condition. It is for the friends that we will make for this cause-for the enlightenment that we will carry to the people, and for the faith and hope that we will instill in the press and the public as we near the goal. If it were simply money that we sought, the national target could be multiplied by ten and it would not deter those who have the guidance of this effort in their hands. But it is not the money-we are asking for exactly what we can wisely and effectively use to press forward, in 1920, the message of the National Tuberculosis Association. It is the better understanding with the public that we are intensely interested in, with our message clarified and rooted deep into the hearts of our people, and then secondarily we are interested in getting a fund large enough to permit of our work going forward without hindrance in the months to come.

The press is ready and in a receptive mood-we have evidence of that. The material with which we shall seek, conservatively and wisely, to inform the people, is compiled and available. The men to do the work, trained in their various branches of endeavor, and of proven efficiency, are either at their posts or on call. The great tide of soldiers and nurses from overseas is sweeping back upon us. The dispatches carry almost daily reports of the desperate condition. of the underfed, half-frenzied people of Europe, now trying to readjust themselves to the emergencies of peace. It all finds us-ready!

In the coming campaign, an outline of which has already reached your hand, and details of which will now rapidly follow, we are relying on every member of this association, every employee and every associated friend, to do simply their part. They have done it before, and splendidly; but never before was the opportunity so vast and so wide open. Never before was the iron at such a white heat. Never before was there such strength in our arm to hit-to strike the blow for liberation from the menace of the White Plague!

The little Red Cross seals will carry the message. The press will do its full share. By an intensive system never before resorted to, and applied wherever possible, the United States of America will be told the story of Warning and of Hope, while at the same moment the fund with which to carry on this work for the coming year, will be gleaned. The spirit of this whole program is that a service must be rendered for the people, to the people, and and the people themselves must be brought to realize that we are able and willing to give them just that service!

And so it is with a consciousness that the emergency of war has brought to us the great emergency of peace, and that we have really been preparing all these years to meet just this crisis, that we step forward equipped with a rational, workable plan and program, and bid those who sit and wait in the shadow of death that we are advancing to their rescue!

Even in 1891 the Folsom physician comments again about tuberculosis. "Accidents, injuries, and deaths have been numerous, but the causes therefore are too patent to require much explanation. Apart from the casualties due to carelessness and contributary negligence, the action of the courts, the recommendations of health boards, and other presumptuous influences have implanted upon us during the past year all the diseased and afflicted humanity during the past year they

possibly could, and ripened fruits thereof are to be found in this report. And it is needless to say that the upas tree is still in bloom, giving promise of another rich harvest for the Grim Reaper during the coming year."

An analysis of the mortality report discloses these important facts: "that 33%, or five of the deaths, were due to phthisis, chronic cases of long standing, all of them." And in 1894 he makes similar comment: "An examination of the hospital records for 1893-4, the year just ended, shows that but six deaths occurred during the year, being at the very unexceptionally low rate of 8.73 plus per thousand. One was from accident; four from chronic diseases of long standing; leaving but one, as in the year previous, due to a symotic disease.

"And this is in the face of the fact that the courts have continued their beneficent efforts in sending the consumptive criminal to Folsom to die; for the large number of cases with which our report is due to the action of the State Board of Health, which body some two years ago recommended that our courts should send all their pulmonary afflicted offenders here. In nearly every case must this advice have been heeded, for we have been taxed to the utmost with the care and treatment of more diseased and debilitated humanity than any other like institution in the country."

Dr. I. L. R. Mansfield, the Resident Physician, in his report to Warden Hale of San Quentin, for 1895, writes: "When it is borne in mind that a large percentage of the men committed to a penal institution are suffering from chronic ailments of some form or other -usually the result of previous vicious habits and unwholsome conditions of life-the mortality among the inmates must be regarded as unusually low. Phthisis pulmonis (consumpbegan in February, 1913, at which time I was tion) has been, as heretofore, the principal cause of death. In nearly every instance, however, those who have died from this cause contracted the disease prior to their admission to the prison, and several were in the last stages when they entered the institution."

The Board of Prison Directors in 1902 were greatly exercised about the crowded condition at San Quentin, not from the standpoint of health, but from a disciplinary and correctional point of view. In their communication to Governor George C. Pardee, the Board writes: "In California, prisons are conducted under what is known as the congregate system, and nearly all the evils under which our prisoners suffer are traceable to the system of prison management. . . . At San Quentin, we have nearly 1500 convicts and only 600 cells, necessitating the placing of five and six convicts in one cell, and, in one instance, fortyfive in one of the larger rooms." Apparently they did not realize the deleterious effects on health of this condition, or if they did, they put that secondary to discipline.

Again in 1904, the newly appointed Warden, J. W. Tompkins, brought out again the crowded condition, commenting that "prisoners crowded together in this manner have ample opportunity to plot and scheme, and even commit felonies without detection. When inmates are in the upper yard, where they are forced to congregate on Sundays and holidays, the limited space makes it almost impossible for them to move about, much less obtain the exercise the physical condition of many of them demand."

Dr. P. F. Casey, in the same year writes: "We have fortunately been free from any epidemic diseases. The death rate from all causes has been small, considering the population handled, being only thirty, including executions, in a population of over two thousand. I would call your attention to the large percentage of diseases of the respiratory organs, about 50% of the deaths occurring having been from tuberculosis. . . . The bad ventilation of the jute mill causes the air to be full of fine particles of dust which injure the air passages, leaving a fertile field for the tubercle bacillus. I would suggest that some form of suction of ventilator be installed over the large dust producing machines to draw up the dust and discharge it into the air over the roof of the mill."

From 1904 to 1913 little was done for the betterment of the health of the inmates, although from 1909 on, an effort was made to perform necessary surgical operations. This was accomplished for the most part by visiting physicians, who rendered their services gratuitously. The surgical equipment was very crude, and comparatively little was done.

My personal experience with San Quentin appointed Assistant Resident Physician. If the surgical equipment was designated as being crude, the care of the tuberculous was primitive, even worse than crude.

At this time there were about twenty patients with active tuberculosis, treated, or rather, housed, in two small rooms on the top floor of the so-called "Old Hospital" which was built in 1859. The ventilation was abominable, the beds were crowded together, air space was extremely limited, a few old-fashioned windows, low and narrow, let in a very little light. The walls were of a dark hue, making the rooms cheerless and foreboding. Whites, Negroes and Indians commingled here indiscriminately. The surroundings were extremely sordid. Here, crowded in abject misery, lacking the essentials for cure-light and air-were these diseased prisoners, coughing, and too enfeebled for the most part, to leave their beds. To add to their discomfort, a dilapidated toilet and unsanitary bath were screened off in one corner by a shell of a partition, while in the center of the room a coal stove gave those men who were able the opportunity to cook the rations of eggs, or other food, they were allotted. These priosners were visited about once a week by the resident physician, although an inmate doctor

stayed in this ward most of the time and ministered to the men as best he could.

The so-called "New Hospital" was a hospital in name only, for the wards were dark, there was no equipment worthy of the name, and one large room on the ground floor served the purpose of a dental office, surgery, dressing room, clerk's office, and general utility

room.

The sanitation of the prison was good, however, for the most part, although the cells were overcrowded and one large room on the top floor of the furniture factory served as a dormitory for about 100 men. No satisfactory ventilation was provided for the cells. The new prison of modern construction had not yet been completed.

Only a few men were kept locked up all the time, there being the so-called "incorrigibles" about ten in number, who were kept in small wooden cells well guarded, for periods varying from six months to years.

After my appointment as Resident Physician in August, 1913, free hand was given me in the hospital management and I was enabled to bring before Warden Hoyle a large number of recommendations for the improvement of the hospital facilities. The Warden approved these plans, but resigned his office before any of them could be acted upon.

J. A. Johnston became Warden, and with his appointment came aid unbounded to the Medical Department. He had held a similar position at Folsom prison for some time, and had become thoroughly convinced of the importance of health measures in prison management. With his arrival a "renaissance" or awakening, took place. He believed that it is useless to attempt to reform a man morally or mentally, until his physical condition is attended to.

Of course, the tuberculosis problem was the first to be attacked, as its importance was of the greatest. To have continued the old tuberculosis ward would have been a crime. Accordingly, a modern open air tuberculosis hospital was built on the flat roofs of the "Old Hospital" and Library building, which joins the "New Hospital." It covers an area of 4800 square feet, and is arranged in the form of two adjacent quadrangles, with concrete floored courts in the center. Surround

ing these courts are the sheltered wards, enclosed by many sliding windows on the outside, and French windows and doors into the courts. In these wards are high iron beds, with sufficient sheets and blankets as well as a canvas spread. Near each bed is a stand.

The whole structure is electrically lighted, has modern plumbing with shower baths, toilets, and lavatories. On summer days the wards may be thrown entirely open, allowing plenty of sunshine and air constantly to fill the place. Valuable suggestions, encouragement, and help in building the hospital were given by Drs. G. R. Hubbell, R. A. Peers, L.

S. Mace and many others interested in this problem.

Even before this open air hospital had been completed, the medical department had begun to make a thorough physical examination of every man who came to prison, in addition to examining cases which appeared to be possibly tuberculous, among the older prisoners. In this way many cases of tuberculosis were discovered as soon as the man entered prison, and many were found among the older prisoners. With this system, instead of having twenty cases under treatment, the number grew until the hospital designed for sixty prisoners was nearly full. As soon as a prisoner is suspected of having tuberculosis, he is immediately placed in the medical ward, where examination is made, sputum tested, temperature chart kept, x-ray pictures taken, and other means employed to make the diagnosis.

Because of the good facilities for caring for tuberculous patients at San Quentin, the Board of Prison Directors in 1915, decided to send all afflicted prisoners from Folsom to this place for care and treatment. About 40 have been transferred during the past three years.

Early in his administration, Warden Johnston abolished the solitary confinement of incorrigibles, and at the present time no man is kept shut away in a cell for a long period of time. As a light on what close confinement may do, it is worthy to note that of the dozen or so incorrigibles confined after the riot in 1911, two of them developed tuberculosis, one dying, and the other making a good recovery after treatment in the open air hospital.

The general sanitation of the prison has been improved in the past few years. Eight hundred single cells, of modern construction, have been built. The cells in the old prison have been equipped with fan ventilation, which pumps into each of them 28 cubic feet of air per minute. Electric lights have replaced the old air consuming oil lamps. And various suction devices have been installed in the furniture factory to draw away offending dust.

The treatment accorded the patients suffering from tuberculosis has been, for the most part, that of rest, air, sunshine and food, although Dr. Hubbell, who formerly visited this prison weekly, administered tuberculin with satisfactory results. On selected cases, artificial pneumothorax has been a therapeutic agent, and some cases have reacted favorably. A glance at the accompanying charts will show that although the prison population is increasing, the morbidity is on the decrease, and that the death rate from tuberculosis is less than in former years. The death rate from tuberculosis at Folsom is nil, because such cases are sent here, while the San Quentin death rate is much lower than former years.

On the whole, the progress in combating this disease in the past five years is encouraging, and shows what can be done if effort is expended.