that may confront you. If I have failed to demonstrate that there are still other worlds to conquer and have not shown their possibilities, I shall always feel like the much lamented Watson, who said, on taking leave of his class in Kings College, "That I have done as well as my slender ability, broken leisure and irregular opportunity would permit."

Miscellany

LACK OF HOSPITAL BEDS COSTS U. S. OVER A BILLION DOLLARS.

Sixteen states and territories of the United States provide no place where the poor consumptive can be treated, except in jails and insane asylums. This statement, together with another, to the effect that not one in thirty of the victims of consumption who want to get in hospitals can find a place there, a fact which will mean a loss to the country of $1,275,000,000 is made by the National Association for the Study and Prevention of Tuberculosis in a bulletin issued recently.

The National Association states that there are in the United States at least 300,000 consumptives who are so poor that they cannot pay for proper medical treatment in tuberculosis sanatoria and hospitals. Some of them can pay small amounts a week for their maintenance, but the great majority of them cannot pay anything. For this large class of patients the entire country has provided only 10,000 beds for the free treatment of tubercu losis. In Alabama, Arkansas, Idaho,, Kansas, Mississippi, Montana, Nevada, North Dakota, Oklahoma, Oregon, Philippine Islands, South Dakota, Texas, Utah, West Virginia and Wyoming there is no place where the consumptive without means can be treated but in jails or insane asylums and in most cases he will get no treatment there. Sixteen other states provide less than 50 beds each for poor consumptives. In only two states, Massachusetts and New York have beds for needy tuberculosis patients been provided, so that at least one in ten may find a place for treatment. In many of the other states, not one in 50 of the destiso that there is really no danger of contagion.

The cure of the tuberculous depends upon the early recognition of the disease and the tute consumptives can find a bed in a hospital or sanatorium.

It costs on an average about $250 to cure an incipient consumptive or to care for an advanced case until death. If he is left in destitute circumstances without proper attention, he will surely infect with his disease at least

two other persons, and possibly many more. Considering that the average life is worth to society in dollars and cents, about $1500, the net loss which would accrue to a community by not treating its poor consumptives in proper institutions would be for each case, includ ing those who are unnecessarily infected, at the very lowest figure, $4250. On this basis, if the poor consumptives in the United States who are now sick were segregated from their families, and either kept in institutions until they died, or else cured of their disease, the saving to the country would be the enormous sum of $1,275,000,000.

Consumption is primarily a poor man's disease. Dr. Woods Hutchinson, of New York City, says: "Roughly speaking, the incipient tuberculous patient can buy as many chances of fresh air and cure as he has money." The percentage of deaths from consumption among the poor is 100 per cent higher than among the well-to-do and the rich-65 per cent of the consumptives in the United States are too poor to provide proper means for treatment. They must either be placed in a sanatorium or a hospital where they can be cured of their disease and where they will be removed from the possibility of infecting other members of their families, or the loss resulting from neglect to care for these poor consumptives will be twice or three times as great as would be the case if they were properly housed in institutions.

The National Association for the Study and Prevention of Tuberculosis declares that if every county or township should erect an institution for the treatment of indigent cases of consumption, this disease would be wiped out in a few years.

DANGER OF THE THERMOS BOTTLE.

The vacuum flask which has recently come into general use to keep hot fluids hot and cold ones cold, makes a very good incubator for bacteria. The danger of keeping contaminated foods warm in such a container is readily seen. Dr. Tuley, of Louisville, recently experimented with one of these bottles after a baby under his care has been made sick from its use (Arch. Pediatrics, Aug., '09). He put a feeding in the bottle, and left one in its usual place over night. In the morning a bacteriological count was made. The feeding which had been kept cool contained 3,500 per cu. mm; that in the vacuum flask contained 1,400,000. It can hardly be doubted that there is decided danger in many foods if kept in this way. If put in while sterile, for example, just after being boiled, the danger could be averted; while things kept hot should undoubtedly suffer no harm.-Detroit Medical Journal.

St. Louis Medical Review

A MONTHLY JOURNAL OF MEDICINE AND THE
ALLIED SCIENCES.
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Entered at St. Louis Post Office as Second-Class Matter.

ST. LOUIS, DECEMBER, 1909.

CONTRACT PRACTICE.

Much has been written at various times about the evils of, the injustice to and the degradation of the medical profession by "contract practice."

Now, contract practice is of two kinds, one obviously justifiable and desirable, the other objectionable and reprehensible.

Of the first form, typical instances are found in the medical services of the Army, Navy and Marine Hospital Service. The guiding principle of this form of contract practice is the recognition by somebody employing large numbers of men, or being charged with an impersonal care for the general health of a more or less extensive community, of its full responsibility, and the making of terms with physicians to fulfill for it that obligation. If it be urged

that the salaries offered are smaller than the returns frequently obtained in private practice by men of the calibre sought, it can be replied that they are also larger than those actually obtained by many others of equal calibre; also that the positions carry social advantages and opportunities, an additional equivalent in board, quarters, and allowances of various kinds, a certain proportion of leave on pay, and opportunities for the scientific pursuit of knowledge. This is the ideal form of contract practice, and it is in this direction that the sanitary services of communities are gradually shaping. There are even those who hope for, and imagine that they can foresee, the time of an eventual establishment of all medical aid on this principle, on

the ground that every man's health concerns the well-being of the community at large. On these lines, also, to some extent, is moulded the medical service of the mercantile marine and of some large mining and other corporations employing a large personnel. In none of these cases does the employer trade with the professional abilities of its medical employes for its own enrichment or advantage. What it obtains from them it gives freely as a duty to its other employes, paying the expense out of its own pocket.

The other form of contract practice may be divided into two classes. 1. There is a large class of cases in which voluntary organizations, by the power of combination, endeavor to force the medical profession to engage its services for small individual fees, such as would not approximately cover the liability of the individual on any actuarial basis; thus affording opportunities for individuals to get for an insignificant sum what they can well afford, in most instances, at least, to pay for at the current professional rates, and would pay for at those rates, did not this professional thumbscrew help them to extort unfair advantages from more needy members of the profession. Of such class are many clubs, lodges, etc. It will be observed that in these cases, it is in the last resort the individual member who pays the doctor's fees, merely using the power of combination to compel him to accept fees far below the normal scale. The same organization which, in a fit of social ethics, bands itself together with a terrible outcry to prevent a lowering of wages for its individual members, uses the same organization to compel a lowering of pay for the medical profession. The organ of "justice for the workman," thus becomes an organ of injustice and oppression for the medical profession.

The second form of this last class is even more contemptible than the first. In brutal and callous selfishness a third party, individual or corporate, endeavors to enrich itself at the cost of the members of the medical profession, whose skill and services it treats as though they were merchandise, buying them at a lower price and selling them at a greater, and pocketing the difference as "profits." Of this character are the so-called "medical corporations" or "companies." They act the part of the middleman without his justification. The distributor-the original middleman, before the creation of various factitious intermediaries each, of course, drawing a commission-by conveying products from places where they are found or manufactured to where they are wanied for use, does confer a benefit in return for his charges, however disproportionately inflated in these latter days those charges have be

come. No actual service, however, of whatever kind, is performed by the medical middleman. He is simply a tax levier by force majeure. He does nothing at all for the public. Everything that is done, is done by the physicians he has enslaved and could be done not only as well, but far better, by those same physicians for the same public dealing with each other individually. All that the middleman does is to take advantage of the needs of certain medical men to extort from them a "rake off" from their just dues for the work they do, by, as it were, usuriously discounting what would be their just receipts if they were to await the returns of practice. Then, to increase these usurious profits, he fleeces his unsuspecting victims, the public, inducing them to undergo as much "treatment" as possible, whether needed or not, whether suitable or not, so long as they have anything left wherewith to pay.

It is, therefore, with no small gratification that we learn of a recent legal decision in New York. The secretary of state has decided that such corporations are illegal, and has refused a certificate of incorporation to one on the ground that a corporation cannot practice medicine, any more than (as had been previously decided) it can practice law. It is to be hoped that all other states will take notice and follow this admirable example.

THE PRESIDENT AND A BUREAU OF PUBLIC HEALTH.

In the message recently sent by the Presi dent of the United States to both houses of Congress, he has evinced his determination and kept his faith in recommending in no uncer tain terms the establishment of a National Bureau of Public Health. No one who has had an opportunity of carefully studying the advances made in preventive medicine and who has seen its practical application, as demonstrated in Panama and in the increasing sanitary regeneration of Cuba and of our own country, as well as in the superlatively satisfactory work shown to the world in the Russo-Japanese war, in which the absence of the usual epidemics, scourges that follow in the wake of such military operations, was particularly illuminating, can fail to appreciate the necessity, in these enlightened times, for the establishment, not only in this country, but in every other civilized community as well, of a Bureau of Public Health.

A special feature in the United States should be made, not only, as recommended by President Taft, of the establishment of a National Bureau of Public Health, but if necessary there should also be established by Constitutional

enactment, a Secretary of Public Health, whose status should be on a par with that of any other member of the President's Cabinet.

The arguments in favor of the accomplishment of this object are so many that it would be impossible to instance them here, but two important arguments stand forth more clearly than all else, namely:

First, the protection afforded the individual and the community against the invasion of those diseases which can be effectively curtailed, or even eliminated, by proper legislation, backed up by, and enforced through, a national association; and second, the economic saving and the prevention of enormous financial loss through preventable disease and mortality.

The establishment of a National Bureau of Public Health can accomplish all this. Legis lation affecting all forms of diseases within the United States, as well as regulations against the importation into our country of foreign pestilences, could be accomplished by its aid, It is pertinent at this time for every medical organization, as well as for the journals representing the various medical centers of this country, to speak in no uncertain terms of the necessity of these advances, particularly so as at this time there are assembled in Washington lawmakers of every state, in whose hands is placed the responsibility for the guidance and the advancement of our republic. With this recommendation on the part of the Chief Executive now before the law making branches of our government, aided by that influence which comes from honest conviction and which can be no better emphasized than by the medical press of this country-we may see realized in the near future that which the medical men of this country have so long striven for-a National Bureau of Public Health.

Editorial Pith

THE QUESTION OF VACCINATION.

The question of vaccination is always before us. It is morally certain that a few perfectly sincere but none the less misguided people will always condemn this procedure, no matter how well proven the fact may be that through its agency smallpox has been conquered for all time. The processes of reasoning that must take place to allow a person to deny in good faith the overwhelming evidence that exists concerning the true prophylactic value of vac cination, can never be understood by the nor mal thinker. Such perversion of ordinary deductive logic is incomprehensible. But it ex ists, just as the ridiculous beliefs of Christian Science exist, and must be accepted in the same

way as nothing else but deplorable and in some respects pitiable vagaries of the human mind.

The agitation as regards vaccination, senseless as it certainly is, has served one purpose, however, and that is to emphasize the essentially surgical character of the operation. Vac cine as now prepared and marketed is safeguarded in every possible way and the dangers of by-infections are entirely eliminated. But the occasional case of tetanus or other infec tion that is encountered and made so much of by the anti-vaccinationists carries its distinct lesson, and that is that the wound of vaccination cannot be neglected. To do so, is to court trouble. A goodly proportion of medical men realize this, and never undertake a vaccination without surrounding the operation with every aseptic precaution. The physicians who thus protect themselves and their patients never have any trouble, and the extremely sore arms of former and more lax days, are seldom seen. There are still doctors, however,-good doctors, too, who pay little or no attention to the operation of vaccination. These are the men who have the tetanus cases and who supply the anti-vaccinationist with ammunition. That invariably the virus, as supplied by recognized manufacturers, is shown to be innocent, while the method of use is proven culpable, does not modify the situation in the eyes of the preju diced. The whole proposition suffers and all the explanations in the world cannot remove the onus.

Vaccination is a surgical operation and the medical man who fails to use every aseptic precaution when performing it is not only jeopardizing the welfare of the patient, but al so the interests of society. Every accident fol lowing vaccination while regrettable for its immediate effects, is infinitely more so for the unwarranted fears and prejudices it creates in the minds of those who see only the gen eral result.

In no way can medical men do more to advance the practice of vaccination and overcome the objections of the anti-vaccinationers than to give the utmost care to the selection of the virus and its method of application. The most painstaking asepsis at the operation is not enough, but the resulting wound must be carefully protected against the possibility of subsequent infection. It is here that the prin cipal danger lies and practically every case of tetanus or other serious infection has been traced to post-operative infection from careless after treatment. The patient should be told the exact situation and urged to present him self on the third day and for several days fol lowing until everything is satisfactory. When the reaction is severe and the wound becomes badly inflamed it should be treated as every

other wound would be treated. To neglect a vaccination wound on the grounds that it will take care of itself, is a grave mistake and noth ing that we know of the course followed by such wounds ever justifies such treatment. The day of cut-rate vaccination is over and no phy sician should undertake the operation unless the patient is willing to consider it on the basis its importance warrants. A price based on the service required should be insisted upon. Per haps if the laity can be shown the protection and safety offered by such a system, as well as the grave results liable to follow a less sensible course, the growing habit of lay vaccination will be stopped before greater harm is done. Those who recognize the threatening evils will hardly deny that the subject deserves the most thoughtful consideration and thus excuse the space we have given to a somewhat hackneyed subject.-American Medicine.

COSTLY SILENCE.

The public has never appreciated the real gravity of the venereal peril, and does not appreciate it today. Physicians themselves have only begun to appreciate it. The truth of the matter is that both by the laity and the profession the whole matter has been treated as a joke. We do not crack jokes about cholera, or yellow fever, or plague. The survivors of Messina, as they sat among their ruined homes, found nothing to joke about in that awful catastrophe; yet grown men are perfectly willing to crack jokes about a subject which involves the future of the race. They are satisfied with the most futile precautions against diseases whose ravages far exceed that of all the plagues in the world. We joke with death, but our chil dren and our children's children pay the price. Is blindness a joke? Is permanent sterility a joke? Is the chronic and incurable invalidism which overtakes many a fair bride a joke? Are mutilating and disabling operations jokes? Is it a joke to bemire the very fountain of life, and turn a sparkling fountain into a sullen and seething mudhole whence shall issue all sorts of creeping and crawling deformities, and mis-shapen things of disease and woe?

What is the medical profession doing to prevent these crimes?-Nothing.

What is the legislature doing?-Nothing. What are the courts doing?-Nothing. What are the educational institutions doing? -Nothing.

To take up the last question first, the essential facts of sexual life are entirely neglected in both home and school training. Mystery shrouds the subject from the time the child asks the first question regarding its origin until the day when its curiosity is satisfied in a

corner by whispering playmates. We begin wrong. Mystery is like the night. In its dark shadows lurks all manner of evil. In our homes proper answers are rarely given to questions to which the children will continue to seek an answer. Usually they get the knowledge clandestinely, and that which was the mystery of their childhood becomes a thing of darkness in the ignorance of their youth.

Parents shun responsibility in this matter. Not long ago a well-meaning and well-conducted journal for women endeavored to arouse its readers on this question of information. on sex questions. The articles were timely,

modest, and informing. The journal was undertaking a necessary and most needful task in a perfectly proper way.

Its course, however, created much criticism. It appeared that many of its subscribers, mothers, were perfectly willing to let their children pick up the same information on the streets in a prurient way, but their delicate sensibilities were shocked that Maria and Jennie should be frankly and openly told the facts. concerning the fountain of life. Their knowledge on these subjects, these poor women thought, should be gained clandestinely. Our educational institutions preserve the same re

serve.

When does a ship need the gleam of the lighthouse?--When it is approaching the rocks. When does a child need instruction and warning on sexual matters?-when it is approaching puberty! [This, alas! is often too late. ED.] Does it get either instruction or warning from its parents?-Rarely.-New York State Journal of Medicine.

The reason cleanly men and women have continued to go on so long drinking after one another is due to the simple fact that they have been unable to get individual cups. Dis eases, such as la grippe, "go through families," as we say, and epidemics go through communities, and yet we wonder why. As a matter of fact, many people, apparently healthy, but who have been sick several months before, carry the germs of an old disease in their mouths. A few months ago an epidemic

of diphtheria occured among twenty-four persons in Rochester. Dr. Forbes, of that city, made an investigation, and traced each case unmistakably to a common drinking cup which all the sick had used.

The crying need of individual drinking cups caused a young man of Boston to search for some economical method of delivering a new cup with each drink. His device, like other successful inventions, is simple. There is an upright tube containing one hundred thirtyfive paraffined paper cups nested closely to

gether, and at the bottom of this stack an ar

rangement for filling the cups with water. The drinker has only to turn a small lever from left to right, and the filled cup drops into view. In places where the general public will use the fountains, a simple slot device, suitable for a penny, is attached. The cups, if put to a test, will hold water for several hours; they are so inexpensive, however, the cost is but a fraction of a cent,-that the drinker either carries his cup away or throws it in a basin provided below.

Several months ago the machine was taken to the New York health authorities, who at once indorsed its universal use for the municipal hospitals and the schools. New York City has managed to reduce its yearly death-rate, through sanitary regulations which have inspired the commendation of the world, from twenty-five per thousand to eighteen. But the public cup had been a cause for the spread of disease. Hence the quick acceptance of the new invention.

The public at last seems to be awakening to the demands made in behalf of health to abolish the common cup. School boards are seeking to do away with the tin cup and chain. A test recently made by Dr. Davison, of Lafay ette College, has caused school authorities to sit up and take notice. Dr. Davison found that a cup which had been in use in a public school for nine days was so completely covered with human cells scraped from the lips of drinkers that a pin-point could not be placed anywhere without touching several bits of skin. The Lackawanna, Norfolk, and Western, the Boston and Maine, and several other railroads, alert to the best methods of protecting the health of their patrons, have installed individual cup venders in their coaches. The managers of railroads as well as department stores and theaters, have responded to the call for an alternative for the common cup. Two large magazines have entered the campaign, and a long-overlooked nuisance may soon be abolished. The individual drinking cup must come.— Journal of the Outdoor Life.