chain of events that signallized this young man's melancholy experience with tuberculosis we are at once impressed by the fact that the same infection that in babyhood first made itself felt in the lymph nodes of the neck was undoubtedly part and parcel and perhaps progenitor of the infection that later bobbed up in the kindey and still later manifested itself in the lungs with such telling effect. Here we should say is a striking instance of the fact that adult disease is the outcropping of childhood infection; and every probability of the case would justify our opinion.

I lately saw a girl of fourteen who had a scar on her neck that showed the overgrowth of tissue that not uncommonly accompanies the healing of a tuberculous sinus that ruptures spontaneously. Her story was as follows: At the age of one she developed "lumps" in her neck. These grew to the point where they "broke down" and the skin was broken through and the contents of the swelling were discarged through the opening. Her neck healed slowly; and all through childhood she had had no further trouble. She had, on the contrary, been an unusually healthy and vigorous youngster. But now upon her entrance to young womanhood more trouble was beginning to develop. A "lump," red, painful and beginning to soften, with every sign of being tuberculosis of a lymph node, had recurred beneath the old scar. After twelve years of freedom from symptoms she again had manifest tuberculosis at the identical spot where she had had it before. To aver or even suppose that this new manifestation was the result of renewed infection from without would strain the imagination immeasurably more than to conclude that an old infection, contracted years before in infancy, had started on what we might call its second lap. And if a second lap is possible, why not a third and fourth, or as many as you please? And must every lap be so spectacular as to arouse the grandstand to the point of notice and acknowledgement?

Every observer of tuberculosis patients could bring forward several instances similar to those just cited to support the belief that adult tuberculosis develops on a basis that is laid down in childhood; and we must admit that this is frequently the natural course of events in human beings. But in thus acknowledging the reality and not uncommon occurrence of this sequence of early infection and a much later outbreak of manifest disease from it, we are far from accepting blindly and unreservedly the doctrine that as a type disease the roots of adult tuberculosis always reach down and back to an infection that was acquired in the first years of life.

Now just what does this doctrine mean and what does it imply?

In the first place, it means exactly what it says, and it is of little use to repeat this. But in addition to its plain statement it implies a great deal more.

that they received after they entered adolescence. Since presumably they might develop disease from infection acquired after this time, provided this infection occurred or could occur, and since it must be granted by all that so far as sources are concerned the opportunity for adult infection exists, it implies further that for some reason or other adults cannot become infected even though they establish contact with tubercle bacilli.

Pursued more rigidly, it implies further that, no matter what their opportunities of contact, children can be infected only once. For if infection can occur in children again and again, why cannot the same thing happen in adults? And if it should happen in adults why can these not develop manifest tuberculosis from comparatively recent infections? It must be perfectly certain that if adults do acquire more recent infections then in some cases, and no one can estimate how many,these would surely eventuate into manifest tuberculous disease. It must be just as certain that if adults, who have been infected in childhood, develop manifest tuberculosis only on the basis of their early infection, then something has happened to them because of their childhood experience that prevents later infections; for if later infections were possible, then, we repeat, they would on occasion go on to outspoken disease. And if an early infection prevents reinfection in adults, it must of necessity exercise the same effect in the child who is already once infected. If this is true, and there seems to be no escape from the argument, then tuberculous infection can occur once and once only during the life of man. This would be an astounding statement,— really astounding, especially when we to consider its full bearing on the whole tuberculosis problem. If such a state of affairs really exists, it would mean that once we had detected by Pirquet test or otherwise that an individual,—an infant, a child, or any other person,-harbored tubercle bacilli, we need never again worry about the possibility of his subsequent coming in contact with tubercle bacilli in the world at large. For if he can be infected only once from without he can brave the perils of contact with consumptives anywhere and under any conditions. And our programme for the control of tuberculosis would be enormously simplified. Can this be true? Well, in the absence of definite information one way or the other, there is no compelling reason to believe that it is impossible. We have learned to say that an individual who has once acquired syphilitic infection is refractory to subsequent reinfecttion, even though his infection is quiescent and is not making itself felt by symptoms of illness. But do the same conditions obtain so far as tuberculous infection is concerned?

come

A discussion of this possibility would take us into the very heart of the scientific aspects of tuberculosis. It would be a discussion of much that we do not know as well as of a little that we do know, and belongs properly to the next essay.

continued in the April number.)

66

Dear Sid:

101 LAKE AVE., SARANAC.

I'll say I was glad to get youre letter, old man. It come yesterday an, believe me, you wasent none to promped about ansering, was you. However, I gess you haven't none to much on your hands now, eh Sid. It sure does keep a fella humpin' to get the necessarys of life, these days, what with prohibition an 1 thing or a other. But they haven't got no prohibition hear, Sid. Not so you could notice it. I have not had no busts hear so far, but I aint sayin' how long my teetotelness is goin' to last. This here buisness of layin' on your back in one of them colapsible chairs till you don't know wether your layin' down or standin' on the back of your neck half the time, aint exacly condusive to a quite an' sobber life. I'll say it ain't, Sid! For a man like I to half to lay a round an' twidle my thums ain't no easy job, not withstandin' opinions to the otherwise.

But the other night, old man, when I was so dam fed up with the hole buisness an' was just figgerin' whether I could make a quick exit from this world off tears by lettin' Toughy Home, next door, rap me gentle behind the ear or wether I could do a better job off it with a safety razer blade, when old Tibb says "How about a little party to-night, Kelly?"

"What's doin'?" I says.

“Oh,” he says, "we can take a little toot down to the Arlington and maybe have a little shoot or two, just to make us sleep good." "What kind of a place is this Arlington joint?" I asks.

"Oh," he says, "it's a kind of Salvation Army and Y. M. C. A. all rolled into one. They's refreshments on the side an' I can give you a nock down to a coupla lady friends of mine who'll be glad of youre company an' they'll be only to glad to make things plesent for you an' interduce you to all the fellasyou know-bar-tenders an' them kind what'll give you a sociable time."

"Yes," I says. "I've met them kind before. So they take a drink?"

"Sure," says he. "I've never saw no one like them girls for puttin' down the Coca Cola."

"Oh," I says. "Do they sell Sarsparilla to, at this here joint?"

"Sure," says he. "Anything you wantGinger Ale, Oxo, Lemen Sour,-the hole buisness an' the sky's the limit."

"Can you get a shot of good old 2 per cent near beer with a good kick to it?" I asks.

"Oh my God, no!" he says, horrified like. "Woodrow wouldn't never stand for that."

"But I thought this here was supposed to

be a free country," I says. "The land of the free an' the home of the brave, etc."

"An' so it is," says he. "So it is. I bet they aint a nother country in the world where the goverment officials an' the politicians is as free as they are right hear. They can't nobody never question the freedom of the good old U. S. A. No sir."

"Well," I says, "the proof of the puddin' is where its eaten.'

"Why, man," says he. "If its proof you want, why just go and read the words of the Star Spangled Banner. They ain't nothin' clearer than them."

Well, Sid, I aint posted good enough on America history to be abel to argu with him -specialy when he starts bringin' in old documents wrote by Geo. Washington an' them guys, so I never said nothin' but just let him rave. But that aint what I started to tell you about, old man, but the time I had down to this here place I was tellin' you about.

Well, me an' Tibb started out that night and first off, he takes me into a hotel hear they call the Grand Union. Honest Sid, it should ought to of been called the Grand Reunion. When we gets inside, it looks like all the Wops an' Frenchmen an' Greeks, an' a hole lot that looked like they was a little bit of each, had met there to discuss the Peace question. An' believe me, Sid, it was sure a Grand Union all right. Well, we goes up to the bar and after we had united with 3 or 4 beers, Tibb nocks me down to the bar tender.

"What'll it be?" he asks me, shakin' hands. "Glad to meet you," I says. "Make it a slow gin rickey a la mule."

"Up here chasin' the cure?" says he, pleasant like.

"Yes," I says, "an' I seem to be chasin' it into some dam funny places."

"This is the right place to come, Mr. Kelly," says the bar tender. "There wasn't never no bugs we couldn't fix at this here hotel."

"What and the hell are you tryin' to tell me," I says. "I never heard of no booze cure." "Aw say," he says, "you can't work when your drunk, can you?"

"No," I says.

"Well, neither can the bugs," says he. "Keep 'em soused an' your all O. K." "That ain't a 1⁄2 bad way of lookin' at it," I says. "Do you claim you can keep 'em under control at a reasonable price?" "No one can't do no better," he says, "than right hear at the Grand Union. In Union there is strength."

"You said somethin'," I says, gettin' a whiff of his breath. "And that aint no idle dream." Well, Sid, we stuck a round for about 1⁄2 hour chewin' the rag and watchin' the foreign delegates to the Peace conference arguin' the question out among thereselves. Some of

them birds must of thougt they wasn't gettin' there money's worth of entertainment an' they started into settle the conference with there hands an' feat.

"Come on, Tibb," I says. "This aint no place for us."

So we lit out, Sid, an' there ain't nothin' for it but we should go over to the Arlington an' meet these hear dames who I was tellin' you about and who was friends of Tibbs. I wasn't none to keene about makin' a reglar spree out'n it, but Tibb was set on doin' the thing up right an' he says it's stricktley aganst his principels to go to bed before 4 A. M. once he gets started. You know, Sid, I wasn't never one off them kind that's all ways tootin' a round every night, lappin' up the fire water like a cat drinks milk, an' I didn't have no particuler desire to give a first class immitation of a house on fire. You know I was never much on that stuff, old man. But I might as well tell you rigt hear, Sid, in case you might be thinkin' I drunk to much, that they ain't no drink made what I can't stand 3 or 4 of without turnin' a hare an' I didn't have no more than 3 or 4 of each kind, this night, so you see,_old man, I couldn't of had to much like what Tibb had. But when I was at the Grand Union, Sid, I was feelin' hungry, so I boughten a sandwich off'n the lunch counter guy an' I didn't feel rigt for the balance of the night. They must have been some kind off dope in the bread or somethin', Sid, because I got feelin' funny an' kind of light headed like. Of course I never said nothin' to the guy about it because he'd probabely say it was the liquer I had took, not knowin' how much I can hold without it not havin' no affect on me, and what is the cense off arguin' with a fella like that anyways. It don't make no

diference now.

Well, old man, first off, Tibb takes me into the back room, were they is one of them roller rink pianoes doin' its dammest in responce to some drunken guy who had, in a mad momment, slipped a nickle in the slot an' then fled to escape the terible consequences. They was tabbles set all a round a dancing floor in the middle off the room, an' Tibb heads strate for 1 of the tables where they's 2 dames settin' alone an' lookin' like they was waitin' for a coupel bottles of Scotch to come floatin there way or maybee they was hopin' some kind friend might deposit five dolars for 'em with the bar tender. Anyway they brightens up considerable when they sees us comin' an' Tibb performs the interductions like he was

presentin' me at court. But them dames wasn't queenly—not a bit, Sid. As soon as we was nocked down to each other one of them eyes me an' says:

"Hello, sweet petootie."

"Hello, liver an' onions," I says. “Who hit you in the face?"

"No one hit me in the face," she says. "What do you mean?"

"Oh," I says. "It must be natural then. It don't hurt you, does it?"

"Your a fresh guy," she says. "You was picked to soon."

"Maybe," I says, "but I wasn't left on the tree till I was over ripe anyway, like some folks I know not so very far away."

Well, Sid, we wasn't gettin' on just as good as we might have done an' Tibb, he notices it too, an' he starts talkin' to my dame an' I an' his girl gets up and starts a one step. You know, Sid, I ain't no star on these here dance steps but I was feelin' just like I could of did anything after I had ate that sandwhich an' I didn't do to bad neither. Tibb's dame was not so worse at all, Sid. She had a voice on her like a subway guard, but her looks was O. K.

Well, Sid, we hung around prety late, an' that there sandwhich I et had me doped so I can't remember nothin' much about what we done later on. I got a kind of vage reccoletion of comin' home alone an' when I come to, propper, I was home in bed. I didn't have no cloths off, thoug, Sid, but I was all O. K. The bed cloths was puled up over my head an' my overshoes had not improved the white bed-spred none. Also my good overcoat was a trifle crushed from me sleepin' in it all night an' that there good fur cap what Gert give me last year had a big patch burnt off'n it bigger'n a silver $. But I ain't worry'n. From what old Tibb says, I must of had a prety fare time, after all things is done an' said, an' I bet some of them there bugs in my sistem got run in for bein' drunk an' disorderly before the night was done.

Well, old man, I must close. Don't show this here letter to Gert, Sid, or I wouldn't never hear the end to it. Give her my love and tell her I ain't bein' overfed on cookies etc. up here. Does she still do that sort of cookin', Sid? Well, write soon an' give me the

J.

This article is in substance a circular issued to the people of Framingham entitled, "What has the Health Demonstration done thus far for Framingham? How can the benefits be made permanent ?"

A PERMANENT HEALTH BASIS The object of this bulletin, which you are urged to read carefully, is not to boast of things accomplished, but to give you the information which is your right as a citizen of Framingham, regarding the work of the Health Demonstration, and to inspire you to demand the best of permanent results from this work for Framingham.

Framingham itself has done much to make the "Health Town" a reality. It has provided nurses for tuberculosis and infant welfare work, physicians, dentists, and nurses for the schools and factories, unusual baby clinics, remarkable domestic science teaching, an elaborate civic and educational program, neighborhood committees for health and patriotic endeavors, etc.

The whole country knows of Framingham's cooperation in the health movement. It is the right of every citizen of Framingham to know the details of the work which the Health Demonstration has started and is carrying on here. It is the privilege of Framingham citizens to insist that organization for health be perfected in Framingham, in order that the work may have permanent value for the town.

The aim of the Demonstration has been to show the world that unnecessary sickness and death, particularly tuberculosis, can be eliminated by medical and nursing care, personal hygiene, and adequate health administration. The best benefits, the permanent benefits of this work are still to come, and they depend not so much upon the Health Demonstrations as upon the people of the "Health Town."

All Framingham people and agencies, consciously or unconsciously, are working either to increase the death rate, or to decrease the death rate.

The people of Framingham have a right to insist that the work which has been started, which has already materially decreased preventable deaths in Framingham, should be placed on a responsible permanent basis. Framingham has led the world as a health experiment; it should continue to lead as a health example.

To this end there are two things that you can do:

1. Practice the principles of personal hygiene.

2. Take an interest in Framingham health affairs, and have enough respect for health in Framingham, to insist that only the best local administration, both as to organization and personnel, is good enough for Framingham.

TWENTY-TWO POINTS

Probably many citizens do not know what have been the direct benefits thus far to the town from the Health Demonstration. If you are one of these, your attention is respectfully urged to the following points :

1. Framingham, The "Health Town" Constant inquiries from all parts of the Union demonstrate that Framingham has been given a greater prominence throughout the country than any other town of its size in the United States.

2. Free Medical Examinations Over 6,000 citizens have been thoroughly examined, and 4,000 referred to their local physicians for treatment, thereby heading off much early disease. (Cost, $12,000.)

3. Tuberculosis Controlled

Two hundred and fifty mostly early cases have been brought under advice or treatment, in many of which the disease is arrested and the patients at work, further infection being guarded against. (Cost, $3,850.)

4. Cooperation in Tuberculosis Treatment

Financial and other aid has been given in many cases including equipment, food, milk, transportation, etc. Local charitable activities have been advanced by provision of workers for investigation of charity cases, contributions to the Associated Charities, etc. Nursing assistance has been provided for the town tuberculosis nurse in caring for the cases under treatment in Framingham.

5. An Expert Medical Consultation Service

This expert service is being used by nearly all the Framingham physicians, for tuberculosis, influenza, and other diseases, thereby encouraging the early diagnosis, proper treatment, and reporting of sickness. (Cost, $6,000.)

6. Assistance for the Draft Board Expert medical diagnostic aid has been furnished the draft board since the beginning of the war, assisting the board in the maintenance of an enviable record, practically no cases hitherto unrecognized being returned from the cantonments for pulmonary disease.

7. Medical Care for Special Groups of Cases

Groups of children discovered in the examination work, with nose and throat and glandu

lar abnormalities, have been followed up, defects being removed whenever possible.

8. A Post-Graduate Medical Lecture Course A lecture course for the medical club has been financed, doctors of international reputation being secured to address and hold clinics for the Framingham physicians. (Cost, $600.) 9. Influenza

During the epidemic, nurses and equipment were provided for the hospitals, a consultation service for the physicians, an examination service for returning factory employes, educational material for the factories and the press, etc. Federal, state, and local authorities were conferred with regarding the control of the epidemic, vaccines and sera secured, etc.

10. X-ray Equipment

A model x-ray equipment, available to all physicians has been added to one of the hospitals, for use in tuberculosis and other diseases. (Cost, $500.)

11. The Health of the Infant

An infant welfare nurse was provided for over a year, financial aid given in Baby Week expert assistance secured from the Federal Government, etc. (Cost, $2,000.)

12. A Summer Camp

About 400 pre-school age children have been provided with summer camp facilities covering a period of two years, diseases and defects discovered being followed up for correction and treatment. (Cost, $4,500.)

13. The Health of the School Child Equipment for a school dental clinic was provided through a fund secured by the Health Station from private sources, the cost of equipment and dental nurse's salary guaranteed for prophylactic dental work, the equipment and supplies provided for school lunches in one school building, financial aid given for the Community House in the Italian section, Health Crusader clubs formed among the school children, etc. (Cost. $2,700.)

14. The Health of the Factory Worker Factory health conditions have been effected by the provision of medical examinations for the industrial age group, of expert medical consultation service for the factory clinic work, by the distribution of free educational literature, etc.

15. Domestic Science Work Popular domestic science and food economy classes have been financed in cooperation with the Framingham Normal School staff. (Cost, $150.) 16. Local Milk Conditions

These have been carefully studied, with the cooperation of the Federal Government officials, and plans developed for the improvement of economic and sanitary aspects of milk handling in Framingham.

17. A Study of Health Dangers

A careful analysis of health. dangers in

Framingham has been undertaken with the cooperation of national experts, in the school, factory, and general sanitary conditions, resulting in recommendations for improvement. 18. Patriotic Endeavors

Assistance has been given numerous patriotic activities, such as the Red Cross, the Liberty Loan Campaigns, the War Savings Stamps Campaign, the United War Work Campaign, etc., by means of educational displays, literature, newspaper articles, field canvassing, preparation of maps and selection of district committees, etc.

19. Health Education

An extensive health educational campaign has been carried on through the use of leaflets, special bulletins, exhibits, health letters in the press, dissemination of propaganda with the cooperation of neighborhood committees, etc. 20. Civic Activities

Financial and other aid has been given various civic and social activities wherever their programs touched matters of health. (Cost, $1,700.)

21. Summary of Cost

What has been the cost of these health efforts to the Demonstration? How much has the Demonstration directly devoted to the welfare of Framingham? The following figures approximately recapitulate the expenditures for the indicated activities. These do not, of course, include the cost of office maintenance, rent, the salary of executives, the expense of publications, the preparation of exhibits, the employment of experts for service and investigative work, etc.

Further, many of these expenses are for initial equipment or for experimental and investigative work. It was necessary to make these expenditures to find out the facts; that does not mean that to have the work continued it would cost the permanent health organization more than a small fraction of this total for routine activities. The town has already aided generously in the work and is now spending approximately 80 cents per capita for health. This expenditure covers all kinds of health work, including tuberculosis. Consequently, it is possible for Framingham to show other communities that an adequate health program can be carried out at moderate expense to the community. Medical Examinations

.$12,000.00