The decision referred to above to the effect that since the patient died the attending physician could not recover for services rendered, is little less than startling. It does not seem possible in the event of the conditions being exactly as described, that the higher courts will fail to reverse the verdict. Of course, there are several things to be considered and without full and complete data it would be ridiculous to express any hard and fast criticism concerning this Georgia decision.

The contingent fee in the United States is almost unheard of among ethical and reputable physicians. The quack physician makes much of "no cure, no pay" but since he takes the stand of no pay, no treatment, and usually exacts a good big fee in advance, it is a rather empty claim. The honorable physician bases his charges on the services rendered. There is but one object in view, to secure the best possible result, in the best possible way and in the shortest possible time. It is possible that the physician suing in the case under discussion made some contingency concerning his pay in the event of the nonsuccess of his treatment. It is possible that the physicians of his locality, for local reasons, treat all or part of their cases on a contingent basis. If it could be shown that this was the custom of the locality, we can understand how the court might hold, in the event of absence of a definite understanding between the physician and the father of the child, that death of the patient abrogated all claims of the attending physician.

To the best of our knowledge and belief Georgia physicians are practicing on no other basis than that followed by the other

, 1910

, Vol. V.

is nothing in the reports of the case to point to the fact that the suing physician took the case on a contingent basis. The holding of the court that the death of the patient invalidated the claim of the physician for services actually rendered, is, therefore, apparently a grave miscarriage of both law and justice. The error is so palpable that it must be corrected by the next court. The whole practice of medicine as it stands to-day is jeopardized. To force physicians to take up contingent practice would strike at the very foundation of honorable medicine. No physician can conscientiously predicate his results in any case. Every physician, in assuming charge of a patient, contracts to use diligent care as defined by the requirements of each case, and to use ordinary skill as defined by the standards of other practitioners of the same school, in the given locality. Each physician may exercise as much more care or use as much greater skill as lies within his power. Under our present fee system of charging for services rendered, every physician assumes the moral obligation of doing his utmost. It is the most honorable, fair and sensible system and insures the highest type of service. It recognizes the limitations of the medical attendant, the possible development of new and unavoidable complications, and makes the patient assume his own share of responsibility. From every standpoint it is best for the patient, fairest to both patient and physician, and maintains the dignity, honor and ideals of the conscientious practitioner. It creates no false hopes and promises nothing but the best possible service.

The contingent fee, however, is open to all manner of abuse. It creates false

hopes, puts a price on dishonesty, and lowers the whole practice of medicine. It makes a practitioner a tradesman, a bickerer, and often a gambler who takes a long chance. It fits in with quackery and charlatanism, but it has no place in connection with scientific medicine.

The ruling of the Georgia court should, and certainly will arouse widespread indignation among honorable physicians if on closer examination it proves to be as unjust and ill founded as it now appears

to be.

The discussion of the venereal peril in lay literature is a desirable outcome of efforts made in that direction for a number of years. It has long been known by all physicians that no headway was possible in the crusade against this plague, until it became a popular movement. The stumbling block was the very natural repugnance to discussing such affairs in any periodicals which reach the family circle. The smug middle-class man has always assumed that his daughters were feebleminded things who could not understand their own organization or the world in which they live, but happily the girls are resenting the reflection on their intelligence. They rightly insist upon knowing what is to their interest. Now that they know that 80 or 90 per cent. of their surgical troubles in married life and many of the deaths are the results of immoral conduct of boys, they are most laudably declining to be murdered any further. In other words, our ideas as to what is proper for "the young person" to know, have undergone a remarkable change in the last few years. Editors are suddenly realizing that these matters are not only fit to print,

but that there is an actual demand for them. So we are not at all surprised at seeing in family-circle magazines, articles formerly confined to medical literature. It is a good sign of an awakened conscience whose lethargy has hitherto allowed the destruction of the best of our women or invalided them or sterilized them. Our young folks are not defiled by knowing what might defile them, but they are forewarned and forearmed and able to avoid defilement. They who know all about gonorrhea and live healthy lives, are far better off that the old-fashioned "pure in heart," who died of gonorrheal complications in utter ignorance that there was such a thing. So let the good work go on, even if it drives three-fourths of our gynecologists out of business for lack of cases.

The cooling of hospital wards in hot weather has been neglected in a manner amazingly stupid. Although it is an easy, cheap and perfectly practicable thing to do, we yet allow the dreadful summer mortality to continue year after year. When a sweltering hot wave comes and the sick begin to drop off and we can actually calculate in advance the daily number of extra deaths for each degree the thermometer rises, we throw up our hands helplessly and beseech Heaven to send a cool wave, utterly oblivious of the fact that the Lord helps those who help themselves -and helps precious few others. We know to a certainty that cold air will save the lives of the sick, and yet we won't give it to them until after they die. The dead rooms are kept cool and why not the living rooms when engineers have already devised methods of doing it? Medical literature is full of learned papers showing

how certain diseases are cured in the cold air of winter, and not in summer; hospitals now use the roof, verandahs or any old thing to get the patients out where they can breathe cold air; we are regaled by doleful tales of the awful results of hot weather; and yet it does not seem to have occurred to a soul among us to install an air cooling apparatus which will keep down the ward temperature in summer so that the patients will get well.

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It is possible to keep a ward at any temperature we desire, and well tilated too, at a cost so trifling that in comparison to the life saving, the expense is nothing. Why are we so slow? Hospital trustees, wake up! Find the money and use it, so that the little tots saved in summer will rise up and call you blessed. Ladies of the ice charities! Why don't you get busy too? You know only too well what a world of good you are doing by furnishing ice to the sick, so why not extend your influence further and see that they get the only thing which will save. them in our hot weather-fresh cold air

to breathe and plenty of it. Any cold storage engineer will tell you how it's done and any doctor will explain its value. Office buildings are cooled in summer to keep a man well, but if he sickens, he must swelter to death in a hot ward, when for a few dollars spent on air cooling apparatus he could recover. We are in a very unnatural climate, much colder in winter and hotter in summer than our northern physique can stand, yet we seem to think that heating the house air in winter is all that is necessary, whereas it must also be cooled in summer. So let us do it at once. In particular we desire to call this matter to the attention of that new and estimable society for the prevention

of infant mortality. Recent observations have shown that every degree over 80° adds to the difficulty of recovery from any disease, and the higher the temperature the higher the mortality. So insist upon having some rooms which can be kept below 70°, then in hot weather rush in the gasping babies, rich or poor, and watch them get well without any other treatment worth mentioning. Then you will be doing something practical and the Lord will help you without the asking. If, as many of our best men believe, the infantile pneumonias must have very cold air in winter, why in the name of common sense, don't we give it to them in summer too?

Post dysenteric conditions were described by Mr. James Cantlie of London in an article recently published in the Journal of Tropical Medicine, and though he was not entirely supported by those present at the reading of the paper, he called attention to some matters which are of importance to physicians of all climates. In the first place, he shows what the American physicians in Manila have long known; namely, that the lesions of amebic dysentery are not infrequently confined to the lower end of the descending colon and sigmoid or to the latter or even to the rectum. What he now emphasizes is the frequency with which stricture or cancer is later found in these situations in after years. He thinks there is a natural tendency for such conditions to occur at the end of the sigmoid from the anatomical shape of the parts and though this may not be the cause, it is well to know the fact of this localization. There is a well grounded suspicion that amebic infection is much more common in America

than the general profession has hitherto believed. Even in the tropics, quite an extensive infection can exist without symptoms, and it would not be at all surprising if many cases in cooler climates go on to ulcer formation unrecognized. If it is true that in such cases the trouble is localized in the sigmoid or rectum and later becomes the seat of dangerous cicatrices or malignant growths, its importance is quite evident. Luckily the ordinary case does not form ulcers, but leaves a mucous colitis which, though quite persistent, is amenable to treatment and eventually disappears unless there has been much thickening of the submucous connective tissue. Perhaps we are on the track of clearing up the etiology of a large group of intestinal cases which have hitherto been looked upon as not due to any infection at all. The ameba may have these far-reaching effects and deserve more investigation in America.

The Mode of Infection in Poliomyelitis. -In a previous editorial communication occasion was taken to mention the importance of recognizing diphtheria when present in the nose.

It is well known that the mucous membrane of the upper respiratory passages permits free osmosis of fluids, a fact which is manifest in the one direction when any irritant is applied to them and is followed by a copious outflow of secretion, and in the opposite direction by the great rapidity with which such toxic substances as cocaine are absorbed into the general circulation when applied directly to the nasal or pharyngeal tissue.

In a recent communication to the Journal of the American Medical Association

(February 12th, 1910) Drs. Flexner and Lewis, following up their preliminary report on epidemic poliomyelitis in monkeys, describe what they believe to be a mode of spontaneous infection. The groundwork for this investigation was laid some three years ago when it was discovered that upon infecting a monkey with diplococcus intracellularis by injecting cultures of this organism into the spinal canal, migration of the diplococcus into the nasopharynx readily took place. Organisms contained within leucocytes and lying free outside of them were found upon microscopical examination. Hence the authors cited concluded that the nasopharynx is probably both the site of origin and of elimination. of the meningitis germ in man.

Following the same method in their untiring efforts to determine the nature of poliomyelitis, Flexner and Lewis have been able to produce paralysis and to prove that the nasal mucous membrane contains the virus of this disease. When a properly prepared solution of an excised portion of nasal mucous membrane suspected of containing the virus was injected into the brain of a monkey, it set up characteristic symptoms including the complicating paralysis of poliomyelitic infection. Paralysis also followed the inoculation of the fluid removed from the spinal canal when injected into the brain.

The value of this experimental result is very great in showing that the same path by which infection is introduced into the system through the nasopharyngeal mucosa is followed when the virus is eliminated in reverse order.

As a corollary to this demonstration it would seem desirable to attempt prevention of epidemic infantile paralysis and also of cerebrospinal meningitis by dis

infecting both the nose and mouth in an effort to destroy the secretions in which the infectious excitant of either of these diseases may possibly exist.

The authors state that studies are now being carried on relative to the resistance of this poliomyelitic virus to the disinfecting agents most commonly employed. It is to be hoped that some drug will be found which will kill kill the micro-organisms without at the same time injuring or destroying the delicate structures upon which they live and grow. To this end the much-discussed lactic acid bacilli may yet prove helpful, but of course little or nothing can be said upon this subject until the investigations now under way are completed.

It is likely, however, that not only meningitis and epidemic infantile paralysis are thus conveyed into the system, but that many other infectious diseases also here find a portal of entry, which has hitherto been very generally overlooked. For when one recalls the anatomy of the upper respiratory passages, their great vascularity and the large content of lymphoid and glandular tissue, it can be readily conceived that such a soil is very rich in the essentials for the propagation of disease excitants.

We shall await further reports on this subject with much interest.

Attacks on house disinfection are becoming so frequent that it would not be at all surprising if the medical profession were to reverse present beliefs. Before we knew what were the infecting agents and how they reached us we were like men fighting enemies in the dark. We fired our ammunition haphazard and naturally wasted most of it. Soldiers always riddle a

hill with bullets until they locate the trenches of the enemy and then every shell is exploded where it kills. Similarly we wasted millions of dollars in yellow fever disinfection until we located the enemy entrenched in mosquitoes, and now we ignore everything but these insects. The increasing evidence that infected persons are the main, if not the only ones, who harbor living pathogenic organisms, is the cause of the present discussion. Of course there are some parasites which can retain vitality quite a time after leaving our bodies, but it is undoubted that most kinds perish more or less promptly. The discovery of more and more "carriers" formerly unsuspected, explains those remarkable instances in which "fomites" were formerly believed to live a long time adherent to dead materials, such as clothes and houses. It has been positively proved that certain recurrences of small pox were due to the importation of a new mild unrecognized case and not to infected clothing left over from the previous epidemic. Hence we see an increasing desire to disinfect or isolate persons and not things.

The ineffectiveness of much disinfection is the point made by M. Comby, physician to the Paris Children's Hospital, and the foremost European apostle of the new crusade. He shows that the means used would not necessarily kill the organisms even if they were alive, and that measles and scarlet fever are really transmitted by convalescents. or apparently healthy "carriers." He even presents facts which show to his satisfaction that the desquamated scarlatinal skin is not nearly so often the carrier as we now think-indeed there are doubts as to its virulence at all-but even if it were dangerous the ordinary fumigations and