In the western portions of Texas there are additional reasons for the public control of tuberculosis. Consumptives from all parts of the country come to these places to secure the advantage to be derived from the climate. The vital statistics of San Antonio for 1902 show that 27 per cent of all deaths were due to tuberculosis, and the same rate doubtless exists in other places where the vital statistics are not kept so accurately. In most cities from 10 to 14 per cent of all deaths are due to this disease.

The experience of San Antonio is merely a repetition of that of Denver, where the death rate from tuberculosis is over 26 per cent of the total mortality. In both cities fully half of these deaths occur among non-residents. In both cases, however, there has been a steady increase in the mortality rate from tuberculosis among the permanent residents. This has been very ably shown by Dr. Frank Paschal in San Antonio and by the late Dr. Wm. P. Munn in Denver.

No one can deny that tuberculosis is due to a specific microorganism, or that every case of the disease is caused by the bacteria given off by some person or animal suffering from the disease.

The spread of the disease can be prevented by destroying or disinfecting the discharges (chiefly the sputum) before they are allowed to dry; and by disinfecting rooms, carpets, etc., that have become infected through prolonged occupancy by a consumptive. Even though a patient is careful to collect the sputum in cups and not use handkerchiefs, some fine droplets are given off in the act of coughing, which make it necessary to disinfect and thoroughly clean a room that has been occupied for a long time by a phthisical patient.

Exposure for a short time to dust containing tubercle bacilli is not sufficient to cause the disease. Infection only follows repeated exposures or exposure for a long time. Prophylactic measures entail no hardships of isolation and quarantine as in dealing with the acute infections. These precautionary measures are easily carried out by the individual, but the disease should be under the con

trol of the public health authorities to make certain that they are not neglected.

Statistics show that in Germany one-third of all deaths occurring between the ages of 15 and 60 are due to tuberculosis. The United States Census Report for 1900 shows that over 80 per cent of the deaths from tuberculosis for that year occurred between the ages of 15 and 60.

With these data before us as to the number of deaths from tuberculosis at the very best time of life, it must be clear to every thoughtful person that it is the imperative duty of States and municipalities to make every reasonable effort to check the spread of this disease. No less a statesman than Disraeli said: "It is the first duty of the State to protect the lives and health of its citizens." If tuberculosis ran a short course, like the acute contagious diseases, the people would demand that they be protected against it, as is the case with smallpox, diphtheria or scarlet fever.

The vastness of the task can be no argument against doing what we can. When Jenner announced his discovery of vaccination, smallpox was causing a greater death rate than tuberculosis is now. Doubtless at that time pessimists thought it impossible to alter the mortality rate from that disease by prophylactic measures, just as they contend at the present day that it is impracticable to attack the tuberculosis problem by public health measures. But where vaccination has been carried out systematically, as in Germany, the results speak for themselves.

Since a specific cure has been found for diphtheria, those who oppose preventive medicine might contend that it is not necessary to give as much attention to the prevention of this disease now as was formerly given. Instead of that, preventive measures are more rigidly enforced now than ever before. Not only do cities maintain bacteriological laboratories for the early recognition of doubtful cases and to determine the duration of isolation, but each year we see additional steps taken, at great expense, for the medical inspection of schools, largely to do away with the "school influence" in spreading this disease.

No sane man would today contend that a case of smallpox or a case of diphtheria should not be isolated, because in the one case individuals may be protected by vaccination, or because, in the other, the disease can be cured with certainty by the early use of antitoxin. If preventive measures are desirable in these diseases, how much more necessary are they in the case of tuberculosis, which can not be prevented by increasing the resistance of every individual, and for which we possess no certain and specific remedy!

It is stated by some that the public control of tuberculosis is a matter of such proportions that it can not be carried out. It should be remembered that this disease is easily prevented, and the prophylactic measures, both private and public, can be taken with less expense, inconvenience and hardship than is frequently imagined.

The control of tuberculosis by the public health authorities does not present the difficulties that are met with in the prevention of typhoid fever by the purification of public water supplies. Municipalities do not hesitate at such undertakings, although the saving of life is less than can be accomplished by reasonable measures to control the spread of tuberculosis.

The question may be asked: Is it practicable to influence the mortality rate from tuberculosis by the public control of the disease? Can the public health authorities deal with the tuberculosis problem, or must it be solved by physicians in attending to each individual case?

We can best answer this by comparing the mortality rate from tuberculosis in cities where this disease is recognized and dealt with as a communicable disease, with the rate in other cities where no attention is paid to the matter by the public health authorities.

Dr. Hermann M. Biggs, in a paper published last year on "The Sanitary Measures for the Prevention of Tuberculosis in New York City, and Their Results," showed conclusively that the mortality is being very rapidly reduced in that city. The reduction is out of proportion to the general decrease in the mortality from this dis

ease.

In 1890 the mortality from tuberculosis in New York City was

3.97; in 1900 it was 3.01. This shows a reduction of .96 (i. e., per 1000 of population). For the entire registration area of the census districts the reduction for the same time was .549; for the cities of the United States in which vital statistics are recorded it was .57; for all the cities of New York State it was .536.

In other words, the reduction in the death rate from tuberculosis in New York City was nearly double that in other communities. No other city can boast of such results, and yet the registration of tuberculous patients was only made compulsory in 1897, although it had been requested of private physicians and required of public institutions since 1893.

It has been contended that this result is more apparent than real; that very many cases are sent where they can get purer air with better chances of recovery, and that they die away from home. Against this argument we would point out that the mortality in New York City remains relatively higher than for any other large American city.

In 1900 tuberculosis caused 11.8 per cent of all deaths in New York; 10.8 per cent in Philadelphia; 9.9 per cent in Boston; 10.5 per cent in Baltimore; 11 per cent in Chicago; and 7.7 per cent in Cleveland.

Surely, the physicians of these other cities are just as careful in the diagnosis and hygienic treatment of this disease as are those of New York, and if this were a factor in the disproportionate reduction in the death rate in that city, it would be apparent when the mortality is compared with that of other cities.

The health authorities of New York City have been pioneers in the crusade against tuberculosis, and have set an example to the world as to what may be done by public health measures in this direction.

WHAT PUBLIC HEALTH MEASURES ARE DESIRABLE AND NECESSARY FOR THE CONTROL OF TUBERCULOSIS.

1. The registration of all cases with the public health authorities. The registration of all cases of tuberculosis as soon as the

diagnosis is made should be made compulsory by State law or municipal ordinance. This must be the starting point for all other preventive measures, such as the disinfection of the sputum; the prohibition of promiscuous spitting; the education of patients and their friends as to the methods of preventing the spread of the disease; the disinfection of rooms, carpets, etc.

The opposition which was so vigorously raised ten years ago against the registration of tuberculous patients is largely dying out. The imaginary hardships to consumptive patients do not actually occur where the registration is carried on, and it has now been tried long enough to demonstrate the practicability of this measure. It is worthy of note that these contentions have arisen chiefly where the registration system has not been tried, and we do not hear such strenuous objections to it where the system is in operation.

Experience shows that the predictions of those who opposed the registration of tuberculosis when it was first proposed have not been realized. Tuberculous patients are not branded as lepers; they are not isolated from their family and friends; they are not unable to get employment, or rent a house, or enter a hotel or boarding house, all as the result of the registration of his case. Where such inconvenience is experienced it is because people are ignorant of the way the disease is communicated and the simple means by which it can be prevented from spreading. Neither the consumptive nor his friends experience as much difficulty in these ways in New York as in many other places. When tuberculosis is dealt with by the public health authorities as a communicable and preventable disease, people do not fear the patient who carries a pocket sputum flask and is careful to disinfect or destroy his sputum. On the other hand, people view with alarm the man with a chronic cough who constantly expectorates promiscuously in a community where no effort is made to check the spread of tuberculosis.

Registration is necessary for the purpose of education and also for the disinfection of infected rooms. It does not necessitate publicity and need not work a hardship on any one.

People should be taught that registration does not mean quaran