to no longer screen such culprits by the system of prudery-so often called professional etiquette. Men and women are afraid of surgery today because they or their friends have been "doped" so many times, and it is even difficult at times to get the consent of families for an operation even though all symptoms indicate its necessity.

The other practice which I want to mention is so called commission business, and although not commonly known among the laity, is no less a curse upon them and is imposed by the medical profession without their knowledge. This business is openly advocated by some men today and by others is said to be a necessary evil. To make the matter absolutely clear, I mean by this, the practice some surgeons have today of offering a percentage of all the work that is sent to them by the referring physicians. Some men give 25 per cent, some 35 per cent and some 50 per cent and the competition has become so keen in this business that some men offer as much as 65 per cent for work sent them. But let me point out just a few things in this practice that are so damaging, are so dishonest and are so dangerous to the health, yes even to the lives of those whom we claim to serve, The medical men who practice this business are not unlike other Americans today and when they have a case that they think needs operation and even though they may think they are honest, It is a great temptation to send their cases where they can get a part of the fee-and the tendency is always to send the cases, where they can get the largest percentage. This as is well known is the most fruitful source of the business of the incompetent surgeon and it might just as well be spoken plainly that if this business could be stopped most of these men would lose most of their business almost immediately. As individuals it might be hard on them, but the public would be benefited and the surgical business would go to those who are more competent to perform the work. The commission business is closely related to the first subject mentioned-namely, too much surgery. If a physician in a small town makes a diagnosis, whether it is accurate or not, and he decides that an operation must be performed, he then decides which surgeon shall do the work, and either calls the surgeon or sends the patient into the city. The surgeon in this business is almost compelled to operate, for if he does not, the physician's judgment is questioned, he gets no rake off and he refuses to send this surgeon any more business. There are other men who will ask no questions and will operate in any case and these are the men who are seemingly winning out in the race.

In any case the health, the life of the patient is jeopardized for the sake of gain.

These things must be remedied, the people have a right to know these things which so vitally concern their pocket books as well as their health and lives, and it is the duty of the medical men to make these things known-for whether they do or not, it will gradually leak out and become known. These things have much to do with the constantly increasing loss of respect in which the profession is held today, and much of it is well deserved. We are in a very real sensé sawing off with great rapidity, the branch on which we sit. A few years ago it was not considered dishonest to accept a railroad pass, but today it is punished by law, and this is surely what will come of the commission business and illegitimate surgery and it will be wise of the profession if they get into the front rank and insist on the prevention of this, the worst kind of graft known to men-before it is forced upon us from the outside.

Discussion by Dr. Hewitt, Friend.

"I am a country practitioner. I am not in favor of the commission business nor in favor of the Mayo Bros.' principles as to the payment for professional services. It has been my experience along this line that the surgeon comes out, sizes up the patient, and charges them according to their wealth. The country doctor often runs the chances of getting what he can out of the case. I believe there should be a legitimate price to be charged for this work and that it should not be based on the wealth of the patient."

Discussion by Dr. Grote, Ponca, Neb.

"This matter of accepting a commission is radically wrong. Any physician, who is willing to act as a hustler for a surgeon, lowers himself or herself as a worker in the science of medicine. The Physician really has the greater responsibility for having made the diagnosis, if the diagnosis is wrong, the physician's reputation suffers, not the surgeon's; the surgeon's fee is entirely disproportionate. I feel that the fees generally paid the physician should be very much larger than they are today, and paid by the patient. The laity should be educated along this line, that the physician's work is just as important a part as that of the surgeon and, therefore, led to realize that the physician is entitled to more for his services than he is paid at the present time."

Discussion by Dr. Louis I. Borglum, Lincoln, Neb.

"I have had some personal experience in this regard. A few years ago, I took my little daughter, then an infant eight weeks old, to Omaha, for consultation. My daughter had a congenital hernia. The pediatrician consulted referred me to a surgeon, who had demonstrated a special truss before the Medical Society. After an examination of the child, the surgeon advised an operation. But when I asked about the truss, he showed me how to make it and the child was cured by its application.

"I think it is high time to do away with surgery for surgery's sake. I think in most cases the physician should decide whether or not surgery is needed and when the decision is made, it is time for the surgeon, not before."

Discussion by Dr. M. L. Hildreth, Lyons, Neb.

"There is a danger I think in this regard and I think the surgeons are beginning to see the light, and during the last few years, they are becoming more conservative. I believe that we can do more by publicity to scare these grafters out of the line, than by any other way. It cannot be regulated by law. I believe that publicity is the only way to clear these people out of the ranks of the surgeons. I do not believe altogether with Dr. Philbrick, as to exposing these troubles of the husband to the wife. I will cite an instance. I had a patient. Both he and his wife, whom he had just infected, used to come to me and both came together. He was a pretty good church fellow, but had seasons of relapse, and in one of these seasons, he became repentant, and told his wife of his trouble. Afterward, he came and told me that he had told his wife. I said that he was a fool to do so, as it could do her no good, and she would not have the same confidence in him any more. After that, I could not talk to him nor to his wife, in each other's presence, as she knew I knew, and he knew I knew, in fact, we all three knew, and I could not talk to the woman, and it was a terrible situation. However, I do believe in the principle and that we should all work together in that direction. The man should be held responsible. But publicity and education of the public are the only ways to clear up this matter, and the education of the boys, should begin early as possible. Regarding the commission business, again, I think the commission taker is as bad as the giver. The physician has not the nerve to steal for himself and he is, therefore, more contemptible than the surgeon, who gives the commission. Sometime ago an Omaha surgeon said to me, "There is but one other surgeon in Omaha, who does not pay commissions, and I am not so sure of him." I am sure that this statement was very much overdrawn, but it is suggestive. Publicity is the solution of the problem. I do not know so well as to the situation in Lincoln."

Discussion by Dr. I. Philbrick, Lincoln, Neb.

"The doctor has struck the keynote of the solution of this problem. The solution is the socialization of medical practice. I feel that some day medical practitioners will be salaried as should all professional men and women. The time is coming when the state will appoint committees to pass on those who are to have surgical operations and will fix the maximum amount to be paid for such operations.

"I wish to say in behalf of the sex to which I belong and which is always the victim of graft in any profession, that I most heartily approve of the doctor's paper. There is only one kind of ethics. I think our so-called medical ethics should be thrown to the winds. We must be honest in our practice, with ourselves, and with our patients. The concealing from our patients of their condition to protect the husbands, should not be done, especially in the venereal diseases. We should tell them the source of that trouble. It may cause trouble and strife in the present, but it will help to establish higher moral ideals in the future."

Discussion by Dr. Robert McConaughy, York.

"I discovered this fact of the commissions through a little personal experience. Of course, these things will not leak out right away. I had taken a patient to a competent surgeon for an operation and while in the hospital, I noticed that another surgeon was doing more surgery than the one I employed. I learned that he was giving large commissions to the other doctors all around there and they were sending him their surgical work. He was a prominent man and considered an honest and well respected person in the community. Now, I think this is an evil and we have to fight it in some way. We have got to get rid of it."

Discussion by Dr. Inches, Scribner.

"All Hail! Hail these words of Dr. Hiltner. But what did I hear someone say in the discussion? What are you talking, Socialism? This thing is

all over our country and touching every phase of life. It is a question of ethics after all. It is the question of what the human mind is reaching out for and what they are all after-the almighty dollar! There is no use in attacking the specialists. We are all in the swim. We pay as much as the other fellow. We must bear with the doctor. Don't ever talk of the state's regulating the prices. The paying of commissions can not be stamped out by legislation. It is like attempting to do away with the Merry Widow Hat. It is here to stay and legislation will do no good. It can't be done. Don't talk of the state's regulating the prices, it is a matter of ethics after all."

The Value of the Ehrlich-Hata Remedy "606" in Syphilis. By E. J. ANGLE, A. M., M. D., Lincoln, Neb.

In the year 1852, the duality of the Chancre and Chancroid was established. For a period of fifty years, little or no advancement was made in our knowledge of Syphilis. In 1903, Metschnikoff and Roux succeeded in inoculating the higher apes with Syphilis. This in turn stimulated research for the cause and when Schaudinn and Hoffmann, in 1905, announced the Spirochaeta Pallida, the diagnosis was placed on a scientific basis. In 190 7the Bordet-Gengou complement-fixation test was applied to Syphilis by Wassermann. This with the dark field illuminator and various staining methods, gave us complete means for diagnosis. The discovery of a more potent remedy only remained to make this grand pageant of discoveries complete, and this Prof. Ehrlich has done in dioxydiamidoarsenobenzol dihydrochloride. The announcement to the profession was made on June 22, 1910, by Alt Schreiber and Wechsel

mann.

It having been definitely established that Syphilis with many others, was a protozoan disease, Prof. Ehrlich received the inspiration for extensive studies in these affections. Immunotherapy by the use of vaccines and serums, which is so successful in many bacterial diseases, was seen to be inapplicable to the protozoan group. This led Ehrlich to search for some chemical agent which would destroy the parasites with a single injection, without any toxic effect on the organism. The ideal remedy would be a substance which, when introduced into the circulation, would direct its activity against the parasites and not against the anatomical elements of their host, or in other words, a remedy with a parasitotropic value of 100 and with an organotropic value of 0.

Not only for practical reasons is the sterilization with one dose of a powerful drug preferable, but also theoretically, it seems best for the trypanosomes in time develop a toleration of drugs, i. e., immunity. Prof. Ehrlich has a strain of trypa

nosomes in his laboratory, which has been "arsenfast" for four years. This explains satisfactorily why our treatment in the past, with mercury, occasionally failed. The treatment in the early period has been mild, where it should have been intensive, and finally the parasites become immune to the medication. The virulence of certain strains of infection may be due to a toleration of mercury in their preceding host.

Chemistry—

"606" is the dihydrochloride of dioxydiamidoarsenobenzol.* It forms salts with both acids and strong alkalies. It occurs as a sulphur-yellow powder which is highly unstable and comes. in sterile, sealed, glass, vacuum bulbs. It is soluble in water, resulting in decomposition with the liberation of hydrochloric acid. If the free acid is neutralized with an alkali the base is liberated in the form of a flocculent suspension.

Animal Experiments

Michaelis experimented with monkeys and found the enormous dose of 0.15 gm. per kilogram without poisonous effects, while one-thirtieth of this dose, caused the spirochaetae to disappear. The difference between the e;cient dose and the lethal dose is significant and gives "606" its great practical value. Hata, injected "606" into rabbits and found that within fortyeight hours all spirochaetae had disappeared from large primary sores and these ulcers quickly healed afterwards. He found that the Wassermann promptly became negative. It was only after these animal experiments that Wechselmann began an investigation of the new remedy at the Rudolf Virchow Hospital. Hesitating to use the compound in any except doomed cases of syphilis, he first used it in Syphilitic Pemphigus of the new born. The entire body literally swarms with the spirochaetae in these cases and the outcome is nearly always fatal. The results were striking and many of the infants were saved. Dosage

The amount of metallic arsenic in a 0.5 gm. dose according to Blaschka is 2.63 grains. Doses of 1.0 gm. have been given with no untoward effects. In general the dose depends upon the age of the patient, method of administration, length and severity of the infection. Doses of 0.002 gm. are suitable for babies of five to six weeks, although Ehrlich does not recommend its administration to children under one year-not that the remedy is dangerous per se or that death results from its direct action, but from the endotoxins liberated from the in