the surgeon, the uncollected and uncollectable bills, the enormous amount of time, effort, and money that is or should be spent by the surgeon in the progressive perfecting of his knowledge and technic. There is an American tendency to generalize upon a too narrow basis of facts-a tendency that is sometimes manifest even in our centers of higher learning.

Would surgeons be able to do as much free work for the poor if they were prevented from securing high fees from patients who can afford to pay them? In virtually every editorial that has been written on the Johns Hopkins ruling, every one that has come to my attention, it is assumed that the general adoption of this ruling would mean a marked reduction in surgeons' free service to the poor. I seriously doubt this assumption. The average surgeon is much more priest than profiteer, and, unless I wholly misjudge him, his free work for the poor would be the last part of his service he would surrender. He would be more likely to recoup through a general raising of fees in the cases of patients who now pay from one hundred to five hundred dollars for an operation. Only in the event of inability to secure from such sources what surgeons might regard as an adequate income would the free service to the poor be seriously curtailed.

Would not the very wealthy be the only ones who would be benefited by a maximum fee of one thousand dollars? Again, yes, without a doubt. Would not such a system of standardized fees destroy the surgeon's incentive to expertness by enabling the man of lesser ability to charge the same as his more expert colleague? I think not. In the first place, the Johns Hopkins rul

ing does not mean the establishment of standardized fees, only the establishment of a maximum fee, and that maximum subject to increase under justifiable circumstances. In the second place, money is probably the incentive to expertness more rarely than we think. think. Money may be the incentive to vast effort in many enterprises, but it is rarely the dominant incentive in the arts or the sciences. And the creative motive of the artist may move the big business man more often than we imagine. Certainly every great physician or surgeon whom I know has much of the disinterested passion for perfection that marks the artist. Any attempt upon the part of inferior surgeons to make the maximum fee their common charge would only drive patients to the superior surgeon.

If we may judge the future by the past, little will come of the Johns Hopkins ruling. The thing has been widely discussed and tried in Europe, but never successfully. Some years ago the matter was seriously considered by the Government, the courts, and the scientific bodies of France, but the final verdict was an approval of the traditional system. An elaborate regulative system was likewise tried by Russia, but without success.

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All this makes interesting speculation, but, as I have said before, these matters are of little importance compared with the larger problem of a statesmanlike organization of the medical service of the nation. A quit-claim deed to immortality is awaiting the physician, surgeon, or statesman who can think of health in terms of a nation instead of a patient, and who can effect the beginnings of a national health

program that will insure to every man, woman, and child in the United States the full and continuous benefits of the best in medical science and service.

Let us play with this idea for a moment, tracing out some of its possible implications. It is a ticklish subject to discuss if the writer wishes to preserve a reputation for careful sanity. Merely to set down in their relation and in proper perspective suggestions that have been made by the more creative minds in the medical profession is enough to brand a writer as the irresponsible architect of a private Utopia, if not a dangerous citizen of communistic leanings. But nothing ventured, nothing gained. Here, then, are certain suggestions that strike me as obviously sound. Many of them I have heard from the lips of eminent doctors in moments of critical frankness. Many of them are radical, involving a complete reversal of existing practices. Some of them may be impossible of realization, at least of realization in the immediate future. All of them are, I hope, challenging, provocative of thought.

First of all, I think we need a fresh, comprehensive, and fearlessly truthful investigation and critique of the medical profession, its ethics, its equipment, its fee system, its limitations, and its possibilities. Here and there courageous critics are arising in the ranks of the profession, but it is too much to expect that any practising physician or surgeon will cast "discretion" to the winds and give us the fundamental critique that we must have before the mind either of the nation or of the profession will be opened to a sympathetic consideration of a truly national or

ganization of medical service that will mean a decided break with most of the traditions. The finely imaginative sort of program that an H. G. Wells or a Bernard Shaw might suggest will not meet our needs. Such adventures in constructive criticism are valuable in stimulating lay thought, but the chance is against their being taken seriously by the medical profession. This sweeping critique I have in mind must be written by some man who sustains enough of a relation to the medical profession to be regarded by physicians and surgeons as one of them, a man whose sanity and scholarship will command their respect. Its author must be above the suspicion of head-line hunting.

With the mind of the nation and of the profession shaken into alertness by such a critique, there might develop a fighting chance for a national health program. Such a program must spring from a sincere belief that the health of the American people is the most important problem and responsibility of national and state politics. If we really appreciated the importance of national health, as we do not, we might evolve a new definition of treason. It was Lord Palmerston, I believe, who suggested that for every death from typhoid somebody should be hanged. In some far Utopian future we shall realize that the first test of every industry should be its reaction upon the health of its workmen. No industry is profitable to the nation if it shortens the lives and stunts the bodies of its workmen, and some day we shall look upon the head of such an industry as a traitor to the state, although he may be a highly respectable citizen who has done valiant service in tracking down radicals who have spoken slightingly

of the Constitution. Some day we shall test every educational system by its reaction upon the health of its student. Its buildings, its curriculum, its teaching methods, must conspire to preserve the student's health while he is in school and must teach him to preserve it after he leaves school. Is it fantastic to think that some day the state will see to it that grocers and cooks, before they are allowed to practise their professions, know something about the relation between the distribution and preparation of food and the health of the American family? Some day we shall know that an architect whose building is not conducive to health is a bad architect despite the beauty he may have captured in the lines of his structure.

The heads of industries that blight the health of workmen, educators who forget the body in the training of the mind, grocers and cooks who are salesmen and servants only, architects who have not learned that a building must be useful before it can be beautiful in a social sense-all these will some day be regarded as biologic traitors.

We are far from any such realization of the importance of health to-day. We believe all these things theoretically, but they remain mere intellectual beliefs, not rising to the importance of convictions that move men to act. We calmly spend barrels of money in the enforcement of prohibition, feeling quite righteous over the fact that we have dared to take such heroic measures in the interest of the health and vital stamina of the American people. Why can we not harness the power of the reforming instinct that achieved prohibition to the broader and more important issue of a national health army, a national health program, a

national health campaign? Inattention on the part of the average American to the simplest rules of sane physical living, and the fact that our doctors are a haphazardly located collection of competitive private tradesmen instead of officers in a national health army organized to serve the last man, woman, and child in the country, mean a greater annual loss of life and reduction of national vitality than alcohol ever meant. ever meant. But passion can make speeches against King Alcohol, whereas it takes active intelligence to evolve and execute a national health program.

When we get around to the organization of a real health service for the nation, if we ever do, we shall be forced, I think, to an agreement upon the following things as essential.

First, the virtual elimination of the private practice of medicine, with the substitution of a national health organization in which all doctors shall be servants of the state, with all or a basic part of their income guaranteed. We shall be forced to this if we apply intelligence to the health problem not as a socialistic theory, but as a social necessity. Here are some of the considerations that will force us to this conclusion.

Under the existing régime of the private practice of medicine we have no guaranty that doctors will be wisely and strategically located, no guaranty that every community in America will have access to the medical science and service that it must have if America is to keep at its physical maximum. To-day doctors locate for practice exactly as tailors locate for tailoring, in search of a privately profitable future, with the result that many communities

are undersupplied, while other communities are oversupplied with doctors. In an intelligently organized world only one consideration would dictate the location of doctors, namely, the accurate supplying of medical counsel and service to every community in America, and to every man, woman, and child in every community. Some day we shall zone the country for medical purposes, as we have zoned the country for our federal reserve banks.

Under the existing system of the private practice of medicine doctors have a "vested interest in ill health" instead of a vested interest in good health. I am not falling into the facile assumption that doctors habitually perform unnecessary operations and prolong sicknesses in order to run up a bill. I shall leave that libel to Bernard Shaw, and, stated flatly as he states it, it is a libel upon the most unselfish set of professional men in the world.

But the fact remains that the existing system, in its ultimate outworking, does put a premium upon disease rather than upon health. In In the main, doctors secure their income from curing sick folk, not from advising well folk how to keep well. The tendency toward retaining doctors as health-advisers is growing, but it is a tiny tendency that to-day affects the total health problem only slightly. It should be said, in passing, that no man in America recognizes more fully the wasteful insanity of making doctors healers of disease rather than protectors of health than does the doctor himself. But until we evolve a system under which doctors are not obliged to make their income from attending cases of sickness, our only hope of a healthier nation lies with the

unselfish doctor who will consciously reduce his income by foisting upon sick patients health advice that will tend to keep them from falling sick again. And, mark you, he must usually give this preventive advice as a side issue to medical attention, give it to a sick patient whose mind, at the moment, is more upon his immediate plight than upon the future regulation of his habits. The doctors are not to blame. We are. Our national motto seems to be, Millions for pills, but not one cent for preventive advice.

Under the existing system of the private practice of medicine we have no assurance that every doctor will spend as much time as he should in preparation for practice, no assurance that after he begins practice he will keep constantly in touch with the latest results of research and experiment, no assurance that he will periodically refresh his knowledge and perfect his technic by attendance upon lectures and clinics. We are convicted of plain bankruptcy of political intelligence by our failure to make it possible for any and every student of medicine to spend as long a time as may be necessary in study and preparation for practice, regardless of his personal financial resources. It may be said that I overlook the fact that we have definite and required standards of preparation in our medical schools, that our licensing systems prevent men from entering the practice of medicine until they have undergone the required preparation. I have not overlooked that fact. My point is that the requirements of our medical schools are, even at this late date, conditioned and restricted by the economics of the situation, the amount of money that students can pay, the

amount of money that can be wheedled from private pockets into endowment funds. In the final summing up of the case, the length of time required in preparation for the practice of medicine, the number and quality of men who serve upon medical faculties, the physical equipment of laboratories, and the like, are all, to a greater or less degree, determined not by what the institution needs, but by what the institution can pay for. In a state based upon intelligence instead of upon expediency and drift, these things would be determined only by the health needs of the nation. However large the necessary funds, they would be supplied by taxation and not wait upon the whims of philanthropists.

Under the existing system of the private practice of medicine most doctors do not become rich men. Thousands upon thousands of doctors are not financially able to secure the latest information, week by week, from the great research laboratories. True, we have medical journals here and abroad, but they are, in the main, private properties run for private profit, or by societies which doctors join or not as they desire or can afford, and their content as well as the extent of the information they supply must be tested by the question, Will it pay its way? An intelligent state would see to it that every doctor in America received weekly bulletins that contained the latest and most authentic reports of the progress of medical science. Thousands upon thousands of doctors simply cannot afford to attend lectures and clinics periodically. Again, an intelligent state would see to it that every doctor in America was not only enabled, but required, thus to refresh his knowledge from time to time.

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In short, if we faced the health problem scientifically, if we loosed ourselves from the dead hand of tradition, we should district or zone the nation, locate our health army of doctors solely upon the basis of the needs of each community, relieve the doctor of the necessity of depending upon sickness as a source of income, organize the medical profession upon the basis of an intelligent division of labor, with the result that the people of every district or zone would have ready access not only to general practitioners, but to specialists, for diagnosis and treatment. This access to specialists would not depend, as it now does, upon whether the people of a given community are within easy reach of a city. The personnel of the medical staff in each zone or district would be made up of the required specialists and general practitioners. These specialists would be required not only to diagnose and treat cases of sickness, but they would be required to collaborate with the general practitioner in the periodic physical examination of the families he served.

With such an organization in operation we could really launch a national war on disease, not only on the manifestations of disease, but on the causes of disease. Here, if anywhere, we could find that "moral equivalent of war" for which the race is searching. Gorgas trailing yellow fever to its endemic home entered upon as thrilling and as adventurous an undertaking as any conceivable military campaign. A national health army would face just as thrilling and colorful an undertaking in the United States-an undertaking that would absorb that fighting instinct which cynics like to