sumptives, consists chiefly in a plentiful supply of sunlight and fresh air, together, of course, with the necessary rest, proper food, medical and hygienic treatment, — patients when suffering from tuberculosis being placed on a terrace in the open air or in a balcony sheltered from cold winds, but exposed for many hours during the day to the full, direct rays of the sun.

Another no less important predisposing cause of phthisis is habit of life and occupation. It has been observed that those who follow an outdoor life under normal healthy conditions are comparatively free from the disease, while those who lead sedentary lives habitually indoors are very subject to consumption, the maximum incidence of this affection being found among persons who constantly inhale impure air in badly ventilated rooms and in occupations associated with a dusty atmosphere. Thus stone-cutters, knife-grinders, potters, plasterers, dyers, wool-carders, cigar-makers, polishers, and the like, suffer particularly from phthisis. Printers, compositors, tailors, dressmakers, bakers, and all those who work in a constrained position in poorly ventilated and lighted or damp places, or where smoke and various irritating gases are generated, also readily contract the disease. And how many of our tenement house dwellers do we find working at such occupations under bad hygienic conditions!

But admitting that these evils, and others conducive to tuberculosis, exist in the tenement house districts, what can be done to ameliorate or remove them? The problem is unquestionably a difficult one, probably the gravest and most difficult of the day, and as such it is worthy of the consideration of all thoughtful men, - but though it may take a long time and the expenditure of much money to solve it, I do not think that it is hopeless of solution.

Apart from the erection of public hospitals and sanatoria for the care and treatment of the consumptive poor, which we need not consider here, much might be done in the way of legislative enactments regulating the width of the streets of cities, the construction and height of the houses, and, above all, the preservation of parks or open spaces. The establishment of public wash-houses would have a very beneficial effect in minimizing the frequency with which washing and drying of clothes is carried on in small rooms. In the same way, the evils resulting from working at home at sedentary occupations in illventilated apartments might to some extent be obviated by the establishment of public workrooms, where on payment of a small fee, tailoring, shoemaking, and other similar employments might be followed; and it would be well if all such deleterious home work were prohibited. The erection of model tenement houses, constructed on true hygienic principles, by generous and liberal-minded private individuals, is a noble and far-reaching charity, and is much to be com

mended; and could municipalities undertake such a work it would be an investment which, both directly and indirectly, would return a handsome interest. The building of cottage homes on the outskirts of cities, together with cheap rapid transit facilities, for rehousing of the working classes on the destruction of unsanitary tenements in the congested districts, is also to be encouraged; and this would afford, perhaps, the most practical means toward a final solution of the problem.

Meanwhile, the overcrowding of tenements should be restricted by regulating the air space, allowing not less than 600 cubic feet to each adult and 200 cubic feet to each child of five years, and by enforcing the ventilation and lighting of rooms by means of a current of air from windows opening upon the outer air, or at least upon large air shafts. Undoubtedly all back to back and rear houses should be absolutely condemned. Not only should the height of new houses be regulated according to the width of the streets, but the erection of additional stories to houses already standing on narrow streets should be forbidden. In a city like New York, where the price of building lots is ever on the increase, the natural tendency is to make the houses higher and higher, until in many of them the amount of daylight which reaches the rooms on the ground floor is so small that only the upper stories are fit to live in, the rooms in the lower stories being too dark and damp for anything but an abode for rats. Sufficient air space should be left behind the houses to allow thorough ventilation, nor should the corner lot be permitted to cover the entire lot; and streets should be open from end to end, so that all houses have free ventilation both back and front.

Every landlord should be required, before letting his tenements to different families, (1) to make ample and suitable water-closet provision for the number of persons who are to occupy the houses (best a separate water-closet to each set of apartments); (2) to supply each set of apartments with a separate water supply and bath (cheap public baths are a fair substitute, but there is nothing like a private bath to encourage cleanly habits); (3) to provide separate storage for coals; (4) to provide sufficient means for washing clothes; and (5) to provide pantry accommodation for the keeping of food. These are not luxuries, but absolute necessaries of life for civilized beings, and therefore should be provided in every tenement. Their presence tends to promote health; their absence makes for dirt, ill-health, disease, and death, while it also tends to dehumanize people and to breed paupers and criminals. We cannot prevent the increased aggregation of population in cities, but we should at least try to make the evil effects of overcrowding as little felt as possible.

The results of injurious occupations in factories, workshops, etc., have already been greatly mitigated by the introduction of improved

machinery and methods, by the regulation of hours of work, by prohibiting the employment of very young children, and by enforcing the use of fans to carry off the dust and deleterious gases; but there is still room for improvement in these matters.

Much has been done by the sanitary authorities as pioneers in the crusade against consumption, by the adoption of improved measures of sanitation, by the enforced disinfection and renovation of infected premises, by the compulsory notification of tuberculosis as an infectious and communicable disease, by the prohibition of spitting in public places and conveyances, and by the distribution of circulars of informa tion regarding the nature of consumption; but these laws and regulations should be more rigorously enforced. And especially by every means in our power-through societies for the prevention of tuberculosis and through the press, the pulpit, and the schools, as well as through boards of health—we should endeavor to educate the public as to the character of this disease, what it is and how to prevent it, and more particularly with regard to the danger of communicating the malady through the expectoration of consumptives; and by the flooding of cities, especially tenements, workshops, schools, and stores with simple notices of these facts, we should keep on advertising them, so to speak, on the highways and byways, until, like other advertisements, they are read and remembered.

But it may be asked, Will it pay to do all this? The AngloSaxons are frequently called "a nation of shopkeepers," and we Americans particularly are said to "worship the Almighty Dollar." Some time ago I attempted to estimate the pecuniary loss to the community, as the result of the mortality and disqualifying power of consumption; and perhaps this estimate is worth recalling in connection with the relation of tuberculosis to the tenement house problem.

It is not easy to place a money value upon human life, but according to one of the best authorities on this subject, the economic value of the individual is what he has cost his family, the community, or the state for his living, development, and education, the loan, as it were, which the individual has made to him to reach the age when he can restore it by his labor. The average life value has been estimated by different economists in Europe at amounts ranging from $750 to $1000 and over; and the law often allows far larger sums than this for loss of life and limb. It is certainly not an overestimate, therefore, to place the pecuniary life value of a citizen of New York at $1000. Now there are, according to the official records, over 8000 deaths per annum at present in New York City due to pulmonary tuberculosis alone, and at least 7300 of these, or about 91 per cent, occur between the ages of 15 and 65, that is, during the period of the greatest productive capacity of the individual. Thus taking $1000

to be the value of adult human life in this city and the annual mortality from consumption of persons between 15 and 65 years of age to be 7300, there would be an actual loss to the community from this cause of $7,300,000. But a sufferer from this disease is usually incapacitated from work for a considerable period before his death, during which time he earns no wages, and a corresponding loss in producing power thus accrues to the community. Many consumptives die within the first few months, and, from this point of view, influence the question comparatively little. Others again live for a number of months and some for several years. It is possible that a few of these are in the full exercise of their power and that their earning capacity is unimpaired; but the majority are in all probability simply burdens on their relatives or on the city. Assuming, however, that the average consumptive is incapacitated from active work for three months or 90 days only, and estimating the daily wages of the common laborer to be $1.50, - the average number of deaths from consumption between 15 and 65 years of age being 7300, there would be a further loss to the community in productive capacity of $985,500 per annum. Computing these amounts, and leaving out of consideration all other possible expenses connected with the illness and death of the individual, we find that there is at least a yearly tax of 88,285,500 levied on New York City by this dread disease. In this calculation, however, only the reported deaths are considered; whereas at least 30 per cent more should be added to these, which, though reported as due to some other disease, are really tubercular. There are, moreover, at a conservative estimate not less than 20,000 cases of well-developed and recognized pulmonary tuberculosis now in the city, and an additional large number of obscure or incipient cases. If we include these two classes, a considerable proportion of which are doubtless also incapacitated from work, we may safely estimate the annual pecuniary loss to the community from consumption to be little short of $10,000,000. And the greater part of this loss, remember, occurs. in the tenement house districts.

Taking, therefore, only a sordid view of the matter, it will certainly pay to expend money and time in the effort to check the ravages of a disease which causes such an enormous loss that it is almost incalculable. But tuberculosis does more than this; it not only gives rise to a greater loss of life and money in the world than war, pestilence, or famine, but it is the source of more misery, suffering, poverty, and perhaps crime than all the other ills that human flesh is heir to.

And yet there is no doubt that this is a preventable disease and can be more easily prevented, with our present knowledge of its origin and nature, than cholera, smallpox, or the bubonic plague,

other bacterial diseases, which in the Middle Ages, under the name of "The Black Death," decimated the populations of the earth, as the result of still more unhygienic conditions and of greater ignorance, poverty, and filth, but which now have been entirely rooted out from all civilized countries, because the necessary sanitary precautions were taken to prevent them.

Tuberculosis, though an evil much to be dreaded, is not an inevitable decree of fate, not an unavoidable dispensation of Providence, as it has been commonly thought to be; but, like many other ills from which mankind unhappily suffers, the remedy for it exists to a great extent in ourselves.

The sceptics tell us that to hope to eradicate tuberculosis is the dream of the sanitary enthusiasts, far-fetched and utopian. But already the mortality from this disease has been much reduced, owing to the adoption of improved sanitary methods, though carried out on a limited scale and in an irregular manner. May we not reasonably assume, then, that more vigorous and systematic measures, together with organized and coöperative action, will accomplish infinitely better results? This is an age of combinations, unions, and alliances of all kinds. Why should we not combine the vast interests of doing good in this great work of practical sanitation, with the full belief and expectation that the day will come when this widespread and fatal scourge may be completely exterminated?

TABLE

SHOWING THE NUMBER OF DEATHS BY AGES FROM PHTHISIS; THE Number of Deaths FROM PHTHISIS BETWEEN THE AGES OF 15 AND 65; THE TOTAL NUMBER OF DEATHS FROM PHTHISIS IRRESPECTIVE OF AGE; AND THE TOTAL NUMBER OF DEATHS FROM All Causes in New York City (Manhattan and the Bronx, and GREATER NEW York) for THE YEARS 1897-1899, FROM THE OFFICIAL RECORDS