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allowed to run riot as they are in certain parts of Europe, have
certainly been of such a character to lessen the channels of such
hypothetical infection ever since 1899, and we should consequently
expect a much more rapid decline since that date, especially in those
places where special measures have been devised, such as Sheffield,
&c., compared with previous years, in which there was only an
improvement in general sanitary conditions. Further, it will be seen
that last year there was a decline in the deaths from other forms of
tuberculosis, a decline which again is simply a continuation of one
started long ago, and which occurs in those manifestations of the
disease in which any direct measures against theoretical infection
are out of the question. This would lead one to infer that the
personal resistive power to infection is the factor of importance in
the prevalence and fatality of the disease.
Perhaps experience gained from the notification of Poor Law
cases now in vogue may lead to a different conclusion, although
it has not done so up to the moment of writing. The prevailing
opinion was almost unanimous that infection occurred through
breathing air containing tubercle bacilli. The view has recently
been gaining ground that the infection first passes into the
stomach, subsequently attacking the lungs; and it has also been suggested
that cases of phthisis in the adult are merely the starting
into activity of a focus of the disease, the cause of which was taken
in long previously. On this view it will be seen how important
are the recent enactments with regard to the milk supply in relation
to infection by tubercle, and I feel convinced that it is to this
side of the question that we must look for the further and more rapid
diminution in the mortality from phthisis. I quite agree with some
of the pronounced advocates of notification in their opinion that
phthisis will disappear ; but not so much on the grounds of treating
it as an infectious disease as to the establishment of a pure milk
supply, improved conditions of housing, abolition of overcrowding,
and last, but not by any means the least, to improved economic
conditions, whereby undeserved want, one of the most frequent of
causes, will disappear.
The situation is admirably summed up by Sir Shirley Murphy
in his Annual Report to the London County Council. When
speaking of the decrease of phthisis and the improvement in the
dwellings, the workshops, and the food of the people, he says :
"Whether this improvement has resulted in making the population
more resistent to a contagium of constant virulence, or whether the
virulence of the phthisis contagium has itself declined, must be
matter for speculation. The relative strength of each of the two
opposing forces must finally determine the death-rate, but there
is much reason for thinking that the power of resistance is the
all-important factor in determining the liability to attack from a
widely distributed infection."
The direct means, if they are to be successful, should bring
about a very great improvement within the next five years, whereas
the agencies I have mentioned above will work more slowly but more