, 1913

, Vol. VIII,

The Bath and Its Hygienic Importance.1-The hygienic value of bathing was never more widely appreciated than it is to-day. The custom of building special baths or swimming pools in the mansions and palaces of our multi-millionaires is not new, however, for as an editorial writer in the Lancet (London, Nov. 2, 1912), points out the practice of bathing as a luxury or for therapeutic or hygienic purposes, as distinguished from the mere removal of discomforting superficial dirt, probably took its rise in oriental countries, passing thence through Greece to Rome, where it attained the maximum of luxuriousness in the later empire. At that time many wealthy people had complete bathing establishments attached to their villas, while there are said to have been upwards of 870 public baths in Rome. The bath consisted of several rooms; the apodyterium, or undressing room; the frigidarium, or cool room, containing also a cold plunge bath; the tepidarium, or warm room; and the calidarium, or hot-air room, having a hot-water bath at one end of it. To these, in later Latin times, was added the laconicum (so called from Laconia, where it originated), or sudatorium, where the heat was very great. The bather passed through all these rooms in succession until he arrived at the calidarium, or the laconicum. Then he returned to the tepidarium, where cold-water affusion was practised, and he underwent a thorough scraping, friction, kneading of his muscles, and stretching of his joints at the hands of an attendant, and was subsequently anointed all over. A long rest for cooling off was then taken, prior to passing once more into the open air. The private baths of the wealthy were constructed on a similar pattern. They were highly and expensively ornate. To the public baths were attached gymnasia, colonnades, often fragrantly scented, an amphitheatre, and even libraries, so that they became the favourite lounging places of the wealthier and more fashionable citizens. In an interesting monograph1 Dr. W. Oscar Jennings gives

'Le Bain Turco-Romain, les Applications Hygiéniques et Thérapeutiques. Etude Médicohistorique, par le Docteur Oscar Jennings, de la Faculté de Médecine de Paris, Fellow of the Royal Society of Medicine. Préface du Docteur J. Lucas-Championnière, Membre de l'Institut, Membre de l'Académie de Médecine. Paris: Vigot Frères. 1912. Pp. 69.

full information on many of these particulars and traces the history of the bath among the Greeks, the Romans, through the Middle Ages, concluding the historical part of his book with references to the baths in France, Germany, England, Russia, Finland, and among the Turks, Egyptians, Indians, Mexicans, and Irish. Cortez found public baths among the Aztecs. Dr. Jennings especially emphasizes the universal use of the bath as a hygienic measure. Dealing in the second part of his monograph with the Turkish bath, viewed from a hygienic and therapeutic standpoint, as we know it to-day, Dr. Jennings reminds us that notwithstanding that "Hammams" appeared in England at the close of the seventeenth century, we owe its revival in modern times largely to the publication in 1850 by David Urquhart of "The Pillars of Hercules." This book led to the erection of a so-called Turkish bath (but rather a hot air than a vapour bath) at Blarney, by Dr. Barter, and a short time afterwards to one by Sir John Fife, physician to the Newcastle-onTyne Infirmary. As a regulator of the bodily functions and an eliminator of toxins, Dr. Jennings extols the Turco-Roman bath-a combination of sudorotherapy, massotherapy, and hydrotherapy-which, he says, is regarded with enthusiasm by practically every practitioner who has tried it himself. He highly recommends it in conditions of faulty metabolism, and especially in alcoholic and drug addiction. As is well known, the condition of extreme depression following the stimulant effect of the dose is the chief factor in compelling those who have once become addicted to keep on having recourse to the drug. But it is precisely the dispersion of this sense of depression, restlessness, and sinking, of mental and physical collapse, for which the alccholic or the drug habitué has recourse to his poison, that is the distinguishing therapeutic characteristic of the Turkish bath. There exists, says Dr. Jennings, a certain vague resemblance between the sensations aroused by the bath and those derived from the morphine injection. Caution must be observed, it is true, especially in not being tempted to overdo it, either in duration or in the degree of temperature: and particularly must care be taken by the novice not to allow himself to be carried away by the enthusiasm of the old

habitué of the bath, who is very prone to play the part of a proselytizing professor of balneotherapy. It is remarkable what a small proportion of people in this country have ever taken a Turkish bath. It is equally remarkable that few, if any, of those who have done so fail to experience the delightful sense of euphoria, and physiological elation, which is at the same time indicative of its hygienic value and suggestive of its therapeutical possibilities. As a therapeutic measure, however, it should be practised only under the sagacious counsel of a medical man well cognizant of its effects and acquainted with the patient's condition.

A Careful House Surgeon.-F. W. Langridge quotes the following anecdote related by Harrison Cripps: (Clinical Jour., Oct. 2, 1912). A patient swallowed a half penny one afternoon and next morning the house surgeon on examining him extracted this halfpenny from the rectum. It had passed down without much trouble, but had been unable to pass the rectum. This was the case in which the house surgeon got into trouble with the lay governing body of the hospital. He was charged with having extracted a fee from an outpatient. But as the amount in dispute was small he thought he had better hand it over to the hospital authorities to avoid prosecution.

Malta fever in Texas has at last established itself as was so confidently predicted as soon as the cause was proved to be a permanent resident of certain goats. Doctors Gentry and Ferenbaugh of the Army have found numerous cases among those who have been herding goats or drinking goat's milk. The results of this epoch-making work have been published in a series of articles in the Journal of the Amer. Medical Association. Many other cases have existed unrecognized or have been reported under other names. therefore time to take preventive measures where there is danger of contracting the infection. Fortunately the organism does not multiply anywhere except in the goat -that is, there is yet no evidence that it

It is

, 1913

, Vol. VIII,

does except perhaps in the butter and cheese made from goat's milk. By simple care to avoid such articles of diet, the disease may be kept in check, but that is a difficult matter in a district now being given over to the new industry of goat raising. Besides, the organism may find other culture media in this country. It is difficult to predict what any parasite will do when taken to a new home and this disease may soon be found elsewhere. Should the fever become widespread, there may be necessity for extensive inspections of the herds to eliminate susceptible animals, as is now being done abroad.

Malta fever can be controlled. Gibraltar got rid of the disease by getting rid of the goats, but that cannot be done in a new industry which bids fair to become very extensive and profitable. We are certainly in for a prolonged sanitary crusade and the thought naturally arises as to whether an ounce of prevention now will not save pounds of cure a little later. At least it is one more argument for a national health department, as it is a problem for which we have no governmental machinery, and the menace would have been anticipated if there were officials whose duty it is to consider such matters from a national and not a local viewpoint. The new movement of our stock breeders in the direction of importing animals and plants from all over the world to create new varieties of more profit than the old, is quite sure to let loose a Pandora's box of evils sometime. So it is only common sense to anticipate a little and we can do so in this case without the slightest suspicion of holding alarmist views. The disease is here and must be dealt with now. Nor are we alone in our trouble, for the infection has been carried wherever Maltese goats have been carried, and in some Mediterranean districts this breed is being excluded in spite of its great milk producing powers. We may be compelled to take similar steps in the interests of public health. Ten years ago Malta fever was an appalling scourge to Europeans living in the endemic areas of the Mediterranean but it is now under almost complete control. We can do the same though it will require rather drastic meas

ures.

ORIGINAL ARTICLES.

THE ECONOMICS OF MEDICINE.

BY

IRVING WILSON VOORHEES, M. S., M. D., New York City.

On November 19th, 1912, a company of fifteen representative doctors of New York City came together at a dinner for the purpose of considering some of the problems dealing directly with the welfare of the public in its relation to the practising physician. The intensity and earnestness of the occasion mark it as the beginning of one of the great movements in modern medicine.

Although the ubiquitous reporter was kept in ignorance of what was going on and the flashlight man was conspicuous by his absence, there was a very decided unanimity of opinion and all the discussions were remarkably free from personal bias or predilection. It is altogether probable that never before in the history of medicine have opposing factions and "schools" sat down together at the same festal board. Representative men from the Homeopathic, the Eclectic and the so-called Regular branches of the profession rubbed elbows and exchanged funny stories until coffee was served and the regular business came before the Council. The man who is responsible for this effort at unification is Dr. E. Eliot Harris, who for many years. has been prominent in both the New York County and State Medical Societies, and has had a very important part in shaping at Albany medical legislation which has been a benefit both to the public and to the profession. Dr. Harris believes in a liberal policy in the treatment of those practitioners of medicine who have hitherto

been assigned to outer darkness because they choose to differ in their manner and method of giving drugs from the so-called Allopathic School. He believes that the barriers of sectionalism should be burned away and that those who have been admitted to the "practice of medicine in the State of New York" as that phrase is defined by the Statutes should unite in a common. bond for the study of problems of individual and social welfare.

The value of unifying and coordinating the activities of all medical men can scarcely be overestimated. Not that doctors in the future would never disagree that is out of the question and would not be desirable in all respects even if it were possible. But for the study of those problems which lie outside of scientific medicine such as the abuses of hospitals and dispensaries by those who can well afford to pay, medical insurance acts, lodge practice, the overtrained nurse, the unscrupulous pharmacist, adulterated foods-in short, for the study. of those matters which lie close to the public health, and for the prevention of disease and untimely death this Society hopes to bring about great good. However, no Utopian dreams of instantaneous regeneration are entertained. Opposition is expected, and from some quarters bitter opposition, but this will be welcomed because it is needed to clarify the atmosphere and to open up new avenues of thought and new methods of attacking the old monsters of doubt and prejudice and unscrupulous

ness.

After much deliberation and discussion it was decided to name the new organization "The American Society of Medical Economics" but with the distinct understanding that the word American means all countries both of North and South Amer

Complete Series, Vol. XIX.

ica. The parent organization incorporated under the laws of the State of New York will need much grooming and much thoughtful consideration before its internal affairs are systematized so that the Society can serve every practitioner in every remote hamlet, but that at least is its purpose and the purpose is certainly laudable. Every practitioner of medicine who is qualified by licensure under the laws of this state can become eligible to membership upon payment of the yearly dues of $5.00. This money is to be used in circularizing the profession and for the salaries of its officers who shall give up their entire time to the furthering of the common interests of the public and the profession.

It cannot be gainsaid that the ultimate basis of the present discontent and elements of unrest in the medical profession are due to a lack of income sufficient to maintain the doctor and his family in a dignified and decent position in society. Of late years the younger men have been having a particularly hard time of it because immediately upon beginning practice they have been subjected to the keenest competition. The many new healing sects and "irregulars" have made great inroads upon the sum total of patients who originally were divided among the Regulars and Homeopaths. Thus Osteopathy, Christian Science, Chiropracty, Mechano-NeuralTherapy and scores of other cults have thrived, partly because of their novelty and partly because they offer to the sufferer a new hope which the old schools have been unable to supply. There also has been a very marked and manifest decrease in the total amount of disease, especially of the acute infections which are in reality the type of ailment which responds most readily and successfully to the doctor's skill.

New Series, Vol. VIII, No. 2.

The regular profession has never been extremely successful with chronic ailments and it is just these which have improved or in some instances have yielded to the strong arm of the Manipulator who was not slow to recognize the great importance of exercise, rest, diet, fresh air, etc., as accessories in his work. Moreover, the requirements for graduation and licensure have been growing increasingly higher in the medical schools, so that no man could hope to begin active work very much before his 30th year. During the first five years of his career the young doctor has found it well-nigh impossible to make a living without resorting to school inspection, Board of Health work or some other salaried position so that out of this feeling of want have grown the contract practice evil, "lodge" work, fee-splitting and other irregularities, all of which are loudly denounced by the great body of medical men. The young doctor has, therefore, all too frequently found himself facing the horns of of a very unpleasant dilemma, and it is no wonder if he has sometimes yielded to the great call of the "Love of Life.”

There has doubtless been an unwholesome degree of conservatism in the profession which is largely responsible for present conditions. The well-to-do physician in his comfortable quarters has raised a hue and cry about "ethics" and the preservation tion of professional decorum, railing against irregular practitioners or trying to ignore their influence altogether, but doing nothing openly to combat the ills which beset his unfortunate brother. some respects, at least, medicine has failed to keep pace with modern progress; for the physician has made little or no direct effort to get business, preferring to think that his superior training and culture would.

In

bring him a clientele in spite of everything. This attitude has not produced the desired result, because true conservatism never means to stand still and do nothing. The world is on the move and we must move with it.

The public wishes to be told what the profession can do against the ills which beset it. It does not now know where superior or special service can be found; therefore it goes to the druggist and asks for some drug which it thinks will cure, often making a bad matter worse and leading to harmful and indiscriminate drugtaking. The profession has paid a great price for its unwillingness to tell what it can do; and it is altogether absurd that a patient must needs find out indirectly or through subterfuge where a doctor can be found who is capable of curing nasal obstruction, or headache or constipation. That is why catarrh snuffs that engender drug habit and acentanilid that depresses and finally paralyzes the heart and irritating salts that make a bad bowel difficulty worse, are sold over the counter in such large quantities. The public wishes to know when, how and where it can be cured of these ills and it is one of the highest and most important duties of the profession to tell it. It is little short of criminal to leave these matters to the advertising quack. Why cannot the regular profession in a dignified and correct manner inform the public who the physicians are that are making treatment of certain diseases a specialty? This is a matter for the new Society of Medical Economics to inquire into, and I have no doubt that within five years the physician who has spent years in getting ready to practice a specialty, will, by means of a simple card in the newspapers or a single phrase on his sign,

announce to the public the kind of work he chooses most of all to undertake. This is now the case in Germany and Austria; why not in America?

One of the things which will come up for very early discussion is the preparation of the general medical practitioner to enter special fields. It is now generally conceded that every physician should first have from three to five years in general practice in order that he may learn to recognize the symptoms that lead to a diagnosis of general disease. He will then avoid the very disastrous habit of seeing every symptom only in reference to the patient's eye or ear and will get the entourage, the setting of the localized lesion, treatment of which is all that is needed to relieve the complaints involving the concerned special organs. A campaign of education to bring about this desired end will soon be started, and physicians will be invited and probably later compelled to go into the clinics for systematic and thorough instruction by men who are authorized after severe tests to give such instruction. In this the voices of the incorporators of the Society of Medical Economics spoke as one. Every physician present at the first meeting is a master in his field, and is not only willing but anxious to teach. The holding of Hospital privileges for one's own private ends was loudly condemned, and the "open clinic" was acknowledged to be the only way of combating this evil. There was, of course, a variety of opinions as to the method of organization and systematization of such teaching, but that is a detail which can be worked out satisfactorily later on.

Selfishness and prejudice should have no place in medical science. We need men of broad and liberal training who are capable of viewing the economic aspect of medicine