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 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

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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

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

conditions have been carefully chosen; in England these have been subordinated to the question of convenience. In Germany the cost of maintenance has averaged about £2 per bed; in England some of the sanatoriums for the poor are conducted on lines of rigid economy. In Germany, accordingly, we have

sanatorium treatment carried out under conditions calculated to give the best results possible — conditions that England can probably never provide. Yet what do we find? With German thoroughness the German Imperial Health Office analyzed the results of treatment in 6273 cases treated between 1899 and 1900 and showed that in the opinion of the sanatorium physicians 87.7 per cent. were cured or improved. This sounds magnificent; but when we further find that in the opinion of the same physicians only 67.3 per cent. were fully able to work at their former occupation, we begin to understand that "cured and "improved" are vague terms without precise practical significance. Still, if even 67.3 per cent. of consumptives could be permanently restored to working life the economic value of sanatoriums for the poor would be immense. The question, however, at once arises, Is the restoration to working life permanent or merely temporary? And in order to determine this most important question the German Imperial Health Office investigated the after-history of 2147 persons, with the following most remarkable results: Of each 100 cases dismissed as being wholly or partly able to work, only 21 per cent, were able to work four years later; while of each 100 cases dismissed as being wholly or partly unable to work, 18.27 were able to work four years later. These figures are most startling; they would seem to prove both the fallibility of prognosis and the futility of treatment. Can prognosis be of much value when 100 cases dismissed as able to work and 100 cases dismissed as unable to work show at the end of four years almost the same number of working survivors? Can treatment be of much value when so many of its supposed failures survive and outwork its supposed successes?

Even accepting the very questionable explanation of the German Imperial Health Office-i. e., that the unexpected stamina

of the unsuccessful cases is due to hygienic education at the sanatorium even accepting this explanation and assuming, further, that none of the cases (whether considered good or bad) would have been able to work at the end of four years without sanatorium treatment but owed their lives and their working capacity to sanatorium treatment, still we cannot consider the result very satisfactory. And the result seems less satisfactory still when we remember that most of the cases were insurance cases and that according to the report of the Imperial Health Office: "Sanatoriums patronized wholly or chiefly by insurance institutions were specially rich in doubtful cases characterized by light catarrh of one apex,' 'catarrh of the lungs,' apices suspected,' and the like." In the light of such results under such conditions we are forced to the conclusion that 20 per cent. of cures is the highest percentage of cures that sanatoriums on their present basis (unless in Alpine climates) can attain and that in England such a percentage can probably never be reached. In the light of such results, too, it is plain that both the public and the profession have been carried away by a wave of enthusiasm quite unwarrantable, howsoever commendable, and that it is time the whole situation should be calmly reconsidered.

It is true that with sufficient sanatoriums even 20 per cent. of cures might considerably reduce the death-rate from consumption, but, as I have pointed out, it is improbable that English sanatoriums can ever reach such a percentage and even if they could reach it the situation would be economically unsound and financially intolerable unless under the German system of compulsory insurance. Let us consider the cost of a life saved by sanatorium treatment on the assumption that 20 per cent. of cases treated are cured. As shown by the Sandgate Select Committee each efficient sanatorium bed means an annual expenditure of £100. The average sojourn of a patient in a sanatorium may be estimated as four months. Thus the cost of treating each patient would be about £33 and the cost of each life would be about £165 (at present in England each life probably costs double that). This is both greater than necessary (as I shall afterwards point out) and greater than public charity will defray.