duty of placement in civilian occupation of all rehabilitated men, cooperation with the employment bureau of the Department of Labor is very close and cordial.

Agencies of nation-wide scope outside of Government departments are also cooperating splendidly. To name but a few: The American Red Cross, the American Federation of Labor, the National Association of Manufacturers, the U. S. Chamber of Commerce, the Council of National Defence, the Y. M. C. A., the K. of C., the International Rotary Clubs and numerous Societies and individuals are all helping in the work.

Last, but by no means least, your own Association is lending its powerful aid. One of your officers, Dr. H. A. Pattison, has been detailed for duty for a time with the Federal Board and a strong advisory committee has also been named from among your members to assist in framing and carrying out a wise scheme of vocational training for the large number of tuberculous men discharged from military or naval service. In a report dated Sept. 11, 1918, which was presented to the Congress and is contained in House Document No. 1294, the following statement is made: "Fourteen thousand men have already been discharged from the Army on account of this disease." May I add that if Canadian experience is any guide, there will also be a considerable number of tuberculous men returned from overseas. The problem, therefore, is a serious one in point of numbers, as well as complexity.

The officials of the Division of Rehabilitation of the Federal Board have already interviewed a number of tuberculous men who have been discharged from the Army and some arrested cases have been placed in training for suitable occupations.

As intimated a moment ago, a broad scheme is being worked out, but it was necessary to lay down at once one or two principles for the guidance of the vocational officers. For example, it was decided that no discharged soldiers or sailors in whom the disease is still active should be granted courses of re-education, but that they should instead be encouraged to take the treatment in a sanatorium which is offered to all discharged men by the Bureau of War-Risk Insurance. For those men in whom the disease is arrested, a very careful study is made of each case; the opinion of a tuberculosis specialist being always obtained before training for any specific occupation is recommended.

I said just now that we have learned many lessons from the war, and one of the most important is the value of occupational therapy for men in hospitals or convalescent homes.

One of the first things undertaken in Canadian hospitals for disabled soldiers by the Military Hospitals Commission (now the Invalided Soldiers' Commission) was the provision of opportunities for occupation, as far as medical requirements would allow, for all men undergoing convalescent treatment in the

commission's hospitals. Commencing in a small way, this has grown until in or in connection with each institution where disabled men are undergoing treatment in Canada, there is provided a wide range of opportunities for occupational work during a man's hospital period. The value of this work is manifold; first, from the therapeutic standpoint, I think the Commission has proved the value of occupation for mind and body of the sick man. Of course, this was not an entirely new thing, for something of the sort had been in operation for some years in connection with the treatment of mental cases in many of the more advanced institutions. I think, however, that it was the first time that the work had been undertaken on so large a scale and to embrace such a variety of occupations. The facilities included class rooms for general educational work, commercial training, work-shops for arts and crafts, and a variety of mechanical and other occupations, and also outdoor work in gardening and poultry-keeping.

A second point of value was that it was disciplinary both for the disabled man himself in that it prevented that moral and social deterioration, which is always a result of a prolonged period of idleness, and was also of value in the discipline of the institution itself. There was at first a tendency to spoil our returned men by over-attention and for this it was found that active, interesting occupations formed the best antidote.

A third point which I think was proved most conclusively was that in a great many cases a man's deficiencies of education could be supplemented, or he could be given an opportunity of improving himself in some way, so that upon his return to civil life his earning capacity was increased as the result of his hospital experience. In hundreds of instances men who have passed through the hospital schools in Canada are to-day holding better positions and earning more money than they were able to earn before they enlisted. I believe that the results in this respect alone have been worth the expenditure of all the time and money which this work has entailed. Later on, cases requiring active treatment were returned to Canada and for these men light ward occupations were provided, but in my opinion such work can have but little vocational value, although it may form an important theapeutic agency in the restoration of the man to health.

A little over two years ago occupational therapy and vocational training were introduced into one of the Canadian Sanatoriums where soldiers were being treated. From the first the work was a success and its effects especially in disciplinary and moral directions were, on the testimony of the Medical Officer commanding, of the utmost value. The work soon spread to other institutions in which tuberculous men were being treated throughout Canada and the various medical officers concerned have all found it valuable as an auxiliary means of treatment. I am sure that

you will be glad to learn that it is highly probable that occupational and vocational training will be introduced at an early date in the United States Public Health Sanatorium at Fort Stanton, New Mexico, in which a number of the discharged soldiers and sailors are being treated under the provisions of the War-Risk Insurance Act. It is proposed to provide instruction in general subjects, commercial branches and light arts and crafts work. If possible, gardening and greenhouse work will also be provided. Of course, throughout any such work, it must always be clearly understood by the vocational staff that the Medical Officer's authority is supreme. The vocational staff should regard themselves as additional aides in the treatment of the patients. Work should always be prescribed by the Medical Officers and educational requirements should always be subordinated to medical aims. An experienced vocational counsellor will be in charge of the work, and if possible all the training that a man undertakes will have a definite vocational bearing. If, upon the conclusion of a man's treatment, he is able to return to his former occupation,

it is confidently hoped that the work which he has done during his stay in the Sanatorium will help him in earning his living. If his former occupation were such that it becomes necessary to direct him towards some new occupation, it is believed that a great deal of preparatory training may be given during his period of treatment. Of course it is the hope that if this experiment prove successful, it will lead to the general introduction of similar work in all institutions in which discharged soldiers and sailors, suffering from tuberculosis, are being treated.

Already occupational training plays an important part in several of the leading Sanatoriums for civilians in this country and I believe we may confidently anticipate that in the future no tuberculosis Sanatorium or indeed any general hospital, will be considered complete if it is not equipped with opportunities for occupation for its patients.

We have a big task before us and the solution of the problem of the disabled soldier is not a matter for governments alone, but for every man and woman who has the welfare of the nation at heart.

(More or less well-remembered maxims, from various sources, picked up in the Lecture Hall and the "shacks" during a half-year's sojourn at "The San.")

It is not a question of what a man has in his lungs but what he has in his head that determines whether he will get well or not.

Any fool can get sick; it takes a wise man to get well.

Most people go to a sanatorium too late and come home too soon.

One winter is better than two summers (when chasing the cure.)

The only night air that is not good is last night's air-open the windows and let it out. You don't cheat the doctor when you turn in a wrong temperature report you cheat yourself.

In many maladies man goes to bed to die; but with tuberculosis he goes to bed to get well.

As the body builds up, the throat and lungs build up with it.

It is not what you do during your working hours that causes your breakdown but the manner in which you spend your time after working hours.

It is within man's power to banish all infectious diseases (including tuberculosis) from the face of the earth.

A lunger will die with T. B., but not necessarily of T. B.

The bosom friends of tuberculosis are darkness, dampness, lack of sunlight and lack of fresh air.

If you expect to get well you must work for it.

Fighting pulmonary trouble is a twentyfour-hour-a-day job.

The only question in the treatment of tuberculosis is that of nutrition; digestion and assimilation control the situation.

Get the patient fat and strong and the diseased lung area may be left to take care of itself.

T. B. The mite of a bacillus that multiplies to kill us.

Sanatoria: What Trudeau and others gave us that multiply to save us.

There be these three: Rest, good food and fresh air and the greatest of these is REST. Join the Brotherhood of the great outdoors and read the JOURNAL OF THE OUTDOOR LIFE. FRANK T. KOONS, Baltimore, Mo.

The whole matter of infection, at the current time, seems to be very much in the air. It is supposed (1) that infection occurs in the early years of life; (2) that a large part of early infection is bovine; (3) open, active tuberculosis of adults is due to the lighting up of a former process; (4) adult tuberculosis is in only 10 per cent. bovine,-which does not seem to be a very logical conclusion. Can you straighten out the dilemma?

Another thing that has always interested me from a pathological point of view is the theory of the persistence of lesions. Of course, I know that certain tuberculous foci are encapsulated, and I have seen nodules in a lung, where no tuberculosis has ever been suspected, that amounted to practically pure cultures of bacilli; but I also know, from having followed the patients, that we can have an extensive peritoneal tuberculosis, and a few months later have the tubercles much less in number, and a number of years later on opening the abdomen find that the peritoneum has returned to its normal condition. Why can we not conclude that the same process takes place on the pleural surfaces and also in the lungs? If there is destruction of tissue we have scar tissue forming, but why must we always assume that once infected a person is liable to break out again with tuberculosis?-From a letter to the author from Dr. Arthur K. Stone, Chairman of the Trustees of Hospitals for Consumptives of the Commonwealth of Massachusetts.

But even

In any exhaustive analysis of the matter of tuberculous infection we may discuss ad infinitum and almost ad nauseam the sources of infection. We may, in addition, investigate in detail the modes of transmission by which the bacilli get from sources to man. We may grow emphatic, and wax positive and dogmatic over whether it is phthisical man or the tuberculous cow that most menaces us. though we may have settled to our own satisfaction any one or all of these and other several phases of infection, we still remain aware that before we can come to any adequate solution of the mysteries of the residence of the tubercle bacilli within our bodies, there are puzzles to be explained away that all of our experimental work, or all of our investigation of the cadaver, or all of our mountains of careful clinical investigation of the living patient, each of itself fails to clear up. Pursuing the experimental method we learn some things that we could by no known direct methods detect or prove in the patient. We get so far, not all the way,-and no further, in our search after the whole truth. By close study, again, of the tuberculous human being, sick or well, we learn other things that have thus far been forbidden the experimental method to disclose. At the autopsy table, also, we may be able to glean totally new and unsuspected facts, while the statistical method or the bringing together of data that apply to vast numbers of people in more or less closely-related circumstances may furnish us with much that is germane to our purpose. A subject that is so vast and intricate as is

that of tuberculous infection demands that, before any decision is ventured, all the facts that can be laid bare by every method of approach be collected, weighed and sifted, and brought into correlation. And even after all this is done, we dare not stand aloof from those common and external facts of existence that make up the multifarious environment in which we live and move. Before we may with confidence assert that the real answer is ours we must make our great body of information, wrung from laboratory, from bedside, from dead-house, from the laws of averages, and from where-not,-all intelligently assembled, dissected and reassembled, reflected upon and woven together into a single garment,all this we must make square with the facts of the world outside ourselves that furnishes the tubercle bacilli for us and in some way or other introduces them to us.

Reflections such as these would seem but little short of the acme of platitude. And they are set down here, not from a desire to fill space, but with a sense of melancholy: of melancholy, because time goes on and on, and pages upon pages on infection come and are still coming, and the long-suffering tuberculosis world, whose burden of "literature" is the ever-increasing weight of pamphlets that would contribute to the solution of a problem that is every bit as long and as broad as that of civilization itself, is periodically arrested and asked to hearken to the proponent of one or another method of infection in terms that are so direct and so ridiculously simple that we marvel at the waste of talent that for fifty years and more has been using up its precious mortal hours on attempts to appreciate and understand the situation.

Just what is this situation? Let us once again call to mind the basic facts that we cannot explain away but which we must explain.

Every year in this country about 150,000 people die of tuberculosis that has been duly recognized and labelled as tuberculosis. For every person who dies of tuberculosis there may be five, there may be ten, there may be twenty who are ill and who are suffering more or less permanent disability because of the activities of the tubercle bacillus within them. Their number is surely not less than five times the number of deaths; it is probably not more than twenty.* But we may confidently conclude that from one to two per cent. of our population is always below the peak of effi

* An estimate of this kind includes tuberculosis at all ages and of all forms,-tuberculous manifestations that may be obscure, such as eye and glandular affections, which are extremely common and the mortality of which is practically nil.

ciency because the tubercle bacillus is active enough in them to make itself felt.

Now of the 150,000 who die, about 85 per cent. go down to their graves overcome with pulmonary tuberculosis. The rest yield to the ravages of the germ elsewhere than in the lungs. In other words, as a cause of death and after exerting its effect on all ages, it is tuberculous disease of the lungs that kills most people who fall ill with tuberculosis.

Roughly corresponding figures would hold good for practically every other part of the world where white men live in preponderant numbers. And if the physicians of this white men's world were to foregather and discuss the tuberculosis situation they would tell one another in concert that everyday experience had taught them that the tubercle bacillus had a peculiar habit of addressing itself to the consciousness of man. They would become voluble over what even the non-professional have noted since the beginning of recorded time. They would sav that by far the greatest number of human beings, who had passed childhood and who had come under their observation because of deviations from health that were brought about by the tubercle bacillus, were suffering from consumption of the lungs, from a disease in which the expression of the mortal effects of the germ were relatively centered in the lungs. They had grown men, it is true, whom they were treating for tuberculosis elsewhere than in the lungs. They had as patients men and women with red and swollen and painful knees and elbows and hips; men and women with enlarged and hard and inflamed lymph nodes of the neck; men and women whose days and nights were made miserable by kidneys that were not properly performing their function or who were developing a slowlygrowing palsy of an arm or a leg,-all symptoms and signs that they had definitely made out were due to anatomic change that the tubercle bacillus was setting up. They even could tell of a few men and women who had lately died of tuberculous meningitis or because tubercle bacilli had been scattered broadcast and had found their way to every organ and tissue of the body. But all these patients were relatively few. As physicians, nine-tenths and more of their acquaintance with the tubercle bacillus in adults was made up of ministering to the needs of those who had "lung trouble."

But with their younger patients the case was different. Mothers were continually bringing their children to the doctor because these little people were not as plump or as rosy as they should be, or because they could not play as hard as they should, or because at times they seemed hot and fretful or even apathetic. Many of these children had little that the doctor could put his finger on and declare to be the cause of the trouble. A large number had sore eyes that stubbornly refused to heal; and that was all. Not a few others had "lumps" in the neck, and nothing else. Still others

had eruptions on the body that were hard to account for. Some were slightly lame and walking to them was an effort. Not a few had swollen and puffed-out bellies. Here and there one walked in with back beginning to hunch or with neck held stiff. Some coughed -with a hard and dry and unproductive ring that made one at once pay attention to what might be going on inside the chest. A few came in their mother's arms in sleep, in coma or in stupor, with plump and peaceful faces in that deep sleep that cannot be disturbed and is the prelude to the slumber that knows no awakening.

And the physicians would affirm that all this variegated office experience of theirs-these sore eyes, these "lumps," these skin rashes, these fixed and bent joints, these coughs, these unnatural slumbers, all this was part of the evidences of the activities of the tubercle bacillus in children. Unlike what happens in adults the residence of the bacillus in these little patients was not so much one that made itself eloquent by a more or less latent consumption of the lungs. In children the germ preferred to stick out its ugly head and announce its presence in other places. It brought about manifest disease of the lungs in children, it is true, but by no manner of means was this so frequent or so sharp-cut as in adults. In adults pulmonary disease was the type manifestation of the germ's activity; in children pulmonary disease was in no way the common manifestation of tuberculous activity.

These are facts, everyday data, gleaned from universal experience. And in the book of life they write down one thing clear and large. This is, that for some reason or other, in our early years the tubercle bacillus finds many soils, many of our tissues and organs, fertile ground for growth and development, but that as we add to our years, some obscure events occur that either make some tissues relatively sterile and leave the fertility of one or two others untouched, or something happens that, starting from the point of localization of first infection, channels, that are relatively previous in childhood and thus allow an easy transmission of bacilli from point to point, as we add to our days gradually become blocked until only a few like those to the lungs remain open. On the basis of statistical evidence alone we would not conclude that the lungs are natively less resistant to the onslaughts of the germ than are many other tissues. The facts of childhood disease belie such an assumption. We might of course reason that as we grow older the lungs become less resistant than they originally were. Yet we can with equal justice argue that their resistance remains static or even increases while the factors that make for the dissemination of bacilli to all parts of the body with a consequent development of disease-multilocular disease in many places, such as we find in childhood, diminish. We might take the ground that the incidence of pulmonary tuberculosis in adults was actually and in absolute

figures no greater than the amount of childhood pulmonary infection and manifest disease would lead us to expect. And, going further, we might venture that as compared with the child pulmonary disease stood out so prominently in the adult because many avenues that made for the spread of germs in childhood became blocked as we grew older, and that relations were thus changed because the same conditions no longer obtained for widespread massive infection with its consequent widespread disease.

Stripped bare of all subsidiary factors, the puzzle of infection that we must now explain is why in the adult tuberculosis bulks so large as a disease of the lungs while in man's early years lung disease is a relatively uncommon manifestation of tuberculosis. If year by year we take every age of the human being into consideration, and if in so doing we pay attention to the average number of infected individuals at different ages, then nothing can be more certain than that as we grow older manifest tuberculosis of tissues other than the lungs tends to decrease even if we consider absolute figures. And until the contrary can be proved we may be justified in assuming that lung tuberculosis is actually not more frequent in adults than in children (considering of course the total infections at various ages). It is just as likely that we have imagined a dilemma because non-pulmonary tuberculosis is less frequent and we have fallen into the old error of confusing relative with absolute figures.

But this can be only one possible explanation of a small though very complex phase of the tuberculosis situation. Others suggest themselves and will be taken up in their place. And before we reach the proper place we must once more reach out into the experiences of life and try to glean therefrom a few more facts.

Dr. Stone, a part of whose letter is prefixed to this essay, has for years taken an important interest in tuberculosis work in this country; and the questions that he raises are several of the many that have always engaged the attention and wonderment of students of tuberculosis. It is indeed difficult to bring into harmony the various points of view that he sets down. Some are based on certainties, while one or two are theories that serve to crystallize our imperfect information of the details of infection and its further development. But taken together they embody puzzles that we must discuss before we go further into the mysteries of infection, and before we can attempt to arrive at any satisfactory explanation of the varied relations that are continually going on between man and the tubercle bacillus.

It is no supposition "that the infection occurs in the early years of life." To-day this is one of the real and absolute certainties of tuberculosis lore. It is as certain as that at bottom all specific tuberculous changes are due to the presence in tissues of the tubercle bacillus. Continuous and never-ending

throughout life and keeping pace with the multiplication and diversity of our activities in the world outside must be our opportunities for contact with the bacillus.* No matter whether we incline to dust, or to droplets, or to raw sputum, or to cow's milk as potent media of contagion, continuous and neverending must be our contact with one or several of these. And if we have contact with them, then sooner or later we will be infected, and it must be true that we will be infected frequently.

Infection tests of great reliability and observations at autopsy make it perfectly certain that a large proportion-and, as they grow older a continually increasing proportion of children are infected with the tubercle bacillus. In the great majority of instances, however, the infected children have never exhibited a single manifestation of illness due to tuberculosis, nor will they ever do so. In other words, their infection is a dormant one and they have it well under control.

For infection to be detected at autopsy it must be of some size and visible to the naked eye. Such lesions we generally find in the lungs or the bronchial or intestinal or neck nodes in children who have during life always been apparently healthy so far as tuberculosis is concerned. When, however, we detect tuberculous infection without manifest disease in the living patient, it is the rule for changes in the body to be so slight and so hidden that we are utterly unable to determine where in individual cases they may be. But as a result of widely-recorded clinical experience we can, with some security, predict where these changes would probably be found if the child's tissues were available for minute anatomical and bacteriological examination. We should undoubtedly find that the tonsils and lymph nodes of the neck and bronchi would reveal small and hitherto unsuspected tubercle in the greater number. If we could make exhaustive and complete and thoroughgoing studies in all the patients we should surely come across all kinds of tubercles that ranged in size from the very smallest,-consisting perhaps of only a very few cells, to those that were well within the range of visibility. And there might even be infection, denoted by the presence of the germ, even though no anatomic change had as yet taken place.

The use of the x-ray is a comparatively new method of detecting tuberculous changes in the body. It will take years before by its practice there are collected together sufficiently large numbers of observations to allow us to generalize with any degree of safety as to the frequency and location of unsuspected tubercle in the body. Its use is constantly expanding and every year more and more children are being examined by it; and to anyone who is so fortunately situated that he can thus observe large numbers of patients, it is little