H.—3l

4

If, therefore, we could claim no absolute cures we should still have justified the setting-up of your annexes; but, as a matter of fact, we can claim more, and as time goes on the benefits of such places will not only appear greater, but will actually be so. At this point I would like to direct your attention to a fact which is apt to be overlooked, more especially in view of the campaign which is now being prosecuted, and that is, that the death-rate from tubercle is gradually decreasing, and has been so for many years. Look at this table of England and Wales : — Quinquennia. Death-rate per 10,000. 1866-70 .. .. .. ■• •• •• •• •■ 244 1871-75 .. .. .. •• •• •• •• •• 22 -! 1876-80 .. .. .. .. •• •• •• •■ 204 1881-85 .. .. .. . • ■ • • ■ • • • • 18 3 1886-90 .. .. • • • • • • • • • • • ■ 16-3 1891-95 .. .. .. •• •• •• •• •• 14-5 1896-1900 .. .. • • • • • • • • • • • • 13 2 1901-5 .. .. .. •• •• •• •• 12 -! A fall, you see, of almost half during the period 1866-1905. I want to emphasize this, because many people seem to imagine that the disease has only recently been discovered, and that the efforts which are being made to check it are indicative of the fact that the disease is increasing. These figures show you that it is not so, and that we should take heart and go on with the good work. Speaking on this aspect of the problem, one writer states, " In so far therefore as England and Wales are concerned, it would appear that if the decline in the phthisis death-rate continues ... ere long it will result in the total extinction of the malady ; that the malady may, indeed, follow the course taken by such diseases as leprosy, relapsing fever, typhus fever, malaria, &c, all of which have for the time being, at any rate, disappeared from the country." Bearing intimately upon this is another point which I would wish to state with all the power I can, and that is that consumption is a curable disease. As far back as 1672 Harvey wrote, "Itis a great chance, we find, to arrive at one's grave in this English climate without a smack of consumption, death's direct door to most hard students, divines, physicians, philosophers, deep lovers, zealots in religion." Then, too, there is the saying of the famous German : " Jederman hat am ende em bischen tuberculose " - everybody has a bit of tubercle in him —a proposition, as Bulstrode says, which is largely supported by post-mortem records, which show that among the poorer a considerable proportion of persons have at some time or other developed tuberculosis possibly without being aware of it, but have nevertheless become, in effect, cured of the disease. For the sake of the many brave men and women who are fighting this disease and the men, such as you, who are lending a helping hand, I would like this fact remembered : consumption is a curable disease. But while it is true that consumption is a curable disease, it does not follow that all cases of consumption can be cured, but still must we do something. To my mind, some—l would say a good deal -of the disappointment which some of us have suffered with regard to the sanatorium treatment of the disease has arisen through our not keeping this distinction clear in our minds. _ It stands to reason that if it has taken a person twelve or eighteen months to reach a certain stage in the disease, some such similar period of time must elapse ere we can hope for betterment or cure. For a person who has lost a third of one lung through consumption to expect a cure in the sense that one may get in a case of ordinary inflammation of the lungs is foolish. Highly specialised tissue, such as the lung is composed of, can rarely be reproduced. This difficulty in regrowing destroyed limbs and special tissues is the penalty we pay for being at the top of the animal kingdom. The crab can grow another leg, but the man cannot. And so it is that, even under the best conditions, the hole in the lung, when it does heal, heals with lower-grade stuff, and is usually lost as a breathing-machine for all time. Fortunately, however, a man can manage to get along fairly well with something less than his full breathingarea, if he has a little training ; but—and this is a fact we have to remember—many are so far gone before they come under the care of the sanatorium officer that it is obvious that nothing permanent in the way of cure can be hoped for. These are the cases which have raised the doubt in your minds as to the wisdom of the expenditure upon the annexe. Such cases it is which all the world over have caused honest workers to halt and wonder if some mistake has not been made. Personally—and I speak from an intimate knowledge of the life-history of a great number of cases—l have no hesitation in saying that even in these advanced cases sanatoria have justified themselves. What we want, however, if we are to get the best out of such institutions, is that we must get the cases early. The intimate association of phthisis and overcrowding has been recognised for many years, and there are numerous illustrations of such association. In certain aspects overcrowding may be regarded as one of the expressions of poverty, but although overcrowding is almost always associated with poverty, it does not follow that poverty is always associated with overcrowding. With regard to association of phthisis and overcrowding, it would be well to keep in mind the fact that persons already tuberculous naturally tend to drift to overcrowded districts. But there are indications that this is not by any means the whole explanation of the observed association of the two conditions. It was shown by Carnelley, Haldane, and Anderson that in Dundee, in houses with four rooms and upwards, the death-rate from phthisis was 32 per 10,000, as compared with a death-rate of 55-2 in houses with three rooms, 64-1 in houses with two rooms, and 74-4 in houses of one room. It is in securing early cases of .phthisis for sanatorium treatment that Germany would seem to be in advance of most countries, a circumstance due, no doubt, in no small degree to the far-reaching system of compulsory insurance of workpeople against sickness and incapacity which is in force in the German Empire. By means of this system the workman, when attacked by tuberculosis, has a legal claim on insurance funds for medical treatment and maintenance in his own case, and for the support