, 1910

Series, Vol. V., No.

Cost of Maintaining a Tuberculosis Sanatorium. In a preliminary bulletin on the cost of maintaining a tuberculosis sanatorium, the National Association for the Study and Prevention of Tuberculosis announces that the average cost per patient per day in thirty semi-charitable sanatoria scattered in all parts of the United States is $1.669. These institutions represent an annual expenditure of over $1,300,000 and over 815,000 days of treatment given each year. The bulletin which is part of an extensive study the National Association is making for its bureau of information, points out how the country could save annually at least $150,000,000, if the indigent consumptives were properly segregated.

It was found that the food cost in most institutions represented one-third of the annual expenditures. The average daily food cost per patient was $0.544. The expenditures for salaries and wages represented nearly another third, being $0.481 per day per patient out of a total of $1.669. The fuel, oil and light cost was $0.206 per capita per diem or about one-eighth of the total cost.

The daily cost in the several institutions ranged all the way from $0.946 per patient to $2.555. In the far West and Southwest, as in Colorado and New Mexico and California the cost was higher than in the East, in New York and New England, being $2.025 per patient as against $1.748.

The total expenditures of the thirty institutions were $1,363,953.28, while the total receipts from all sources were $1,548,525.74. More than seventy per cent of the receipts were received from public funds and private benefactions, only 28.8 per cent. being from patients. Stated in another way, only thirty-five per cent. of the total expenditures were received from patients, the remainder being made up from other sources.

Computing that there are in the United States at least 300,000 indigent consumptives who should be cared for in charitable or semi-charitable sanatoria and hospitals, the National Association estimates that the annual cost to the country for the treatment of these persons would be $50,000,000 at the rate of $1.669 per day per patient.

At the lowest possible estimate, the country loses $200,000,000 a year from the incapacity of these indigent victims of tuberculosis. This would mean a net saving of $150,000,000 a year to the United States if all cases who are too poor to afford proper treatment in expensive sanatoria were cared for at the expense of the municipality, county or state. And this annual gain does not include the enormous saving that would accrue from the lessened infection due to the segregation of the dangerous consumptives in institutions.

Infantile Paralysis.-The August issue of Pediatrics is a special edition of 100 pages devoted exclusively to the study of Acute Poliomyelitis. "The Pathology of Acute Poliomyelitis" is written by I. Strauss, A. M., M. D., of New York City. "Experimental Poliomyelitis" is from the pen of Simon Flexner, M. D., New York City. "A Small Epidemic of 17 Cases of Acute Poliomyelitis" from John Milton Armstrong, M. D., St. Paul, Minn. "Additional Observations on Acute Poliomyelitis" by F. E. Coulter, M. D., Omaha, Nebraska. "A Contribution to the Study of Acute Poliomyelitis, Based on the Observation of Thirty-eight Recent Cases" is from Colin K. Russel, M. D., F. R. C. P., Montreal, Can. "A Plea for the 'Abolition' of the Term 'Infantile Paralysis' as a Synonym for 'Acute Poliomyelitis'" is contributed by Geo. P. Shidler, A. B., York, Nebraska. "Acute Poliomyelitis" by J. S. Fowler, M. D., F. R. C. P., Edinburgh. "Report of an Epidemic of Two Hundred and Seventynine Cases of Acute Poliomyelitis" is written by C. A. Anderson, M. D., Stromsburgh, Nebraska.

The discussions before the conjoined meeting of the American Orthopedic and Pediatric Societies bearing on this subject are included.

The retrospect of current pediatric literature in this number contains the digest of the latest teachings of the world's greatest authorities and writers on the subject of Poliomyelitis, during the past year, and the whole issue makes one of the most valuable compilations on the subject ever presented.

Complete Series, Vol. XVI., No. 10. New Series, Vol. V., No. 10.

Medical Education in the United States and Canada is the subject of an extended report by Abraham Flexner to the Carnegie Foundation for the Advancement of Teaching, and as we had occasion to state last month, though in general it presents nothing which has not been discussed for many years, it lays bare many sore spots most effectively because of the great mass of data. There is an unfortunate pessimistic tone to the whole report as well as all other discussions of the problem, whereas the facts should give rise to great hopefulness. It must be remembered that a century and a half ago medicine was a trade learned by an individual apprenticeship, and that teaching in classes was very slowly developed as a supplement. The severe things said about the schools which give no practical training, show that it would not be a bad plan to return to the apprenticeship system in part at least. What a grand thing it would be if every graduate could spend a year or two as the paid assistant of a practitioner of ability! We try to walk before we have learned to stand. The large classes due to the abandonment of apprenticeships have been largely responsible for that dreadful over-crowding which we have so frequently mentioned and which forms so great a part of Flexner's report. If all the graduates were competent the public would be the gainer but the point is that too many

are not properly trained and entirely too many are lacking in intelligence-men who should be behind the plow where they were born. The plea that the poor colleges are for poverty stricken men somehow assumes that poverty is an indication of intelligence, whereas it often, if not generally, means inherited inefficiency. It may sound brutal to say that we should give no considera tion to the boy who is poor though ambitious, but if he has a real back bone supporting his alleged brain, he will find ways and means.

The third profession between that of physician and pharmacist as it has grown up here and there in Europe has not even been mentioned by Flexner. Experience shows that the ideal of an academic degree prior to the medical course, is hopelessly out of reach of the vast majority of students, and the compromise of two years in college is not sufficient for the highest and best training, while the present accepted high school course of preparation is generally recognized as a mere temporary measure. Hence in those countries where medical training is far advanced, the people do not have sufficient doctors. and never dream of calling on one for the minor ills which fall to the care of midwives and pharmacists. Our fault has been the giving of degrees to men who should be limited to very narrow bounds of activity, and who abroad would not be

allowed license for any kind of work. In 'spite of overcrowding, laymen the world over insist upon a third profession, so that "counter-prescribing" by reason of its illegitimacy has become an enormous evil and is also an agency for the sale of worthless or dangerous quack "remedies." Some people always will consult the drug clerk and he always will sell them something. Moreover it is doubtful whether the public will tolerate a law prohibiting them buying what non-poisonous medicines they please. As the custom is worldwide and ineradicable, why not control it at once? A dangerous dragon which cannot be killed had better be fenced in and tamed to usefulness instead of pretending it does not exist.

The decay of medical sectarianism is the bright spot in Flexner's report. There is only one science and art of medicine, and though it is perfectly natural for differences of opinion to arise, they invariably disappear with increase of knowledge. What concerns us now, is the repeated

revelation of the awful condition of most

of the sectarian schools still surviving long known facts, by-the-way. They will all die in time, as a matter of course, but it does seem that euthanasia might be practiced on them all-and the sooner the better, for they are not dying quick enough and their struggle for existence is too painful. There is really very little pub

lic demand for them.

Medical examining boards are coming in for a great deal of discussion now-adays, and it is natural that Flexner should investigate them a little. Though they seem outside of his theme, they are strictly part of the topic, for they become necessary because the possession of a diploma was long

ago recognized as no proof of ability to practice. The American Medical Association is taking active steps towards securing uniform legislation in all the States, and we already see evidence of the dawn of a better day. The first medical practice law was passed in New York in 1760, and yet after all this time, examining boards still confine themselves to testing the applicant's memory, with the result that good students of poor schools make fine records even though so utterly devoid of practical training as to be unfit to practice. This is being remedied, but rather slowly. Perhaps in time a diploma will be evidence of fitness, and the boards will disappear as no longer of use, but in the long meantime there must be better examinations and better examiners. The opinion seems to be pretty general that the boards. should be separate from boards of health, members being selected by the Governor from nominations by the State Medifrom nominations by cal Society, that teachers should be ineligible, sectarianism recognized, graduation from a medical college be a and that requirement for applicants

materia medica and therapeutics as well as practical and clinical work be included in the examination. The board must have power to determine the standing of colleges, revoke or suspend licenses of practitioners for misconduct and penalize certain actions. These are the main conclusions of the recent conference of the Council on Medical Education and the Legislative Council, and will no doubt be widely accepted, though there is a growing idea that it is safe to omit therapeutics if the candidate is learned in everything else.

Licenses for special practice are being advocated more and more, and the matter

must eventually be taken up by examining boards though this is the time for discussion. It is now generally recognized that in major surgery and such specialties as ophthalmology, much training and experience are necessary before it is safe to permit one to practice. Here too, the postgraduate schools which were established to give the instruction and practice, cannot be trusted, for many of them are known to be deplorably inefficient, so bad indeed that a few should be disbanded as doing more harm than good. It does seem that as in the case of dentists, a special license will be required before any man be permitted to indulge in such specialities as surgery, ophthalmology and otology. like manner there is a growing opinion that every kind of limited practice should be controlled by a license after examination following proper training—midwifery, massage, refraction, etc. Indeed, it is thought by some that even the cults like osteopathy and Christian Science should be recognized and licensed. It surely would destroy all fads if the practitioners were required to be so highly trained as to be able to make a correct diagnosis.

In

The need of a definition of the practice of medicine is becoming more and more acute, but unfortunately no two States seem to agree. The foolish jurist, who decided that none practiced unless they prescribed drugs, opened the eyes of the medical profession and of the laity, to the danger to public health from the bench itself. There is a unanimous demand for a definition which can be adopted in each State as a part of the medical laws for the purpose of excluding the unqualified. A committee of the American Medical Association has suggested the following: "A person prac

tices medicine and surgery within the meaning of this act, who holds himself or herself out as being able to diagnose, treat, operate or prescribe for any human disease, pain, injury, deformity, physical or abnormal mental condition and who shall either offer or undertake by any means or methods to diagnose, treat, operate or prescribe for any human disease, pain, injury, deformity, abnormal mental or physical condition." This definition is certainly far shorter than any of those devised by lawyers to cover all special cases which now escape punishment for misconduct, but it does seem that though there was a unanimous objection to including definitions of limited practice or licensing such people after examination, it would be wiser to follow the general trend of placing everyone under control no matter how little he does,—even the chiropodists and barbers.

Reciprocity has been growing at such a rate that fully 90 per cent. of the States now provide for it in some form, and it is safe to predict that it will soon be universal. The refusal to reciprocate was due to the fact that, here and there, licensing boards fixed too low a standard of examination or merely accepted a diploma. The result has been a general rise of standards all over the country, but as there is still considerable room for improvement, it is not safe to let down the bars at once. There is a very widespread opinion that each individual applicant's qualifications. should be left to the examining board to determine as they think best, and that they need not resort to an actual oral or written examination unless the applicant's credentials do not conclusively show him to be qualified. Where the board is required by