the bodies of the perspiring patients and the vapor of the hot water at the high temperature maintained, the conditions become objectionable and insanitary in the extreme.

One of the most unsatisfactory features of administration comes from the small size of the houses, and the general assumption that one person in a supervisory capacity is sufficient. The result is that in no single instance is there anyone to efficiently oversee and direct the bathing. The manager, who is the only person in charge, is so closely confined to his desk, and so fully occupied in selling, punching, and redeeming tickets, locking up and unlocking valuables, caring for umbrellas and coats, and in answering inquiries, that it is rarely possible for him to be in the bath halls more than a few minutes at a time until after bathing hours, and consequently he has very little knowledge of how accurately the bathing directions of physicians are being carried out. The possibility of devoting his attentions to the actual service that forms the basis of the lease is always in inverse ratio to the number of patients being treated.

There should be a head attendant in each bathing department to see that the baths are administered with careful attention to details, and to supervise and direct the work of the attendants. He should not be permitted to bathe patients himself, nor to be absent from the bath department proper during bathing hours. To procure the services of competent men a salary of not less than $75 per month should be paid. More complaints are made by physicians upon this pointthe lack of supervision in carrying out bathing directions-than on any other one feature of the service.

The employment of exclusively supervisory head attendants for each bathing department may not be at once practicable, especially in the smaller houses where the number of tubs does not justify the expense. But certain measures of supervision should be insisted upon, while plans for the erection of new buildings, or for the remodeling of old ones, should require such enlargement as would make the essential feature of thorough and effective supervision in administration a matter of course.

As indicating inefficient supervision, the clocks used in timing the baths are not infrequently found stopped, recording a time several hours past, a number of patients having been bathed in the meantime. This is partly due to negligence, but partly to the attendants being required to provide the clocks, with the result that a cheap and inferior timepiece has been purchased.

The same general criticism may be made on the thermometers. The use of these instruments of precision was required in order that the baths might be administered at the exact temperature prescribed, but those provided were of so cheap a grade and so grossly inaccurate that it is certain in many instances the temperature of the water could have been more correctly determined by the hand. A rough test of the accuracy of the thermometers in use was made November 3, 1910, by placing 242 of them in a tub of water at 98° F., with the result that only 90 recorded the true temperature. Fifty-seven showed variations between 4° and 31°, while the difference between the highest and lowest reading was 59°. In 11 the columns of mercury were broken. To correct these conditions orders have been issued directing the use of standardized instruments.

The hot rooms are of the old type, and are so constructed that the patient has to breathe the foul and superheated air of a small chamber or cabinet. In the new houses now in process of construction there will be modern equipment, and sweating can be produced in the hot-air cabinets while the patient breathes the air of a wellventilated room. With this arrangement it is believed that the temperature of the bath halls can be reduced to about 90°, thus making the conditions much more tolerable.

Heretofore there has been very little tendency to employ the various forms of baths described in textbooks on hydrotherapy. The benefits obtained have been ascribed to the water almost exclusively, rather than to varying methods in its use. The new houses, however, with more complete equipment, will provide opportunities to make use of these different methods should physicians desire to employ them.

During the past six months a number of pieces of sanitary whiteenamel iron furniture have been tested, and its superiority should cause it to be installed in the bath halls, cooling, and dressing rooms. The wooden furniture heretofore in use soon loses its varnish, becomes soaked with water and perspiration, and stained with soap and dirt, so as to appear very unattractive.

Another objectionable and insanitary feature is the method commonly employed of keeping the bathers' soap. Patients complain that they do not get their own cakes of soap, or that their soap has been used on some one else, and often express the fear that they may in this way contract disease. Steps have been taken to correct this, and it is believed that a satisfactory system will be installed in the near future.

The laundry service has been as a whole very unsatisfactorily performed. Rule 12 of the bathhouse regulations has been interpreted to require the attendants to wash the towels, and where they have also had to provide soap for this purpose undue economy in its use has commonly been practiced. Few houses have a laundry equipment in any way commensurate with their needs, nor is it possible in the present buildings to install one. Towels are not sterilized except in rare instances, nor is there generally efficient supervision exercised over this process. This part of the service has been dealt with at length in special reports, and it is hoped that an acceptable plan for improvement will soon be in operation.

The method commonly employed of cooling the water in uncovered tanks is open to several objections. First, and of greatest importance, it is the generally accepted belief that the remedial properties are in the contained gases. The water has been found to be radioactive, and its therapeutic value is greatly lessened when it has been long exposed to the air. During the summer months it is difficult to cool it sufficiently, and at times it has been necessary to use the city water to obtain the desired effect. Contamination by dust and insects is unavoidable with the open tanks. At one establishment an improved system has been installed in which the cooling is effected in closed pipes, but this particular plan is probably impracticable for general use. It is asserted by physicians that the results of treatment in this house are much better than when the water was cooled in the open tanks. The best possible water service

is of paramount importance, and the advice of a competent engineer should be obtained to devise a satisfactory system.

The physiological effects of the water have never been scientifically and accurately determined, and as its rational use can not be thoroughly understood in any other way it is recommended that a competent physiological chemist be employed to conduct a series of experiments in this direction.

In most houses massage and mercury-rubbing departments are maintained. These have frequently been criticized by physicians chiefly on account of a tendency on the part of the operators to diagnose and treat cases themselves, and to solicit patronage in objectionable ways. This matter has been the subject of a special investigation and report, and doubtless will be satisfactorily adjusted at an early date.

Great interest is felt as to the probable effect of the already widespread use of salvarsan on the number of patients coming to Hot Springs for treatment. Should this new remedy prove as efficient as has been predicted there may be a material diminution in the number of bathers; but as this reduction will be almost wholly among those who are suffering from a disease the prevalence of which in Hot Springs has tended to prevent many of the better class from visiting this resort on account of forced association with these unfortunates, it is not unlikely that the ultimate result will be most gratifying.

The use of common drinking cups, hair brushes, and combs, has been discontinued, and, in so far as it has been practicable with the old houses, carpets and mattings have been removed, and draperies replaced by sheets that can frequently be laundered. All of the new houses should be screened throughout, that flies and mosquitos may not transmit infectious diseases.

GOVERNMENT FREE BATHHOUSE.

The second duty assigned was the full charge of the Government bathhouse and the employees therein.

In the center of bathhouse row and in the rear of the line of leased bathhouses stands the Government free bathhouse, established by act of Congress of December 16, 1878. This benevolent institution is another mark of the recognition by Congress of the great and general faith in the curative properties of the water, amounting to an invitation to the indigent invalids of the entire country to come to Hot Springs for relief. These sufferers have come from every State in the Union, and are still coming, often as a last resort, and in the hope that the mysterious and miraculous water may cure after their home physicians have failed to afford relief. Churches, fraternal organizations, relatives, and friends often contribute small amounts to enable the sufferer to obtain the benefits of a course of baths. Frequently a man beats his way on a freight train and arrives practically destitute, and at times unable to work, thus becoming at once an object of charity. A considerable number come in the belief that the Government maintains, in conjunction with the free bathhouse, a hospital or home at which they will be cared for in every way. Not infrequently the progress of disease results in a degree of helplessness and destitution pitiable in the extreme. At times practically the last cent has been

spent in coming here for conditions in which the baths are of little benefit or even contraindicated.

Here may be seen one of the great clinics of the world. During the fiscal year ended June 30, 1911, there were given in this institution 220,435 baths. There has been heretofore no medical supervision. Practically all applicants who declared themselves unable to pay were admitted with very little, if any, reference to the nature of their disease or whether such treatment was likely to prove beneficial or the reverse. There was no one qualified to determine these questions. Cases of cancer and tuberculosis were bathed, and occasionally smallpox and other infectious diseases crept in until accidentally recognized by the manager, or by one of the attendants. Many came for conditions that could not possibly be materially benefited by the water, thus delaying proper treatment, while incurring the unnecessary expense, suffering, or inconvenience incident to a separation from home and friends, and finally departing with the impression that the baths were of no value or that their cases were incurable. Others have fallen ready victims to quacks, nostrum frauds, and irresponsible venders of secret remedies. Many held tickets issued months previously, occasionally taking a bath simply for cleanliness. Young children not suffering from any disease whatever were allowed access, and were brought in close contact with the most repulsive forms of venereal disease. Patients were admitted without regard to the number already in the bath halls, so that during the most favored hours it was difficult to walk between them without soiling one's clothes by contact with the perspiring bodies of waiting bathers. There was no ventilation, and the foul air and offensive odors were beyond belief.

The inauguration of a system of issuing tickets good only for certain specified hours has eliminated this overcrowding. To still further correct existing conditions and abuses a decision was requested as to whether baths were to be furnished to all indigents, or only to those who were suffering from diseases likely to be benefited or cured by bathing in the water. This question was appropriately dealt with by the department, resulting in the passage by Congress of the act of March 2, 1911, limiting the privileges of the baths to those who are suffering from ailments for which bathing in the water of the hot springs will afford relief or effect a cure, and who make oath that they are without and unable to obtain the means to pay for baths. This legislation has proved to be of the greatest value, in that it enables the officer in charge to exclude those whose condition would be made worse, those who could receive no benefit, those who are not sick but have been in the habit of coming for a weekly cleansing, and healthy children who apply unaccompanied by parent or guardian. Attention is respectfully invited to the great need for a new building. Congress made an appropriation in 1890 for the erection of the present structure, and from that time to this the records, so far as obtainable, show that nearly 4,000,000 baths have been administered therein. The evidence of wear and tear attest the truth of these figures. The stone steps at the entrance have been half worn through by the feet of invalids who have here sought relief. The house is less than half the size required for modern service, and only accommodates the patients by the use of pools in which large numbers bathe at the same time. Necessary adjuncts, such as examining rooms, a

dispensary, an emergency ward, office accommodations, and all forms of equipment for scientific hydrotherapy are entirely lacking. There are a few tubs, but the therapeutic resources do not extend beyond those of the municipal free baths of other cities, except that the water from the springs is used instead of city water. There is no possibility even of regulating the temperature of the bath to individual needs, except for the few who can be bathed in the tubs. Modern hydrotherapy has developed many different ways of using water, with quite as varying effects as may be obtained from drugs, and it should be made possible to introduce and use these improved methods.

The present building can never be made sanitary at a reasonable cost, nor can it be satisfactorily enlarged. There is practically no ventilation; the toilets are insufficient in number; the roof leaks at both ends of the building; the plaster has fallen in several places; and the water service, including the tanks, will soon need extensive repairs. These conditions are not conducive to improvements in the pay bathhouses, and the Government is represented by a markedly inferior service. It is recommended that the building be abandoned at the earliest practicable date and that a new, model house, with complete modern equipments, be provided.

Allotments amounting to $375 have been made for the purchase of medical supplies which have been dispensed to those unable to procure them, but no attempt has been made to furnish treatment except where the need was great. A complete medical service would require a considerably increased personnel.

It is very desirable that the attendants in this house should wear uniform white suits, and that in cleanliness and personal appearance they should serve as examples for the employees of the leased bathhouses. Their pay, however, is less than half that of the latter in many instances, so that this can not be effected unless the department furnishes and launders the suits, as is the custom in some hospitals. It is believed that the example in neatness, cleanliness, and sanitation would be well worth the cost.

Baths administered at the Government free bathhouse for the fiscal year 1910–11.

The third and fourth duties assigned this office, the "maintenance of a clinic for the education of bathhouse operators and their attendants" and the "determination of the fitness of all attendants, physically and otherwise, for the employment in bathhouses, both those operated by lessees and the Government bathhouse," may be best considered together.