take upon themselves advisory, corrective and police duties, our official and professional labors will be made the easier; but it is we who must organize and direct this movement,-with never a qualm of discouragement. The object to be achieved is without a single demerit; no cause can be stronger whether from the point of view of utility, of aestheticism or even of morals. For these reasons it invites our very best efforts; and when these are applied it will succeed.

Pathological and experimental data furnish us information upon which we may base other premises for a progressive programme against tuberculosis. It is absolutely certain that only in very rare instances does a tuberculous infection from without proceed uninterruptedly to the development of a condition that we recognize as disease. Between any exogenous infection and the appearance of symptoms there is a longer or shorter period of latency, of quiescence, of maturation, of development, call it what you will. I am not here to debate what has become almost a doctrine, namely, the development of adult manifestations from childhood infectoin or to dispute whether one or many infections is the common lot of man. I state merely what I think has been definitely proved,-that few infections go straight on to manifest disease. In many instances, particularly in children, there may be, however, ceratin definite disturbances which although surely tuberculous are not generally recognized as such and which therefore are overlooked so far as their connection with tuberculosis is concerned. In many children and adults warning signals of a relatively obscure and intangible nature are frequently thrown out long before frank tuberculosis develops, yet this relationship to tuberculosis is only too often unthought of. There arise, therefore, several premises which we might fit into our progressive programme. None are concerned with preventing infection, but all would aim at reducing morbidity.

One of these premises would make it incumbent for us to arouse the medical profession to the significance of affections like pylyctenular conjunctivitis. This minor disease is quite prevalent, especially among children; and the weight of the better medical opinion is that it is nearly always a manifestation of tuberculous infection. In very many cases, it may be the sole symptom. Now and then it precedes the graver evidences by several weeks or months. As matters now stand, its tuberculous background is completely disregarded by the rank and file of physicians. It is treated as a minor and independent ailment of the eyes, whereas it should be treated as tuberculosis. There is no doubt that if its full meaning were appreciated and if a modified tuberculosis regimen were employed in the treatment of phlyctenular conjunctivitis, not a few attacks of undoubted tuberculosis and consequently a certain number of deaths would be averted.

We might indulge in the same prediction if practising physicians as a class were alive to their full obligations when consulted for a variety of obscure constitutional conditions-unusual nervous irritability, abnormal tendency to fatigue, chronic undernutrition, obscure though slight

anaemia, etc. I am not now discussing the early diagnosis of clinical tuberculosis. As often as not, we cannot find enough to dignify the trouble with the term, tuberculosis; and as often as not the distemper is transient and passes over without special measures being directed against it. Yet in only too many of these cases the future explosion proves that tuberculosis has insidiously been getting in its work. Where a positive diagnosis of any disease cannot be made, I believe that these cases call for a modified tuberculosis treatment. The word tuberculosis should never be mentioned to these patients, except by way of warning them of eventualities that may occur; but a therapy that approximates that for tuberculosis would undoubtedly save much illness and many lives. Let us use the term "presumptively tuberculosis" as expressing that common condition of ill-defined lack of health, where the balance between quiescence and activity of infection is adjusted with exquisite delicacy. If then we could drive it home to every physician that he should handle the presumptively tuberculous woman's pregnancy, parturition and puerperium just a little differently from those of the ordinary woman or that he should treat the acute infections of all presumptively tuberculous patients a bit more conservatively than is his ordinary habit, there is no doubt that we would contribute much to the reduction of tuberculosis morbidity and mortality. All education of this kind is a highly practical and productive method of combating tuberculosis.

We come now to establish a major premise of the first order, one of such importance that it takes rank with the elimination of public spitting; yet unlike the latter it is not directly preventive, but is aimed at the reduction or abolition of morbidity.

This premise is based on three facts, all of which are perfectly well authenticated. They may be stated as follows: First, infection is almost universal, yet morbidity is relatively very low; second, a long interval elapses between infection and the manifestations of disease that may result from the infection, and third, the manifestations of disease are not uncommonly ushered in or precipitated by collateral events in the life of the individual.

In other terms, something besides mere infection is necessary to the clinical expression of infection, Morbid infection depends not so much upon infection as such as upon non-specific contributory factors. Inasmuch as almost all of us still go about our daily business infected yet healthy people, and because it is tuberculosis morbidity that is really responsible for all the evils of tuberculosis--if in every case infection could be confined it would give us little or no concern-perhaps our most important practical task is, for the time being at least, to accept infection as part and parcel of the normal make-up of man, and to lay the emphasis on preventing morbidity. In my opinion, so long as the present situation exists, this is the heart of any conceivable progressive programme; and I should like to discuss this phase at some length.

I might begin by reciting list upon list of

particular things that make for disease once infection is established-of constitutional defects: of vicious habits; of abnormal customs and modes of living; of social, economic and industrial conditions; of intercurrent diseases. But such a tabulation in this place would involve only a waste of time. If we are alive to the full significance of all clinical experience, we can at once hew our way through all confusing detail and assert with full assurance that the contributory factors of tuberculosis morbidity include anything and everything that adversely influence the health of man. Upon some such broad platform we must take our stand. Some such all-inclusive slogan must be our battle cry. Any less pretentious point of view will not fit the facts. The generalization is strictly scientific. It is certainly more so than to lay a preponderant and almost exclusive emphasis on this or that specific factor, and undoubtedly less likely to create a false perspective and bring on uncomfortable days of reckoning, when, while we do away one or another contributory factor, tuberculosis still flourishes and the people ask us why.

Along comes someone and tells us, "Tuberculosis is a disease of undernutrition. Give every man sufficient food and it will disappear." Certainly lack of food may play its part in awakening infection into life-we will grant that much— but when these "one-track minds" put side by side columns of diminishing calory figures and increasing tuberculosis statistics they do not prove their case one bit. They seem to forget that there are underlying factors that as a rule make for insufficient feeding-poverty is surely a most prevalent one; and that these same underlying factors-poverty again, for instance-may bring in their train evils of many kinds; improper housing, inadequate clothing, abnormal work and fatigue, unusual exposure to the elements and to every variety of infectious disease. Why then be so cock-sure that it is specifically the lack of food that is getting in its work? The same mental antagonism is likely to greet the positive assertion that alcoholism has a direct influence on specific resistance to tuberculous infection; certainly figures that show an unusual amount of consumption among alcoholics do not prove the proposition.

Alcoholism pre-supposes

and definitely produces irregularities and exposures of many kinds and it is a most potent breeder of poverty-wherefore, tuberculosis because of alcoholism. But do not expect too much from the abolition of alcoholism unless many other things go with it.

I realize that much of this argument may seem like mere quibbling. But the point I want to make is that we should be very careful not to give the people the wrong impression. By picking out two or three or more superficial concomitants of a high tuberculosis morbidity, and hammering away at these with a disregard of the larger field, promising the while vast and mighty results, we are surely getting ourselves into trouble; and, by not getting at the root of the matter, we are not likely to make as much headway against the disease as we might. The people are not likely to be responsive interminably; and run from one anti-tuberculosis method

to another, as one becomes disposed of while two or more crop up. You know and I know that there are scores and hundreds of determinants of tuberculosis. Then let us carry this news to the people to the point of impressing them with it. Let us, of course, continue our efforts against particular evils-it can be only by paying attention to details that we can affect the mass. But behind and ahead and on all sides of specific measures let us always project the larger vision,-manifest tuberculosis is due to anything and everything that adversely influences health.

If you grant the validity of this statement, it follows with certainty that any fruitful antituberculosis programme must involve nothing less than a thorough understanding of what has in general come to be known as public health and an active participation in it. The tuberculosis worker and propagandist can no more stand aloof from all the manifold currents that determine public health than can the public health worker neglect tuberculosis as a prime and almost predominant factor in his field. The tuberculosis worker who confines his interest and attention to what may be called the specificities of tuberculosis-the tubercle bacillus, its habitats and its habits, and particular measures directed against it and its effects; and whose eyes are closed or unresponsive to all the non-specific factors the inefficient teeth and throats of children, the faulty habits and environment (altogether apart from such things as "lung blocks" and dangerous coughers and spitters) of the human being, the excesses of ordinary existence whether they be excesses of labor, of play or of the passions that summon tuberculosis morbidity to the forefront, is not serving his cause well. He is merely pecking away at the flanks and commanding an attack which, no matter how showy and noisy its launching, can lead only to discouragement. He has failed to grasp the location and nature of the enemy's stronghold For the centre of this whole thing that we call the tuberculosis situation is as fixedly and immutably non-specific as the cause of pathogenic tubercle is specific. Transcendent though the event of the disclosure of the tubercle bacillus was, its results have not been entirely happy. The knowing that there is such a living mite has now and again served us a scurvy trick. It has more than once made of our campaign a mere tournament against the bacillus, while we have forgotten or neglected the fact that morbid tuberculosis, the prevention of disease-of symptoms, of functional disability-is our real objective. And this thing to be aimed at this tuberculosis come to light-is in every particular the culminative result of several or a host of nonspecific factors or determinants that have operated for days, for years, aye, even for generations.

In its climb from Lazarus to Dives a family probably does not change greatly so far as concerns the numbers of tubercle bacilli that are embraced from without by the individuals of each generation; but we can predict with more than a little assurance that the incidence of morbid tuberculosis in the family will vary. In like manner it may take a hundred years for Dives of a positive Pirquet test to be brought down to

Pirquet-positive Lazarus; and in these hundred years little happens to bacilli yet much will happen to morbid familial tuberculosis. If you get my meaning you will have grasped the first and central principle of any and every attack on tuberculosis that may convey a promise of

success.

or

Now, as we approach the conclusion of this address, let us look this whole thing in the face. The medical and scientific premises for a successful programme against tuberculosis have, with one two exceptions, been privileged knowledge for twenty years. I have mentioned only a few of them, a few which I consider of major importance and of a character that invites their practical application. If you expected me to tell you anything new or novel that has emerged from the welter of bedside and laboratory study I am sorry that I have been obliged to disappoint you; for the fact remains that save for the readjustment and crystallization of our ideas concerning infection and morbidity nothing of the first importance for our present purpose has been disclosed since 1900.

But the mere statement of a premise is a sorry and unprofitable pastime, and may be a long way from the attainment of a conclusion; and it is only by the proper application and working out of premises that proper conclusions may be reached. It is really our business to deal less with the erection of premsies and to devote most of our energy to putting them to work. I really am growing a bit weary from observing our professors storm our gatherings with a deluge of papers on early diagnosis, and then go back to their classes and continue to graduate men who know nothing about early diagnosis or just little enough to make them smugly dangerous. There is enough on record about the desirability and necessity of undergraduate instruction in tuberculosis to guide successfully the veriest tyro; yet today in the United States there does not exist a single department of tuberculosis that can adequately instruct all the students of the school. There is to my knowledge not a single first class general hospital that knowingly admits cases of pulmonary tuberculosis to its wards "because of the fear of infection," they say; fit concepts for 1885 or 1890; yet these same hospitals will crowd every type of acute pneumonia and typhoid fever with every variety of acute and infectious disease. You and I contribute to the continuance of dirty milk and promiscuous spitting and inadequate housing and the social and industrial standards that keep up tuberculous infection and morbidity and which are at the root of these. We either fail to see that, so long as the health of the people is so profoundly depressed by their social environment as it is today and always has been, no devotee or practitioner of an improvement in public health can be an advocate or adherent of the social status quo; or, seeing this, we do not act because our motives are directed by some of us to larger or more personal considerations.

We will get the grip on tuberculosis when we create a universal and correct public sentiment concerning it, then, and no sooner. Of public health, we may say the same thing. Our task as

professionals in the field is to remain the professionals, yet to become less professional and more human. To attain results, never was an activity in the world quite so much in need of the human touch as is the endeavor to promote the public practice of hygiene. To exhibit pictures of bacteria and cross sections of the human torso and columns of figures to the dweller of the tenement whose belly cries for food and whose eyes are heavy with smoke and dirt is brainless business, busy though we seem to be. To show this man how his surroundings may approximate yours and to prove to him that you are working with him to make them so is making progress. The inventor of the glass window probably did more for public hygiene than all the millions of physicians who preceded the period of the inventor. Similarly, the man or company of men who can bring about conditions of life that will ameliorate existence to the point of promoting public health will do more good than all pure bacteriologists, pure chemists and pure statisticians, past, present and propective. When we train physicians, we should train men first, and repositories of morbid phenomenology second. When we initiate public health workers into the mysteries of their subject we should develop the smypathies that sympathy which Terence has immortalized-first, and technical aptitude second.

I would not for a moment have you think that I am trying to depreciate study, the value of study of any kind. I am merely trying to give detached study its proper place in the scheme of things. The study of phenomena will always attract a most unselfish side of man's nature and will enlarge the vision and capabilities of the race. What I have in mind may be stated somewhat as follows: That while much of our knowledge of bacteria must be got together in laboratories and altogether apart from the interests of the crowd, it is on the social mass and largely through and by reason of the character of the social mass that bacteria produce their effects, and that therefore in attempting to influence these effects in any far-reaching way we must work from the angle of changing the individual end, therefore, the social point of view.

There is an old saw that nothing is so hard to change as the habits and customs of a people. This may be true; but I have always had a sneaking idea that the maxim was highly debatable unless we introduced the reservation, "provided its environment is not changed." If, therefore, a scheme for the control of tuberculosis that is based on changing the social point of view were set down as impossible because it premised changes of habits and customs I would refuse to be put out of countenance, for the simple reason that it is environmental change which is the thing we must aim for. We might just as well look at the situation squarely. I think we will all agree that a fixed social environment means a fixed tuberculosis standard. If, therefore, we are to influence tuberculosis we must, in some way or other, bring about an alteration of social environment. And, as members of that body that is making an attack on tuberculosis, that is exactly what we are here for, that, and nothing else, whether we admit

it or not. It is time to change the emphasis, which only too long has been laid in the sophomoric and unpleasant, though occasionally necessary, exercise of chasing the "lunger" about the block, to the real work to be done, namely that of reducing illness by making life less hazardous.

How are we to go about this real work?

The sum and substance of our task is that we must carry tuberculosis to the people,-to all the people. And we should remember that in so doing we shall be laying before the public practically the entire field of public health. There can be little doubt that tuberculosis is or should be the hub and centre of the whole public health movement. There is more than a presumption of plausibility that it should be made the pivot on which almost all good-health measures turn. Whatever makes for better conditions as regards tuberculosis infection and disease tends with a very few exceptions to reduce the incidence or deleterious effects of all other diseases. A community of no-tuberculosis at once presupposes a community of cleanliness; of temperance and sobriety; of adequate light, space and air, both within and without its habitations, offices and factories; of labor enough for all; of economic and industrial overstrain for none; of opportunities and facilities for the rational employment of leisure; of an intelligent and enlightened medical profession to correct the disabilities of man; of a strong and sympathetic citizenry with an advanced point of view. "Idealistic, Utopian, Quixotic, crack-brained," you say, "There is human nature in the way, egocentric, self-indulgent, prejudiced, uncooperative, etc., etc." Oh, well, maybe, so; but take a look down the ages, and perhaps you will find that today we are living in a society that was idealistic to the thinkers of Plymouth and Jamestown. Perhaps too what is Utopia to us may be the common state of tomorrow. They must be thinking these things right now in your neighboring city of Framingham; and I am sure that, if they search the depths, they will, when their work is finished, speak to you in a language something like that which I have used above.

Take tuberculosis to the people, and of necessity, you must preach the doctrine of all good health, and the way to get there, to the people. But when I say the people, I mean all the people. For any programme to be even measurably successful we must bring about a thorough vulgarization of our knowledge of tuberculosis. The truth must be told and the remedies must be made universally common knowledge. Once appreciation of what is what dawns upon the intelligence of the man of Wall Street, the ranchman of the Texan plain, the Slovak of the coalbreaker, the bent and cross-legged needleman of Hester Street, the people will begin to apply the remedy. If the remedy means the employment of a mechanism through political intervention, let the people take care of this phase. I do not believe that, as public health bodies or officials, we should ever mix actively in political movements, except in a defensive way. If shortsighted, venal or selfish politicians attempt to undermine ground that has already been gained, then we should fight back and lead the people to the attack. But, to attain reforms that may at

pro

any time be non-existent, we should never become involved in all the manipulations, jockeying and jumbling of issues that characterize the methods of party politics. We dare not court disaster in this way. We must keep our skirts clean; and, with a clear eye, crystallize our objective; and our one and only purpose (in propaganda) must be to work through publicity for those conditions that mean less tuberculosis. Then, with full knowledge, the people must assume the responsibility of action;-strike where it may. This position and this position only— inasmuch as our status is quasi-public or political-we can defend against all attack. their Tuberculosis public health-for grammes are identical-must achieve a publicity such as heretofore has probably never been dreamed of. Our organizations must be enlarged ten and a hundred fold, and in every hamlet the preacher of public health must be as familiar and active a figure as the school teacher, or the friar in the lanes of old Quebec. We must enlist every newspaper syndicate to our cause and have them day in and day out lay the fact of disease and its prevention before their readers. Our leaders in tuberculosis must lay aside their "ethical" scruples, come down to true and effective simples and become lay preachers through the press; for the time has about arrived when we should take the writing of newspaper medicine out of the hands of charlatans and of hack writers who have to a certain extent preempted the field and who have no nobler motive than self-advertisement or the lust for money.

The very fact that every newspaper carries as "feature" matter a "health" column for the instruction and entertainment of its readers shows at once how hungry people are for information on how to keep well. We all know of what a dubious nature most of this health news now is and what more dubious motives have impelled the writing of all but a small fraction of it. Yet we sit supinely by, behind all the professionalism that hedges what we should be and really is the most humane and most human of activities, and allow this misinformation to go on. We all know how to prevent infection and disease, yet for the most part simply keep telling each other about it, and make but feeble efforts to put this knowledge where it will do the most good, that is, feeble compared to what we could do.

I can go further and affirm that it is probable that the newspaper syndicates would aid wholeheartedly in the right kind of a campaign. In fact, within the last month I have been told by the head of a prominent syndicate, that if the right people in tuberculosis were interested, practically all the large syndicates could be got to go before the people with the subject and make it as much a part of their daily lives as any chief topic of the day.

I once more, therefore, come back to the point where I started, the point that I have more than once repeated in this address.

We professionals may know and know things. We may plan and plan and plan things. We may do many things; pasteurize milk here and (Concluded on page 22)

Mental Attitudes Toward Public Service Everyone, in his own field, and less directly by committee or less intimate contact with other associated activities, constantly sees typified in his associates several conspicuous types of mental reactions toward the proposed assumption of hitherto unassumed functions by the State. This applies, of course, to other fields than health and tuberculosis, and the "State" stands for the concept of the official government agency, whether it be local, state or national, or now, indeed, international.

We may perhaps classify the minds of our associates in this regard as follows:

a) The Engulfing Minds

Now and again one meets an individual who believes that all activities belong to the State, and who views with ill will the initiation or continuance of what he deems to be an essential public function by a private agency. He would have the State engulf everything. This group is in reality made up of at least two distinct sub-divisions:

1. The State socialists, the consistent theorists.

2. The State official of a certain type, who is practical rather than theoretic, but who distrusts private agencies, claims that they are inefficient, is perhaps jealous of power, perhaps in reality fears outside surveillance, and at any rate is eminently self-satisfied.

b) The Discouraged Minds

Then one meets frequently the individual who insists, in season and out, that the only agencies to be trusted are the private agencies. He would keep the hands of the State off of community service functions as long as and as completely as possible. This group is also composed of at least two sub-types:

1. The individualists, those theorists who, without embracing the ideal of anarchy, do consistently hold that "the least government is the best government." They are consistently

Paper read before the American Public Health Association at New Orleans, October 27-30, 1919, published in the JOURNAL OF OUTDOOR LIFE through the courtesy of the American Journal of Public Health.

"strong" for the protection of "private initiative."

2. Disheartened citizens, with practical rather than theoretical interests, depressed with the failure of official government, deploring the inevitable fluctuations in public service associated with the change in public officials, and perhaps unjustifiably discouraged "men of little faith." Perhaps these individuals are really idealists, who cannot brook the lack of 100 per cent. efficiency in public service, and who are in this direction at least blind to the fact that partial failure is inevitable, and to be judged by relative rather than absolute standards.

c) The Courageous Minds

Intermediate between the engulfing and the discouraged minds are the pragmatic progressives, the hopeful ones-those who combine a knowledge of history and of scientific procedure with faith in democracy. This is probably the field to which most of us belong. An analysis of this point of view is particularly pertinent to the public health and tuberculosis program today. The essential characteristics of the courageous mind include the following:

1. The courageous mind believes that private agencies are primarily for research,, experiment and demonstration. They should open up new fields, determine the value of practical services and act in a stimulatory and advisory capacity. Private organizations are more likely to be above routine, and there is to be found in them more of the free and creative imagination essential to progress in tuberculosis or other health work.

In

2. The private association should be interested in the co-ordination, efficiency, and interrelation of public as well as private agencies. It may frequently with advantage serve as a central organization or clearing-house. discussing this point only recently at Atlantic City, Dr. David R. Lyman, the recent president of the National Tuberculosis Association, referred to the National Tuberculosis Association, and to the relationship which this organization should bear to other tuberculosis agencies, as follows:

"One might, for example, visualize the central organization as a switchboard through