gives a particularly accurate picture of the fatalities in thirty-seven states of the Union, the District of Columbia, and thirteen cities and non-registration states, with a total established population of more than ninetythree million people, approximately 85.3 per cent. of the established population of the United States. It is not necessarily a true picture of the comparative incidence of the various diseases during 1921 and 1922, because of the possible variations in the virulence of infections during the different years. Thus in different years the fatality rate of influenza may vary and the lower rate may exist during the year of the greater prevalence of the disease.

As a whole, however, from the standpoint of practical health administration, the mortality figures are of great significance in determining upon policies and programs which are designed to lighten the death load of the community. Regardless of questions of the diminished virulence of infecting organisms, the marked fall of the mortality rate of those diseases against which health authorities have campaigned most vigorously would indicate the value and efficacy of the public health activities that have been employed. Certainly, the enlightenment of the lay population concerning the causes, symptoms and methods of treatment of tuberculosis have been of tremendous importance in decreasing the mortality and probably the incidence of tuberculosis. Beyond doubt or argument is the fact that the low death rate of infants from diarrhea and enteritis may be attributed to the education of mothers in the proper hygienic measures essential for protecting the safety of their infants, combined with the more general introduction of milk pasteurization, and the development of baby welfare stations.

While there has been a considerable saving of life during the first two years after

birth, the growth of medical inspection of schools, and the introduction of follow-up nursing systems have been valuable forces in diminishing the illnesses and fatalities of children during the school age. The growth of interest in maternity service, as exemplified in such legislation as the SheppardTowner Bill, and its acceptance by most states, has already brought about some suggestive results and gives ample promise of further reduction in maternal deaths and a decrease of the accidents and diseases attendant upon childbirth.

The period of life that merits the largest degree of consideration today is the period of industrial activity, when in

dustrial wear and tear combine with inherent weaknesses and defects to increase the likelihood of diseases of the heart, kidneys and blood vessels. The solution of the problems of this age of maximum activity

constitutes a challenge and there is reason to believe that it is being accepted with enthusiasm thruout the country. Certainly the growth of interest in the annual medical examination is an indication of the desire of the laity to protect themselves more vigorously against the onslaught of unsuspected foes that are attacking and undermining general good health. This, however, is merely the beginning of a type of service that is designed to counteract the increase in the mortality rates from preventable causes during middle life.

The time is not yet ripe to attack directly as a single problem the relatively high mortality of old age. Nevertheless, the work upon cancer continues to grow and the awakening of the public to the nature of the early symptoms of this disease suggests that even this disease may be shorn of some of its death-dealing power. Taken all in all, the growth of the public health movement is reflected in the alteration of our mortality

statistics as they are compiled from year to year, and there is an annual renewal of confidence in the increasing directness, efficacy and worth of public health administration. as organized in this country.

Heliotherapy and Surgery.-Heliotherapy, as devised by Rollier, has proven a valuable adjunct in the scientific treatment of tuberculosis. H. LoGrasso, in the Boston Medical and Surgical Journal, February 7, 1924, describes the successful utilization of this method at Perrysburg, New York. He cautions the necessity for variations in technic, dependent upon the physical condition of the patient, the location of the lesion and the reaction or tolerance to sunlight. He describes, however, the particular modification that he has found most serviceable in the treatment of children with osteoarticular tuberculosis. The solar radiations. have a special suitability and effectiveness in the treatment of tuberculous conditions of children, but there has not been a sufficiently forceful medical opinion to create opportunities for the treatment of tuberculous children by means of heliotherapy. Tuberculosis, however, is not the only disease for which the sun treatment is indicated. Sunlight is acknowledged to be a factor in the prevention and control of rickets and anemia. It is helpful for convalescence from acute diseases and appears to be vitally effective in promoting the nutrition of children enervated by deficient nutritional development. Hence, institutions giving special attention to sunlight treatment have a definite prophylactic and therapeutic value to the community.

Fresh air and sunshine are essential factors in promoting health, cheerfulness and contentment. Sunshine is not merely a dispeller of darkness, but is a constructive

dispenser of joy. It promotes metabolic activity, encourages appetite, aids digestion and fosters a sunny disposition. These terms are not mere idle words, but illustrate effective purposes for which heliotherapy may be employed.

The sun cure is a constructive force in the management of bone and joint tuberculosis, in that it promotes the healing of tuberculous areas in such a manner as to help in the maintenance or restoration of the function of the diseased parts. Surgical interference is justified only when other methods are predestined to failure, or when it is necessary to evacuate abscesses, or afford support to a local tissue during the process of cure. It should be employed, however, only after a trial has been made of heliotherapy.

There are occasions when the surgical treatment of pulmonary tuberculosis represents the last resort for victims of pulmonary tuberculosis. When heliotherapy and sanatorium regimen have failed, and when one or both lungs are so severely infected that life appears to be threatened, and permanent cure seems unlikely, recourse may be had to creating a therapeutic pneumothorax, or, indeed, the performance of a thoracoplasty.

Howard Lilienthal, in the American Journal of Surgery, January, 1924, discusses "The Selection of Patients and of Operation in the Surgical Treatment of Pulmonary Tuberculosis." He concludes that surgery should be resorted to when medical and hygienic treatment have nothing more to offer, and the patient's life is intolerable, or the prognosis is grave. There is little doubt that the surgical treatment of tuberculosis of the lungs is receiving enthusiastic attention at the very time when the surgical treatment of bone and joint tuberculosis. is being relegated to a position of conserva

tive, secondary importance. There is every reason to believe that with a wider knowledge concerning surgical procedures for advanced pulmonary tuberculosis, there will be an increase in its utilization. The theory of its application is sound and the results thus far reported appear to indicate that it possesses a definite place in phthisiology. Surgery becomes necessary in tuberculous diseases as an adjuvant to medical and hygienic treatment, and is not to be regarded as a substitute for either one. The patient who has had a thoracoplasty continues to be tuberculous, just as the child with tuberculous osteomyelitis presents merely a local manifestation of a constitutional disease, with a primary infection usually in the lungs or the lymph nodes.

The improvement evidenced in the decreased mortality figures of tuberculosis may be attributed to the recognition of the fact that the patient is being treated in terms of hygiene, rather than by means of medicines or surgical procedures. Preventoria and sanatoria are mainly institutions that afford the environment most conducive to good health; and a large part of their successfulness may be attributed to the

action of sunshine, fresh air, adequate food and ample rest. Even heliotherapy is not to be regarded as effective, when divorced from these other energizing factors.

Mah Jongg Dermatitis.-Almost all of man's pleasures bring about situations necessitating medical or surgical attention. Baseball, golf, football, swimming, skating, or horseback riding, and even card playing may be attended by conditions akin to occupational diseases. The increasing number of avocations naturally provides, therefore, a larger number of pathologic manifestations

growing out of the avocational pleasures. Mah Jongg has swept the country during the last two years as a type of game possessing interest, because of its Oriental importation, its possibilities as a gambling device and its numerous combinations for harmless and more or less interesting amusement. It is interesting, therefore, to note that there are being reported instances of dermatitis, as dermatitis, as a result of handling Mah Jongg sets in beautiful lacquered boxes. The disease is not due to playing Mah Jongg, but merely to the handling of containers of the sets upon which there has been used a varnish, poisonous to some per

sons.

In the Journal of the American Medical Association, February 9, 1924, O. L. Levine of New York and E. P. Zeisler of Chicago, report instances of "Dermatitis Venenata from the Lacquer on the Boxes of Mah Jongg Sets." The chemical irritation ap

pears to be due to a non-volatile substance that is a constituent of a varnish made from an abstract from the Japanese lacquer tree (Rhus vernicifera). The persistence of this toxic material is patent from the report that

Toyama was able to produce a dermatitis with lacquer taken from an ancient jar, which has been buried in a Japanese room for approximately a thousand years.

The dermatitis arises from the introduction of the harmful chemical agent, named urushiol, into the hair follicles or sweat pores. The lesions appear clinically within a few hours to a week after contact and are most frequently distributed on exposed areas of the body, such as the neck, face and hands. The extent and intensity of the dermatitis varies with individual susceptibilities and the duration of the contact. The essential clinical factors are burning

and pruritus, erythema, vesicles, and even bullæ. The course of the dermatitis is two or three weeks and in susceptibles recurrence is possible after each exposure.

In all fairness to Mah Jongg players, it must be said that the cheaper the set, the less likely the dermatitis. It is the most beautiful and most expensive imported sets upon which the lacquer is lavishly used that harbor the greatest likelihood of inducing the chemical irritation. The simple relation between ivy poisoning of the wood rambler and the Rhus poisoning from the Mah Jongg box reveals the necessity for care in selecting one's pleasure afield and at home. Incidentally, it may be remarked that it is not possible that some instances of ordinary, so-called ivy poisoning may have been due in the past to lacquer irritation, in view of the popularity of little Japanese containers of various kinds, as part of household ornamentation.

The wide field of distribution of chemical irritants and the variation of individual susceptibilities offer interesting problems in chemistry and biology. What constitutes the thing which we term susceptibility or idiosyncrasy, whence have arisen these biologic peculiarities? The facts of allergy and anaphylactic phenomena have been carefully studied and considerable light has been given to methods of diagnosis and treatment, but there is still a lack of basic knowledge concerning the whys and the wherefores of these peculiar biologic reactions.

Contracting for Health. Recently, considerable publicity has been given to a legal contract between the President of the Baldwin Locomotive Works and his family physician. According to the terms of this

contract, the physician is employed to keep his patient in good health. He agrees to a reduction of his stipulated annual fee on the basis of definite reductions from his compensation as a penalty for any suspension of work by his patient by reason of ill health, or physical weakness.

Probably the only new feature is the drawing up of an actual legal document to stipulate the terms of the contract for medical service. The principle of having a physician guarantee his patient against physical illness is by no means new. Nor is there any doubt at the present time concerning the value of the service that a physician. may offer a patient who is willing to abide by advice and to follow such a regimen as may be prescribed. There is much wisdom. in the statement of the patient that, "This idea of paying a stack of doctor's bills just for the privilege of being sick belongs back in the dark ages, when one thought it wasn't quite proper to be wholly healthy."

The principle of paying a physician an annual retainer to be kept well has been employed by a number of wealthy men, occupying positions of great responsibility. As is usual, men in positions of trust and responsibility, with great demands upon their time and strength, are soon faced with the need of conserving their vitality. Being sick is not merely lack of health, but is also a wastage of economic opportunity. It is worth money to be well, and the costs of retaining health are infinitesimal compared with the financial losses incident to its impairment.

Just as large corporations were the first to realize the financial value of temperance and sobriety, and the importance of annual physical examinations of employees, so now they appear to be gaining an insight into the real meaning of preventive medicine, as pro

vided by intelligent personal hygiene, under direction. The significant fact lies in the shift of emphasis from the value of medical services for the relief of illnesses to the importance of the care designed to prevent unnecessary interference with living.

The Newer Conception of Public Health Work.-With the newer conception of public health work, there is an almost implied contract between health departments and the citizens supporting them to offer them such education and training as will make it possible to keep well, avoid diseases, gain various immunities and strengthen vitality. There cannot be personal oversight of the goings and comings of individual citizens, but the general principles of health and hygiene can be spread broadcast, so as to safeguard the poorest members of the community to a considerable extent.

If it were possible to awaken the general public to the advantages of good health as an actual asset, there would probably be a marked increase in the number of physicians being retained by the year for the promotion of familial health, tho probably without any provision being made for actual penalties in case of failure.

That this idea is by no means wild or radical is apparent from the actual existence of several communal societies, organized and maintained at private expense, to assure their members practical education and training in the art of living in accord with accepted scientific facts and beliefs. Physicians and nurses are employed by these organizations, at annual salaries, to keep them well. When illness actually occurs, despite the efforts of their medical teachers and guides, recourse is had to the regular family physician.

This plan probably will be copied ex

tensively during the next few years, in order that families of moderate means may have the benefit of counsel along lines desired by those more able financially to retain a personal physician for the purpose of securing the greatest guarantee as to daily ability to function normally, without a loss. of economic returns.

The single contract of a wealthy man may attract attention and be given considerable publicity, because of its news value. It serves as the index of the adoption of a new idea. The ultimate value of the news story lies in its practical incorporation as a desirable course of procedure for communal groups less abundantly provided with worldly goods.

The health society concerns itself with groups of persons bound together by an intellectual appreciation of the value of health and a coordinated appreciation of the feasibility of retaining it to a greater extent thru cooperative activity. The health society will be reaching its thousands, just as today, what is termed contract practice, reaches millions thru fraternal orders and unions. The health societies, however, possess a truly constructive program that aims to benefit all persons, whereas the common form of contract practice yields a poor measure of service to those who are sick. The health society represents the fundamental varieties of modern medicine, whereas ordinary contract practice still flourishes. on the basis of traditions and the unsound methods of merely treating the sick.

Mr. Vauclain, President of the Baldwin Locomotive Works, has a health society with but one member. His example presents a pattern for thousand of individuals of means, and indicates the basis of organization of health societies for the multitude. Contracting for health is the order of the future.