminate upon its surface. Also 
called "Tubes of Induction.55 See Electricity; 
Magnetism ; Induction. 
TUBIGON, too-be'gon, Philippines, pueblo, 
province of Bohol; on the west coast; 24 miles 
northeast of Tagbilaran. It is on the coast 
highway. Pop. 15,860. 
TUBINGEN, tii'bing-en, Germany, a town 
in Wiirtemberg, on the Neckar, 16 miles south 
of Stuttgart. The town stands in the midst of 
diversified scenery and is the seat of a national 
university. New buildings have been erected 
in connection with this flourishing institution, 
comprising various medical and physiological 
institutes. The university was founded in 1477. 
The library contains 250,000 volumes. There 
are a botanical garden and fine scientific 
museums and collections, and an observatory. 
Names of celebrities connected with the univer- 
sity are Melanchthon, Reuchlin and Baur. 
There is trade in agricultural produce, wine and 
fruits. Its chief history is connected with the 
30 Years' War and the Reformation. Pop. 
19,076. 
TUBINGEN SCHOOL, a name given to 
two separate and very different schools of 
philosophy, because their founders were con- 
nected with the famous University of Tubingen. 
The old school of Tubingen was orthodox., 
Gottlob Christian Storr, its founder (1746- 
1805), professor of philosophy at Tubingen in 
1775, and professor of theology two years later, 
accepted without reserve the divine authority 
of the Scriptures, and defended miracles. 
Storr severely criticized Kant's book: (Religion 
Within the Limits of Pure Reason,5 and he 
set forth his own system in a work called 
(Theory of Christian Doctrine Drawn from the 
Scriptures.5 The later or modern school is 
that of Ferdinand Christian Baur (1792-1860), 
also professor of theology at Tubingen. Be- 
sides attacking the authenticity of certain of the 
Pauline epistles, he attempted to show that the 
fourth Gospel was not genuine. He admitted 
the morality of Christianity, but denied the 
miracles attributed to Christ and his apostles. 
Although Baur moderated his tone in later 
years his teachings promoted the spread of 
unbelief, and the (Life of Jesus5 by Strauss 
(1832), which attempted to show the Gospel to 
be a philosophic myth, was the outcome in a 
large degree of the critical studies of Baur. In 
1915 there were 2,056 students and 128 in- 
structors, but before the war the student body 
was much larger. Consult Pfleiderer, Otto, 
(Development of Theology in Germany since 
Kant5 (London 1890) ; Nash, H. S., (The His- 
tory of the Higher Criticism of the New Testa- 
ment5 (New York 1906) ; Moore, E. C., Out- 
line of the History of Christian Thought since 
Kant5 (1912). 
TUBMAN, Harriet, negro abolitionist and 
philanthropist: b. in slavery about 1815; d. Au- 
burn, N. Y., 10 March 1913. She escaped from 
her master's plantation in Maryland when 
about 25 years of age, visited Garrison Brown 
and other Abolitionists and became an active 
promoter of the "underground railway.55 She 
first rescued her parents and during the two 
decades before the Civil War made repeated 
journeys to the South and brought a total of 
400 or more of her race to the North and into 
Canada. During the war she served with the 
Massachusetts troops as a scout and guided 
Colonel Montgomery in his memorable expedi- 
tion into South Carolina; By the friendly help 
of Secretary Seward she was able to make her 
home in Auburn, N. Y., after the war, and 
there soon became engaged in philanthropic 
service in behalf of the poor and aged of her 
people. Her efforts led to the Foundation of 
the Harriet Tubman Home for Indigent Aged 
Negroes, to which she gave personal oversight 
until 1908. She married in the South in early 
life a man named Tubman, who died, and 
later married Nelson Davis. 
TUBUAI, too-boo-i, or AUSTRAL IS- 
LANDS, Polynesia, a group of islands belong-