day. I have not told Mrs. Blank as yet. Before she is told some plan must be thought of that will help her to meet the situation. I should not be willing to answer for the consequences if we were not able to give this assistance."

My second story is of a typical migrant case: A family of seven-man, wife, and five children ranging from ten years to the one born shortly after arrival; man in the third stage of tuberculosis; wanderers for nine years from place to place in search of health; relatives not interested and for the most part do not answer letters; a year after arrival they are still largely dependent upon the community.

Another situation: A woman came to a western city from an eastern state five years ago with two small children. After a year's stay her health was greatly improved and she returned home. She discovered that while she was away her husband had been untrue to her, and she secured a divorce and returned to the West. She was self-supporting until about two years ago, when she had double pneumonia and it was necessary for her to call upon the relief agency. Her illness reactivated her old lung condition and she was admitted to a hospital and her children were placed in an orphanage. Her aged father and mother had followed her to the West (the mother dying about a year later), also three married sisters, one with six children and the others with two children each, and a widowed sister. The mother with six children was found to have tuberculosis, second stage. The other two married sisters were found to be tuberculosis suspects, and the widowed sister was very frail. After overwork at holiday time she also became ill. Instead of a mother and two children, there were, in less than four years' time, four women suffering from tuberculosis, another who was very frail, twelve children, and an aged father.

Such examples illustrate the subject to be discussed. There are many different phases of the problem and the tragedy of the lack of facilities for adequate care of the self-respecting, deserving, sick poor faces us in our western communities every day, for our residents as well as for non-residents.

The difficulties that arise in connection with the migrant tuberculous and that have to be met or disregarded by the state and municipalities of the West and Southwest are numerous and varied. Chief among them are the following: First, emergency or extended care for the very ill. Few cities have an adequate number of hospital beds even for their needy resident cases, let alone for the newcomers, and yet it would be counted everywhere only the part of a decent humanity to give the person who is ill or dying a bed and care. Second, temporary or extended financial relief for the patient, and if he has a family, of the family also. A community cannot allow people to starve, especially when they are ill and helpless. Third, a reliable diagnosis and classification as to the stage of the disease. So many come from a small town where there is not a tuberculosis specialist. They do not know of the specialists in nearby cities, and furthermore, with the feeling uppermost that they must go to a western climate, they do not exert themselves to secure reliable findings near home. Fifth, investigation of

residents and fixing of responsibility as to the care of the patient. Sixth, the decision as to the best policy, in view of the medical findings and of the residential and economic status of the patient. Seventh, the securing of financial assistance if the patient is to remain in the West.

Bearing these points in mind, can you visualize the load that Denver, for example, must carry, with probably a thousand cases a year of the migrant tuberculous, while some cities carry an even larger load?

So much for the needs, and any discussion that might arise in connection with them would, as I have implied before, center around our lack of facilities for care of even our own residents in accordance with humanitarian standards, lack of hospital beds, lack of dispensary facilities, lack of adequate financial relief. A summary of the facts of the situation would be for most of us an indictment not only of our treatment of the non-resident but of the resident as well.

But it would seem that certain general minimum requirements might be laid down regarding the responsibility of the state and municipality to the migrant consumptive. First, for one who is helplessly, and it may be hopelessly, ill, there must be temporary and emergency care if the feeblest attempt to maintain humanitarian standards is to prevail. Second, for diagnosis there must be arrangements for adequate dispensary service if the city or town is large enough to maintain a dispensary. If not, there should certainly be, in any health-resort town, arrangements for definite hours of examination by a private physician who is a specialist in tuberculosis. Third, temporary financial aid. Fourth, assistance to the patient as to what he is to do. This last point is the crux of the situation for the individual concerned. He is a sick person and commands our sympathetic help no matter what the other complications of the case are. Has he a legal residence? Can he receive care there? On the other hand, are there better chances for improvement in the new place of abode? Is his mental attitude such that to insist upon a return deprives him of all hope for improvement? The deciding of these questions and many others entails tremendous responsibility.

Shall the responsibility as to this decision be put upon the medical agency or upon the family welfare agency? Few dispensaries with which the writer has been in touch have a social case work staff adequate to handle this responsibility. Should not the final responsibility rest upon the family welfare agency, which in the long run must bear the relief problem? For, granted that the decision as to the return be made upon humanitarian principles, there is always the question of finance. No matter how strongly the doctors feel that it would be advisable for the patient to stay, no matter how strongly the social case worker feels that the social and psychological aspects of the case are such that to stay would contribute toward a cure, the patient must be financed during that period. Whoever handles it, a highly specialized type of case work is called for which should be recognized by the agency and by the authorities in the community. I believe that the western and southwestern states can never bear the

financial burden of the indigent migratory consumptive alone and meet the situation as it should be met. I believe they should not be compelled to try to do so. It is this burden which has stood in the way of adequate relief for their own tuberculous who have become residents, both because of the extra drain upon the financial resources of the community and because of the fear, on the part of the general public and the authorities, that adequate assistance would mean an increased immigration and an enlarged problem.

A greater willingness must be developed on the part of all local communities to care adequately for their residents who are disadvantaged, who are at home or elsewhere. A consideration of the health of the individual client by every agency in every community would mean the detection of the disease at its source, and social treatment could begin at once. With the emphasis previously put at the meetings of this section upon the close interrelationship between the health agency and the social agency, and with Dr. Emerson's emphasis yesterday upon the financial value to the community of adequate dispensary service and of providing for regular health examinations, I do not need to enlarge upon this point. But let me emphasize again that the social treatment must begin when the disease is discovered, before migration begins. With the appreciation of the situation that would come to every community from such an arrangement there would also follow a greater willingness on the part of communities to contribute to the care of their sick, even if away from home, when the prolonged stay abroad seemed advisable.

More information, detailed information, assembled from the relief and medical agency records and given to the public would unquestionably be an important aid in the development of this sense of responsibility. We have some data on the subject, but we have not a picture of the situation that would be convincing to the laity. For the first time here in Denver I think we are on the way toward securing this. Blank questionnaires are being furnished this month to every agency that comes in touch with the tuberculosis problem. The agencies have promised to cooperate. These blanks are to be filled out during the year by the workers in the various agencies and data secured for every case handled. The schedules will be collected a year hence and the material tabulated and analyzed. The study will be much more complete than any thus far attempted, and should give us a real quantitative and qualitative analysis as to our tuberculosis situation in Denver.

How many of us, for our own cities, can answer the following questions? How many of our own residents should have had hospital care last year who did not receive it because no beds were available? What is the result so far as their physical condition is concerned? How much was spent by our agencies on relief among our resident families and individuals afflicted with tuberculosis? What sum would have been adequate? How much was spent on non-residents? For what was this amount spent? How many of these non-residents were chronic indigents in the hopeless class of those who cannot be helped and who we

should admit cannot be helped in order to conserve our time and money for the others? How many were in the self-respecting group of the sick poor? How many had had no aid from charitable organizations until they fell ill?

When figures are available that show the actual need, and that demonstrate that it pays to give adequate assistance, I believe that the provision on the part of the authorities will be more ample. Figures, too, are probably the only means of convincing the public that we shall not increase our problem by meeting it. It is not that we have not realized the need of having all this information. The staffs of the agencies have been and are now inadequate to cope with the situation. But I think that a more careful diagnosis of our problem, a more fearless defining of what we can do or cannot do, of what is hopeless and what is hopeful, might make the work that we do more effective and pave the way for a more appreciative public opinion.

A factor that would help greatly in the entire situation would be the development of strong state public welfare departments and of county and municipal welfare departments. These would contribute to the building up of a strong sense of local responsibility in which would lie the real solution.

It is the private agencies in the West that are handling the problem, on the whole, and it would seem that responsibility should gradually be shifted to the states and municipalities where legal authority rests, for this is needed in many instances for the protection of the community. The whole question of the migrant consumptive is tied up with so many matters of vital municipal concern that the private agency can cope with it only in part at best.

Can the problem of the migrant consumptive be lessened? Two factors in addition to those mentioned would contribute to this. A strict system of followups on the part of tuberculosis dispensaries all over the United States would, I think, be possible of achievement and could, I think, be effective. There is no doubt but that the hopelessly indigent migrant should usually be returned to his home. Climate, his excuse for his migrations, is not even given a chance to function. He is a confirmed wanderer and adventurer like the general tramp, except that the fact that his general instability may have been due to his illness brings our sympathy. He is usually able to "ride the rods" from place to place, although it is true that he is in such physical condition that his appearance is pathetic and appealing.

There is no question but that the building up of a strong United States public health service which would stimulate state health departments and municipal health departments would be a factor in helping solve the problem. Close relationship between county health agencies and state health agencies would render many of the deplorable happenings of the past impossible.

The migrant consumptive will no doubt always be with us. He was one of the first to recognize that civilization was moving westward, and he remains firm in the faith. I believe we can lessen the problem and improve our methods of handling it. We can catalogue him and curtail his movements so that he will

not use up the substance that could be spent to such good advantage for those sometimes classed with him, but whose only points in common are the same illness and the same hopeful and trusting search for health.

LEGAL ASPECTS OF THE INDIGENT MIGRATORY
CONSUMPTIVE PROBLEM

James A. Tobey, Institute of Government Research, Washington

The interstate migration of tuberculous persons is conceded to be a major public health problem and, according to the statistics which have recently been assembled, is likely to continue to be so for many years and even to increase in intensity. The subject has frequently been discussed from its medical, social, and economic aspects, but there seems never to have been a purely legal treatment of it. The object of this paper, therefore, is to present concisely some of those principles of law which apply to the facts as they are and also to the more practical of the many solutions to the problem which have been suggested.

The chief legal phase of this complex situation is one of jurisdiction. When a poverty-stricken consumptive in Connecticut borrows enough money to buy a ticket to Colorado, or is given such a ticket by some misguided charitable organization, and then arrives in Denver in a destitute condition, who is responsible, and whose duty is it to care for him? Is it a matter for the city of Denver, the state of Colorado, his home town in Connecticut, that state, or the federal government? As a matter of fact, in the past it has generally been the city of Denver or the social agencies there which have had to bear the brunt of such exigencies. The question of jurisdiction involves matters of domicile, residence, settlement, and, possibly, of interstate commerce.

Every man is presumed to have a domicile somewhere, and only one. Such a legal residence is his true, fixed, permanent home and principal establishment, to which he intends to return whenever he absents himself from it.' He may abandon it, however, and create a new one. For such a change there must be an acquisition of the new domicile, coupled with the intention not to return to the old. Thus, he may transfer his legal residence from one town to another, or from one state to another. Local statutes may require him to live a certain period in a state before becoming a citizen, but under such conditions he acquires domicile before citizenship. When a man changes his residence merely in order to benefit his health, he does not change his domicile, unless, of course, he has a definite intention to do so. The leading court decision to this effect is Pickering v. Winch.

This case concerned the estate of an Oregon millionaire who died in Cali'See 9 Ruling Case Law 538.

'48 Ore. 500, 87 Pac. 763, 9 L.R.A. (N.S.) 1159 and note.