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in the organization representing the highest type of medical efficiency the world has ever seen, the modern Army Medical Corps, will drop back into their old niches without a ripple?

Does any one suppose that the 66% or 50% not temporarily swept into the paths of military medicine can carry on the medical burden of the country without of necessity adopting sweeping radical changes in every-day medical procedure, most of which must be steps towards socialized medicine?

The conception of free or practically free medical service for the masses, of a type that will not only furnish medical service for the acutely ill, but also medical, institutional and nursing service for the purpose of correcting physical defects, especially those of early life, thus preventing the great loss of national efficiency and productive power that the Nation now suffers from physical inefficiency and preventable illness, is abroad in the land and is rapidly gathering adherents and momentum.

It behooves us as medical men to recognize the existence and rapid growth of this ideal.

It is well to remember that the idea of universal free public schools with compulsory attendance seemed just as revolutionary to our forefathers a hundred years ago, before we dismiss the possibility of this sentiment soon being transformed into a settled national policy.

The facts that can be readily assembled to demonstrate the inefficiency of our present system of disease prevention and care are stunning in their significance, and a people engaged in a life and death struggle for the perpetuation of their national existence and ideals, a struggle that will probably call for the application of the last resources of man power, look at these facts with a deep personal interest such as fifty years of educational propaganda along similar lines in times of peace could never evoke.

Most significant of these facts, the one outstanding fact that at once betrays the shortcomings of our present system of caring for the physical needs of the nation, is the report from the Provost Marshal General's office:

"Of 2,500,000 men of draft age examined for the National Army under the Selective Service Law, 33% were found physically unfit and were rejected."

Any scheme whereby both preventive and curative medical service is proposed to be furnished by the government free, or on a low fee capitation basis, to the great bulk of our population, has certain features which are distinctly repugnant to the medical profession. One device that in practice brings about this result is sickness or health insurance. To most medical men the objections to health insurance from their own standpoint are numerous and grave. Of more serious concern to the Nation as a whole than the preferences or objections of the medical profession is the question of the economic soundness of the scheme. But there is something about the general idea of sickness insurance that appeals. The greatest appeal seems to be to have the other fellow pay for it.

A report recently issued by an organization representing a large proportion of the big employers of labor in the country

says:

"To fail to apply preventive measures to such illnesses, disabilities or conditions as will almost certainly respond and instead to permit them to go uncorrected until the victim becomes a charge on society is absurd. Certainly if the state can contribute to the support of individuals after they become incapable of caring for themselves, it can contribute to prevent them from being incapacitated."

A significant point about this quotation from the standpoint of the physician is the fact that it is put forth by an organization which is economically immensely influential whose proposal is to sidetrack "health insurance" sentiment by adopting and exceeding all the proposals of the proponents of health insurance as regards the furnishing of medical service as a function of the state, while repudiating the cash benefit features of health insurance.

But in either case where does the medical profession get off at? Both the extreme advocates and extreme opponents of health insurance seem to unite on the middle ground of drafting the entire medical profession into the civil service of the govern

I bring these things before you, not to pose as an alarmist, nor as a radical, nor because in all respects I can endorse and be pleased to see these tendencies towards the socializing of medicine growing so rapidly. From many angles I believe that medicine, the public and the Nation would be better off if this tendency could be brought back to the position of even five years ago, but we are in the grip of circumstance.

The times demand desperate social remedies and measures. The wisest thing for American medicine to do is to calmly and patriotically foresee these onrushing readjustments in our profession and to make such sacrifices of its preferences and traditions as the crisis demands.

It becomes our duty to dedicate our entire strength to the service of the Nation no matter how profoundly our future may be changed from our past, or whether our personal destiny leads us to the battlefields of France or the munition plants of Connecticut in our efforts to do our share to make the world "safe for democracy," trusting in democracy's fundamental sense of justice to keep an honorable and reasonably recompensed place for our profession however strangely altered it may emerge from the present social hurricane that sweeps the world.

DISCUSSION.

PROF. C.-E. A. WINSLOW (New Haven): Mr. President and gentlemen : I think it is a great privilege to have listened to this very clear and impressive expression by Dr. Kelley of the great change impending in public and private medicine. As he has pointed out, public health work in this country in the past concerned itself with the surroundings and gradually it is reaching out along the lines of clinics and dispensaries and sanatoria, which used to be the fields of the private practitioners.

We see it perhaps most in the history of medical school inspection. I suppose in 1894 when doctors were first sent into the schools of Boston, if anyone had suggested placing them there to remedy defects of the eyes and teeth he would have been denounced for dangerous socialism. The physicians were sent in to protect the children against each other, to detect early cases of communicable diseases. As soon, however, as the physicians got into the schools they found that communicable disease was a small problem compared with physical defects and they began to devote most of their attention to physical defects; next they found if the detection of physical defects was to be valuable these physical defects

must be cured. So they sent nurses into the homes to get the parents to secure treatment; and when they found that many of the parents were unable to secure treatment, they established school clinics to give it. I think this whole history of school inspection is likely to be repeated in connection with the disease of adult life. It was my privilege to spend last summer in Russia for the American Red Cross and I found that in Russia the historical development has been just the opposite of ours. In Russia they started fifty years ago on state medical service and only recently have those state physicians begun to do preventive public health work. They found there that the only way in which the rural population could receive any medical care was by the state giving it, and so the zemstvos, the provincial and county assemblies, established little two-bed, four-bed, six-bed hospitals all through the country with absolutely free medical service not as a charity but as a duty owed by the state. So we can in this particular learn a good deal from what has been done in the development of Russian medicine. It seems to me the logic of the case is clear. The triumphs of medicine obtained in the last twenty years have been in dealing with typhoid, tuberculosis, infant mortality, and the like, diseases where the problem was handled in a preventive way. What do we learn on the other hand from the statistics of the great group of constitutional diseases? Here there are but scanty achievements to recall, in actual vital statistical terms, in spite of the great medical advance of science. Why? Because it has been applied too late, because you don't get the chance to apply medical science until the patient is so sick that nothing more can be done about it. And that will be the case so long as the initiative rests with the patient and he has to pay for it. Prevention cannot be secured except in rare cases, if it depends on the initiative of the individual. If you are to get cases in the early stages of disease where they can be cured you must get them by some plan where there will be no immediate expense; that is, some plan where the general medical service will be paid for out of the public taxes and each particular treatment will be free. Whether that is coming through state insurance or health insurance or through the tendency to develop board of health clinics, and the like, I don't know. But in some form or other I think that tendency is bound to work itself out if medical knowledge is to be really effective.

DR. BLACK (Hartford): There is not much left to be discussed on this paper after the rare paper of Dr. Kelley and Prof. Winslow's discussion. It is very evident that the new public health is a medical problem, one which circles around the physician and of which the physician is practically the foundation. The new public health so-called is really a matter of medical prevention rather than medical cure. Medical prevention in the minds of the general practitioner and physician carries with it the thought of poor compensation. Physicians by virtue of their profession are more

or less public servants.-Public service in the past has had meagre compensation. The public has to a great extent been an object of charity as far as physicians' services were concerned. As a result, certain of their profession have been backward to undertake public duties for little or no compensation. Fortunately, the new public health with its preponderance of protective measures, the need for physicians will be fully as great as it is now, and their compensation will be as great or greater than it was in the past of curative medicine. I think the various lines of the new public health should be thoroughly considered and studied by physicians, one and all, regardless of some of the bad experiences they have had with the compensation law. I think that the new public health will all work out in the end to the great advantage of the physician and the public.

Dr. Mead (Middletown): I want to ask a word. Why should the medical profession allow the laity to lead in this matter? Why should we sit calmly by until public health legislation is forced upon us? I ask simply for information.

DR. KELLEY (Boston): Some questions are unanswerable, and I think this comes pretty near being in that category. It is pretty difficult to say why the medical profession should allow the laity to take the lead in certain angles of public health development. There are other angles in which the medical profession always has been and always will be in the lead. As to the medical profession as a group, I think we are fundamentally too conservative. I remember a man in the office with me when I used to practice on the Pacific slope reading a life of Pasteur, and as he went over the "scraps" Pasteur had with the medical society in Paris he said, "Well, for all the world in these controversies the attitude of the opposition to Pasteur's new ideas can be translated into the mental reaction of members of our own local medical society." There is always that medical deference to the way it was done in the past. Certainly we lost a great deal when we ignored the possibilities of the logical development of mental therapy and allowed Mary Baker Eddy to come in and so largely preëmpt the field. Certainly we lost a great deal as a profession when we overlooked one thing that the ancient Romans and Greeks knew very well-the value of intelligent and persistent massageand allowed the osteopath to come in and capture it. And I am very much afraid, in the words of Lloyd George we may write "Too late" again over this new crisis that comes to us. It isn't a choice of what we want to do, but when we have fifty per cent of the available personnel of America under arms as we are almost certainly going to have them in a year and a half from now unless some miracle intervenes, we have got to thin out and spread out and turn things upside down, and it would be wise if we spread out and take it into our hands and do it without having some civil administrator thrust it upon us willy-nilly.

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