cases equal to five times the number of deaths per year. Undoubtedly the number of living cases is largely in excess of this, but we now know that the number of cases which can readily be recognized as such and which in the cities of Cleveland and Buffalo have been so recognized and placed upon the register for supervision is equal to five times the annual number of deaths. In this state outside of New York City this would mean, if the same standard prevailed, 25,000 cases of tuberculosis under supervision. We have, perhaps, some 50 per cent. of that number.

As to the sanitary supervision of the cases so reported and registered as contemplated by the tuberculosis law of 1908, a less encouraging report can be given. In drafting the tuberculosis law care was taken to preserve to the individual medical practitioner the privilege of exercising sanitary supervision over cases of tuberculosis reported by him, he becoming to that extent the responsible agent of the local health authority. There have been no more loyal participants in the public health campaign, in its general aspects, than the physicians, always ready to attend an individual patient, or participate in any organized movement. They have, nevertheless, fallen far short, both of reporting their cases of tuberculosis and of exercising an adequate supervision over those whom they elected to continue to care for. The same is to be said of many of the health officers. Their aid has been invaluable in the organization of the work for the prevention of tuberculosis, but in the performance of the details of sanitary supervision of cases of tuberculosis, as set forth in the statute, much remains to be desired. It must be said, to the medical profession at large and to the 1,200 health officers of the state, that the greatest contribution they can make to the tuberculosis campaign in the state is to live up to the law, to report their cases and to exercise a real and effective supervision over the cases not removed to hospitals.

The Machinery at Hand.

So much for results accomplished and for those in sight. This is a time, also, to test our working machinery. to consider which tools have proved most effective. wherein our equipment has been found inadequate. what new auxiliary forces need to be organized. Several stand out clearly.

First in importance is the prompt organization of a substantial tuberculosis division in the State Health Department as provided by the statute of 1913. The reporting of cases and the effectiveness of sanitary supervision would have been enormously increased if during all the past five years we had had not only an active interest, but a strong organization in the State Health Department working toward these results. If, as the Governor said, no larger public health opportunity offers than the prevention of tuberculosis, then the State Health Department has no more important division than that for the prevention of tuber

culosis. Without the supervision and leadership of such a division the mobilized forces are bound to work more or less in the dark, in confusion, at cross purposes perhaps, and with diminished efficiency. By the expenditure of a small sum for supervision and leadership the state can enormously increase the effectiveness of the many times larger sums which the counties, the localities and private organizations are putting into the tuberculosis movement.

Perhaps some may have missed the brass band and fireworks which characterized the tuberculosis movement more largely in its earlier stages than at present. They served their purpose and served it well. Publicity now must be more intensive, directed toward the immediate accomplishment of particular purposes. In those counties in which the people have voted on the establishment of tuberculosis hospitals there has been no lack of public enlightenment. Now that we are at close quarters with the enemy no resources can be spared for those general preparations which were essential at the outset. Those who stand on the firing line must have a definite target. When the bullets begin to whistle the band must go to the rear. We have given up counting the attendance at meetings and the circulars distributed; we have more important things to count-nurses, patients and hospitals.

Research Needed.

Up to this time the knowledge as to tuberculosis which has come largely from across the seas, but partly, also, from laboratory workers and social surveyors in this country, has served to guide us as to the essential things to be done. From now on, however, when the nore obvious necessities have already been secured or are clearly in sight, and when it becomes a question of finding the foe in his hidden retreats, of discovering and dealing with the remnants, it is highly desirable that we should greatly enlarge our knowledge by definite research in various fields directed toward various ends. Every encouragement should be afforded not only to research in laboratories, which is of the first importance, but also to studies of the relation of tuberculosis to housing, to occupations, to habits, and to other social factors.

Five years ago I ventured to call attention to the fact that in large matters New York is wont to move slowly, that the State Capitol was thirty-two years in building, that the Education Building consumed six years from authorization to completion, that the Erie Canal was eight years in construction and twelve years in reconstruction. It would have been an extraordinary phenomenon, if we had been able to realize in full our hopes for 1915. We may, however, review the past eight years and rightly feel that, considering the magnitude of the task and the slenderness of the resources, the results secured have been surpassed by no other large public movement and that complete success is assured for the near future.

My efforts to bring better sanitation to the Philippine people have kept me out of the country for so many years that I doubt very much whether I am in close enough touch with what is being done in the United States to say anything which is of real value. As I have traveled about in this country, however, for the last few weeks since my return, I have remarks like this continually addressed to me: "Are you not very glad you are now again in a country where you are not exposed to those terrible risks that you had to incur in the Philippine Islands?" And I say "No. On the contrary I really live in the United States in fear and trembling. In the Philippine Islands, it is true, we have cholera, we have plague at times, we have amoebic dysentery and other diseases the names of which sound terrifying. But we know the prophylaxis for these diseases; we know how to prevent them. Whereas in this country, I am sorry to say, not as much progress has been made in the field of prophylactic medicine as in the tropics. How may one avoid scarlet fever or rheumatism or pneumonia? Sad to relate, no one can give a satisfactory answer to this question.

From that experience I am encouraged to bring you a few of my experiences in other countries. We are so prone to believe in the United States that we are the last word, the most modern and up-to-date people in the world. I have just visited almost every country in the eastern hemisphere and found many things there which might well be adopted by

us.

I think one of our great troubles is-and we have heard it here this afternoon-that we have a great deal of law, we have still more talk, but we have very little application. I have spent considerable time during the past ten days on sleeping cars. And I have had

An address given before the Second North Atlantic and New York State Conferences on Tuberculosis, Albany, November 5, 1915.

FOUNDATION.

almost to fight with every porter I have met about opening the window in my birth. They say: "No one asks us to open a window during the cold months." After some persuasion, they attempt it, but from lack of use the windows usually cannot be budged except with an implement that resembles a crowbar.

I feel that another thing which makes it difficult to make progress with the problem of tuberculosis in the United States is not so much that you cannot move the ignorant masses, but that the more intelligent people do not set a good example. If more people would open their windows the poorer classes would follow the custom. For the last five mornings I woke early in sleeping cars, and I have particularly watched houses in Pennsylvania, Ohio, Michigan and New York State, and I am sorry to tell you that between the hours of 6.30 and 8.30 in the morning, although I diligently looked, I did not see one single, solitary open window. I do not think that speaks well for the people of the United States, and that applies to the more intelligent classes.

Now let us see what they are doing in Australia. I was very much surprised during a visit to that country to find a death rate of only 8 per thousand. That is for the whole of Australia. The explanation seemed very simple. There the people come to the country in the prime of life and the birth rate is low; so naturally you will have a low death rate. I knew that fact might account for some of it, but I was shown figures fifteen years back when they had a death rate as high as the death rate in this country, and I was shown the figures for ten years ago, and later, all showed a steady decline. This wonderful showing is the result of intelligent health laws and their observance. Let me state what they are doing in tuberculosis.

Take the State of Victoria. They told me that they had isolated every case of tuberculosis in the State of Victoria. I said, "That

sounds very well, but I would like to see some of your work." I found it was as they reported. They do not put laws on the statute books there that they do not observe. They enforce their laws. First of all a statute is nearly always a good law. Before Australia adopts any measure it is their custom first to send out a man to collect information from the entire world with regard to what has been done. They then adapt this experience to suit their conditions, and then they enforce the law they enact.

They go about enforcing isolation of tuberculosis cases as follows: The State tried force, but it did not work. Finally it occarred to them that they needed the wholehearted cooperation of the medical profession. So they passed a law which provided a fee of 10 shillings ($2.50) for every case of tuberculosis which is reported. Note the difference in this country; we threaten the doctor with the law if he doesn't report a case of tuberculosis. There they pay him for his report. In a short while they had the cooperation of the medical profession. That cooperation proves valuable not only to get the first report of a case, but in furnishing later information with regard to it. As soon as a report is received the Health Department sends a physician to the house where that case is, and he states that they understand there is a case of tuberculosis in the home. That the law gives the authorities the power to isolate the case in a sanatorium. If the family are willing to provide specified conditions under which no harm nor danger can come to others, the case can remain at home. The patient is then given a card upon which are printed certain definite rules. The case is then put upon probation. Those rules briefly are as follows:

An open air sleeping porch satisfactory to the inspector of health must be used. The patient must agree to take care of his sputum; to use individual dishes, knives, forks, and to observe those other precautionary measures with which we are all familiar. The patient is told that if it comes to the attention of the health authorities at any time that he has violated any of these rules on two occasions,

he will not be asked whether he wants to remain at home, but he will be taken by due process of the law to a sanatorium, and will be kept there until he is no longer a danger to anyone else. During this period while the patient lives at home an inspector calls regularly.

But they carried their measures even further. Although they are very anxious to induce immigrants to come into Victoria, all such persons have to pass a physical examination and be certified by an official Australian medical officer that they are free from tuberculosis. In the city of London a medical inspection bureau has been established in order that emigrants may ascertain whether they are physically eligible to enter Australia. So you see they are not only eradicating the disease, but have provided against re-infection.

I have recently been advised that the enforcement of these rules in the State of Victoria has resulted in the disappearance of tuberculosis.

Yesterday afternoon I had the pleasure of being with Professor Vaughn at Ann Arbor, and I asked him what the State of Michigan was doing about the tuberculosis problem. He said he was glad he was able to report that in three counties they had made a houseto-house inspection and have examined all the people in those three counties; and for those infected with tuberculosis they are just making arrangements for their isolation either in their own homes or in a sanatorium. to me was indeed very, very encouraging.

That

Now let me tell you just one more thing about Australia. A large percentage of the people of Australia are sleeping out of doors. The public has been educated up to that point. I would like to ask how many people in this audience are sleeping out of doors; how many people who came here in sleeping cars had the window open while sleeping? I see there are very few responses.

In conclusion let me ask one question: If it is possible for Australia effectively to control tuberculosis, why shouldn't it be possible for United States to do so?

Consequently it is necessary for us to engage the enemy on a broader basis, and that is, by taking into consideration the correlative factors that are preventing further progress in the arrest of the mortality rate.

Now these factors practically make our fight from now on, a broad sociological problem, that must be worked out by a higher type form of calculation based upon algebraic rather than arithmetical conception; that is, we cannot longer deal with a narrow, concrete, individual condition but must analyze its component factors and inspect their true relationship to a greatest common divisor, in this case their contact point.

Furthermore, we must take due cognizance of the well and try to establish in all such an ever increasing immunity by teaching them the important but simple factors that make such immunity possible, namely, pure air, sunshine, nourishing food, and careful, periodical health inspection.

Today the value of life, effort, business, in fact all human action is measured in terms of relational value; the service that is rendered determines its importance in the "Land of the Things That Shall Remain." Service again to be most valuable must be founded on intelligent action. The resources of intelligent action are system and system means organization. The organization in order to consider effectively the point at issue, must consist of the following bureaus :

1. Information Bureau: This means a Sanitary Survey to realize the exact extent of disease and its relation. Fortunately for our state such a measure is assured.

The sanitary survey should lay especial stress on actual condition of surroundings where cases are found, this alone will give a working basis for a comprehensive program to be outlined for our organization. For example, if Survey corroborates the one in Wisconsin it would bring out these points:

One-third of the cases of tuberculosis are not clean, which means training in new methods of living.

Thirty-one percent sleep in one window bedrooms and many more in bedrooms with north window exposure. This indicates that the Housing Committee must redouble its efforts.

Fifty percent have bad ventilation, this means our publicity committee must issue convincing literature with illustrations, all in plain form.

2. Exchange Bureau: This for comparative work from outside units of investigation similar to our own, and also those not directly in our line such as Public, Institutional and Police Records, Charity Committee Findings and Social Investigations.

3. Investigating Bureau: This to check up work, weed out useless or exhausted lines of action, and build new relationships and lines of endeavor.

4. Bureau of Standards: This will classify, eliminate and simplify all work of the three

foregoing bureaus so as to make it applicable for instant use.

5. Bureau of Distribution: Which through publications, travelling libraries, correspondence classes, visiting nurses and lecturers will disseminate all knowledge of general interest acquired through the above sources.

The question of preventive medicine after such survey are summarized so forcibly that any person could easily be induced to establish his interest with us because we have a convincing classification of facts which really show that it is poor business to allow the average family to spend eighty-eight dollars a year for preventable diseases. Thus we have won his working capacity to aid us not on a basis of charity but that of good service. Let us trace the question of relationship of health to disease from the standpoint of con

tact.

1. This had its origin in the dawn of history where very early we find people trying to solve the problem by isolating the well.

2. This, however, soon became so complicated that it occurred to them at a later period that it might be simpler to isolate the sick and if necessary remove them.

3. However, this did not prove satisfactory so it led to investigation productive of the discoveries of modern times resulting in attempts to isolate or neutralize the cause and soil, making it impossible for the disease to thrive.

4. As the true cause of disease has dawned on us, we find that a new proposition is established, namely, that of the abnormal individual.

5. The last step follows logically, the close relationship between disease and the abnormal individual sets up the problem that every disease is more or less dependent or complementary to our efforts expended on every other disease or abnormality either in individuals or the whole social fabric. In other words we cannot eradicate one disease without taking into consideration its relationship to every other disease as well as conditions surrounding it.

While Tuberculosis in itself is a serious menace, still it is true that tuberculosis successfully attacks only a minority of us. While it is true that late and careful statistics show that a majority of mankind at sometime may have been infected it is also equally true that it is the healed scar that proves this. While we possess a natural immunity against this malady this is not true of many other diseases and conditions, and because of these other diseases and conditions aiding in tearing down the human economy perhaps even the healed scar we find that this will eventually decrease the natural immunity of the race toward tuberculosis, therefore it is essential that we bestir ourselves and definitely outline the trespassing factors.

If our commonwealth is to be tolerable to, and interested in, our work to a greater extent than it has been, it is for us to arouse in them the very startling and disquieting sense