most conspicuous. Those who are engaged in the relief of distress, unless they are mere automata, are inevitably led on to the consideration of preventive measures. It is certainly most unsatisfactory to be taking part in the relief of families who are in distress because of illness, and at the same to realize that forces are at work and conditions are present which are undermining the health of others, and leading inevitably to the situation in which relief will be required. The personal indignation which is aroused by the neglect of such forces and conditions would be a valuable ally in securing the changes which physicians well know to be essential. The social force which might easily be developed among charitable visitors, professional and volunteer, among clergymen and church visitors, among trade unionists and social reformers can scarcely be exaggerated. I know of only one occasion in which it has been even approximately brought to the point of expression. On that occasion, the recent Tenement-House reform movement in New York City, an absolute revolution in the conditions under which tenement houses may be erected, was brought about-a revolution so complete that even its most radical advocates within a year found it advisable to modify in many slight particulars the law which they had themselves formulated, and it was found that the public opinion upon which the reform rested was sufficiently permanent and well grounded to repel the most vigorous onslaughts of speculative builders whose private interests were contrary to the public interest, and who have usually under such circumstances been able to accomplish their purpose, however averse it might be to the general welfare.

One of the diseases whose insidious and evil effects are most frequently encountered by those who are called upon to inquire why a family cannot be self-supporting is malaria. It not only increases the hardship of wage-earners, causing irregularity of work and reducing physical energy, but it makes precisely the difference between self-support and dependence for many of those who are already near this dreaded border line. It attacks adults as well as children, and its full effects upon the economic position of the family may not be obvious until many years after the fever has first been acquired.

Is it not then important if we would lessen the burden of poverty, and the need for charitable relief, to do everything that science has demonstrated that it is possible to do to lessen the number of its victims? If it is true, to quote Dr. Howard's language, that perfectly satisfactory proof has been gained during the past few years that mosquitoes are responsible for the transmission of the malarial germ from the malarial patient to healthy people," is it not incumbent upon us to utilize to the full every influence that will compel the adoption of the remedy which is thus indicated? Is not the time already longer than should have elapsed between the demonstration and the public policies which are its logical result? Should we not attack malaria in every community in precisely the spirit in which the military governor of Cuba acted upon the results of the experiments and demonstrations at Quemados? Are we likely to secure such action on the part of local health boards and physicians if the subject is treated only, or chiefly, in medical journals and in meetings like this? Should not physicians and investigators, the moment the demonstration is complete, take steps to create public opinion; to prepare newspaper articles, leaflets, pamphlets, and books that shall be at the same time scientifically accurate and to the lay mind intelligible? And should we not summon as allies in the new crusade all those who come into contact with disease, distress, and bad social conditions from other standpoints than that of the medical profession? It is generally understood that physicians must be leaders, but the point which I wish especially to make is that they cannot lead effectively unless they are in constant and intimate relations with all these other groups, relations which must be established gradually, and which should be a constant asset, immediately available when new situations of this kind arise.

Defective eyesight, decayed teeth, an imperfect carriage, are from a social point of view, not merely causes of individual suffering and occasions for the exercise of professional skill: they are also causes of poverty; causes of irregular employment; causes of undue restriction in the field of possible industrial opportunity; causes which may lead to physical deterioration in offspring. Such defects as these can be

remedied, if the public sentiment of the community is alert to remedy them. Knowledge which individual parents may scarcely be expected to possess exists, nevertheless, in the community, and should find expression through the health board, through the school board, or through some other recognized agency. It may indeed be that the remedy would be found to lie chiefly in the education of parents and in the education of future generations; but whether thus indirectly or by more direct means, the prevention of disease, for which the combined efforts of physicians and of others are requisite, remains a most fundamental and a most neglected public duty.

The most striking illustration for our purpose is a movement which in this country we have as yet scarcely inaugurated, but for which there is everywhere a necessity so urgent and so apalling as to make it difficult for us to consider calmly and with due self-restraint its various aspects and the relative merits of the various remedial measures. I refer of course to the movement for the prevention of tuberculosis.

It would not

be appropriate to marshal here the statistics of this scourge, or to describe the beginnings that have been made by acts of legislatures and health boards, by voluntary societies formed for educational purposes, and by private philanthropy in the erection of sanatoria and the pecuniary relief of indigent sufferers. Perhaps, however, it is not carrying coals to Newcastle for me to emphasize the rapidly accumulating personal sentiment, which is the natural result of the proclamation that this disease is communicable, curable and preventable.

The transition in the public mind from submissive despair to eager hopefulness, the change from pessimism to impatient demand for fruits of the new knowledge, the slowly dawning public conviction that if tuberculosis is curable it must be cured oftener, that if it is preventable it must be prevented, that if it is communicable then there is a moral responsibility to stay the infectious plague-all this is a public awakening which may not yet be apparent if the eyes are closed, but it is a dawn of which the first faint streakings are plainly visible to those who walk upon the hilltops of suffering. It is not of our individual doing, nor shall we be able if we would to delay it. The problem

for us is merely how to utilize for the good of mankind the knowledge that we have; how to extend that knowledge where it will have potent influence in the prevention of needless disease and death; how to bridge over the gap between what is written in the medical books and what is written in the sunken cheeks of the consumptives of whom one may easily now see a thousand or more in a single day if he will merely visit the hospitals of the city of New York where less than one in twenty of our entire number are to be found.

Personal interest in this subject does not often need to rest upon an altruistic basis. I do not remember that I have ever spoken about it in the smallest group without noticing some indication that it makes a direct personal appeal to at least one in the group. Nearly every family has lost a member or close friend, or looks forward with apprehension to immediately impending disaster.

It is this catholic impartiality that makes almost inevitable a concerted movement against the disease, yet the impartiality is not complete, for it feeds upon overcrowding and alcoholism and undernutrition, so that again it is found that from him that hath not is taken away even that which he bath, and that the destruction of the poor is their poverty.

The lines upon which cooperation appears to be possible at the present time between the medical profession and agencies for social betterment are at least four:

I. The promulgation through personal interviews, through public lectures, through leaflets, through newspapers and the periodical press, through clubs and classes, through the schools and colleges, and through every other practicable channel of public education of the idea that the consumptive must properly care for his sputum; that tuberculosis should be recognized and treated at the earliest possible moment; that nutritious and suitable food is essential; and that the physical presence of a consumptive who is intelligent and conscientious is not necessarily— or even probably-dangerous to others.

II. The erection of numerous and not too populous houses of rest for advanced cases-where there shall be every attempt to make easier the closing hours of life, to detect and help any

hopeful case, to provide for out-of-door exercise and indoor recreation, to permit occasional or even frequent visits from friends under proper precautions; and in general to create those conditions of cheerfulness and physical comfort that will lead patients readily to enter and to remain whenever the conditions in the patient's home are such as do not permit him to remain there with comfort and safety. Such sanatoria may properly be maintained either by local taxation, or by private benevolence, and they should be numerous enough to make long journeys unnecessary, and to remove all inducement to overcrowding.

Such houses of rest may profitably be supplemented by endowments or by generous private gifts for individual patients to show how much can be done in even apparently hopeless cases if ideal conditions are attained. The interests of humanity and of science alike require numerous experiments even with advanced cases to see whether at least some of the more distressing features cannot be still further mitigated.

III. Well-equipped hospitals for the treatment of lung diseases, favorably situated as to climate, as to altitude, as to remoteness to congested populations, as to scenery, and in all other respects, in order that no known condition favorable to recovery shall be absent if it is feasible to secure it. In these hospitals which may well be comparatively few in number, there should be ample-even lavish provision for essentials of treatment. There should be no hesitation to provide everything in the way of grounds, and buildings, and maintenance, and above all no parsimony as to professional service and no lack of opportunity for laboratory research and experiment.

To the charge that this would be the creation of a favored class of public dependents, it is to be replied that these things are not done solely for the sake of the particular patients who may be cared for, but for the sake of the entire people. We are in the midst of a desperate warfare; and just as we would give every protection to a garrison that was battling for the homes and lives. of all, so we would concentrate here upon the human bodies that are struggling with the bacillus, which is our common enemy, every element of strength that will enable them to resist the disease. Every patient saved, or even taught simple hygienic