was lying in bed presumably asleep, he heard his parents seriously discussing their financial affairs. "I guess we will have to sell the old home," he heard his father say to his mother. The next day, without consulting his parents, he quit school and got a job as an errand boy. He has been working hard ever since. His education has come from reading at nights. His friends would never suspect that he was not a college graduate unless he told them this story.

When he was thirty-five years old he was compelled to give up his business because he had contracted tuberculosis. He was sent to the Bermudas as a place where he could die with the least degree of discomfort. He determined not to die because he thought there was still some service which he might render the world. After he regained a little strength in the Bermudas through the observance of health rules, he came back to New Jersey and bought a farm, giving a mortgage. Through life in the open air and through making a business out of being healthy, he arrived at the point where he could return to the city and enter the business with which he is now connected.

The first opportunity to enlist Mr. Cook in the fight against tuberculosis came in 1892 when he was appointed chairman of the New Jersey Commission for the Prevention of Tuberculosis in Animals. The legislature allowed the Commission only $5,000 to work with. At the same time Massachusetts was spending $200,000 in six months and applying the tuberculin test generally to the cattle in the state. Mr. Cook decided that he would do the

Oh, we are living in the land of T. B.,
But none of us are here who are willing to be.
You all wonder why we kick and refuse
When the Sanatorium is the only place
The doctor will choose.

He will say run along take the cure for awhile, And you all send us off with a jolly good smile;

But the tea is so bitter and coffee so strong Till we soon wish that old doctor in h— Where he belongs.

We crawl over in bed none better than we, Hoping that old temperature will accordingly be.

We lie there for six months afraid to even frown

Before that old temperature will decide to go down.

Then around comes the doctor walking back on his heels,

And says, "I believe I'll let you out to your meals."

You hop out of bed and go skipping around, Till the nurses all think you're a perfect

clown.

job of routing bovine tuberculosis from New Jersey with his $5,000. He started a campaign of education through every Farmers' Institute and grange in the state. It worked. Today New Jersey is reputed to lead the country in the matter of prevention of bovine tuberculosis. No farmer will buy a cow unless it has been tested and every carload of cattle shipped into New Jersey receives the certification of the state veterinarian.

You never hear of a strike in the Pottery industry in Trenton, and you very seldom hear of complaints. The pottery business is supposed to be somewhat dangerous to health, but the Cook Potteries are reported to be very healthful. One of the secrets of this result is that the health problem is attacked by both sides, separately and jointly. In other words, the employees look out for their own health and the employers look out for the health of the employees. At the same time, both groups join together in watching sanitary conditions in the factory. There is a joint committee consisting of three of the men and three of the bosses, and reforms are constantly made before a demand for them is voiced.

Mr. Cook insists that the same principle of popular education which did so much in the field of bovine tuberculosis can be applied to human tuberculosis, and part of his plan for the Mercer County Association is to get every man, woman and child in Trenton and the county talking about Better Health and observing the rules of healthful living.

The country is watching with interest the working out of Mr. Cook's plans in Trenton. T. J. EDMONDS.

OF T. B.

Somewhere in the Scriptures a writer refers to the futility of trying to measure the wind with a yard-stick, and many other writers have been staggered by the problem of expressing the intangible in terms of the tangible. There are movements that simply cannot be reduced to facts and figures, and the tuberculosis movement is one of them. One can only give a hint of it in statistics; the really vital part of the story refuses to be told in that way. And in making a report on the effect of the Michigan Tuberculosis survey as seen two years after the survey closed it is necessary for the most part to eschew fig

ures.

This will not satisfy the person who dotes on statistics, but it can't be helped. Aside from the fact that the greatest part of it cannot be reduced to figures, the tuberculosis movement in Michigan is a live one, and the figures that might be true when written here would probably no longer be true when what is written has been reduced to print.

To come to cases, therefore, the first result of the Tuberculosis Survey in Michigan, as seen after two years, is that the survey has been placed in its proper setting as seen in perspective. It is seen now as an episode in the tuberculosis movement of the state, or rather as a step. It was a logical step in the march of progress, but it was no more than a beginning of a progressive battle.

It was not seen in that light by many of the people of the state in 1915 when the legislature appropriated $100,000 with which to fight tuberculosis. The leaders in the tuberculosis movement, of course, knew that that act of the legislature was only a beginning, but thousands of people in the state naively assumed that by that act the legislature had practically

abolished tuberculosis. In 1915 one hundred thousand dollars looked like a much larger sum to most of us than it does to-day. The war and its finances have revolutionized our ideas about the purchasing power of the dollar, and what the war hasn't done, our old friend H. C. L. has accomplished, so that today an appropriation of $100,000 by the state legislature would not look as big as it did in 1915. Many of the people felt that the legislature, by making the appropriation had hit a staggering blow at tuberculosis and that within a few years there would be little of the disease left. I remember that it was something of a shock to many when, early in the campaign, Dr. William De Kleine, the director of the survey, announced that this appropriation was only a beginning and that it would take a generation of such appropriations to win the fight against tuberculosis.

But to-day the people of the state, generally speaking, understand that that was the literal truth. They understand that an appropriation of $100,000 to attack a disease like tuberculosis is like emptying a reservoir with a teaspoon. And the consciousness of this fact is a valuable result of the Survey. Obviously, a great state of three million people could never hope to make even an adequate beginning in a fight against tuberculosis as long as they kept to the notion that it was a year's or a two years' job. The first essential to success is that people shall obtain a just appreciation of the proportions of the task. Unless that is gained the state can never be expected to gird up its loins in earnest and really go to work at it.

And it requires no unusual vision to understand that the Survey and what followed it will eventually result in just that; that it will

cause the state to go at the work in an adequate way. For the time being the legislature has steered away from the subject, but the public sentiment of the state will inevitably drive the legislators back to it. The people of the state eventually will demand that the legislature give the fight against tuberculosis the attention that it deserves. Indications of what is coming may be seen in many sections of the state even to-day.

Another undoubted result of the Survey as seen two years after is the increase in sanatoria in the state. This statement needs some qualification. For Michigan has not built nearly as many sanatoria as most health workers would like to see erected. In fact, as far as tangible buildings is concerned, very little has been done since the close of the survey in 1917. Grand Rapids and Detroit and a few other places have voted bonds for the erection of sanatoria, but in the average community the project has not reached the bondvoting stage. A skeptic could easily point to this fact and base on it the argument that so far as sanatoria are concerned, the Survey has been largely without results.

But in this the skeptic would be wrong. Even though no buildings have been erected (due largely to the fact that the building restrictions of wartime prevented it), the Survey has not been without results. Not only have several communities made plans for buildings, but the attitude of most communities has radically changed. At the beginning of the Survey boards of supervisors, as a general rule, were not interested in sanatoria. They looked upon all such projects as the impractical dreams of cranks. When a health worker spoke to them on the necessity of building a sanatorium, he was not taken seriously.

But what is the case to-day? Many boards of supervisors are still not ready to build sanatoria, but most of them would like to, if they could see their way clear. And the health worker speaking on the subject is given serious hearing. In many counties committees are at work trying to devise ways and means. And all this is going to result in sanatoria. While the buildings are not yet here in stone and wood, they are slowly taking shape in the minds of the people. Moreover, Michigan has passed a Joint-County Sanatorium law which allows two or more counties to erect a sanatorium together. This, it is expected, will be a practical step forward toward getting the much-needed institutions built.

So far as I know, there are no figures available to show how many visiting nurses have been established throughout Michigan as a result, directly or indirectly, of the State Tuberculosis Survey. But a conservative estimate is that there are at least ten times as many visiting nurses employed as permanent fixtures of county or city government as there were when the survey began. The appointment of visiting nurses was one of the cardinal creeds of the Survey workers. This creed was enunciated early and late. It was always one of the things emphasized. The

counties were told that they could not hope to make a successful fight against tuberculosis unless they appointed a nurse who could help to prevent tuberculosis, for prevention was, of course the method that was stressed all the time.

Here is a typical example. There is one county in the state that obtained a county visiting nurse soon after the Survey began. The claim is not made that in this county she was appointed as a result of the Survey, other factors having helped to work up sentiment for her. But to-day that county has two nurses instead of one. And the increase in number of nurses is still more true in cities than in counties. The larger cities have all greatly increased their nursing staffs, while many a city of from 5,000 to 10,000 has also appointed a nurse. As insisted on before, the Survey does not claim full credit for this, but without the Survey the movement would not have made the headway that it has.

Another thing the Survey speakers constantly dwelt on was the necessity of establishing full-time health departments. Michigan is no different than most states in the matter of health departments. Until a very few years ago the second largest city in the state, namely, Grand Rapids, did not have a full-time health officer. A city of 140,000 was depending on the services of a man who was expected to help out a grossly inadequate salary by private practice. And the same thing was true, and, unfortunately, is still true, in many smaller cities. A city of 10.000 will think nothing of paying its health officer a salary of $500 a year, or often even less. To a good extent as a result of the Survey that kind of thing is changing. The Survey preached first of all that a full-time health officer with a wellequipped office was one of the greatest weapons in the war on tuberculosis. Secondly, it declared that a health officer should be so well paid that he could devote all his attention to the work and could become a health engineer for the community.

A good many cities have since established full-time health departments. Among them are such cities as Flint, Kalamazoo, Battle Creek. Pontiac, Highland Park, and several other cities in various parts of Michigan.

During the Survey Dr. De Kleine, in many of his addresses, made a telling point by comparing the appropriations for health with the appropriations made for police and fire protection. He would go to the city clerk and learn the figures about the police budget and the fire department budget. Then he would get the health budget. Invariably, about five or ten times as much was spent for police and fire protection as for health. He then pointed out that the former was for the protection of property, the latter for the protection of buildings, while the health service was for the protection of human lives and for the increase of human happiness. The figures showed how much more importance the people of the particular town attached to property than to life. At the time this seemed right and natural

to most cities, simply because it had always been so. But there are indications that it does not seem so right anymore to-day. In many places the health appropriations have been increased manyfold, and health departments are beginning to get the equipment and organization that they need for effective work.

Perhaps one of the greatest effects of the Survey has been that people have come and are more and more coming to a realization of the fact that tuberculosis can be and must be treated in Michigan as well as in other states. This is more important than it appears on the face of it. As long as the general public has the impression that the course to follow in a case of tuberculosis is to send the victim out of the state to another climate, no sanatoria are going to be built and little else is going to be done at home. But when people under

"One fact stands out-that the young man entering the army, although he belongs to a physically select class, is in much greater danger of illness and death. than the man of the same age in civil life."* This quotation from no less an authority than Dr. M. P. Ravenel, late Lieutenant-Colonel in the army and former president of the National Tuberculosis Association, should give every thinking health-worker some moments of reflection.

The answer to the questioning why that is raised by this startling statement is not found in the physical qualities of the men selected for our army, nor in the training to which they were subjected, nor in the food with which they were fed. It is found instead in the manner in which they were housed, thinks Dr. Ravenel, that is the large-roomed barrack with its abundant opportunity for the spread of contact infection.

Among the diseases that killed and incapacitated most of our men were the acute infectious group-measles, scarlet fever, pneumonia, meningitis and influenza-all of them spread by secretions of the respiratory tract, and all of them

* "Preventive Medicine and War," M. P. Ravenel, M.D., American Journal of Public Health, January, 1920, p. 22.

preventable or at least reducible to a comparative minimum.

The American soldier, as well as the American civilian from whose ranks he is recruited, is an inveterate distributor of sputum. He spits, sneezes, coughs, moistens things with mouth secretions, and in a hundred ways thereby spreads disease. Given, then, a group of several hundred men housed in tents or barracks without regard to comfort, and the opportunities for disease dissemination are artificially provided in a way that could never exist in civil life.

The soldier or civilian may have a good resistance, but when he is exposed to repeated contacts with virulent infectious disease germs his chances of warding them off diminish with each successive exposure.

Here is a lesson for the health-worker of primary importance. We must build resistance, to be sure, and build it in every way we can. But we must seek by the prevention of spitting, sneezing and coughing to keep the resistant man from being repeatedly subjected to those exposures that will sooner or later break his armament and produce not only the immediate acute infectious diseases, but, worse still, lower his vitality to a point where the latent tubercle can get a chance to do its dastardly work.