factory physicians and others, all under the control of the provincial and district zemstvo assemblies, working under a sanitary code which was in force before the revolution.

In a Rural District

The province of Saratov is given as an example of a more rural district, where, in 1911, the provincial zemstvo maintained a general hospital of 200 beds and a psychiatric hospital of 460 beds for a population of something over 3,000,000. The district zemstvos maintained 123 medical districts with seventyeight hospitals and 1,106 beds or one hospital to 2,525 persons. Each district had its own physician, with feldschers and other medical helpers at fifty-five other points. Clinic cases to the number of 525.9 and resident cases numbering 9.1 per thousand of population were treated, and 33.2 per cent of the provincial and 31.6 per cent of the district budgets were appropriated for medicinal and sanitary purposes, amounting to 50 copecks per capita. The regular zemstvo physician had sanitary supervision of his district, to combat epidemics, inspect schools and educate the public in health matters; there was also a sanitary supervisor with laboratory equipment for simple chemical and bacteriologic examinations, and a bureau of vital statistics with power to employ emergency workers in epidemics,

etc.

Winslow says that not much progress has been made in general milk supervision, though there are infant welfare stations and milk distribution to a certain extent. Infant mortality has not been reduced much, if any, since statistics have been available, except in some of

the western provinces, the chief reason for this being poverty and ignorance.

High Standards of Work

The principal developments of Russian public health have been along medical and bacteriologic lines, in the control of the more acute communicable diseases and in the field of vital statistics. The statistical bureaus of the central council of public health and of the larger cities are better equipped with funds and with highly trained specialists than our own. The bacteriologic and chemical laboratories are also highly developed and in charge of high grade men with leisure and inclination for productive research. Sanitary engineering is somewhat neglected, but when the time comes its development will be fruitful.

The most important future development of public health in Russia, as elsewhere, Winslow believes, must be along educational lines in venereal diseases, tuberculosis and infant mortality, and the largest single task is the last. The great startegic point startegic point in the Russian health situation is the remarkable development of social medicine along curative lines and the close connection between curative and preventive work. The opportunity for developing educational preventive work in connection with such a system is practically unlimited.

"Hygiene is the art of preserving health; that is, of obtaining the most perfect action of body and mind during as long a period as is consistent with the laws of health.". Edmund Alexander Parkes.

Two years ago, Dr. William C. Woodward, health officer of the District of Columbia, said:

In order to make facts pertaining to health contribute most largely to human happiness, two things are necessary: first, to establish such facts and to correlate them, so that we may understand their full signficance and the underlying principles. Second, to weave those facts into the lives of the people.

Public hygiene, so far as it can be contrasted with the hygiene of the individual, is that which is practiced by the government for its citizens. It consists, as one writer has expressed it, chiefly in efforts by the government to maintain a wholesome environment in which to live, including good outdoor air, clean streets, pure water, good sewers, quarantine and legal regulations concerning houses, schools, prisons, hospitals and other public institutions, foods sold in markets, and conditions of employment. It is chiefly useful in preventing acute or infectious maladies, accidents. and occupational diseases.

At the present time, if never before, preventive medicine makes its appeal not merely on the ground of human happiness, but quite as well because of the pressing need of conserving human efficiency. The world needs all the human forces that can be mobilized. There is a growing recognition that public hygiene pays that it can accomplish results of obvious importance. It has become the duty of the government not merely to teach the community, but also to enforce sanitary laws. If men cannot be made healthy by compulsion, they can at least be made to conform to such rules of conduct as to permit their

neighbors to be healthy. Public health is not something that grows and brings forth fruits without special attention from any one. We

must come to understand that the benefits of hygiene cannot be gathered without cost. We recall an instance in which a railroad was forced by a community to construct a viaduct involving an interest charge of $2,000 a year to prevent one needless death; yet the alderment of the same community were spending only $150 to prevent fifty deaths.

What efforts are being made to purchase public health? Surgeon Preble of the U. S. Public Health Service has lately summarized the expenditures of 330 cities in the central and eastern United States for public health work. It appears from his statistics that the average per capita expenditure varies fairly directly with the size of the community. Yet the average salary of the health officers of sixteen cities having a population between 100,000 and 300,00 is less than $2,500 a year. The annual average per capita expenditure for the 330 communities cited by Preble is 27.2 cents, varying from 9 to 39 cents. If we accept as generally agreed that the expenditure of about 50 cents per capita is necessary for satisfactory public health activities, the average city in the group just referred to is expending only slightly more than half the amount that is considered reasonable for the control of health hazards. This is manifested by the results achieved. For the average expenditure of 27.2 cents, Preble found an average sanitary rating of only 66.7, out of a possible 100 per

cent. The larger cities, with an average expenditure of 39 cents, annually, get an average sanitary rating of 80.8 per cent. Hence he justly adds that under efficient management it might seem reasonable to expect that an expenditure of about 50 cents per capita annually would raise the sanitary rating of the group to a point above 90 and result in a marked reduction of sickness and a saving of lives, a worthy return on the investment. Perhaps broader public education in the science and accomplishments of preventive medicine and hygiene will help to make even smaller communities begin to realize that their health officials are too poorly paid and consequently their health activities too poorly organized and administered. We propose to revert repeatedly to the contention that the sanitary status of a larger community in which menaces are varied is likely to remain low as long as the appropriations for its health department remain low so that efficiency cannot be purchased. Surely the chief of a public health establishment is as worthy of his hire as a chief of police or a fire department head. Journal of the

American Medical Association.

SMALLPOX PREVALENCE HIGH IN SEVERAL OTHER

STATES BESIDES OHIO Ohio is not alone in experiencing an unusual prevalence of smallpox. Reports to the United States Public Health Service for the month of December give these state totals: Kansas 519, Michigan 688, Minnesota 344, Maine 199, North Dakota 99, South Dakota 162, Maryland 52, Louisiana 97, Pennsylvania 70, West Virginia 96.

For November Kansas reported

384 cases, Colorado 117, Iowa 251, Maine 227, Mississippi 82, North Dakota 36, South Dakota 135, Alabama 44.

Weekly city reports show cases. over the entire country during December and January, with the prevalence evidently highest in the sections comprised in the Mississippi basin. Kansas City, Mo., has had probably the highest prevalence among the larger cities. Its reports for four weeks of the five-week period from December 9 to January 12 (the report for December 23-29 is missing) total 530.

Other cities which show heavy case totals during the same period are Detroit, Fort Wayne, Grand Rapids, Kansas City, Kans., Minneapolis, Omaha, St. Louis, Des Moines, Indianapolis and Little Rock, Ark.

DISEASE NOTIFICATION MAY HAVE BEARING ON DRAFT CLASSIFICATION An instance of the importance of reporting notifiable diseases, in accordance with the state law, has recently been furnished in an inquiry which came to the Division

of Tuberculosis of the State Department of Health from Local Draft Board No. 5 of Franklin County.

The board wished to know if a report was on file with the department giving evidence that a certain resident of Canal Winchester, who was named, was a victim of tuberculosis. This man, the board explained, had applied for classification in Class 5, which constitutes entire exemption from draft, on the ground that he was in the last stages of tuberculosis. His physician furnished him with a certificate to the same effect.

Search of the records of the department failed to reveal such a report, and the draft board was so notified. The Canal Winchester health officer was asked for information about the case, and an explanation of the circumstances has been called for from the physician who certified to the man's alleged tuberculous condition and yet failed to make the report which the law requires.

ANNUAL REPORT SHOWS WHAT A COUNTY NURSE CAN DO IN ONE YEAR The annual report of Mrs. Marjory Porter McCarthy, county nurse in Hamilton County, covering the year from November, 1916, to November, 1917, offers a clear picture of the great amount of good a county nurse can accomplish. Some details of the report are here presented for the information of counties which do not now employ nurses.

In her work among children, Mrs. McCarthy visited 20 schools, examined 1,928 school children and advised 1,614 school children. One hundred and five children were taken to eye clinics to have glasses fitted. Those taken to hospitals to have tonsils and adenoids removed numbered 109 and those taken to hospitals for other reasons numbered 28. Two children were sent to the State School for the Blind and four to orphanages.

Among adults visited by Mrs. McCarthy, 32 were sent to the Cincinnati municipal tuberculosis sanitarium, 30 to the Ohio State Sanatorium and nine to other hospitals.

Three cases were referred to the court of domestic relations, 26 to charitable organizations for material aid and eight families were

moved into better homes.

The nurse's home visits totaled 1,014 and her miscellaneous visits 908. Cases carried numbered 183, of which 102 were tuberculosis. Mrs. McCarthy made eight talks to mothers' clubs, aided 10 physicians in maternity cases and minor operations and assisted in the examination of 500 girls in a survey at the Convent of the Good Shepherd.

RECENT PROGRESS IN SOCIAL HYGIENE WORK

IN VARIOUS SECTIONS Governor Burnquist of Minnesota has appointed a social hygiene committee of 52 members, having for its purpose the control of venereal diseases, the enforcement of the laws with regard to prostitution, the education of the public in social hygiene and the rehabilitation of prostitutes.

The Minnesota state board of health was given power in recent legislation to make regulations for "the treatment, in hospitals and elsewhere, of persons suffering from communicable diseases, inincluding all manner of venereal diseases and infection, the disinfection and quarantine of persons and places in case of such disease and the reporting of sickness and deaths therefrom."

A recent act of the New Jersey legislature makes it a misdemeanor for a person infected with a venereal disease to marry or to have illicit sexual relations.

Expert investigation in Chicago declared that smoke-filled air made the lungs susceptible to tuberculosis, pneumonia and bronchitis, and that it caused a high mortality among persons of 40 or 50 years.