Our Children to Be Invalids? PERHAPS not, but how much attention do our schools give to teaching our children the rules of health, by which they may avoid tuberculosis and other preventable diseases? The average schoolbook on arithmetic, geography or what not costs $1 or more. It improves the child mind, but does nothing to secure for him that greatest of all assets-Good Health. For less than five cents a copy school children can be supplied with the HEALTH FIRST READER, which teaches not only the physical rules, but the psychology of health as well. It is the recognized child's book on good health; endorsed by the National Tuberculosis Association and many of the foremost men and women in the anti-tuberculosis movement. It is already in use in the schools of Brooklyn, N. Y.; Rochester, N. Y.; Philadelphia, Pa.; Cincinnati, Ohio; Birmingham, Ala.; Memphis, Tenn.; Des Moines, Iowa, and many other cities. Send ten cents in stamps for sample copy and price list. The Strobridge Lithographing Co. 112 West Canal Street Cincinnati, Ohio Huyck Pure Wool Products are the doctor's assistant in cases where fresh outdoor air is desired in comfort. Sitting Out Rugs and Bags Eskimo Suits Pure Wool Blankets Sleeping Bags (For Adults and for use of BUILDING BODIES AND BRAINS--a book relative to fresh air and outdoor schools will be mailed free on request. When dealing with Advertisers please mention JOURNAL OF THE OUTDOOR LIFE OUTDOOR LIFE Volume XIX I The Causes of the Rapidly Increasing By HAVEN EMERSON, M. D., New York City T is well known to sanitarians that the death rate from tuberculosis in the United States, in Great Britain and in Germany had been falling in a fairly uniform manner from a time earlier than Koch's discovery of the tubercle bacillus till the outbreak of the World War. This has made some thoughtful people doubt the claims of organized public and private health agencies to the effect that reduction of tuberculosis has been largely due to, or at least has been very materially increased by, the campaigns of education and enforcement, of early diagnosis, notification, early treatment, segregation, pasteurization of milk, infant welfare, correction of malnutrition, etc. Some evidence has been published to show that where the education and organization of a community to prevent tuberculosis has been thorough, and where the conditions of housing, industry and economic independence have been favorable, the death rates from all forms of tuberculosis have fallen more rapidly than they have elsewhere, even taking into consideration all factors of age, sex and race composition of the communities concerned. This applies more particularly to the large populations of the United States, Great Britain and Germany. In France, in contrast, there has been not only a high tuberculosis death rate, but a rate which has remained at a fairly uniform level over a long period up to the outbreak of the war. The two following tables present conditions in France: Death rates from all forms of tuberculosis per Reprinted from the American Review of Tuberculosis. The article in the Review is illustrated with 12 charts. It may even be shown with a reasonable presumption of accuracy that the backward nations or the less favored parts of nations have shown a slower rate of decline in tuberculosis than has occurred in more prosperous, intelligent and ambitious sections of countries or continents. It may be said that improvement in the standard of living and betterment in all the factors of environment, in home and in place of work, have been coincident with and perhaps have been largely responsible for the decrease in tuberculosis in the past fifty years in various *Reduction due chiefly to deaths in military service of many of the males of ages 18-45 years, of Paris, from tuberculosis and not charged to Paris. IMPORTANT NOTICE TO SUBSCRIBERS parts of this and other countries. Since 1914 in the United States and in New York City there has been so great a change in the rate of decline in the number of deaths from tuberculosis per 100,000 that it is important for us to consider what have been the dominant factors of the many possible causes of such a phenomenon. For it is at once obvious that if these factors can be brought under control and duplicated elsewhere or their action made continuous or permanent, we can foresee the eradication of tuberculosis as a disease of importance within the next twenty years in this country; and, again, that while there are not only great suffering and formidable losses from the disease, and the public is spending large sums to protect itself and deal generously with those already attacked, it is the special duty of public and private agencies engaged in combating the disease to take account of their claims, their methods, their demonstrable accomplishments and, perhaps in the process to develop a change in their point of view and acquire a new sense of proportion and perspective in pushing their present advantage against tuberculosis. In the past fifty years there has been a fall of 77.9 per cent. in the tuberculosis death rate in New York City; in the past eleven years, a fall of 51 per cent.; and in the past calendar year of 1921, a fall of 18.1 per cent. We have to look back to the years 18991902 to find any such striking fall as has occurred from 1918 to 1921. It will be recalled that the year 1899 and the two years following were years of the last previous pandemic of influenza, and its subsequent recurrent waves in this country and particularly in New York City. These approached, if they did not actually equal, the corresponding episodes of the recent influenza epidemic in extent of distribution and severity. The following discussion is offered, not so much to present an entirely acceptable conclusion in the form of a single or suffi⚫cient cause for the remarkable change in the picture of the past few years, but rather to outline a series of problems for which answers will be given with increasing exactness as we follow the experience of the next ten years. It is suggested that among the possible causes of the decline in the death rate from tuberculosis are (1) those intentionally directed as specific measures against the distribution of the tubercle bacillus from the diseased to the well; (2) those that are accessory and tend to affect the general bodily resistance of those particularly exposed or susceptible, or are intended to inform the public so that intelligent self-protection may become more general, and (3) those events, social, economic and so far as the antituberculosis campaign is concerned, quite accidental, in which we may see an unsought, unplanned, and to many an unexpected bearing upon tuberculosis. Specific Measures The following are measures adopted generally by public health services in most of the states of this country and perhaps even more effectively by many of the cities, with the direct object of reducing the dosage or distribution of the tubercle bacillus, the frequency of exposure to infection or reinfection, and specific predisposing factors in conditions of employment: 1. Early and accurate diagnosis of all forms of tuberculosis and especially of the pulmonary form at special public dispensaries as well as by the private practitioner of medicine. In tuberculosis as in each communicable disease, all is guesswork and uncertainty until detection of the disease is provided for, so that all groups, ages and classes of a community are reached and served by trained physicians, skilled in the means of arriving at an early and accurate diagnosis. It would appear that no other single specific factor has been of as much value in the attack upon tuberculosis. In the years 19091920 inclusive, 251,000 new patients were examined for tuberculosis, 1,469,000 separate visits were made by patients to tuberculosis dispensaries and 961,000 separate visits were made by nurses to the homes of tuberculosis patients in New York City. 2. Bacteriological diagnosis of specimens of sputum from those suspected of having pulmonary tuberculosis. Supplementing the clinical diagnosis and providing the individual practitioner with a facility which many even now fail to provide in their own offices for their patients, is the free, public diagnostic laboratory service, first and chiefly for morphological diagnosis of the tubercle bacillus in the sputum, and second, less often, but still of great importance in doubtful cases, for the biological test by inoculation of the susceptible guinea pig. The value of these services in the scheme of control of tuberculosis cannot be measured, either in terms of individual diagnoses confirmed, or as a means of educating physicians, but the specificity of this particular kind of evidence and the fact that only on such proof of the existence of a stage of communicability can administrative action for required segregation be instituted, should always cause this service to be rated high by public health officers. 3. Notification of tuberculosis as a communicable disease to the officers of public health. From the time (1895) when this was first proposed as a reasonable use of the police power of the state by the Department of Health of New York City until the present, there has been a steady and generous increase in the observance of this formality, the logical corollary to items 1 and 2 above in the administrative control of any communicable disease. Although, even where compliance with this requirement of sanitary law by physicians is at its best, we fail to get direct official knowledge of more than half of the open active cases of pulmonary |