Apply these figures to the country. The Bureau of the Census indicates 150,000 deaths a year. On this basis we have 1,200,000 living cases of tuberculosis. Let us not forget, however, that 150,000 recorded deaths is far below the actual number, for it is easy to show in most of our communities that many deaths properly to be assigned to tuberculosis are reported under other terms, and the area of the United States from which no statistics are forthcoming includes precisely those States where the mortality is high and the prevalence of tuberculosis demonstrably widespread. We are still absolutely certain that the mortality from this disease is at least 200,000 each year, and the number of living active cases more than a million and a half.

Such, numerically speaking, is our problem. What are the efforts for its solution?

Since the discovery of the bacillus as the cause of this disease in 1882, an organized campaign has gradually been developed. The inferences from the discovery of the cause were perfectly inevitable and indicated the lines of operation. It became entirely clear that tuberculosis, being due to a specific germ, was infectious, and it was equally clear that the bacillus and its life history being known, the disease was theoretically preventable. Here, too, the outlines of the campaign are simple, even though the details of operation are varied and the end in view baffling to attain.

It was inevitable that the first sporadic efforts based upon slight experience should have been more or less random, and that years of trial and proving should precede the establishment of definite method. Some degree of order is, however, emerging, and we are witnessing an increasing clearness of purpose and definition of attack in the preventive movement against tuberculosis which is now sweeping over the country and the civilized world.

While recognizing the unfortunate complexity of the social conditions whose maladjustment is perhaps the chief underlying factor in the problem, while recognizing fully the obligation to lend all possible aid to the betterment of those conditions, the administration of the campaign against tuberculosis has still conceived its specific task to be a direct attack on the sources of infection; this, because experience has indicated. such procedure to be the best and most feasible means of prevention. As the logical conclusions of laboratory discovery and clinical experience began to express themselves in organized movement, it was recognized that the preliminary task in prevention was one of education; an education which should impress upon the public mind not only the fundamental facts that tuberculosis is infectious and preventable and the methods of its infection and prevention, but an education that should bring about an improved knowledge of public and private hygiene, and particularly

an education which should create a public sentiment which could appreciate conditions and would support and even demand those measures which expert advice and experience might indicate as necessary. This educational propaganda, now so familiar, has been in the United States the particular province of private organization. The union of professional and lay effort in this latter day crusade has been one of the most inspiring of social phenomena and has already resulted in accomplishments of imposing dimensions.

With our political organization such as it is, this enlightened public sentiment is an absolute essential if the responsibility for the situation. is to be an official one, and not left for the suggestive and stimulating but less final and efficient efforts of private philanthropy.

The insistence upon official responsibility has been made an essential point in our American campaign and toward its intelligent acceptance by public authorities all efforts are directed. As may well be appreciated, the attainment of this desired end is slow, even though ultimately inevitable.

In planning the campaign, an ideal program was not difficult to lay down. It included as fundamental:

1. The education of which I have spoken, not only as it applies to tuberculosis but as contributing to the solution of that problem of misery which is, after all, the chief problem of the day and which reduces in the last instance largely to terms of good or ill health.

2. Enactment or enforcement of protective laws of which the basis was that notification and registration agreed upon as preliminary to official knowledge and control of the situation.

3. Adequate institutional provision for all classes of cases; the sanatorium for the curable; the hospital for the advanced and hopeless, and dispensaries for early diagnosis and as centers for that all-important field of action, education and treatment in the homes of the poor.

The developments of the years have not served appreciably to modify the main features of this program. Emphasis has shifted from time to time and will continue so to shift, but the fundamentals remain more firmly established than ever.

In developing the movement in this country, the most effective means of stimulating action in our various communities has been the voluntary association for the prevention of tuberculosis. In organizing these societies the local community has been recognized as the essential centers of action. The effort has been made, therefore, to obtain in every community of considerable size an organization embracing elements both medical and lay which shall charge itself with the task of securing adequate official treatment of the tuberculosis problem as it there presents. itself.

In many of our commonwealths such organizations can best be brought about through the action of a State society, whose special function becomes one of organization and of securing desired legislation. In other cases the initiative is local in origin. Where State societies exist, these act as co-ordinating agents for the affiliated local societies, and the National Association for the Study and Prevention of Tuberculosis acts as a clearing house for them all.

It will be seen at once that such organization is but preliminary, and would be entirely futile, did it not result in preventive measures of a definite sort. There is, however, no other index equally valuable of the vigor and growth of this movement in the United States. Speaking from the national point of view, the organized campaign in this country has been in existence exactly seven years. In 1905 there were in the entire country but twenty-one of these societies, while at the present time there are no less than 660, working in co-operation and presenting a united. front to the enemy. There is no considerable area that does not contain

some such center of intelligent action.

The carrying out of the program outlined a moment ago is the special function of the organized movement. In the development of this program it is historically interesting that it was institutional provision for tuberculosis that first obtained support. It was the sanatorium for the cure of curable cases with its peculiar appeal which first engaged attention. From our present point of view, it was perhaps not the logical beginning, but it was certainly the obvious and perhaps the most fortunate point of attack. The sanatorium with its promise of restoring to a wage-earning capacity those unfortunates who formerly had been regarded as doomed to a speedy and inevitable death, was peculiarly fitted to arrest public attention and to engage public support.

As the movement for sanatorium establishment developed momentum, attention turned to the need of special dispensaries as logical centers of preventive work. Time will not permit even an outline of this phase of the problem. Suffice it to say that with the first general survey of the movement in the United States, six years ago, there were in the country but eighteen dispensaries exclusively devoted to tuberculosis. There are today more than 400 such foundations and their number is increasing at a rapid rate. All those who deal hand to hand with the problem become impressed at once with the fact that tuberculosis is pre-eminently a disease of social life, of living and working conditions. In the absence of adequate institutional facilities it is unavoidable that the problem should be attacked in the homes and workshops of the people, and with such weapons as may be at hand or which can be devised. With early diagnosis and careful instructive nursing supervision, much can be done even in the distressing conditions which characterize the crowded and poorer quarters of our great cities. The center of activity in this field is every

where the dispensary, and the elaboration of its function to include supervision in the homes of indigent patients has been one of the most interesting and important of recent developments.

The third and possibly the most important aspect of institutional provision was the last to be taken up with energy. Every survey of our equipment during recent years has served to emphasize the shocking lack in our facilities for the care of advanced cases of tuberculosis. It has become increasingly evident that as centers of infection the consumptive in the advanced stages presented the most serious problem. Equipped as we were, with a healthily growing movement along educational, sanatorium and dispensary lines, the time seemed ripe for a vigorous attack on this point of weakness. The result has been that during the last four years there has been a concentration of energy in this direction and a notable advance has been made. Without pausing to specify various kinds and degrees of hospitals and sanatoria for the treatment of tuberculosis in the United States, it is encouraging to note that we now have over 500 in the country, as compared with 111 seven years ago. The number of beds contained in these institutions is approximately 30,000, a number small when compared with the need, but encouraging when compared with the situation but a few years since.

The third feature of the program already mentioned, that of legislation, is less susceptible of numerical expression, but it is in many ways the most fundamental and most significant of advancing intelligence. The principle of compulsory notification and registration has been insisted upon from the outset, and it has now come to be fairly generally accepted in all parts of the country. With few exceptions the more important States provide for registration by enactment either of the Legislature or of the State health authorities. In most of our larger cities local regulations are also on the statute books. Unfortunately the enforcement of these regulations is far behind their expression, but the situation is rapidly improving, and the example of such cities as New York in initiating the principle, and of Cleveland in demonstrating its possibilities, is of inestimable value.

In dealing with the question of public hospital establishment, the best adapted political unit has caused much embarrassment where a given community is not large enough to support an independent institution. Federal provision is agreed upon as being out of the question. The State as such is in most instances regarded as having the same limitations to a lesser degree as the national government. It is fairly generally accepted that where the municipality is of sufficient size it should accept responsibility for its problem. In those sections where communities of lesser population are the rule, the county is now in the focus of attention.

Little difficulty has been encountered in procuring the necesary leg

islation for local and county institutional provision. We have now reached the point where the possibility of mandatory State legislation is being considered with care and some favor. In this connection one should note the recent passage by the Legislature of the State of New Jersey of a law which undoubtedly represents the most advanced legislation in the United States and probably in the world. Without going into details, the law in question provides for the establishment of special tuberculosis hospitals in all the counties of the State, for the payment by the State of a certain sum ($3.00 per week per patient) toward the maintenance of such hospitals, for the compulsory segregation in such hospitals of dangerous and incorrigible cases of the disease, and for the general supervision of these provisions by the State Board of Health, though the primary responsibility is placed upon the local health officer. This legislation is of the highest interest, not only in its promise of results, but as an enactment into law of principles formulated as necessary by expert experience even though in advance of public appreciation.

Reaching into every field of social activity as this campaign must do, it is inevitable that new phases of importance should successively make their appearance and demand attention. I should say that perhaps the most striking is the essential importance of the child in the tuberculosis problem. With improved methods of diagnosis and wider facilities for examination, there has been shown a prevalence of tuberculosis in children of school age that is most alarming. It is a conservative statement that there are today in the public schools of the United States 100,000 children who will die of tuberculosis before they reach the age of eighteen if the present rate of mortality be continued. A very recent estimate presented by the United States Bureau of Education states that at least 15,000,000 children now in attendance in the schools of the United States are in need of a physician's attention, and that of this number 1,000,000 have or have had tuberculosis. It has become clear that if our educational campaign in the interest of preventive medicine and public health is to achieve success, the attention must be concentrated upon the coming generation rather than upon those who have already passed their years of plasticity.

We see, then, on every hand the tendency to attack the problem in the schools, and this not only by the establishment of provision for open air teaching and the improvement of the undernourished and the predisposed, but upon insistence of regular and intelligent instruction as to the prevention of disease.

Such in its general outlines is the plan by which we are working. With such a situation and with such a campaign what then is the outlook? I have little sympathy with the enthusiasm which deals in specific predictions or which assigns a date for the practical achievement of theoretical possibilities. It is perhaps inevitable that an impatient