No doubt the question has suggested itself to many of you that the treatment of this subject would have been much more appropriately undertaken by one of wider experience and longer standing in the profession, but it is the peculiar privilege of youth and inexperience to ask the raison d'être, even of truths which we have come to regard as axiomatic and customs which have grown hoary with centuries of observance. Is the system of making a physician's income from a family or community depend solely upon the amount of sickness occurring in it, the best that can be devised for the mutual interests of both parties concerned? Such practically is our system. Its philosophy might be condensed in the motto, "Millions for Cure, but not one cent for Prevention." The astute Chinese, who were discussing civil service reform when our ancestors were building the reed hut and hurling the flint-tipped javelin, are said to pay their medical attendants regularly as long as they enjoy good health, but to promptly discontinue their remittances on the first appearance of sickness, to resume only on recovery; which no doubt has arisen from their absurdly attempting to live up to a foolish old proverb of ours about "an ounce of prevention."

It seems to me that the weakness of our system lies in this one fact, that it gives us such an exceedingly limited opportunity for what has been well called the practice of preventive medicine. No one thinks of consulting us until they at least "feel unwell," and in many instances not until days, or even weeks of precious time have been wasted or worse, in trying to "wear the trouble off," or in blindly applying every crude remedy which household experience, patent quackery, or superstition can suggest; all because they are "not sick enough to call a doctor"-in other words, don't feel uncomfortable enough to be willing to pay more than the price of a bottle of patent medicine for relief. To such an extent has this habit of delaying been carried, that we often find patients hesitating to call us in just because they are unwilling to admit even to themselves that they are so seriously ill as to need our services. In fact, the abominable phrase "sick enough to need a doctor" has become almost the popular synonym for, at best, a serious indisposition and often a well-developed stage of a possibly fatal disease. The phrase and the feeling

that it represents ought to be obliterated from the speech and thought of every civilized community. Through its influence we are brought face to face with the legitimate result of months or even years of violation of the laws of our being, aggravated by days of neglect or maltreatment, and confidently expected to avert the vengeance of outraged nature and undo the work of years in days or weeks. "If I had only been called sooner," is a sadly familiar phrase in our professional vocabulary. To thus stem or even reverse the current of nature, we are driven to use the most powerful agents, many of them deadly poisons, to call "halt !" in tones which will compel the attention of the most obstinate morbid process, and every few decades a not wholly unnatural wave of popular indignation sweeps over the community, not against itself for living so as to render such drugs indispensable, but against physicians, forsooth, for prescribing them. It was on the crest of such ever-recurring waves that the Hahnemanian, Thompsonian, botanical, hydropathic, and faith-cure manias successively came into popular favor. Thus the mutual confidence and sympathy which should exist between the profession and the public is seriously impaired, and the interests of both suffer in consequence. Would not a system of constant medical attendance, remunerated alike in sickness and in health, enabling us to give advice or treatment just when we see it is needed, even if unasked, and rendering professional counsel, not only in disease, but in health, the first thought, the easiest and most natural thing, the rule instead of the exception; would not such a scheme as this, if practicable, most happily modify the condition of affairs and prove a long step toward securing the health and happiness of the race?

But supposing ourselves installed in full charge of a case, are we even then freed from the perplexities of our financial system? Scarcely even then. How often are we annoyed in the very midst of a serious case, when every shadow of change must be instantly noted and promptly met, by the remark of the family, friends, or even of the patient, that they "can't afford to have us come so often." This, fortunately, is not a very common experience, but all of us can testify that when it does occur it is, to say the least, exceedingly disheartening. When, however, we reach the period of convalescence, another

head of the hydra springs up to confront us:

Really, doctor, I feel so much better this morning that I don't think you need call again until I send for you," is the remark of our wanlipped and languid patient, blissfully ignorant of the hundred and one pitfalls which yet lie between him and health, and we can but submit to his decision or run the risk of being thought anxious to make all we can out of the case, and possibly of having our bill for subsequent services protested. How often are we called in hot haste only to find our patient beyond help, or if we escape this, how frequently does the convalescent, dissatisfied with the slow and uncertain progress he is making, conclude with charming consistency that it is the fault of our treatment, "too much strong medicine," perhaps, and resort to some rival physician, quack, or vender of patent medicines, to whom he ascribes all the credit of the cure! These results are patent to the most unskilled eye; but what a prophecy of evil to come can be read in living letters by the eye of the trained observer in the history of many of these half-cured cases, even when their course and termination may have been perfectly satisfactory to the unsuspecting patient and his friends! How many of our most serious and most obstinate chronic troubles spring directly from the halfremoved result of some acute attack! How often are the germs of evils which will curse generations yet unborn, left lurking in the system, simply because the subject thinks himself cured and doesn't want to make his bill any larger! Of course much of this too-early cessation of treatment is due to a simple aversion to taking any kind of trouble unless spurred on by pain or fear; but would not this tendency be greatly checked by a knowledge on the patient's part that his bill at the end of the year would be just the same whether he took further treatment or not, while other advice or new remedies would be an additional expense; as would be the case under a system of constant attendance?

What influence does our present system of attendance give us over the sanitary surroundings, diet, or habits of life of our patients? Almost none. It is true we have the priceless privilege of giving any amount of excellent advice on these subjects, which they may perhaps remember for a week, though usually they regard it simply as a customary and harm

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less prelude to the prescription, which they regard as the "value received" for their fee. Such an effect has the proportioning of our remuneration to the number of distinct, definite services rendered had upon the ideas of the laity, that many of them have no idea of paying for anything except some such tangible benefit as a prescription or an operation. In some instances we are actually obliged to give a prescription in order to secure the right (in their minds) to claim a fee. They will pay a dollar for a prescription and get the advice thrown in for nothing, and as the immortal "Josh Billings" has sagely remarked, "what people gets for nothing they are mighty apt to value at about what they gave for it." the home life of our patients we have almost no control, or even supervision, until after the mischief (which often might have been averted by a few timely precautions) has been done, and even that ceases almost as soon as we began to exercise it. What sort of success would we expect from a nurseryman who was not permitted to prune his trees until they were already misshapen, to destroy their infesting parasites until the foliage was withered, who was not allowed to water them till they began to droop, or manure them till they were almost exhausted? And yet this is the relation to the bodies of our patients in which we are practically placed by our present system. The words "cobbler and tinker" are terms of reproach, and yet cobbling and tinkering is about all we are permitted to do to the vital mechanisms of most of our patrons.

When we consider this fact in the light of the deliberate statement of Mr. Chadwick, the distinguished English sanitarian, that he can build a city which shall have any required death rate from 3 per 1000 up; when we remember that "the white plague of the North," as Holmes aptly calls consumption, which is responsible for the lion's share of our death rate, is more than analogous to the familiar spindling of plants deprived of air and sunlight; that as much as fifty years ago even a layman like Lord Palmerston declared that for every death from typhoid somebody ought to hang;" that an unfailing specific for malaria, diphtheria, and cholera is contained in a six-inch drain-tile-in short, that nearly one half of our existing diseases are absolutely preventable, does not a readjustment of our relation to the public appear urgently

necessary? How would a system of constant attendance at a fixed sum per year or month, including an annual or semiannual sanitary inspection of the residence and surroundings, and review of the diet and habits of life of the family, if practicable, modify the conditions under which we are now attempting to promote the health of the public? I am well aware that this system at present is generally stigmatized by us as a "quack method," if not a form of quackery itself; but I think even the bad hands into which it has to some extent fallen should not prevent our candidly recognizing and, if worthy, appropriating any feature of value which it may possess. Besides, we must remember that the system, in part at least, is in practical operation in the different lodges and benefit associations, in manufacturing establishments and mines all over the country, with generally eminently satisfactory results regarded from an economic standpoint. Of course the principle upon which all these plans are adopted is a purely economical one, to get the greatest amount of service for the least possible cost; and they could only be expected to be a success in this direction.

The plan which I would respectfully submit is much wider in its scope, and is briefly as follows: That at the beginning of the calendar year each individual or family should engage his or their medical attendant for the next twelve months, agreeing to pay him a specified annual salary in advance, either in full or in quarterly or monthly instalments. The physician on his part should agree to render any and all professional services required, except operations or manipulations requiring the skill and training of a specialist, for the annual consideration specified, which might readily be fixed according to some rate per capita or per familiam laid down in the fee bill. The physician should further agree, in consideration of the sum specified, to make an annual or semi-annual inspection of the sanitary condition of the house and premises of his client, and to offer such suggestions as he saw fit in regard to the diet or habits of life of himself or his family-in short, to act as general adviser on all matters of hygiene or therapeutics. The system might briefly and, perhaps, not inaptly be described as a scheme of "health insurance." What are the advantages which seem to be presented by this plan? In the