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51
ment in the social circumstances of the English population has been the material cause of an increased
resistance to disease generally, but specially manifested in the decline of the phthisis death-rate.
The issue by the Local Government Board of a report by Dr. H. Timbrell Bulstrode, on " Sanatoria
for Consumption and Certain other Aspects of the Tuberculosis Question," provides for the use
of local authorities, and indeed all who are concerned in the work of the prevention of tuberculous
disease, a comprehensive statement of the experience which has been gained in dealing with this disease.
So far as the patient is concerned, the whole trend of Dr. Bulstrode's story is that early recognition of
the disease and early treatment are absolute essentials, and in this connection he gives account of the
German system of workmen's insurance, which leads to early medical investigation of the cause of
ill-health and to early treatment of phthisis when this disease is found to exist, a system which it is
claimed in Germany has been operative in reducing the phthisis mortality of that country. In this
connection consideration may well be given to the question whether the opportunities for medical treatment
of sickness among the poor in London are such as to lead to the detection of this disease at a
stage when remedial measures can be more hopefully applied. Not less important is the
" after care" of the patient—a question which experience is increasingly showing to be a necessary
part of the scheme for dealing with the phthisical patient. On the further question whether institutional
treatment should be provided for the person suffering from advanced disease, it matters little
whether the claim for such treatment is based upon hypothesis of the communicability of the disease
from the sick to the healthy or upon the desire to relieve the sufferer so far as this is possible, for it
must be admitted that among the poor the maintenance of the patient during a long period of failing
health is often an insupportable burden, and it is difficult for the community to resist the claims
which the instincts of humanity make upon it in such circumstances. Concerning the value of segregation,
the opinions of competent writers differ. Difficulties, however, stand in the way of the view that
the evidence adduced affords sufficient ground for the belief that the decline in the death-rate would be
materially accelerated by the more extended use of institutional treatment of advanced cases of the
disease. An organised system by which knowledge of the existence of cases of the disease may be
focussed on the medical officer of health would obviously be of advantage, especially if it were in his
power to ensure that the necessary opportunity were given for the treatment of the sufferer. Dr.
Bulstrode's report does not, however, provide any definite evidence that compulsory notification
has led to better results than voluntary notification, the success of both depending in the main upon
the question whether in connection with notification the inducement of assistance to a patient can
be held out. The recently announced intention of the Local Government Board to require notification
to the medical officers of health of cases of phthisis met with in poor-law practice should
provide information of the existence of many cases which occur under circumstances in which the
services of that officer can be most usefully employed.

Cancer.
The deaths from cancer in the Administrative County of London during 1907 (365 days),
numbered 4,487, a decrease of 102 on the year 1906.
The death-rates from this disease in successive periods have been as follows:—

1 See footnote (1), page 8.