seeing that his health is maintained. The benefit to the 60 patients, though of great moment to them and an economy to the Committee, is quite unsubstantial in comparison with the tremendous value our experiment may possess in pointing the way, on a comprehensive scale, for the return of a large proportion of the afflicted to a selfsupporting condition.

In submitting our experience in this hopeful light, it should not be inferred that we believe it to be conclusive. Nor would we underestimate the value of sanatorium care. Though the sanatorium must not be considered the be-all and the end-all in the struggle against tuberculosis, it has made a distinct contribution and will undoubtedly remain an important factor so long as the treatment of tuberculosis is not changed in revolutionary fashion. Errors have, of course, been made and are being made by sanatorium authorities in their failure to utilize their plant to the fullest extent. Their failure to discriminate among various classes of patients is pretty well recognized and some of the old theories with regard to the kind of patients to be admitted have been exploded. As a means of preventing infection they have proven well-nigh useless because the patients admitted have been the least dangerous from the point of view of infection. As a means of permanently improving the patient's health, the recent investigations that have been made, like the one referred to, have shown that they have performed only part of the job. Where they have failed to provide opportunities for work of some kind, they have wrought a distinct injury by encouraging idleness. Moreover, the fact that they provide for only a negligible number of sufferers indicate convincingly that they constitute an inadequate means of combatting the scourge. The cost of providing sufficient sanatoriums is prohibitive.

So long as remedial measures are necessary, the work of the sanatoriums must be supplemented and complemented. The brunt of the responsibility must rest upon those agencies like the clinics and the relief societies and the social service agencies that deal with the family in their homes. In the light of the indication that home treatment can, for some time, maintain the health of the patient, can, in large measure, prevent the development of active tuberculosis in others, and can bring about, in some degree, the economic rehabilitation of the family, the inadequacy of the sanatorium treatment should not be considered unduly discouraging. Home treatment is less expensive than sanatorium treatment; even the combined home and hospital undertaken by the Association for Improving the Condition of the Poor is considerably cheaper.

The community must realize, however, that a generous policy of relief must be adopted and consistently carried out if the home treatment is

to be made effective. It is generally known, I believe, that the relief disbursements of the United Hebrew Charities are as generous as that of any other large relief society in the country, and yet it has been found necessary to grant the families under the care of the Joint Committee, who were in need of material aid, considerably higher allowances. But even at this, the cost of home treatment need not be considered prohibitive.

It may be that further experience of the Committee will demonstrate that equally effective work can be accomplished at less expense. Accurately defined standards of relief were not established by the Committee during the experimental stage, because it was considered desirable to deal freely with the patients and the families in this regard, and the inquiries made into the families' own resources were not as closely scrutinized, perhaps, as is being done by relief agencies. We are now contemplating making studies of the progress made by various relief societies with their tuberculous families in comparison with those made with the families under the care of our Committee, in order to determine whether less expensive standards of relief and service can be established. This may not appear important to those whose primary, and perhaps sole interest, in the subject is the health of the patient. I have sometimes found persons impatient of such considerations, but the practical aspect of it must appeal to those who would like to institute a comprehensive plan of home treatment, one that would reach out to every sufferer in the community.

Nor must it be inferred that our Committee have not been fully cognizant of the limitations under which all of us are working in the struggle against tuberculosis. All of us realize that the combined work of all of the agencies is making only a slight impression, that circumstances over which we have little, if any, control must be completely altered for any substantial impression to be made. We realize, too, the uncertain and changing state of knowledge with regard to the etiology of the disease and its most effective remedies. This discouraging situation exists with regard to other social evils as well, and until their causes can be removed we must continue and do the best we can, even under the limitations imposed upon us. A union of all of the agencies, the sanatoriums and preventoriums, the hospitals for advanced cases, the tuberculosis clinics and camps, the relief agencies and the social service organizations, and last, but not least, the mutual aid societies of the working people themselves, such as unions and fraternal organizations, each with its functions well defined, may constitute a combination of forces that will present a formidable front to the enemy, and though it may not vanquish him, will help to weaken his

attacks.

Although there has been a most gratifying decline in the death rate from tuberculosis in the City of New York, still there were last year 22,141 new cases registered in the city. That means between 7 and 8 registrations for every office hour of the day. Last year 8,825 persons died of tuberculosis in the City of New York, that is one every hour of the twenty-four. There is spent between two and a quarter and two and a half million dollars a year from public and from private funds in the city in the care, control and prevention of tuberculosis. Tuberculosis still constitutes, therefore, a great health and financial problem for the city, even though the death rate is declining,

The two main plans of dealing with tuberculous cases are: First, institutional care in hospitals, homes, sanatoria and preventoria, which is chiefly medical; and, second, home care in clinics and in the patient's own home, which is partly medical and partly social service, including material relief. It is not my purpose to discuss the relative importance of these two lines of work, but in my opinion both are necessary and desirable. It is not my purpose to consider the institutional care, but to confine myself to the home care of tuberculosis. Furthermore I shall not consider all aspects of the home care, but only those that may be classed under that rather vague term, "social" care, which, for the purpose of this paper, may be defined as efforts to assist a family to realize good health, satisfactory employment, practical education, wholesome recreation and vital spirituality.

Outside of such experiments as the Home Hospital, home care consists of the examination and re-examination of persons at the tuberculosis clinics, home visits by nurses and social workers and material aid through the clinic auxiliaries and organized charities. In this home care the city itself spends for medical and visiting nursing care approximately $377,000 a year. The auxiliary committees of the dispensaries spend in relief approximately $47,000, and the private charitable societies for relief and service about $265,000, making a total of $689,000 for home care of tuberculous cases in a single year from both public and private sources. It is evident that the home care of these cases is a problem of great magnitude, and it would seem to be worth while to consider some of the handicaps in this home care. I shall not, however, consider the clinical or medical problem itself, but rather the social or social service problem in the home care of tuberculosis.

* Read before the annual meeting of the New York Association of Tuberculosis Clinics, April 27, 1916.

The first handicaps in the social care of tuberculosis to which I ask your attention are handicaps in the families themselves. Many families are eugenically unfit and cannot be made fit by any amount of social care, be the material relief ever so generous and the service ever so expert. To use a figure from the potter's trade, they are "warped past the aim." They are "seconds." This difficulty is found more generally than is admitted in general relief work, and is probably present in more families in which there is tuberculosis than we are accustomed to think. I am more and more persuaded that it is absolutely useless to prolong the ordinary social care in cases of distinct feeble-mindedness, epilepsy, insanity, alcoholism, and syphilis. If to these stigmata of degeneracy tuberculosis is added, there exists a handicap to the social care of the patient or family which is almost insurmountable. It is almost as difficult to succeed with families that are chronically insufficient or stupidly unteachable.

Furthermore, many families are so exhausted when they come to the attention of the tuberculosis clinics that it is extremely difficult, if not impossible, to rehabilitate them through social care. They are broken down in health, they are industrially dependent, they are not practically educated, they lack the tonic of recreation and spirituality. A recent study of 35 tuberculous relief families returned a most discouraging list of physical and social disabilities.

Of 34 men, 20 were physically below par from causes other than tuberculosis, 18 were industrially below par, 9 were alcoholic, 7 indifferent, 4 cruel and abusive, and 2 were deserters. Of the 37 women, 22 were physically below par from causes other than tuberculosis, 8 were inefficient in their home, 5 were indifferent, 4 alcoholic, 4 immoral, and I feeble-minded. Of the 164 children, 19 were physically below par from causes other than tuberculosis, 4 were unruly, while 10 others showed various disabilities such as irregular school attendance, backwardness in school, premature employment, etc.

When degeneration exists or exhaustion has arrived, or when one is added to the other, and the situation is complicated by trade irregularity, unemployment, widowhood and old age, there is nothing to do but to have mercy. There is no restoration. When to deep-seated and inherited weaknesses you add the last extremity of need in the face of hard conditions, nothing short of a miracle can restore the family.

The second class of handicaps to which I ask your attention is handicaps in the homes. To save any family that lives in a bad house is like

rowing up stream against the current, and if the family is tuberculous it is as if your boat anchor was dragging. Dark rooms depress the spirit of anyone, but they are especially heavy upon the sick and are a positive ally to tuberculosis. In a recent study of 138 families in the care of tuberculosis clinics, it was found that almost half of the apartments had dark rooms and that one-fifth of all the rooms were dark. Unsanitary plumbing and vaults are unhealthy, overcrowded rooms mean not enough air, while at the same time they facilitate infection. Home-work aggravates those conditions. If these elemental requisites for a decent home are lacking, the time, effort and money expended on home care of tuberculous cases cannot be expected to produce results. Money spent on makeshift families in makeshift homes can achieve no constructive good and may easily degenerate mercy into pauperization.

The next class of handicaps to which I ask your attention is found in the very nature of the case. It is well known that it is difficult to persuade a patient to go to a tuberculosis clinic for examination. This may be partly due to the toxic and mental effect of the presence of tuberculosis itself. And when once the patient has presented himself for examination all too frequently it turns out that there is no opening for him in an appropriate institution. Sometimes there are conflicting diagnoses of the case, and the patient is always quick to urge this as a reason for delay or an excuse for not beginning treatment. In like manner it is difficult to get other members of the family examined. But as the fear of tuberculosis is being more and more dissipated, the difficulty of persuading patients to be examined should decrease. When once a patient has been admitted there is not at present adequate power or authority for detaining him; hence he is likely to discharge himself on flimsy excuses.

In a cosmopolitan city like New York, the ignornace of our language and customs on the part of many foreign families makes it difficult to persuade them to be examined and to accept and follow out proper care. Many of these families of foreign traditions are accustomed to a lower standard of living than will maintain good health in New York City, and it is, therefore, a slow process to fortify them against the ravages of tuberculosis.

The economic pressure that continually rests upon a large portion of the wage-earning families in New York City makes it difficult at any time for them to maintain a satisfactory standard of living. This pressure is greatly increased if the care of a tuberculous person is added to the budget of the family, and it becomes almost unbearable if it is the male wage-earner who contracts tuberculosis. If, after a lingering illness, he dies, leaving his widow and children with no savings, and tuberculosis develops among some of the surviving members of the family, the load becomes overwhelming. The range of work available for the family is greatly restricted, with the result that the income is lower and the family is ground between the upper millstone of greater needs and the lower millstone of less income.

To these difficulties is often added that of securing prompt and adequate material relief. The number of cases is so great, the tradition of independence on the part of the families is justly so strong, and the plan of adequate and continued aid is so expensive, and the charitable resources available so limited, that it becomes extremely difficult to secure immediate and adequate assistance for the social care of tuberculous families. This brings me to the two remaining classes of handicaps of which I wish to speak, namely, first, the difference in point of view, or the divided responsibility between the tuberculosis nurse and the social worker, and, second, the lack of funds.

I do not speak of incidental disagreements between the nurse and the social worker, but of a fundamental difference in point of view and purpose. For example, the tuberculosis nurse is interested primarily in the fact of the absence or the presence and development of tuberculosis. This the tuberculosis clinic gives her. The social worker, however, is interested primarily in the other disabilities of the patient and the family. These the tuberculosis clinic does not give her. Even though these other disabilities are suspected by the tuberculosis clinic, no serious effort is made to determine them, and if they were diagnosed there is no assurance that they would be followed up by the tuberculosis nurse. She can hardly be expected to do all this. She moves along the main line of tuberculosis treatment. The social worker wants treatment for all these disabilities, and must move along all these lines.

The nurse fixes her eye on the medical problem, and considers relief only as an aid to the recovery of the patient. She feels that she is in a position to know better than the social worker when, how much, and how long relief should be given. She often feels that the relief is refused by the social worker when it should have been given, and that when given it is often belated, meagre and uncertain. The social worker believes that the nurse asks relief on sentimental and not fully-determined grounds. She believes that relief based on a health need alone may prolong dangerous situations such as desertion, nonsupport, drunkenness, and mental defectiveness. She believes that where there are many disabilities, no single-track plan, even though it be the road to health, will arrive at the terminal of family rehabilitation. To the nurse relief is a health measure, to the social worker it is a means to the economic and social re-establishment of the family as well as a means to health.

Undoubtedly, there are some readjustments which can be made between the tuberculosis nurse and the social worker in this matter of material relief. An appreciation of the point of view and method of the nurse by the social worker would be very helpful. A social-work training for the nurse would be of great value in promoting sympathetic understanding and cordial co-operation. We should require nothing less than these things from both classes of workers, but when this has been done, and it must be done as speedily as possible, there will yet remain a divided responsibility for the giving or the withholding of material relief so long as

the present division of labor continues to exist between the medical social service on the one hand and the family social service on the other. It may be that a working solution of this difficulty can be reached by defining the proper jurisdiction of the two groups of workers, but the one theoretically complete answer is that the public health agency should be given adequate funds to do, and should do all that both groups of workers are now doing in the home care of tuberculosis, thus ending the divided responsibility and placing it squarely where it belongs, on the community itself. There are serious, practical difficulties in the way of the speedy attainment of this end, but I see no sufficient reason why the private agencies should not be willing to have the public health agencies give this relief, providing it can be wisely done, and I believe it can be wisely done.

Moreover, public health, care, and prevention, is a state function, and as the factors demonstrably necessary to the successful performance of that function emerge, they in turn become proper charges upon the public funds.

Not only does it seem to me a perfectly legitimate duty of the state or local government to care for the sick and to promote the public health, but it is also evident that it is impossible to raise sufficient funds for this purpose from private sources. The amount of $689,000 a year now spent in home care of the tubercular from both public and private funds in New York City is still inadequate. So is the $1,750,000 spent for institutional care. How much more money is needed no one at present knows, but the amount raised from private sources cannot be indefinitely increased.

In closing let me say that in my mind this is not fundamentally an argument for charitable relief. To me such relief is incidental to a larger program that includes a living wage first of all, and adequate health insurance to which the state contributes. Until we can realize these more excellent things, adequate relief funds should be available so that we may get 100 per cent efficiency from our social care of tuberculosis.

JAMES ALEXANDER MILLER, M.D.

President

CHARLES J. HATFIELD, M.D. Secretary

Many inquiries have reached the JOURNAL OF THE OUTDOOR LIFE as to the status of the bill introduced into Congress during the past winter, and known in the House as the Kent Bill, providing for federal subsidy for certain hospitals caring for indigent alien consumptives. The work in favor of this bill is being carried on aggressively. Its advocates seem to feel that there is a chance that it may pass; those who do not approve of it see no chance of its passing.

There is an interesting difference of opinion as to the merits of the Kent Bill on the part of sincere and thoughtful workers in the anti-tuberculosis cause. It is by no means a difference between East and West. This is shown conclusively by the answers to the question forwarded to a number of leading antituberculosis associations of the country as to whether the board of directors of the association in question favored the Kent Bill. There were thirty-four answers in the affirmative as compared with fourteen in the negative. Of the affirmative answers nineteen were east of the Mississippi River and fifteen were west of the Mississippi. Of the negative answers, seven were east of the Mississippi and seven west.

The differences of opinion are based entirely upon the economic viewpoint. At the Washington meeting of the National Association the opinions of the Colorado workers opposed to the bill were effectively presented. It would seem that from their point of view federal subsidy in the form prescribed

by this bill would increase the burden of the health resorts and not assist them. The American Association of Societies. for Organizing Charity at the meeting in Indianapolis in May adopted resolutions opposing the passage of the bill "because it would increase the amount of lonely and neglected misery." Another objection has been based upon the danger of instituting a policy of subsidy from federal funds to institutions not under federal management. So much trouble has been caused in various parts of the country by similar practices that students of the question feel strongly the necessity of avoiding this danger.

The opinion of the National Association as a body seems to be that free discussion of the question will ultimately bring a suitable solution. The opinion of the directors is expressed in resolutions adopted in January of this year by the Executive Committee and later confirmed by the Board. These resolutions provide for an endorsement of federal participation in tuberculosis work, the request for a division of tuberculosis in the U. S. Public Health Service, the suggestion that an advisory council of the Public Health Service or an independent commission for the study of tuberculosis be appointed and financed by the Federal Government, and an offer on the part of the Association to help in any way the measures adopted by the Federal Government.

If the Kent Bill is passed, the Association will make the best of the measure and assist in every way in its proper