hold it in a state of innocuous desuetude by a force which we call resistance. Resistance, therefore, is the sine qua non of phthisis, and not infection.

Since infection, then, is universal, how absurd it is for people to try to escape something which they already have. In what a veritable glass house do they live who throw up their hands and say "unclean" to the lunger. The ubiquity of the tubercle bacillus is such as to render escape from it absolutely impossible.

How utterly impossible it is to avoid infection is more readily understood when we consider that only a very small percentage of open cases know that they have the disease. It is estimated that less than five per cent of open cases are, at present, isolated. The other ninety-five per cent confront us on every hand as relative, friend and servant. Since the percentage of people infected, as shown by autopsies and tuberculin tests, is as great today as in the days of Koch, it is evident that much of the anti-tuberculosis work, which has in the main been directed toward prevention of infection, has been futile.

Phthisis, therefore, is the result of imprisoned bacilli being liberated-of breaking the bounds placed about them in late childhood. In speaking of the beginning of this disease, then, "breakdown" is the proper term, not infection. If this were not so, every man who had a tuberculous wife or children, as well as every employe in sanatoria where open cases are kept, would become phthisical. The morbidity among such has been conclusively proven not to exceed that in people living under similar conditions but not exposed to infection. If it were possible to re-infect adults with tubercle bacilli, even the closed cases in sanatoria would be sure to be reinfected by the open cases. With these facts in mind it can safely be stated that ordinary contact with open cases is without danger to adults and even close contact is very little, if at all, dangerous.

Two more or less distinct types of tubercle bacilli are known to attack the human organism. These are designated human and bovine types. About ten per cent of tuberculosis in children is caused by the latter. This type is often excreted in the milk, but probably more often this fluid is infected as the result of contamination with the cows' feces which contain the bacilli Tuberculous cows probably more frequently than the milk.

should, of course, be excluded from the milk producers for these reasons. This is a comparatively simple matter since they are readily detected by the tuberculin test.

Cattle may be infected from the sputum and other excreta The huof human beings but such undoubtedly rarely occurs. man type of bacilli which is practically the only type found in phthisis are relatively non-pathogenic for cattle. It may therefore be safely said that cattle become infected only by bovine

bacilli occurring in the excretions and secretions of other cattle and possibly to a less extent from other domestic animals. The problem of combating the disease in children then is entirely different from that in adults. In the infant, infection must be prevented at all costs. The danger of contact with open cases, no matter how careful they may be can not be over-emphasized. Children under two must be removed from homes where there are phthisis cases or any one with a cough.

Since there are so many open cases who consider themselves healthy, infants should not be brought into contact with any one but the immediate family who are known to be free from the disease. Many of the "chronic bronchitis" and "asthma" cases in older people are now known to be really suffering from phthisis and for this reason fond grandparents are often a source of great danger to infants. For the same reason domestic servants are also frequently dangerous.

When an infant is to be hand fed the milk should be carefully selected. Where there is uncertainty as to its character it should be pasteurized or better, sterilized. As stated before, primary infection before the age of three or four must be prevented at all costs. It is because of this deadly menace to children that open cases should be taught and helped in every way to destroy their sputum.

As the child becomes older and contact with the unknown outside world becomes more and more unavoidable he will likely, sooner or later, receive his primary infection. His first contact with open cases will not, however, be so close as is the case in infants and he will be able to care for these small infections, thus vaccinating himself against further infections. Indeed, it is doubtful if it would be well to prevent these infections which occur in this refractory period since primary infection to adults usually results in acute fatal disease such as occurs when aboriginal races come into contact with civilized races.

Serious and often fatal tuberculosis does at times, though very rarely, occur between the ages of four and fourteen. These cases are usually auto-infections, resulting from "breaking down" of the barriers of resistance by acute diseases such as measles and whooping cough. These diseases produce in the child's body a condition called allergy which renders it susceptible to reinfection by the tubercle bacilli which they have encapsulated within their bodies.

The measures for preventing tuberculosis in late childhood should therefore be directed toward prevention of those other acute infectious diseases and when these do occur, to guard carefully against auto-infection by the tubercle bacillus during convalescence by prolonged rest from studies and bodily fatigue, max. imum of fresh air and nourishing food.

In adults the problem is entirely different. Measures directed toward prevention of infection are here useless, extravagant and actually harmful. Phthisis which comprises over ninety per cent of tuberculosis, does not occur for many, many years after infection and is due to auto-reinfection. Measures of prophylaxis must therefore be directed toward preventing "breakdown". Improvement of economic conditions, and education of both laity and physicians as to the early symptoms of breakdown are the outstanding needs. Philanthropic agencies may do much more by concentrating their attention on improvement of economic conditions than sending agents to tell adults that it is dangerous to remain in the proximity of a consumptive. Labor unions will do better to demand higher wages and shorter hours than to drive their unfortunate phthisical brother from his only means of supporting himself and family.

The inadequacy of the training of Iowa physicians regarding tuberculosis is only too well shown by the erroneous advice which has been given to a large percentage of consumptives before reaching Oakdale. This ignorance of the causes, early signs, and treatment of this most important of all diseases, is not limited to the older physicians. This condition would, to a certain extent be eliminated, I believe, if we would arrange to. have under-graduate medical students spend a month or so at Oakdale before receiving their degrees in medicine. This is done with much success in some other places.

"Catching cold" is one of the chief means of re-activating latent foci of tuberculosis. Ordinary colds (acute bronchitis, rhinitis, sinusitis, etc.) not only cost the state of Iowa millions of dollars annually in loss of time, but may prepare the soil for the inroads of tuberculosis. Colds are simply acute infections passed from person to person, largely by means of the sneeze and the cough. Temperature has very little, if anything, to do with them, except in so far as it crowds people together in poorly ventilated rooms where the ejected bacteria can become concentrated and pass to the victim more readily. The cough of the sufferer from an acute cold carries into the air bacteria so deadly that not only can they produce colds but may cause death in the individuals who inhale them. Yet we hardly expect these people to cover their mouths, let alone burn their sputum.

If public sentiment were trained to expect every one to carry a square of gauze with which to cover the mouth and nose when sneezing and coughing, even if one has "only a cold" it would certainly make it less difficult for the consumptive to try to protect his neighbor's children.

At present uninformed "social" workers, anti-tuberculosis campaigners, etc., are doing immeasurable harm by telling people to shun the lunger, and in the same breath saying there is no

danger, even to infants, from the careful consumptive. Phthisiophobia, the disease which these enemies of society are spreading is nearly as bad as phthisis. It results in the poor consumptive being shoved from pillar to post with scarcely a soul to call his own. Fear of these phthisiophobes makes it imperative for the unfortunate lunger to conceal his malady, thus preventing him from taking proper measures for preventing the infection of infants who are the only ones who need fear his disease. After all, it is to him we must look for protection of our little ones.

Williams Garrot Brown, in his "Confessions of a Consumptive" says: "The public depends for protection from such danger as our continued existence involves, not on its own exertion but on ours. We must continually take, for the sake of the public, precautions which are disagreeable and costly; and meanwhile a great part of the public is, by its attitude toward us, steadily tempting us, and even sometimes fairly compelling us, if we would live, to discontinue these precautions and go on as if there were nothing the matter with us. The folly and stupidity of this attitude it is impossible to estimate. It is of itself the chief cause and source of the persistence of this scourge. Known and recognized and decently entreated, we are not dangerous (to adults). Shunned and proscribed and forced to concealments we are dangerous. Victims ourselves of this same regime of ignorant and self-deceiving humanity, we are called on every hour of our lives for a magnanimous consideration of others."

In bringing my paper to an end let me recapitulate: tuberculosis in children is malignant to the last degree and is the result of infection, which is preventable. Phthisis, the form of the disease which occurs in adults, is the result of breakdown, and is not prevented by avoiding consumptives. Phthisiophobia is absurd, unfair and dangerous. Tuberculophobia (fear of infant infection) is proper and benevolent.

CHILD PLACING.

Ralph Reed, Secretary of the Welfare Bureau of the

Chamber of Commerce of Des Moines, Iowa.

It was both a sense of pride in being so honored and a sense of duty that lead me to very promptly say "Yes" when a few days ago your secretary asked me to prepare a paper for this meeting. On more than one occasion it has given me real satisfaction to be privileged to sit in these conferences as a listener. Many other times I have found real help in the printed reports of the papers presented here. I do not know what other states are doing, but I am sure that Iowa has cause to congratulate herself upon both the ability and spirit of those who are directing her various state institutions. We who work in local communities, are especially appreciative of the obvious purpose and effort on the part of both this board and the management of each individual institution to cooperate at all times in helping to solve our most difficult and perplexing problems. It is because this cooperation depends so much on a mutual understanding of our respective jobs that it seemed a duty, regardless of the fact that I was conscious of no particular message that I wished to bring to this group, and this is why I so readily let myself in for the task of preparing a paper.

There are three problems of mutual interest to the members of this conference and to us, whose duties are confined to local communities which it has occurred to me to discuss today. These three problems or needs as I see them are,

1 A trained social worker in every county.

2 Our adoption laws need changing.

3 Child placing practices and institutions in Iowa should be studied.

How can the board of control and the superintendents of the various state institutions most help local communities in their welfare work?

How can the local community more effectively help and supplement the work of our state institutions?

The correct answer as I see it to both questions is, work and boost to get a trained social worker in each county. Trained service under a responsible organization helps insure that those needing institutional care will be put in line to receive it early and before their condition has become hopeless. A qualified local worker cooperating with the superintendents can maintain the most effective cooperation possible between the individuals in your charge and the families from which they came. And fin