to neglect, ignorance or unfortunate proximity, and because it can be limited as easily as any of these when once understood.

Let me give you a few figures showing the extent of this scourge. In this country, at present rates, one-tenth of those now living will die from consumption. This means 7,000,000 in the United States, 500,000 in Illinois, 300,000 in Missouri and 70,000 in St, Louis; but as the urban rate is one-seventh, 100,000 is nearer the loss in our own city. In St. Louis there are probably 5,000 active cases of consumption in the different stages; in Chicago 8,000, and in Missouri and Illinois 20,000 and 30.000.

The New York Board of Health estimates that there are 30 000 cases in that city, and over 5,000 in Boston. In Great Britain there are 200,000 cases of consumption among the dependent poor alone, costing $155,000,000 annually. Last year in Illinois, with a population of about 5,000,ooo, there were 7,000 deaths from consumption, and in Missouri a little over 4,000.

The economic loss is equally startling. Last year the estimate from official statistics was: Money loss in Illinois in the education of those who died before the age of twenty, $1,187,000; wage loss of those sick, $30,000,000; loss of savings of those who die before the end of the producing age, $5,139,000; cost of sickness, $225,000, making a total of $36,551,000, not including the value of each of the 7,000 lives lost by consumption during the year. In Iowa the annual loss is estimated to be $10,443.000; in Missouri, $24,000,000; in the United States, $547.385.000, or $8 for every man, woman and child(Boice).

Is it not true that we should study and strive to limit a disease so insidious, so destructive to life and finance as this? In the greatest modern war the loss of life was not so great and the daily cost to each side of $1,000,000 is little more than one-half of what consumption costs the United States.

In the study of the disease there are three main features to be remembered: (1) it is a communicable disease; (2) it is preventable; (3) it is curable.

Consumption does not depend upon heredity as a main factor in dissemination, but upon the same kind of condi

tions as multiply other infectious diseases. Even more than smallpox, cholera and the plague it may be called a filth disease, for unsanitary surroundings invite it, and a parasite or germ distributed by filthy habits is its main cause.

Consumption is now known to be a curable disease. Not in every instance, not in all stages, but enough has already been done to make the proof beyond question. Twenty-five hundred years ago Hippocrates said that all consumptives die, and unfortunately many people and too many physicians have a profound veneration for this most ancient dictum. On the other hand, Dr. Flick, the medical director of the great Phipps institution for the study, treatment and prevention of tuberculosis, says in his book of last year, tuberculosis is one of the most curable of all diseases." Bouchard, of Paris, concluded his lectures on consump. tion a few years ago by saying, "This disease, which has a strong hold on humanity, is curable in the largest number of cases. On the post-mortem table it is not uncommon to find healed portions of tubercular lungs, and the clinical evidence from our sanatoria is beyond dispute.

LIMITATION.

The object of my paper, however, is not to discuss the process of this disease and its care in the individual. I take it that the best thought of the hour is upon the question of limitation of consumption and the very important rôle which we as citizens have in its accomplishment. Right here let me say that the limitation of tuberculosis is not a Utopian hypothesis. It can be done; it is being done. Pasteur has said: "It is in the power of man to cause all parasitic diseases to disappear from the world." Consumption is preeminently a parasitic disease, caused by a micro-organism which grows on living organic matter. Other diseases of infectious type and germ origin are controlled. We have practically stamped out smallpox. We no longer fear cholera; the terrible bubonic plague has been kept from our American cities, and diphtheria is curable and limitable to a degree little dreamed of a dozen years ago, yet here is a parasitic disease in which the germ cause is easily recognized, which is mainly dependent upon ignorance and carelessness,

which can be largely controlled and is curable, and we permit it to hold unchallenged sway. Figures are of more value, however, than mere statements, however authoritative. In Germany the decrease in the number of deaths from tuberculosis during the last year has been 50 per cent., and in England about the same. In New York the death rate has fallen from 4.2 per 1,000 to 2.9, a reduction of more than 40 per cent., and in Philadelphia the decrease in ten years was 43 per cent. Dr. Benjamin Lee, Health Officer of Philadel phia, assigns as causes for this decrease : "First, improved pavements; secondly, improved drainage; thirdly, generally improved sanitary conditions of small streets and alleys; fourthly, the diffusion of information by the Pennsylvania Society for the Prevention of Tuberculosis; and fifthly, the notification by physicians and disinfection of premises, both prescribed by the City Board of Health." In New In New York the result is largely due to the yeoman service of Drs. Biggs, Knopf, Jacobi, and others, and the Committee on the Prevention of Tuberculosis of the Charity Organization Society, resulting in cleaner streets, improvement in tenement-houses and the treatment of tuberculosis as infectious. Upon the basis of the New York and Philadelphia results, 40 per cent. of the estimated 100 000 victims among those now living would be 40,000 lives saved in our city alone. Forty per cent. saved of the 5,000 cases now existing in St. Louis would be 2,000 less to suffer and endanger others, 2,000 more bread-winners each year. It means a saving of $9,000,000 annually to Missouri and of about $350,000,000 each year to the United States. Can we as citizens of a great common. wealth make any better investment of our time and money than the accomplishment of this object? If the lives of its citi zens are a country's most precious possession, surely here is something worthy the best thought and the most careful legislation.

STUDY OF TUBERCULAR INFECTION.

To be able to decide upon methods of action for the limitation of tuberculosis, we must know something of the manner of infection, and the conditions that favor it. Let me repeat that tuberculosis is no longer classed as hereditary. It is true that certain physical conformations and

tendencies may be inherited, but not the disease itself. It is acquired first and most frequently by the inhalation of the dried particles of sputum from a tubercular patient. A consumptive may expectorate many millions of bacilli daily. Under proper conditions of moisture and temperature these bacilli are potent for a long time. When the sputum becomes dry and is pulverized the micro-organisms are easily carried by currents of air or by whatever may disturb ordinary dust and may be inhaled. Should they lodge in the throat or lung where there has been even a slight bronchial or pneumonic irritation they readily penetrate into the deeper structures and colonize. The result is a local tuberculosis, the finale is consumption.

The first great step in the limitation of tuberculosis is to impress upon the public the infectiousness of tuberculous sputum. Spitting, except in proper receptacles, should be made a misdemeanor, We have in St. Louis an "anti-spitting" law, and you see many reminders that the Civic League and our association are at work along these lines. There is nothing more. horrible, for instance, than to ride in one of our crowded street cars, every window closed, the vitiated atmosphere overheated, and withal the consciousness that you are grinding under your feet the foul expectoration of some previous passenger, and possibly inhaling his bacilli, certainly inhaling the air loaded with impurities which others have just exhaled. The nausea of it is bad enough without the danger.

If little pieces of burning débris were to be found in our public conveyances, in our streets, in the church and theatre, and most of all in the home, how soon would the fire department and the insurance companies be on the alert, not only to remedy the present evil, but to prevent its repetition? The danger from the foul and criminal habit of promiscuous spitting is greater than the other, but is passed by by those of us who know better, because we hesitate to offend.

Let me cite an illustration of this proposition pro and con. A young court official was confined to his room for several months before death and was exceedingly careless of his sputum. Two years after his widow, of healthy parentage, died of tuberculosis, and recently his daughter,

grown almost to womanhood, died of the same disease. It is not hard in such cases to trace the influence, not of heredity, but of infection. On the other hand, in our large consumptive hospitals, where there are patients in all stages, it is almost unknown that an attendant acquires the dis

ease.

At Mount St. Rose the physicians and the Sisters in charge are in daily and almost hourly contact with cases of every degree without the slightest fear, whereas, if no more care were exercised than is used in many homes, and these not always the poor ones, the house and grounds would be infected in a fortnight. That we are all exposed to this danger is evident; that this danger is great is shown by its results. While tuberculosis is a parasitic disease-a filth disease, if you please the opportunities for the inhalation of the bacilli are everywhere. If the draperies in the sleeping-car and the heavy, unwashed colored blankets in the berth could tell us how many consumptives had breathed upon them the breath of death before our occupancy; if our room at the fashionable health resort could reveal what had therein transpired of sickness and death, if it did not make us miserable, it certainly would make us insist on greater care. A friend wrote me that he found a room which was rented in a city in the Southwest had a record of eleven

deaths from consumption, and the landlord was, so far as he knew, innocent of any attempt at disinfection or of changing the mattress, carpets or furniture. Infection may also take place by food and by inoculation, but these are not the great danger that inhalation of the bacilli is.

Enough has been said to show that tuberculosis is an all-pervading disease, that it is communicated by the bacilli which enter the system either by the lungs or the respiratory tract. Two important questions remain. What is necessary to limit the danger, and what can we as members of the brotherhood of man do to accomplish this most important end? In the limitation of tuberculosis there are two lines of attack-treatment and prevention. I would not so much emphasize treatment, for, after all, drugs are mainly adjuncts. Pure food, fresh air, proper clothing and general hygiene are potent, necessary means to a cure in any given case. These are also of vital importance in the prevention of tuberculosis, and for

brevity's sake we will speak of them under that division a little farther on.

PREVENTION.

That consumption can be prevented, or at least greatly limited, is beyond doubt. The first step necessary is to educate the people. They should be taught that the disease is infectious and that infection can be prevented.

The sputum should be cared for, and this can easily be done. It has been shown by Twitchell, Sawinsky and others that bacilli subjected to the ordinary condition of the floors and draperies of a modern dwelling house may retain their virulence for seventy days. The use of a cuspidor or a covered cup, with a weak solution of the common concentrated lye, renders the sputum harmless. It should be taught that it is a crime to expectorate on the floor or the sidewalk or anywhere but in receptacles provided for this purpose. These cuspidors or cups should always be partly filled with a water containing a germicide, the best and cheapest being the powdered concentrated lye of the shops. It undoubtedly follows that the same care should be insisted upon in the disinfection of all dishes and drinking cups used by the tubercular. Special utensils should be provided for the sick, and as a temperature of less than 200° kills the bacilli, frequent washing of the dishes and of much of the clothing as is possible in boiling water should be taught.

Fresh air is a necessity. Physicians in the van of the crusade say "climate is of little value in consumption; it is the outside air which counts"-air that has not been breathed before, which has its full equivalent of oxygen, and it matters not whether it is the air in the Adirondacks, in New Mexico or in St. Louis. Dr. Hector McKenzie has his tubercular patients living day and night on the balconies of St. Thomas' Hospital, in London, where the climatic conditions are less inviting than in St. Louis. At Mount St. Rose our patients sleep in winter with their windows open. In summer they sleep on the verandas, and we have built open pavilions where they may live every day of spring, summer and fall.

Let us look for a moment at life as it is now lived in reference to this very subject. The well to do live in sealed houses, artificial heat keeping the temperature to 72°,

windows seldom opened in winter, the air reheated and reinhaled. They go to a church on Sunday, where the sexton uses his judgment, based sometimes on a poorly placed thermometer, and while his tender ministrations warm them up, the devitalized atmosphere puts them to sleep, and after having used for an hour and a half second-hand air, which has previously given up part of its oxygen to his neighbor, the good man goes home to a big dinner and straightway forgetteth the text. Monday morning he goes to business in a crowded street-car, every ventilator closed, and breathes air which is even more foul than that of the day before-certainly more democratic. Then comes the business hours, and in the evening perhaps the theatre or the lecture room, where the same conditions generally prevail.

With the poor man the error in living is often greater. The close, little rooms, the fear of an open window, the odor of cooking and unwashed clothing and unhealthy human bodies are sometimes in our tenement-houses almost staggering. Nor is the workshop or factory often much better. The crowded car which takes the laborer to and from his work is too often foul, though ventilation has been made a special order by the worthy superintendent of our transit system. In a paper, almost dramatic in its force, "The Plague in Its Stronghold," by Dr. Ernest Poole, of New York, he begins with, "Breath, breathgive me breath! A Yeddish whisper on a night in April, 1903, from the heart of the New York ghetto." Pure air, or other unused air, is God's remedy and preventive, yet we persistently shut it out. I may be tempted to use a common drinking cup, I have taken a whiff from a dirty pipe, passed by a dirtier old chief, but I will not, if I can help it, drink in the air which has just escaped from some one else, be his condition what it may. I would not be understood as saying that one may pick up tuberculosis any and everywhere, for, fortunately for us, the bacilli require certain conditions for living, but I do say that all that hinders the distribution of the bacilli and favors right hygienic living to that extent limits tuberculosis.

There is much more that might be said regarding the prevention of tuberculosis. The topics of food, clothing, the isolation of the tubercular as far as may be in sana

toria or separate rooms, the hygiene of the tenement-house, the sterilization of the sick-room and kindred topics are all pertinent, but time fails.

CONSUMPTION IS CURABLE AND

LIMITABLE.

Its limitation is largely a matter of education. The rich should be instructed and the poor instructed and helped. The crowded tenement and filthy alleys and streets are the hot-beds for the propagation of tuberculosis. It has been limited 40 per cent. in New York; in Philadelphia 43 per cent., and the decrease in other cities has been about in proportion to the intelligent effort exerted for its control.

If we may believe statistics and careful deductions, it is possible that we may by the same methods save 40,000 of those now living in St. Louis from death by tuberculosis. What is accomplished in New York is possible in Chicago, and in every city of the West. I repeat the word "we," for somehow I have the faith that in this audience are some whom the sense of responsibility in the matter will lead to definite active effort for the safety and preservation of ourselves and those dear to us, which is in accord with the highest law.

Your boards of health will aid in every possible way, but it needs our help. In St. Louis our Health Commission is doing yeoman service in carrying out advanced plans for the best care of the tubercular poor and for the safety of those in danger from infection. The press has shown the greatest interest in the subject, and will give its most valued assistance. The great Civic League and the Provident Association and all our great charities stand ready. We simply need to make a practical application of the means to an end. I take it that the keynote is education and care. Dr. Trudeau, to whom we owe so much of hope and direction, says, in a recent letter: "Give the tuberculous patients education by means of a pamphlet, so that they may learn not to infect others and to care for themselves."

WHAT IS BEING DONE TO FURTHER THIS WORK?

First of all, there has recently been. formed the National Association for the Study and Prevention of Tuberculosis, comprising the leading workers in this

department, with annual meetings for the report of progress. In many States provision is made or being made for the building and maintaining of special sanatoria for consumptives. Massachusetts erected a State sanatorium at Rutland in 1895; New York has a half-million institution under way; New Jersey has appropriated $300,000; Illinois is far along with her plans, and other States are discussing the subject. Private institutions are found in almost every large city, and camp and settlements are being everywhere located from the Adirondacks to the Mexican border, for it is now a proven fact that there is no special climate for the cure of consumption, but that it can be cured in any climate.

WHAT IS BEING DONE IN MY OWN CITY AND STATE?

The pass year has seen advance in this civic duty. Mount St. Rose, although a private institution, has been adding to its claims for recognition. Special wards are set apart for the consumptives at our City Hospital, and special hours for the treatment of this class of cases are soon to be designated by the Health Commissioner. A new plant for the better treatment of the tuberculous poor will soon be in operation. Our local association has not been idle. It has carefully studied and urged a bill giving the Health Department power to oversee, register and provide for disinfection, a most important step. It aided in the passage of a bill providing for a State institution for the consumptive. The passage of this bill has been accomplished, and the corner-stone of the Missouri Sanatorium for Tuberculosis was laid by the Governor two months ago, and will be ready for patients early in 1907. The association has placed placards in the streetcars, in the factories, and distributed 550,000 leaflets and pamphlets through our schools, police departments and industrial associations. A public-spirited citizen offers to erect, as we may suggest, pavilions for the open air treatment of cases, a stepping stone, we hope, for a pavilion camp or settlement. Quite recently an association for relief of consumptives has been formed.

THE WORK HAS BUT BEGUN.

Lectures must be given in our schools. New vigor must be instilled into the en

forcement of the "anti-spitting" law. Material must be furnished for the press, which is ever ready to aid in this work. Inspection, with the aid of our great charity organizations, must be made systematic. Registration of cases in compliance with the bill just spoken of must be enforced and sanitary conditions improved in the tenement districts. A day camp for incipient cases is much needed in every city, and the cost will not be great. This should be in addition to the buildings for outdoor treatment furnished for the city poor.

I believe that the St. Louis Association for Prevention of Tuberculosis has invested the few hundred dollars committed to its care in a way that will benefit our people many times that amount, and we can invest thousands at the same rate of interest. Recognizing the largeness and importance of the work, our association has been carefully planned, and in it are men who will not lay down the task which they have unselfishly undertaken, but they must have support. The city which carried to success the greatest Exposition ever held, which is making gigantic strides not only as a city of beautiful homes but as a business centre of the first magnitude, the citizens of this city will furnish the means for more effective work in this great crusade, and the work will be done. Forty thousand lives saved in one city in this generation, twice that many in Chicago! How many may that be in the families represented in this audience?

One more thought in conclusion: The comparatively little that has been expended in any State or city for this purpose is the best investment ever made by that State or city for its citizens. This work is not wholly charitable; it is that and it is protective. By helping to stamp out consumptlon you are protecting your own. A lady patron, in giving her contribution, said: "It is for others, but it is also for myself." A life insurance, if you please. Every case prevented is one less danger to your home. If the death-rate from consumption is one in seven, what is it worth to you to have the danger reduced onehalf! To this add the protection you are giving other homes and you must help us, you cannot help but help us, for, after all, it is largely the work of the general practitioner.

422 Commercial Bldg.