beds in Connecticut. I hope ere long to see two more institutions of this character in our state. Two hundred beds in a state the size of Connecticut is ample for the purpose for which the state can justly be asked to contribute, and any further extension of the work should be left to private philanthropy. These Connecticut sanatoria are absolutely non-political, and their management is entirely under private control. Another sanatorium under private control with state aid is that most admirable institution at White Haven, Pennsylvania. Other instances might be mentioned, but it is unnecessary. If it can be done in Connecticut and Pennsylvania, it can be done everywhere.

Who will do the work called for in the development of a sanatorium? Will men accept such a responsibility that means many days of hard work, frequent periods of discouragement, and unfortunately much bitter criticism and misinterpretation of their motives? Yes, men will do it, do it gladly, and find their reward in the growth of the work and the good that it accomplishes. I trust that it may ever be one of the most important functions of our National Association for the Study and Prevention of Tuberculosis to arouse the public all over our land to an appreciation of the importance of organized effort if the disease is to be controlled. When the public is once aroused the private state sanatorium can be easily maintained.

I wish to read a letter that I received recently, written in response to one in which I had briefly outlined my views as to the proper form in which the public sanatorium work should be developed. It is from Dr. Trudeau, and I have his permission to read it. The doctor writes: "The more I think of the matter of state sanatoria the more I think that the plan of having every communtiy build its own institution and receive support pro rata from the state is the best and most efficient plan of combating the disease and eliminating the evils of large political institutions. Each community will be more willing to pay, too, for its own consumptives than to pay tribute to support all the consumptives in the state institution to which, perhaps, none of the particular community's invalids may be able to gain access. Besides, each community likes to manage, as far as it may, its own affairs."

I have been asked, What should be done in a state where no interest was shown in the building of a sanatorium? There is a very simple answer. Let it go without. The day is at hand when to be without such provision for the public welfare will be a reproach.

It has been my endeavor to show that the relation of the state to tuberculosis is two-fold: Measures to prevent, by wise sanitary legislation; measures to educate, and if possible to cure. I have outlined a plan for public sanatoria that I believe will develop the work for the best interest of the individual and the state.

To arouse the state government to a proper appreciation of the measures advocated calls for organization. Let there be anti-tuberculosis associations in every state. In these associations enroll the members of all societies working upon sociological problems. What helps one helps all in this crusade against unsanitary living. The time for action is at hand. The work is to be done. I have full faith that in time it will be done, and done well.

SANATORIUMS FOR THE POOR AND THE ERADICATION OF CONSUMPTION.*

BY RONALD CAMPBELL MACFIE, M. A., M. B., C. M. ABERD., LATELY MEDICAL SUPERINTENDENT, SIDLAW SANATORIUM,

DUNDEE.

BY

INVISIBLY, insidiously, incessantly, the bacillus tuberculosis gathers its annual harvest of a million lives. In Great Britain alone hundreds are daily garnered and the yearly dead would people a considerable city. And though of recent years sanatoriums have sprung up like mushrooms all over the land, yet the therapeutic problem has never been fully and adequately considered. As confession of an evil, as symptom of an awakening, sanatoriums must be heartily welcomed; but the evil, though publicly confessed, has not yet been fairly faced, and

Reprinted from the London Lancet of Sept. 30, 1905.

though men are awakening they are not yet quite wideawake. The sudden realization of an evil has tempted the rash improvization of a remedy, and it is time that the whole therapeutic question should be reconsidered “ab ovo usque ad mala." Before impulsive and optimistic charity builds more sanatoriums it surely were wise to investigate carefully and thoroughly the utilities and futilities of the sanatorium system. We are fighting a slim and formidable foe; it will not do merely to muddle through the business; we must not waste our ammunition; we must use to best advantage the sinews of war; and we must marshal our facts and courtmartial our fictions.

Let us examine the matter. Are sanatoriums, as at present conducted, the best offensive and defensive measures against consumption? It is true that they are popular and impressive measures, but are they sane and sound strategy? As one who has been for years in the thick of the battle I have no hesitation in giving my personal opinion that in the warfare against consumption sanatoriums cannot be more than useful auxiliaries and that they are at present not even so much. They may save a few lives; they may educate a few people; they may advertise a great evil; they may indicate a new crusade; but they can never succeed, per se, in exterminating the ubiquitous and insidious foe; for consumption is essentially a disease of poverty, and sanatoriums for the poor on their present basis are, and must be, financially extravagant and medically futile. In the land of poverty the Armageddon must be fought and sanatoriums for the poor, as at present conceived, are little better than castles in the air.

Consider the following facts. There are in Great Britain at present about 200,000 poor consumptives and about 1000 sanatorium beds for these. Therefore, about 3000 patientsi. e., about 1 in 70-a year can be treated; and therefore, if all patients treated were cured the death-rate from consumption would be lowered by about 1/4 per cent. As a matter of fact, however, only a small percentage of the patients treated are cured. In Tuberculosis - the official organ of the Association for the Prevention of Tuberculosis the following note appears

in the April number, 1904: "We do not believe that in this country we shall ever succeed in getting sanatoria for the working classes filled with early cases. The working man will, as a rule, endeavor to keep at work until the disease has made. so much headway that it thoroughly incapacitates him. Those who are managing sanatoria must not at present expect to get many patients who are capable of doing most things for themselves nor anticipate to send out many cured after three or four months' treatment." This is, indeed, a discomfiting and discomforting statement; but, alas, it has only too many corroborations. We read that at Sheffield 39 per cent. of cases admitted were clinically hopeless — that only 57 per cent. appeared to have a chance of being restored to working life and that eventually four (possibly six) of 28 cases were sufficiently cured to be at work four years after discharge. We read that at the Durham Sanatorium at Stanhope 122 out of 168 were advanced cases and that about half of the whole number have

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died within four years. We read that at Heswell sanatorium "the patients in too many cases only came to the sanatorium when too late to receive such benefit as it was calculated to confer." We find eminent sanatorium authorities stating that 'not more than 10 per cent. of sanatorium patients are early cases;" that "however satisfactory the immediate results of the treatment in the case of the working man the risk of subsequent relapse is very great;" that "most of our patients do not seek hospital relief until they are practically beyond medical aid; " that the average duration of treatment of patients is "insufficient either to cure them or to instruct them in the hygienic rules on which their well-being depends;" and we might multiply such pessimistic opinions. We may therefore rightly and safely assume that only a small proportion of cases treated are cured, and if we put the percentage at 15 per cent. I am certain that we shall err on the side of optimism. And accordingly the much vaunted sanatorium crusade which was going to stamp out tuberculosis is found hardly appreciably to affect the death-rate.

As a matter of fact sanatoriums for the poor, as at present

conducted in England, are simply a tragical farce. The illinstructed optimism is farcical: the results must be tragical. On the one hand, enthusiasts predict that sanatoriums will stamp out tuberculosis — and the sanatorium boom goes merrily on; on the other hand, the facts are as I have indicated. But it may be objected that the sanatorium system in England is still in its infancy and that its failure is due to administrative deficiencies. Doubtless its failure would be less deplorable if its administration were more perfect, but even perfect administration on present lines will result in only partial efficiency. In Germany the sanatorium experiment has been made on a huge scale under almost ideal administrative conditions and in a most business-like and scientific way, yet even in Germany, as I shall show, sanatoriums for the poor have not proved an unqualified success. If the system be weighed it will be found wanting.

When legislative measures were passed in Germany compelling all those with incomes under £100 a year to insure against sickness, old age, and accident, the insurance companies found the sick pay of consumptives a heavy tax on their resources and considered it a good financial policy to give relief (as the law permitted) in the form of sanatorium treatment, and since 1892 the state and insurance companies have given sanatorium relief on a colossal scale. Every year the insurance companies spend some hundreds of thousands of pounds in the building and subsidizing of sanatoriums; and, further, a large number of private societies—notably the Berlin, Brandenburg, and Red Cross Societies - have been founded to assist in the erection of popular sanatoriums. There are now in Germany more than 70 sanatoriums, capable of treating 30,000 persons in the course of a year.

This sanatorium treatment is carried out in Germany on a much larger scale than in England, and not only in extent, but in many other respects, the sanatorium movement in Germany compares favorably with the sanatorium movement in England. In Germany compulsory insurance allows of the most careful selection of suitable cases; in England cases are more or less indiscriminately accepted. In Germany sites and climatic