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41
the same time shrinking the wastage from many other preventable
diseases.
Institutions are wanted which are not provided primarily for the
benefit of the patient, but for the isolation of the patient for the
benefit of others, and which may therefore be fairly supported out of
the public funds. There are no such institutions in London, if we
exclude the inadequate provision for phthisical paupers, and until they
are provided we lack one of the essential provisions for coping with
the disease. But whatever the extent of the provision made in a
sanatorium or isolation hospital, the great majority of the sufferers
from phthisis would remain outside with their families and at their'
work until the latest stages of the disease are reached, rather than
enter an institution for several months. Consumption, then, must be
variously dealt with in its different stages, In the earlier stages what
is wanted is education and open-air treatment for those able and willing
to avail themselves of it. In the latter stages isolation is needed,
for every word that the patient speaks and every cough is the
cause of the dissemination of the tubercle bacillus, and then, whatever
instruction has been given to the patient in the sanatorium, nothing
can prevent him from being a source of danger to all about him.
Above all we must aim at raising the general standard of healthy
living, because in the low standard of domestic and personal
hygiene, and in overcrowding and bad sanitation, we have the conditions
which favour the disease. The importance of a careful selection
of occupation for those who inherit a predisposition to phthisis and,
where practicable, for those who are discharged from sanatoriums,
cannot be exaggerated; and since, otherwise, work has often to be
persisted in by a phthisical patient to the detriment of his own
recovery and the safety of his fellow-workers, the German measure of
compulsory insurance has much to recommend it. In Germany at
present all persons, male and female, engaged for wages or salary
in trade or business (excluding domestic servants and agricultural
labourers), are compulsorily insured against sickness and death, the
employer paying one-third, and the employee the remaining two-thirds
of the premium. In this as in some other respects a comparison with
Continental methods is not to our advantage.