the surgeon, the uncollected and uncol- ing does not mean the establishment of lectable bills, the enormous amount of standardized fees, only the establishtime, effort, and money that is or ment of a maximum fee, and that maxishould be spent by the surgeon in the mum subject to increase under justifiprogressive perfecting of his knowl- able circumstances. In the second edge and technic. There is an Ameri- place, money is probably the incentive can tendency to generalize upon a too to expertness more rarely than we narrow basis of facts-a tendency that think. Money may be the incentive is sometimes manifest even in our to vast effort in many enterprises, but centers of higher learning.

it is rarely the dominant incentive in Would surgeons be able to do as the arts or the sciences. And the much free work for the poor if they creative motive of the artist may move were prevented from securing high the big business man more often than fees from patients who can afford to we imagine. Certainly every great pay them? In virtually every edito- physician or surgeon whom I know has rial that has been written on the Johns much of the disinterested passion for Hopkins ruling, every one that has perfection that marks the artist. Any come to my attention, it is assumed attempt upon the part of inferior surthat the general adoption of this ruling geons to make the maximum fee their would mean a marked reduction in common charge would only drive surgeons' free service to the poor. I patients to the superior surgeon. seriously doubt this assumption. The If we may judge the future by the average surgeon is much more priest past, little will come of the Johns than profiteer, and, unless I wholly Hopkins ruling. The thing has been misjudge him, his free work for the widely discussed and tried in Europe, poor would be the last part of his ser- but never successfully. Some years ago vice he would surrender. He would the matter was seriously considered be more likely to recoup through a by the Government, the courts, and general raising of fees in the cases of the scientific bodies of France, but the patients who now pay from one hun- final verdict was an approval of the dred to five hundred dollars for an traditional system. An elaborate regoperation. Only in the event of ina- ulative system was likewise tried by bility to secure from such sources what Russia, but without success. surgeons might regard as an adequate income would the free service to the

& 3 poor be seriously curtailed.

All this makes interesting speculaWould not the very wealthy be the tion, but, as I have said before, these only ones who would be benefited by a matters are of little importance commaximum fee of one thousand dollars? pared with the larger problem of a Again, yes, without a doubt. Would statesmanlike organization of the mednot such a system of standardized fees ical service of the nation. A quit-claim destroy the surgeon's incentive to ex- deed to immortality is awaiting the pertness by enabling the man of lesser physician, surgeon, or statesman who ability to charge the same as his more can think of health in terms of a nation expert colleague? I think not. In instead of a patient, and who can effect the first place, the Johns Hopkins rul- the beginnings of a national health

a

program that will insure to every man, ganization of medical service that will woman, and child in the United States mean a decided break with most of the the full and continuous benefits of the traditions. The finely imaginative best in medical science and service. sort of program that an H. G. Wells or

Let us play with this idea for a a Bernard Shaw might suggest will not moment, tracing out some of its possi- meet our needs. Such adventures in ble implications. It is a ticklish sub- constructive criticism are valuable in ject to discuss if the writer wishes stimulating lay thought, but the to preserve a reputation for careful chance is against their being taken serisanity. Merely to set down in their ously by the medical profession. This relation and in proper perspective sweeping critique I have in mind must suggestions that have been made by be written by some man who sustains the more creative minds in the medical enough of a relation to the medical profession is enough to brand a writer profession to be regarded by physicians as the irresponsible architect of a pri- and surgeons as one of them, a man vate Utopia, if not a dangerous citizen whose sanity and scholarship will comof communistic leanings. But noth- mand their respect. Its author must ing ventured, nothing gained. Here, be above the suspicion of head-line then, are certain suggestions that strike hunting. me as obviously sound. Many of them With the mind of the nation and of I have heard from the lips of eminent the profession shaken into alertness by doctors in moments of critical frank- such a critique, there might develop a ness. Many of them are radical, in- fighting chance for a national health volving a complete reversal of existing program. Such a program must spring practices. Some of them may be im- from a sincere belief that the health of possible of realization, at least of reali- the American people is the most imzation in the immediate future. All portant problem and responsibility of of them are, I hope, challenging, pro- national and state politics. If we vocative of thought.

really appreciated the importance of

national health, as we do not, we might § 4

evolve a new definition of treason. It First of all, I think we need a fresh, was Lord Palmerston, I believe, who comprehensive, and fearlessly truthful suggested that for every death from investigation and critique of the medi- typhoid somebody should be hanged. cal profession, its ethics, its equipment, In some far Utopian future we shall its fee system, its limitations, and its realize that the first test of every inpossibilities. Here and there coura- dustry should be its reaction upon the geous critics are arising in the ranks of health of its workmen. No industry the profession, but it is too much to is profitable to the nation if it shortens expect that any practising physician the lives and stunts the bodies of its or surgeon will cast "discretion" to the workmen, and some day we shall look winds and give us the fundamental upon the head of such an industry as a critique that we must have before the traitor to the state, although he may mind either of the nation or of the pro- be a highly respectable citizen who has fession will be opened to a sympathetic done valiant service in tracking down consideration of a truly national or- radicals who have spoken slightingly of the Constitution. Some day we national health campaign? Inattenshall test every educational system by tion on the part of the average Ameriits reaction upon the health of its stu- can to the simplest rules of sane physident. Its buildings, its curriculum, cal living, and the fact that our doctors its teaching methods, must conspire to are a haphazardly located collection of preserve the student's health while he competitive private tradesmen instead is in school and must teach him to pre- of officers in a national health army serve it after he leaves school. Is it organized to serve the last man, fantastic to think that some day the woman, and child in the country, mean state will see to it that grocers and a greater annual loss of life and reduccooks, before they are allowed to prac- tion of national vitality than alcohol tise their professions, know something ever meant. But passion can make about the relation between the dis- speeches against King Alcohol, wheretribution and preparation of food and as it takes active intelligence to evolve the health of the American family? and execute a national health program. Some day we shall know that an archi

85 tect whose building is not conducive to health is a bad architect despite the When we get around to the organibeauty he may have captured in the zation of a real health service for the lines of his structure.

nation, if we ever do, we shall be The heads of industries that blight forced, I think, to an agreement upon the health of workmen, educators who the following things as essential. forget the body in the training of the First, the virtual elimination of the mind, grocers and cooks who are sales- private practice of medicine, with the men and servants only, architects who substitution of a national health orhave not learned that a building must ganization in which all doctors shall be useful before it can be beautiful in a be servants of the state, with all or a social sense all these will some day be basic part of their income guaranteed. regarded as biologic traitors.

We shall be forced to this if we apply We are far from any such realization intelligence to the health problem not of the importance of health to-day. as a socialistic theory, but as a social We believe all these things theoreti- necessity. Here are some of the concally, but they remain mere intellec- siderations that will force us to this tual beliefs, not rising to the importance conclusion.

, of convictions that move men to act. Under the existing régime of the priWe calmly spend barrels of money in vate practice of medicine we have no the enforcement of prohibition, feeling guaranty that doctors will be wisely quite righteous over the fact that we and strategically located, no guaranty have dared to take such heroic meas- that every community in America will ures in the interest of the health and have access to the medical science and vital stamina of the American people. service that it must have if America is Why can we not harness the power of to keep at its physical maximum. the reforming instinct that achieved To-day doctors locate for practice exprohibition to the broader and more actly as tailors locate for tailoring, in important issue of a national health search of a privately profitable future, army, a national health program, a with the result that many communities

a

are undersupplied, while other com- unselfish doctor who will consciously munities are oversupplied with doc- reduce his income by foisting upon sick tors. In an intelligently organized patients health advice that will tend world only one consideration would to keep them from falling sick again. dictate the location of doctors, namely, And, mark you, he must usually give the accurate supplying of medical this preventive advice as a side issue to counsel and service to every com- medical attention, give it to a sick munity in America, and to every man, patient whose mind, at the moment, is woman, and child in every community. more upon his immediate plight than Some day we shall zone the country for upon the future regulation of his habits. medical purposes, as we have zoned The doctors are not to blame. We are. the country for our federal reserve Our national motto seems to be, banks.

Millions for pills, but not one cent for Under the existing system of the preventive advice. private practice of medicine doctors Under the existing system of the have a “vested interest in ill health” private practice of medicine we have instead of a vested interest in good no assurance that every doctor will health. I am not falling into the spend as much time as he should in facile assumption that doctors habitu- preparation for practice, no assurance ally perform unnecessary operations that after he begins practice he will and prolong sicknesses in order to run keep constantly in touch with the up a bill. I shall leave that libel to latest results of research and experiBernard Shaw, and, stated flatly as he ment, no assurance that he will periodstates it, it is a libel upon the most un- ically refresh his knowledge and perfect selfish set of professional men in the his technic by attendance upon lecworld. But the fact remains that the tures and clinics.

tures and clinics. We are convicted of existing system, in its ultimate out- plain bankruptcy of political intelliworking, does put a premium upon gence by our failure to make it possible disease rather than upon health. In for any and every student of medicine the main, doctors secure their income to spend as long a time as may be necfrom curing sick folk, not from advising essary in study and preparation for well folk how to keep well. The ten- practice, regardless of his personal dency toward retaining doctors as financial resources. It may be said health-advisers is growing, but it is that I overlook the fact that we have a tiny tendency that to-day affects the definite and required standards of total health problem only slightly. preparation in our medical schools, It should be said, in passing, that no that our licensing systems prevent man in America recognizes more fully men from entering the practice of the wasteful insanity of making doc- medicine until they have undergone tors healers of disease rather than pro- the required preparation. I have not tectors of health than does the doctor overlooked that fact. My point is himself. But until we evolve a sys- that the requirements of our medical tem under which doctors are not schools are, even at this late date, conobliged to make their income from ditioned and restricted by the ecoattending cases of sickness, our only nomics of the situation, the amount hope of a healthier nation lies with the of money that students can pay, the

a

amount of money that can be wheedled

86 from private pockets into endowment funds. In the final summing up of the In short, if we faced the health case, the length of time required in problem scientifically, if we loosed ourpreparation for the practice of medi- selves from the dead hand of tradition, cine, the number and quality of men we should district or zone the nation, who serve upon medical faculties, the locate our health army of doctors solely physical equipment of laboratoriesupon the basis of the needs of each and the like, are all, to a greater or less community, relieve the doctor of the degree, determined not by what the necessity of depending upon sickness institution needs, but by what the as a source of income, organize the institution can pay for. In a state medical profession upon the basis of an based upon intelligence instead of intelligent division of labor, with the upon expediency and drift, these things result that the people of every district would be determined only by the or zone would have ready access not health needs of the nation. However only to general practitioners, but to large the necessary funds, they would specialists, for diagnosis and treatment. be supplied by taxation and not wait This access to specialists would not upon the whims of philanthropists. depend, as it now does, upon whether

Under the existing system of the the people of a given community are private practice of medicine most doc- within easy reach of a city. The pertors do not become rich men. Thou- sonnel of the medical staff in each zone sands upon thousands of doctors are or district would be made up of the renot financially able to secure the lat- quired specialists and general practiest information, week by week, from tioners. These specialists would be the great research laboratories. True, required not only to diagnose and treat we have medical journals here and cases of sickness, but they would be abroad, but they are, in the main, required to collaborate with the general private properties run for private practitioner in the periodic physical profit, or by societies which doctors examination of the families he served. join or not as they desire or can af- With such an organization in operaford, and their content as well as the tion we could really launch a national extent of the information they supply war on disease, not only on the manimust be tested by the question, Will festations of disease, but on the causes it pay its way? An intelligent state of disease. Here, if anywhere, we would see to it that every doctor in could find that "moral equivalent of America received weekly bulletins that war” for which the race is searching. contained the latest and most authen- Gorgas trailing yellow fever to its tic reports of the progress of medical endemic home entered upon as thrillscience. Thousands upon thousands ing and as adventurous an undertakof doctors simply cannot afford to at ing as any conceivable military camtend lectures and clinics periodically. paign. A national health army would Again, an intelligent state would see to face just as thrilling and colorful an it that every doctor in America was not undertaking in the United States-an only enabled, but required, thus to re- undertaking that would absorb that fresh his knowledge from time to time. fighting instinct which cynics like to