been done in France. While the hygienic conditions prior to and during the war cannot be considered superior to those in France, the milder climate in the greater part of Italy and particularly the greater number of sunny days were doubtlessly responsible for a relatively smaller tuberculosis morbidity and mortality than would be the case were it less favored by the natural conditions which are conducive to the prevention and cure of tuberculosis.

Valuable additional information concerning the tuberculosis situation in that country has come to me through the courtesy of Col. Homer Folks, former Charity Commissioner of New York City, who has just returned from an extensive visit to Italy, Greece, and Servia, where he investigated the general economic and sanitary conditions of those stricken countries. The tuberculosis situation in all these countries is exceedingly grave. He reports an increase in the tuberculosis mortality of 17 per cent. throughout Italy from 1914 to 1916, and a further increase in the cities of 12 per cent. in 1917. In Greece matters seem to be even worse. There had been a deathrate of 1 in 6 from tuberculosis in Athens before 1914, which, owing to war conditions, has undoubtedly increased, although exact statistics were not available.

When one considers the terrific sacrifices England and her colonies have made in men, material, and finances in the war, one cannot but wonder at the relatively favorable tuberculosis situation in the British Empire. But the British Journal of Tuberculosis freely admits that in England, also, tuberculosis has become more prevalent and damaging, and has claimed a larger number of victims. According to Dr. Halliday G. Sutherland, the death rate from pulmonary tuberculosis since 1914 has risen 12 per cent. Here as everywhere else, the war resulted in a diminution of the activities in the tuberculosis movement, but with that energy characteristic of the British race, England and her colonies are working hard to meet the new problem. During a recent visit to Canada I was privileged to inspect the new and splendidly located Laval Hospital for the tuberculous at Quebec, and in Montreal I was shown a magnificent site, formerly occupied by a religious order, which that city has purchased for the erection of a large, modern tuberculosis hospital-sanatorium for its consumptive poor. From a very interesting communication, entitled "How Canada is Meeting the Tuberculosis War Problem," by Lieut. Col. Jabez H. Elliott, of Toronto (Transactions of the National Tuberculosis Association, 1918), we learn of the thorough work which is being done by our neighbors to the North to meet the needs for hospitalization, vocational education, and pensions for her tuberculous soldiers. No less than 19 sanatoria are receiving the Canadian tuberculous heroes, eager to restore them to health and earning capacity. Only a few days ago I received a letter from Sir William Osler who, in discussing the tuberculosis situation in England, says: "All goes

well here and I hope we will get the tuberculosis problem settled ere long on national lines."

Less happy news comes to us from our smaller allies, Roumania and Serbia. Pathetic is the tuberculosis situation in Roumania, but more so it is in Armenia and Serbia. No exact statistics are available, but we have heard and read enough of the indescribable sufferings which poor Armenia had had to endure while under Turkish dominion and during the war. All that tends to the propagation of tuberculosis and makes cures impossible, such as privation of food and shelter, exposure to the inclemency of the weather, to excessive cold and excessive heat, the herding together of masses in filthy and unsanitary houses, mental anguish and physical suffering, the Turks took good care to prepare for the few million Armenians whom they had not murdered outright.

In Serbia, which held the enemy forces at bay for 14 months, the people have perhaps suffered from tuberculosis more than any country of the Allied or Central powers. Col. Homer Folks estimates that the Serbian population is now 25 per cent. less than it was at the outbreak of the war. The mortality from tuberculosis in Old Serbia, i. e., the northern part, including the city of Belgrade, was already high bofore the war-324 per 100,000 in 1911. In Belgrade in 1912 it was 720 per 100,000; in 1917, according to an Austrian report, it had risen to 1,483 per 100,000. Dr. Rosalia Slaughter Morton, who has only recently returned from Serbia, likewise described the tuberculosis situation to me personally as simply appalling. Men, women, and children were dying by the thousands from this disease. Out of 14,000 Serbian prisoners who were returned to their home country after the armistice, 6,000 had contracted tuberculosis, and in the new Czecho-Slovac republic_conditions seem to be fully as bad. Dr. J. C. Beck, of Chicago, who has been with the Czecho-Slavs as a military surgeon, reports to me that tuberculosis in Prague among children alone has increased to a veritably alarming degree. In 1914 the tuberculosis morbidity rate in Prague among children was 3 per cent.; in 1919 it was 29 per cent. These figures were given to Dr. Beck by Dr. Alice Masaryck, the president of the Czecho-Slovac Red Cross, who is the daughter of the president of the new republic.

From the newly created Polish republic there comes sad news concerning the tuberculosis situation. Thus it was stated by Consul General C. Buszczynski, the head of the Polish mission which recently arrived in this country, that in Eastern Poland there existed in April of this year no less than 500,000 cases of tuberculosis.

Russia, once our ally, is to-day a country without an ally and without a government. Its homes are devastated and millions of men, women, and children are on the brink of starvation, not because of a foreign war, but from

the destructive forces of its own people, misguided by a few fanatics. These leaders cannot, or will not, see that order, work, and brotherly love are alone capable of producing an ideal government and a satisfied people. How many tuberculous cases have developed during the last five years in Russia, how many will develop there before peace and order again reign supreme and the people work for instead of against each other, is difficult even to imagine. There is little doubt, however, that since Russia in peace times was known to have the greatest morbidity and mortality from tuberculosis among all civilized nations, its present condition of chaos will multiply the deathrate from this disease many times, which to-morrow will be a staggering problem for the men who will succeed in saving Russia and making a peaceful republic there.

We now come to our own country, which, of course, has suffered the least of all the great nations involved in this world war. The tuberculosis situation in the United States, as compared with other countries, has seemingly not been so greatly affected. Thanks to the most thorough method of examination and re-examination of all men who had volunteered or were drafted into the army or navy and also of the candidates for officers, a relatively small amount of tuberculosis developed in our fighting forces. That, in spite of this careful examination, a certain number of tuberculous cases should develop among over two million fighting men in the U. S. Army and Navy was inevitable. But here again, thanks to the foresight of Surgeon General Gorgas, his successor, Surgeon General Ireland, and the Surgeon General of the Navy, our federal government has done and is doing its utmost. Six government sanatoria, with a capacity of 6,000 patients, are now in operation. These institutions are located at New Haven, Conn.; Otisville, N. Y.; Spartanburg, S. C.; Oteen, N. C.; Denver, Colo.; Fort Bayard, N. Mex. Under the direction of Surgeon General Braisted, of the Navy, an excellent institution for tuberculous sailors is in operation at Fort Lyon, Las Animas, Colo., and the United States Public Health Service operates an institution for several hundred patients at Fort Bayard, N. M.

In accordance with Public Act 326, approved March 3, 1919, entitled "An Act to authorize the Secretary of the Treasury to provide hospital and sanatorium facilities for discharged sick and disabled soldiers, sailors, and marines," the Bureau is authorized to send to any relief station of the Public Health Service any discharged sick or disabled soldier, sailor or marine, Army or Navy nurse (male or female), provided that the disability for which he seeks treatment is due to illness, including tuberculosis, or injury incurred previous to discharge from the military forces.

Thus, to provide for additional numbers of soldiers and sailors whose disease is already diagnosed as tuberculous or may be so on their return home, Surgeon General Blue, of the United States Public Health Service, is

contemplating a chain of tuberculosis hospitals all over the country. The sum of $7,000,000 has already been appropriated by Congress for that purpose. It is planned to erect the hospitals on government property in the following cities: Boston, Mass.; Hill, Mass.; Chicago, Ill.; Cleveland, Ohio; Detroit, Mich.; Evansville, Ind.; Louisville, Ky.; Norfolk, Va.; New Orleans, La.; San Francisco, Cal.; Seattle, Wash.; St. Louis, Mo.; Wilmington, N. C.; Fort Slocum, Mo.

How very thorough the work is, which is being done for our tuberculous soldiers may be learned from a letter sent by Surgeon General Ireland to all army surgeons and hospitals, defining the policy of the War Department in regard to the disabled United States soldiers:

"It is the plan of the Department to retain so far as practicable under military control, for the purpose of medical and surgical treatment (a) officers and soldiers suffering from acute diseases or acute exacerbation of chronic diseases or unhealed lesions; (b) officers and soldiers suffering from communicable diseases or who are 'carriers,' whose discharge would be a danger to the civil community; (c) officers and soldiers suffering from disabilities incurred in the line of duty which are correctible within the term of service or enlistment; (d) officers and soldiers suffering from chronic or permanent disabilities incurred in the line of duty, which are susceptible of improvement by measures for mental or physical reconstruction designed to fit them for return to their home, for the resumption of their former vocations, or, with their consent, for the industrial opportunities or the training courses provided by the Federal Board for Vocational Education.

"In the accomplishment of this policy, it is the intention to restore officers and soldiers, who are held in service as provided above, to health and function as fully as possible, considering the nature of their disabilities, the limitations of the military service, and the other provisions which the government has made for the care of the permanently disabled.

"Instructions as to specific cases provide that 'cases of tuberculosis should be kept under treatment in military hospitals until the disease is arrested or until it is ascertained that they are pregressive in type or incurable.'

I recently visited a splendidly equipped government tuberculosis hospital at Denver, Colo., known as the "Recuperation Hospital." All sorts of occupations which the cured tuberculous soldier is hoped to be able to pursue are there taught by experts in the rehabilitation and reconstruction of the diseased and disabled. Similar work is done in all the other government tuberculosis hospitals.

Because of the 62,000 cases of tuberculosis discovered among the young men of draft age when examined by the medical members of local boards and the 20,000 more who had to be rejected after they had arrived at the

training camp because of distinct symptoms of that disease, the National Tuberculosis Association, with the help of the Surgeon General's office, has inaugurated a follow-up system, and it is hoped that thereby many cases will ultimately be reached and properly treated.

While it is impossible at this time to state to what extent the fearful influenza epidemic of the past year has increased the number of tuberculous individuals among the civilian population, the opinion has been expressed by many general practitioners and specialists throughout the country, which from my own observation I certainly feel inclined to confirm, that the unusually severe influenza epidemic is responsible for the development of many latent and formerly unrecognized cases into active tuberculous disease.

The educational, preventive, and therapeutic tuberculosis work among the civilian population in the United States has really not suffered much because of the war. To the best of my knowledge in not a single institution were civilian patients discharged to make room for tuberculous soldiers or sailors, and the building of new sanatoria has not ceased in spite of the war. Popular tuberculosis education has gone on almost uninterruptedly in the United States. The anti-tuberculosis activities of most of the State and City Health Departments are increasing more than ever. Thanks to the help extended to us by the Red Cross, more tuberculosis committees and State tuberculosis societies have been established and are enabled to do more intensive work. Lastly, the membership of the National Tuberculosis Association is constantly on the in

crease.

Dr. Philip P. Jacobs, the Assistant Secretary of the Executive Staff of the National Tuberculosis Association, has been kind enough to furnish me with the following figures concerning the association's activities and the present status of the anti-tuberculosis situation in the United States. Up to June first the Society had a membership of 4,066; at the present time there are approximately 600 hospitals and sanatoria for the tuberculous in the United States. Since some hospitals take early cases and some sanatoria also admit advanced cases, it is difficult to distinguish between the two kinds of institutions. It is equally difficult to ascertain accurately the number of open-air schools for the reason that many people include fresh-air classes and open-window rooms among the open-air schools. Dr. Jacobs estimates the institutions where instruction is given in the open air to be between 1,000 and 1,500 in the United States. Of typical preventoria, such as those in Framingham, Mass., and Farmingdale, N. J., there exist about a dozen and perhaps twice that number of preventoria are working in conjunction with tuberculosis hospitals. There are about 500 tuberculosis dispensaries in operation in the United States. There are approximately 1,400 tuberculosis associations and committees, including a well organized and businesslike state association in

every state, and each has a full time secretary. There is also an association with a full time secretary for practically every large center of population. The Red Cross appropriation of $2,500,000 is being distributed as follows:

(1) Ten per cent. is set aside for the budget of the National Association, and an Emergency or Missionary Fund................

(2) Each state association is guaranteed an amount equal to the gross proceeds of the seal sale for 1917, the aggregate of these amounts being approximately

(3) The remaining sum, amounting
to approximately

is being distributed to the states
on a pro rata basis; the ratio of
each state being determined by
the proportion of members en-
rolled in each state in the Red
Cross Christmas Roll Call of
1918.

(4) Appropriations for the Mission-
ary Fund are being made to
needy states, particularly the
weaker or more recently organ-
ized ones, on specific request of
the National Association.

$250,000

1,819,000

431,000

A rather new feature of State activity was inaugurated by the New York Health Department under the leadership of Professor Hermann M. Biggs. Free clinics are held throughout the State to which tuberculosis experts are sent to aid the local physician in early diagnosis of tuberculous disease in children and adults, and in the installation of proper hygienic, dietic, and therapeutic measures. This method has been helpful through the discovery of many early unsuspected cases of tuberculosis. By placing these patients under proper treatment at the right time, these popular clinics are helpful in saving many valuable lives. Similar State clinics are now in operation in Massachusetts, Vermont, and elsewhere. It was my privilege to hold some of these clinics for the Health Department of the State of New York, and it was indeed inspiring to see with what wholeheartedness the local physicians entered into this work for the common good. It gave a splendid proof of their altruism and genuine desire to aid the State Department in an effective anti-tuberculosis campaign.

Encouraging and hopeful as are these manifold activities in our own country, we must not stop here. While much is done, there is still more to do. More sanatoria and hospitals for the poor as well as for the moderately well-to-do, workshops and work colonies for the tuberculous invalids (partially recovered), more preventoria and similar institutions are needed as well as extensive educational propaganda. We must still look to our generoushearted wealthy fellow citizens for help in establishing and maintaining such institutions.

Municipal, State, and even federal funds do not suffice alone to cope with the problem. But by whatever is done now through public means or private philanthropy in preventing and curing tuberculosis, we all will be the gainers in the end. The commonwealth will have fewer paupers and more breadwinners and we will all be a happier and healthier people.

And now, after this hasty glance at the tuberculosis situation before and during the world war in our own country, the countries of our Allies, and the countries of the Central Powers, what is it going to be necessary to do to cope with this enormous problem, which now more than ever is really a world problem? It has been suggested that Geneva become the general Red Cross center from which all relief for nations in distress, owing to disease or physical disasters, should be directed. I hope that a great International Bureau, composed of tuberculosis experts from all over the world may form a part of the great Red Cross headquarters. From there, the best that is known in prophylactic measures should be taught to all the nations in need of advice and guidance in popular antituberculosis propaganda. Experts in the construction, equipment, and management of tuberculosis hospitals and sanatoria, preventoria, dispensaries, work colonies, factories, and workshops for tuberculous invalids (after the model of the Altro Shop of New York City), should form a sub-division of the International Tuberculosis Bureau; and last but not least, through its medical and scientific division all the accumulated knowledge and all the new discoveries regarding phthisiotherapy, including early diagnosis and the prevention of relapses in tuberculosis, should be made available to all mankind.

The financial aid necessary to carry out educational and therapeutic measures to combat tuberculosis in our own and in countries too poor to do it for themselves, or only able to do a part, can best be distributed through the Red Cross headquarters. Because of their machinery they will be better able to judge how much and where the money for tuberculosis relief work can and should go. The American Red Cross has its national headquarters in Washington, D. C.; the President

This shop is occupied exclusively by ex-sanatorium patients. They work 2, 4, 6, or 8 hours a day, whichever amount in the judgment of the supervising physician they may do without any fear of relapse. If they do not earn sufficient to support their families, philanthropic associations supplement the difference. Thus, all anxiety is relieved from the patient's mind. Such a factory or workshop, even though it may not be self-supporting, will pay in the health restored and self-respect regained. It saves the community the cost of relapse as well as a large expenditure for relief. Under proper management and on a sufficiently large scale, such factories or workshops may be entirely self-supporting. All work is done with the windows wide open, in winter and in summer, and under strictest sanitary conditions in general. (For further details concerning this unique humane and yet businesslike enterprise see Hochhauser: "Discharged Tuberculous Patients in Factory Work"; Transactions, National Tuberculosis Association, 1918, p. 456).

of the United States, Woodrow Wilson, is also the president of this organization; the Hon. William H. Taft and Mr. Robert W. De Forest are its vice-presidents; Professor Livingston Farrand, M.D., is the Chairman of the Executive Committee. The Secretary General of the International League of the Red Cross societies is Dr. William Rappard, Professor of Political Economy of the Universities of Harvard and Geneva, with headquarters in the latter city. The office of the National Tuberculosis Association is located at 381 Fourth Avenue, New York City. The executive office staff consists of: Charles J. Hatfield, M.D., managing director; Philip P. Jacobs, Ph.D., Donald B. Armstrong, M.D., assistant secretaries; Charles M. De Forest, modern health crusader executive; Frederick D. Hopkins, field secretary; H. A. Pattison, M.D., medical field secretary; Basil G. Eaves, publicity secretary; George Everson, Spokane; Regional Secretaries: Severance Burrage, D.P.H., Denver; Murray A. Auerbach, Atlanta; Leet B. Myers, New York. An annual Red Cross seal sale for the benefit of the antituberculosis work in the United States is conducted by this office.

D. D. B. Armstrong is also the director of the Framingham Health and Tuberculosis Unit. This Health Unit, which came into life through the donation of $100,000 by the Metropolitan Life Insurance Company, demonstrates what may be accomplished in a community by the strictest sanitary, prophylactic, and curative methods in preventing and curing disease, particularly tuberculosis. The work is done by a thorough coordination of public and private agencies. The value of such "health and tuberculosis demonstration" must be obvious and offers a great field of philanthropy to wealthy individuals and corporations.

Valuable information concerning general anti-tuberculosis propaganda and the progress of tuberculosis science can be gathered from the following publications: The American National Tuberculosis Association publishes as its official organ the JOURNAL OF THE OUTDOOR LIFE, of which Dr. Philip P. Jacobs is the managing editor. The aim of this journal is to be helpful to persons seeking health by an outdoor life, and particularly to disseminate reliable information looking to the prevention of tuberculosis. In addition to this widelyread journal, the Association publishes also The American Review of Tuberculosis, with Dr. Edward R. Baldwin, of Saranac Lake, as editor in chief and Dr. Allen K. Krause, of Baltimore, as managing editor. This periodical is mainly devoted to the discussion of the purely medical and scientific aspects of tuberculosis.

After such general suggestions there are, of course, an infinite number of other things which arise in one's mind when viewing the actual situation. There is the question of birth control in devastated countries where there are still thousands of people with little food and poor shelter. In regard to this I am willing to subscribe absolutely to what was re

cently said by Dr. C. K. Millard, Health Officer for Leicester, England. He writes as follows: "The question of the birth rate is intimately bound up with that of birth control. It is unfortunate that scientific study of the subject has been hitherto neglected. Owing to the supposed moral stigma many had tabooed it, and it is only quite recently that unbiased discussion had become possible. The subject is of special interest and importance at the present day, through conditions arising out of the war. In many parts of Europe the social contitions of the people, with starvation staring them in the face, without proper clothing or shelter, with civilization itself broken down, are deplorable in the extreme.

It appears

eminently desirable that rigid birth control should be practiced in those countries, and probably in others also, if acute maternal suffering and terrible infant mortality are to be avoided. The best thing for the people of those countries to do is temporarily to stop having children, so far as it can be avoided, until happier and more prosperous times arrive. It seems to be taken for granted in most countries that rapid increase in population is needed in the national interest, and that a stationary population would be disastrous. No doubt this sentiment is really based on militarist considerations, and in the past, when such considerations were vital, it might have been wise to encourage it. But now, with the international situation fundamentally altered, and with the League of Nations (whose special function it would be to safeguard the nations with small populations), it is time to reconsider our attitude. International competition in birth rates is to be avoided, just as was competition in armaments. There are certain countries which are already "saturated" as regards population, in the sense that any further increase would not tend to increase the happiness or prosperity of the inhabitants. Whereever that point has arrived, or is nearly at hand, birth control must be regarded as the proper remedy, and as greatly preferable, in most cases, to emigration. The case of England is complicated by the fact that she is the mother country of an empire. Many people would agree that the population of the British Isles is large enough, but they wanted to see her great colonies filled up with an all-British population. No doubt this is very patriotic, from the standpoint of conditions before the war; but from the point of view of the League of Nations they ought to regard their colonies as the natural outlet for the surplus population of all European countries. It is so necessary for the peace of Europe that such an outlet should exist that they need not be in any hurry to see those territories filled up. As to the question of practical methods, physicians have not given it sufficient attention to enable them to speak very authoritatively. Certain physicians, with obviously a strong bias on moral grounds, have condemned all methods as highly injurious, but the bishops in a special report on this subject presented to the Pan

Anglican Conference in 1908, have seized an isolated medical opinion of this kind and used it as though it were the considered verdict of the medical profession.

"To ascertain what is the real opinion of the profession of the present day, Dr. Millard has recently issued a questionnaire to medical practitioners, and from some eighty replies received he is quite satisfied that the great majority of the profession does not regard birth control as necessarily injurious.". (London Letter, March 27, 1919, to Jour. of the A. M. A., April 19, 1919).

In spite of this sound reasoning and advice, many tuberculous mothers will bear children, and if the mothers do not survive some of the children may. These and other children who have contracted tuberculosis, it is the duty of the physicians to endeavor to save. Maternity sanatoria where the mother with an early tuberculosis may stay before and a sufficiently long time after her confinement, to give her a reasonable chance for recovery, must be created. Tuberculosis dispensaries to act as clearing houses for all kinds of tuberculous afflictions, and attached to them a corps of visiting nurses; preventoria, where the strongly predisposed child may have a chance to overcome its predisposition; children's sanatoria where the young having pulmonary, glandular, and bone tuberculosis may be treated for their afflictions; favorably situated sanatoria for the early cases, hospital-sanatoria near large centers of popultion for the more advanced cases; special institutions for post-sanatorium treatment where the arrested cases can be prepared to resume their physical labor and general occupation without danger of relapses; special sanitary workshops for vocational training of tuberculous invalids and ex-sanatorium patients; horticultural and agricultural colonies for the tuberculous able and willing to pursue these open-air occupations; and lastly, open-air schools for tuberculous children and tuberculous teachers constitute the chain of institutions which an enlightened community must provide in order to cope effectually with the tuberculosis problem.

It goes without saying that a nation's antituberculosis crusade must include all the other modern measures which this world-war has taught us as being necessary in preventing disease (particularly tuberculosis) and in increasing the physical and mental well-being of the masses, such as child welfare work, compulsory general education, including practical lessons in hygiene from kindergarten to university, repeated periodic physical examination of all people, and the institution of remedial measures to correct defects. A three-months' physical training of all girls between the ages of 16 and 18 and a six-months' physical training of all boys between the ages of 18 and 20, to make the physique of these future fathers and mothers as nearly perfect as possible, would be an additional assurance of a healthier and happier future race. However, to obtain (Concluded on page 274)