A WATER-BORNE TYPHOID FEVER EPIDEMIC.

548 and so remained during the two years following, 3 showed no effect, and 5 proved unsuitable. These results are distinctly encouraging, but it is to be regretted that in this, as in other investigations of new treatments for consumption, no endeavour is made to report on other cases treated at the same time, but by the more usual methods, as controls for comparison. The recovery of tuberculous patients seems to depend so much on climate, food, and the clinical acumen of the physician that, consequently, a table of recoveries of patients under a special specified treatment may really be due to the greater skill of their physician. If, however, the cases of consumption entering a hospital, or some particular physician’s clinic in that hospital, are numbered consecutively, and the even numbers, for example, are all treated with this remedy, while the others receive the treatment hitherto current, all being under the care of the same physician, marked improvement in the results observed could be ascribed with The prosome confidence to the specific treatment. fession would become instantly curious, and would at once give trial to the method.

MEDICINE, INDUSTRY, AND RESEARCH. THE industrial welfare movement is one of the few good things which during the war received the impetus necessary for expansion, and which has survived. Previously in this country there had been small beginnings made by a few far-seeing and enlightened employers. The Ministry of Munitions seized upon these beginnings as a base from which to commence large-scale operations; but their activities ceased with the armistice. Since then the Home Office through Welfare orders made under Sec. 7 of the Police, Factories, &c. (Miscellaneous) Act, 1916, have consolidated much of the ground won. But without doubt the life of the movement to-day lies outside official circles. An instance of this was given by the Conference held at the Mansion House by the Industrial Welfare Society which was addressed by its president, the Duke of York. This society, which is keen and active and supported by the majority of male welfare workers, approaches the subject from the social and psychological side ; its point of view is expressed every month in the Journal of Industrial Welfare, a publication the progress of which we have been watching with interest. During the past six months this journal has greatly improved, it may not have been mere coincidence that the improvement followed hard upon certain friendly criticisms which appeared in these columns. Practical articles dealing with such subjects as industrial fatigue, psychology, and ventilation have appeared; a key to current literature is given; and informing reviews are published. Nevertheless, we still look in vain for any record of research undertaken by welfare workers. Another instance of welfare activity is the Welfare Workers’ Institute, which receives the support of and also publishes a useful women welfare workers, journal-Welfare Work. But here, too, the social side of the work predominates, and little attention is paid to research as the foundation of welfare as a science. The tendency to look upon welfare as an art or mystery is pronounced, and equally pronounced is the absence of any clear recognition of the importance of health in

medical profession is taking in it. Yet the movement is aimed at obtaining for the worker a healthy mind in a healthy body. So far as can be judged the tendency in America is in the opposite direction. Workshop after workshop continues to appoint whole-time doctors, who select healthy workers by preliminary examinations, and keep them in health when obtained. These factory medical officers initiate in every direction welfare activities based on knowledge of what is required. In this country we have a band of medical men, certifying factory surgeons, brought intimately into touch with industry, and we naturally look to them for light and leading. The annual report of their association for 1920 is before us; it contains no word of a forward constructive policy. To judge from the report this association is mainly concerned with the inadequacy of fees allowed for carrying out the few duties entrusted to them. No reference is made to the important part which industrial medicine should be taking in the life of the community. The world is moving fast, and under our eyes a new science, the science of health in industry, is emerging. The publications of the Industrial Fatigue Research Board have been disclosing principles underlying human activity and indicating how health may be maintained. The hasty decision to extinguish the excellent work of this Board on the plea of so-called economy has been reconsidered. Wiser counsels have prevailed. In the past the maintenance of health has never had a practical economic interest for any definite group of persons ; now in industrial employment it has. For there is to-day no more paying proposition than to engage a factory medical officer who knows his work. America has been quick to make the discovery and to seize the opportunity. Unless we follow we shall fall behind in industrial competition-and in national health.

part which the

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A WATER-BORNE TYPHOID FEVER

EPIDEMIC.

WATER-BORNE epidemics of typhoid fever on a large scale are, fortunately, not now so frequent in this country as they were some years ago. The efforts made by local sanitary authorities to protect their water-supplies from contamination have proved eminently successful. Typical water-borne epidemics of typhoid fever are often preceded by a period of heavy rainfall or a rapid thaw, by which surface and other impurities are carried, sometimes considerable distances, to water-supplies, this mode of pollution and being of a sort that in ordinary circumstances would not have been anticipated in many instances. Often the first indication that such an epidemic is impending is the occurrence of a sudden and widespread prevalence of diarrhoea of varying severity, affecting a large proportion of the population; the outbreak of typhoid fever follows in about three or four weeks’ time, corresponding to the incubation period of the disease, with an added week or so to give the medical practitioner time to arrive at a diagnosis before notification. Although such water-borne epidemics, as has been said, are now of comparatively rare occurrence with us, they are not uncommon in the United States. An interesting and typical instance on a somewhat extensive scale occurred towards the end of 1920 at Salem, an industrial town of about 10,000 inhabitants in the State of Ohio (not to be confused with the welfare. The welfare movement as a whole must gain further famous old Massachasetts city), a report on which was power from Sec. 20 of the Mining Industry Act, 1920. published in the Journal of the American Medical The water-supply Under this section a fund is gathered from a levy Association for Nov. 27th last. of one penny per ton of coal raised, which must be of this town is derived from several groups of deep applied for purposes connected with the social well- wells, from which the water is pumped to conduits being, recreation, and conditions of living of workers in which convey it by gravitation to a covered service or about coal-mines, and with mining education and reservoir. Repeated analyses showed the supply to be research. A small expert committee has recently been pure and of good quality. There are still some 400 appointed by the Secretary for Mines to allocate the fund. privies in use in and on the outskirts of Salem. For Research is definitely included in the subjects upon some years typhoid fever had been practically absent which this fund may be expended, and one member of from the town, and not a single case had been reported the committee is a medical man. We may hope that in the 12 months ended August, 1920. Towards the end in the mining industry the welfare movement will of that month and beginning of September, however, start with a scientific and medical bias. No one who three cases came under observation. Very heavy and watches the development of the industrial welfare prolonged rainfall took place at the end of September movement can fail to be struck with the rapidity and beginning of October, immediately after which a with which it is spreading and with the small widespread prevalence of " enteritis " occurred, anect-

549 more than half of the whole population of Salem. Some three weeks later cases of typhoid fever began to be notified in rapidly increasing numbers until Nov. lst, when the height of the epidemic was reached. On that day 54 fresh cases were reported, the total attacks up to Nov. 20th amounting to 785, or nearly After this the epidemic 9 per cent. ofthe inhabitants. rapidly declined. The type of the disease was not severe, for only 12 deaths were recorded up to Nov. 20th. It was expected, however, that other fatal cases would occur, for on the last-mentioned date there were many persons still in the acute stages of the disease. The sudden and widespread occurrence of " enteritis " in the town during the early part of October cast suspicion on the water-supply as the source of the trouble. Bacteriological investigations showed that one of the conduits from a group of wells was conveying contaminated water to the service reservoir ; it was therefore at once cut off from the public supply, and an emergency chlorinating outfit was installed, warning notices at the same time being issued to householders to boil all water used for domestic purposes. No doubt these measures helped to control the spread of the infection, but before they came into action the polluted water had already been drunk by many persons who afterwards developed the disease. The precise manner in which the water became polluted has not yet been stated, as at the time the report was published the investigations had not been completed. Among the other measures employed by the local health authority to control the spread of the disease was the offer of antityphoid inoculation, and this was accepted by about a fourth of the inhabitants of the town. Four emergency hospitals were established for the reception of the fever patients. The sewage of Salem is treated on intermittent sand filters, from which the effluent is discharged into the Beaver Creek, a tributary of the Ohio River. As soon as it was apparent that typhoid fever was becoming epidemic this efnuent was chlorinated, with the object of protecting from infection the communities using the river water below Salem. One of the lessons to be learned from this epidemic is the necessity for constant and vigilant supervision of all sources of water-supply, no matter how pure these originally may have been.

ing, it is said,

" SACRALISATION." word has been recently coined by French orthopaedists to describe a condition which has long been known to the anatomist but has been strangely neglected by the surgeon. By" sacralisation" is understood the overlapping to a greater or less degree of the wing of the sacrum by the overgrown lateral process of the fifth lumbar vertebra. Ledouble, indeed, describes six varieties, the first two consisting of enlargement of the lateral process with overlap. The various papers contributed on this subject are ably summarised by Professor P. Mauclaire in the Paris Médical,l who points out that as a rule the condition gives rise to no pain. Curiously enough, when pain is present it appears, as a general rule, after the complete development of the pelvis during the third decade of life. Various hypotheses have been put forward to account for the pain, the favourite explanation being pressure on the lumbo-sacral nerve or on the nerves of the cauda equina. As for the cause of hypertrophy of the lateral process, this also remains undetermined, though an attractive theory has recently been put forward by Dr. E. Landoux and G. Caillods.2 These investigators suggest that the transverse process of the last lumbar vertebra assumes the osteogenetic function of a sacral vertebrum. The practical conclusion would appear to be that in every case of backache of uncertain or unknown origin the lumbar region of the spine should be investigated under X rays. Resection of the enlarged process alone offers a satisA

NEW

FEES FOR LIFE ASSURANCE WORK. FROM time to time protests reach us in regard to the remuneration offered by life assurance companies to their medical referees. We have just received the specific complaint that to be paid half a guinea for a .?100 policy or less and a guinea for policies of more than this amount is illogical and unfair, because the work involved is the same in both cases. The annoyance is natural, for no professional man likes to be asked to give his best work for an insufficient fee, or to be obliged to offer less than his best because the fee is inadequate. But there is something to be said on the other side. The companies state that reports they receive from their medical referees are often perfunctory, whatever the amount of fee paid, while they may lack data necessary for a just assessment of the risk or contain statements that are contradictory and mutually destructive. Some actuaries go so far as to assert that the protection afforded by medical examination lasts only for the first three years, and that, apart from these three years, a medical report might be dispensed with altogether; and it is admitted that were it not for adverse selection no medical examination of any kind would be necessary at all, for the risks could be worked out accurately from life tables on an actuarial basis. For this and other reasons many companies are extending largely their non-medical tables with apparently satisfactory results, and there is a real " danger of this procedure increasing. We say " danger advisedly, because we feel that non-medical insurance, while dealing a severe blow at medical prestige, would not be in the best interests of the community. No doubt in the past the fees offered may have been quite inadequate, and it was a public duty to resist them. Now when it is a question of standardising the examination fee at a higher level certain facts must be borne in mind. The premiums paid in the smaller insurances allow no margin for heavy medical expenses, and a disparity, though illogical, may be unavoidable. In ordinary practice the squire’s daughter and the gardener’s wife may demand equal care and attention, and yet the fee cannot be the same for each. The demand for larger fees would command a greater prospect of success in the case of policies for large amounts. Again, it must be remembered that individual prognosis remains fallible whatever the skill and care devoted to the examination, and no one knows this better than those responsible for the management of life assurance companies. Referees may rightly claim that the remuneration for work done should reward them fairly for their time and trouble; they should also have a care to convince business men that medical reports are essential to the economic working of life assurance schemes. -

VENTILATION OF THE HOUSE OF COMMONS. WE do not know the exact date of the first

com-

plaint concerning the ventilation of the debating chamber and other parts of the House of Commonsthe House of Lords has apparently never required similar attention-but the subject probably came up within a very few years of 1852, when the legislature took possession of its present quarters. From time to time questions have been asked, select committees appointed, reports presented, and alterations undertaken-as, for example, the substitution of fans for exhaust furnaces-but close proximity to the river and the structure of the building itself seem to have been the main obstacles to any great improvement. In 1893, for instance, we noted in our columns that in spite of " electric light and purified

air" Members of the House still suffered from " lassitude." It had already been pointed out that the floor matting which covered the air inlets, or lay near them, was a source of atmospheric pollution; during 1905 Dr. Mervyn H. Gordon issued a full report in which the air of the debating chamber was shown to factory cure. be too dry, and, together with the air below the inlets, demonstrably contaminated by the matting. 1La Sacralisation douloureuse de la 5e vertèbre lombaire, Paris It was hoped that the gradual disappearance of Médical, Jan. 29th, 1921, p. 81. 2 La Presse Médicale, Feb. 12th, 1921, p. 123. i horse traffic from the London streets would improve