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of veterinary surgeons, and the relaxation of municipalmuzzling regulations ; and, in the second place andmore latterly, to the importation of dogs by soldiersreturning from expeditionary units in the East-acondition analogous to that responsible for the recentreappearance of canine rabies in this country. Theresults of the Pasteur treatment obtained in theprovincial laboratory compare very favourably withthose of the parent institute in Paris, although thesame classification of patients is not in use, and hencedirect comparison is not possible. It is evident thata large number of persons undergoing treatmentat Lyons are in very slight danger of the disease,since about a third of the patients are persons whohave been licked by rabid animals and in whom thechances of developing the disease are presumablyslight. The figures for the mortality do not give us.an accurate picture of the death-rate in persons whohave been bitten by rabid animals, but rather of thatobtaining in persons in whom the Pasteur treatmenthas had full scope to do its best. Cases ending fatallyduring the treatment, or within 15 days of its termina-tion, are not included in the statistics, since it isrecognised that it is only some 15 days after the endof the treatment that immunity is fully established.If we take 20 days as the average duration of thecourse, and add to this the 15 days which mustsubsequently elapse before the patient enters into thestatistics of the Institute, we find that all cases inwhich the incubation period is less than 35 days, andin which the disease evolves normally in spite of thetreatment, are excluded.Trousseau tells us, in his vivid account of this

malady, that the average length of the incubationperiod is from one to three months, so that a certainnumber of cases evolving normally will not appear inthe results of the Institute, which thus come to excludeto a certain extent cases of short incubation. Thoughprobably more academically correct, this narrowedpresentation of the figures does not, therefore, satisfythe desire to know in a more general fashion whatare the chances of an individual who is bitten by amad dog of developing rabies when treated on modernlines. ____

ECONOMY AND RESIDENTIAL TREATMENTFOR TUBERCULOSIS.

ANYTHING would be a calamity that postponesindefinitely the resuscitation of a number of publichealth activities which had only begun to recover fromthe state of suspended animation imposed on them bythe war. It is a welcome relief to meet with oneproduct of the economy campaign which may havepositive constructive value to public health adminis-trat,ors and through them to the community at large.This pleasing phenomenon appears in the form ofa circular (No. 280) issued by the Ministry of Healthon Jan. 17th last to the authorities responsible forthe provision of residential treatment for tuberculosis.The circular discusses the general principles of economyin sanatorium administration.We would direct attention in particular to the second

portion of the circular, which brings under reviewthe cost of residential treatment. After comparisonof the claims received from local authorities in respectof their expenditure during 1920-21, the Ministry ofHealth has been struck by the wide variations in thecosts involved in residential treatment. In respect ofsalaries, for example, the cost per patient per weekvaried from less than 9s. to over ;S1 ; the cost of pro-visions per patient week from below 21s. to over 35s. ;that for drugs from less than ls. up to 3s. 6d. perpatient week. This information in itself, scantythough it be, is of real value to local authoritiesresponsible for the treatment of tuberculosis, in thatit gives them an opportunity of comparing theirexpenditure on certain definite items with that ofother authorities similarly placed. Allowing for thevariations dependent on the type of patient undertreatment, the geographical position and structure ofthe institution, and other local factors, the analysis of

expenditure on these few items is likely to throwunexpected light on avoidable waste in some areas.Obviously, this is only the first stage in a much moreintimate analysis, which can be rendered of value onlyby verifying the methods of tabulation of costs inpractice in the numerous areas concerned. It istherefore encouraging to find that the Ministry ofHealth proposes to submit a model form of summaryof accounts for consideration by representatives ofthe County Councils Association, the Association ofMunicipal Corporations, the Society of Superintendentsof Tuberculosis Institutions, the County AccountantsSociety, and the Institute of Municipal Treasurersand Accountants, in conjunction with officers of theMinistry. Having established a common basis ofstatement of accounts, the Ministry may publish anannual detailed analysis of the costs in the variousareas. There can be no question that such a procedurewould have a most beneficial effect in stimulatinginterest in the whole problem of residential treatment,and in concentrating attention on the essential whilediscouraging the non-essential features of such treat-ment. The overhauling of administrative machinerywould before long lead to a material improvement inthe methods and in the results of treatment.

HEALTH AND INDUSTRIAL OUTPUT.

THE study of human efficiency in industry promisesgreat returns in productivity, and yet 12 monthsago we narrowly escaped throwing away our lead inthis study, as may be read between the lines ofthe second annual report of the Industrial FatigueResearch Board which covers a period of 18 monthsending September, 1921. During this period, whenthe foundations of a new science were just begun, thecareer of the Board nearly terminated at short notice,but reconstruction has taken place and the Board hasnow become an integral part of the organisation ofthe Medical Research Council,who have also establishedfour allied committees to deal with industrial healthstatistics, with the physiology of muscular work, withthe physiology of the respiratory and cardio-vascularsystems, and with industrial psychology. The Board,in view of its financial restrictions, now appeals toindustries in their own interests to assume partialresponsibility for investigations. Every science musthave means of measurement and the Board, havingproved their value, has employed, as measures ofhuman efficiency, output (with regard to quantityand quality), sickness and mortality records, labourturnover, lost time, and accident frequency. Investi-gations have established that hours of work shouldvary for heavy, moderately heavy, and light labour,and that if hours are over-long output can be increasedby reducing them, but that this increase is only to beexpected where the human element, rather than themachine, rules the pace. Indications that spells ofwork are over-long are to be found in a fall of outputas the spell lengthens ; under good conditions outputshould rather improve up to the end of each spell,throughout the day, and from day to day throughoutthe week. Spells of work when too long ought to bebroken by organised rest pauses instead of allowingworkers to interpolate their own unorganised pauses.Seasonal influences due to temperature, humidity,and lighting are found to be considerable and to becontrollable by well-planned ventilation and illumina-tion. Attention to these principles, underlying humanefficiency, which are steadily emerging spells thedifference between profit or loss on the one hand, andpleasure in work or industrial discontent on the other.Even when everything has been done to make the

conditions of work with regard to hours of employ-ment and the environment of the worker satisfactory,still there remain other problems for inquiry.Vocational guidance to direct newcomers to work forwhich they are fitted, and vocational selection to pickout those suited for the work in hand are matters

1 Second Annual Report of the Industrial Fatigue ResearchBoard to September, 1921. H.M. Stationery Office. 1922. 1s. 6d.

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calling urgently for investigation. In both thesedirections beginnings have already been made. At alater stage the manual labourer needs instruction asto how best to apply his energy. Left to himself hetends to be wasteful and uneconomical in his move-ments. Here the work of the Board promises themost rapid returns. Those familia,r with the pioneerwork done by Taylor and Gilbreth will appreciatehow in this direction the Board’s initial efforts promiseto revolutionise previous ideas ; the end kept in viewis to save the worker rather than to increase output;but the result has been in every case not onlyto save the worker but greatly to increase output.The scope of the activities of the Board from whichsuch laws as those indicated above are emerging hasbeen wide. Investigations have been conducted insheIl-makirig, in blast furnaces, in foundries, in silk-weaving, in metal polishing, in the tinplate industry,in boot and shoe manufacture, in the iron and steelindustry, in cotton-spinning, the manufacture ofsweets, in the cutlery trade, in laundries, to mention ’,only some. The prospect which this new scienceholds out as within the grasp of industry is nothing ’,less than an increase from 50 to 100 per cent. in outputfor the same wages paid, and a vast diminution ofindustrial sickness with its heavy call upon NationalHealth Insurance funds. These tangible benefitsmay well be accompanied by a decrease in socialunrest.

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PUBLIC HEALTH AND THE CITY OF LONDON.

ON Friday, Feb. 17th, the Lord Mayor of London,Sir Charles Baddeley, entertained the President andthe Council of the Society of Medical Officers ofHealth to luncheon at the Mansion House. Amongthe guests of the Lord Mayor, with whom was theLady Mayoress, were Sir Alfred Mond, Minister ofHealth ; Sir George Newman, Chief Medical Officerto the Ministry ; Lieut.-Colonel F. E. Fremantle,M.P.; Alderman De Courcy Moore ; Mr. Sheriff MillsMcKay ; Sir Dawson Williams ; Sir Squire Sprigge ;Dr. J. W. Howarth, M.O.H., City of London, andPresident of the Society of Medical Officers of Health ;Mrs. Howarth; and Mr. G. S. Elliston, Secretaryto the Society of Medical Officers of Health.

Sir Alfred Mond, in a simple and earnest speech,pointed out that even in the days of necessary retrench-ment it was false economy to underpay those whoguarded public health, true economy being expressedin the policy of keeping the medical service of thecountry up to the highest level, though the coat mustbe cut according to its cloth. Dr. Howarth, in aneloquent address, alluded to the sanitary policy of theCity of London as having throughout the history ofsanitation led the way not only in this country andall its dependencies, but on the continent and inAmerica. He showed that the progressive action ofthe City in health matters had caused our country tobe looked up to throughout the world as the pioneerin preventive sanitation. The Lord Mayor, replyingto a vote of thanks, proposed by Lieut.-ColonelFremantle, claimed that the City of London was at Ithe time the healthiest in the world, and expressed thedetermination of the corporation to maintain thisposition. ____

A DIPLOMA IN TUBERCULOSIS.

SOME two years ago we commented on a demandby Sir Henry Gauvain for the establishment of aspecial diploma in tuberculosis and shortly afterreported a discussion by the Tuberculosis Society onthis question. 2 This suggestion has now materialised,for the Welsh National School of Medicine announcethe institution of a tuberculosis diseases diploma.Candidates must be qualified, at least 25 years of age,and have held, for a period of not less than five years,whole-time appointments for work on tuberculosis.Alternatively, provided he has been qualified for atleast one year, a candidate will be admitted to examina-

1 THE LANCET, 1920, i., 275. 2 Ibid., 608.

tion on production of a certificate of satisfactorypursuance of a six months’ course of study of theclinical and epidemiological aspects of tuberculosisat a recognised centre, together with evidence of threemonths’ practical laboratory work and three months’attendance at a tuberculosis institute or dispensary.The examination for the diploma will be divided intotwo parts, of which the first will consist of a writtenexamination on the clinical and epidemiologicalproblems of tuberculosis as well as oral and practicalwork, while the second will comprise a written andpractical examination on the pathology and bacterio-logy of tuberculosis. Under certain given circumstancesPart II. may be remitted. The first examination willbe held in July, 1922, and post-graduate courses ofinstruction in preparation therefor will shortly bestarted under the direction of Prof. S. Lyle Cummins,who believes that the institution of a standard examina-tion, study for which must include knowledge ofsurgical conditions, will do much to improve themethods of dealing with tuberculous patients in thefuture.To single out one chronic inflammatory process

for separate study, and to develop a race of medicalmen specially qualified in its diagnosis and treat-ment, is a policy which cannot be regarded as

strictly logical. But since the balance has alreadybeen disturbed by the creation of a separate serviceof tuberculosis officers, it is onlv wise to see thatthey are well equipped. Whether this object willbe best achieved by a special tuberculosis diseasesdiploma (T.D.D.) or by the revision of the curriculum for the D.P.H. is another question. Thetime has perhaps come for an investigation and arevision of the conditions under which various bodiesissue the last-named diploma. The syllabus as nowplanned caters chiefly for the needs of the M.O.H.,whereas those aiming at the specialised branches learnan unnecessary amount of sanitary law and too littleof their own special subjects. Now that the wholesubject has grown to such unwieldy proportions, adiploma of public health can fairly be compared withother higher examinations open only to qualifiedmen. The London graduate may take the M.D. inPathology, Mental Diseases, Midwifery. State Medicine,and Tropical Medicine, as well as in Medicine proper,in every case submitting one paper in generalmedicine. There seems no good reason why a similarplan should not be adopted for the D.P.H. Supposinga medical men who had taken a D.P.H. in tuberculosiswished at a later date to proceed to a position asmedical officer of health, he might be eligible on takingan additional paper in that part of the curriculumwhich he had previously omitted. Without wishingin any way to disparage the excellent scheme of theWelsh National School of Medicine, we would suggestthat the inadequate place allotted to the study oftuberculosis in most of the present curricula for theD.P.H. also demands attention.

THE FELLOWSHIP OF MEDICINE.WE have heard that, in quarters where such an error

would have serious consequences, a belief has gainedground that the staffs of the London hospitals arcno longer working in connexion with the Fellowshipof Medicine. For some time three of the metro-politan hospitals have not been affiliated to theFellowship, but the report we allude to above is amisrepresentation of the facts. All the honoraryofficers and teachers of the hospitals, who are men-tioned weekly in the Bulletin, are working withthe Fellowship, and assisting in the special coursesnow laid down. We learn that there is at themoment a sum of 21270 remaining to be distributedamong the hospitals and teachers, in proportionto the services rendered, making up a total dis-bursement by the Fellowship of 4400. The sumis small compared to the work done, but it isnot negligible, and is an excellent earnest of whatmay be accomplished in time by organisation andcooperation.