country that has been criticised severely from certain quarters for its so-called attempts at autocracy is said to be behind the bill, while it is said on the other hand that certain drug and proprietary medicine in terests are opposed to the bill. The present method of the solving of public health problems is certainly not all that it should be but the question is, are the doctors of the United States ready to establish a great central system which shall be the hub of their medical organization and the regulator of their modes and methods of dealing with health problems and the counterpart of other national departments for the proper administration of the public good. The question is being forced upon us and sooner or later we must answer it by bringing influence to bear upon our legislators. Every doctor is entitled to a voice and should inform himself as to the issue. All prejudice should be laid aside and the question studied in the light of past experiences and future needs. It is argued by some that what we need most is a reform in our present system of public health administration. This is not reasonable for we have no system at present. We have a chaotic and almost hopeless confusion, there being so many systems that experts are liable to stop study and count on their fingers when you ask them how many kinds there are. There is the Bureau of Pure Food and Drugs, the Bureau of Chemistry, the Bureau of Animal Industry, of Vital Statistics, of Sanitation, the United States Naval War and Marine Hospital Service, et cetera. Some of these bureaus are under the domination of the Department of War, others under the Department of the Interior, and still others under the Department of Agriculture. Our Department of Agriculture is given about $8,000,000 annually for plants, pigs, cattle, bugs, and beetles, while the millions that have been appropriated in recent years for the building up of our powerful navy has caused endless wonder and approbation on the one hand and a great amount of caustic criticism on the other. There is surely a striking contrast, however, when one considers the small amount that has ever been set aside for biologic research or the search for germs. It is not the intent to depredate the good work of the bureaus above mentioned, nor of the excellent services performed by the U. S. War, Naval and Marine Hospital services; the latter is chiefly concerned with maritime and quarantine measures. In fact, it is not a provision of the Owen bill that either the medical department of the Army or Navy be under the administration of the proposed National Department of Health. There are some that regard the idea of a National Health Department as a purely academic question, and not a good administrative policy, that the time is not ripe yet for a separate cabinet department to be known as the National Department of Health, but that it should come as a process of evolution. Notwithstanding this fact our medical system such as it is, founded at a time when our national life was simple, has nevertheless shown a remarkable elasticity in adapting itself to the ever changing conditions and increased complexity of a rapidly developing age. President Taft when visited by a delegation of eighteen doctors last summer for his opinion regarding a national department of health stated in his most pleasing and versatile manner to the committee that he thought it should be less pretentious and ask merely for a bureau and that later it might be evolved into a department. A Surgeon general of the Marine Hospital Service has gone so far as to say that there were not over two or perhaps three doctors in the whole United States with sufficient administrative ability to preside over such a department. If this were true it would certainly be a sad commentary upon our noble profession. Can an entire profession be so given over to an unending record of faithful services in the pursuance of the proper discharge of the Hippocratic oath that we have developed no administrative ability? Can an entire profession be filled with incompetents? Are all the really able men in the ranks of statesmen and other professions? The function of a National Department of Health should be the human life problem for the preservation and elevation of the human race. It should have entire supervision over the manufacture of all serums and antitoxins. When disease and infection become interstate in character it should be under the supervision of a federal department which should have a jurisdiction similar to the United States courts. The sanitary and engineering problems connected with the question of malarial, typhoid and yellow fever are of too costly a nature ever to be handled by local or state governments working independently of each other and often at cross purposes. No local state legislature can ever protect a state from an infection without its borders and therefore beyond its control. If we trace the course of the streams which flow from Pennsylvania, Connecticut and Vermont waters into New York waters, we can readily see that it will be of no use for us to institute expensive drainage system if a neighboring state neglects similar precautions. The National Government many years ago undertook the maintenance of river and harbor improvement and until it takes hold of the problems connected with the propagation of typhoid fever and the diseases transmitted by the mosquito we shall never be rid of them. National health is national wealth. Great epidemics always hinder the wheels of commerce, if they do not bring them to a standstill altogether. It is impossible at this time to go into details as to the operation or organization of a national department of health. It should propose at least to do three important things. It should have supervision over all means of preventing epidemics and warding off pestilence that are national or interstate in character, the establishment of national hygienic laboratories for the manufacture of curative serum and antitoxins. Second, the supervision of the construction and maintenance of sanatoria for the sufferers from the Great White Plague which carries off 160,000 and upward of people annually. The death rate from cancer is constantly increasing and up to the present time has presented the most baffling problem that the student of human pathology has had to wrestle with. It seems to follow none of the established laws of other diseases. Poverty, alcoholism and vice seem to play no part in its etiology and places it apart from all other known maladies. Its steady increase in spite of all means for fighting it which have been devised by man after patient and painstaking study for years would indicate the necessity of the governmental establishment of laboratories for cancer research. Third, a more or less rigid supervision over state and local health boards having control over the better understood and more common diseases. The apparent advantage of the district visiting nurses established in so many of our large cities especially in connection with tuberculosis clinics for the seeking out and caring for incipient cases of tuberculosis, and the success that has crowned the effort of the department of social service established by the Massachusetts General Hospital has led the writer to predict the establishment in the not too far distant future of subsidiary bureaus of health located at convenient locations according to population. This would eventually put the administration of the local public health on much the same basis as our educational system and its public schools, or our system of maintaining law and order through the various courts and police stations or our postoffice system with its main buildings and distributing stations. All of these systems for the protection and of the well being of the populace have been developed by a process of evolution from a more or less crude state to a complete organization of usefulness. Although we have our hospitals and our free dispensaries, our efficient health boards for the control of infectious and contagious diseases, the masses of the people making up what might be called the middle classes have no proper medical supervision. The hospitals take care of the very ill and the emergency cases, and our free dispensaries supply the needs of the very poor. Dispensaries are abused in many cases as is well known. Even the physicians in attendance serve without pay which is an injustice. In many cases capable young physicians feel forced by necessity to influence clinic patients to visit them at their offices and in that way help to build up practice. Although in many cases there may be no injustice in this, still on the other hand it seems contrary to the purpose for which clinics are created. The public including its many corporate bodies have become so accustomed to the altruistic methods of our profession that in many public events, patriotic celebrations, etc., the medical profession is presumed to furnish its services gratis while nurses, orderlies and the like receive pay. At a recent celebration in the city, the medical men not only served faithfully and ungrudgingly without pay, but were supposed either to go without meat and drink or to get it under humiliating circumstances, while the most ordinary menial left his duties at the tap of the bell to return at his leisure and with ample money supplied him for his needs. Still again, many young physicians well endowed with the ability necessary to make successful clinicians are deterred from gaining their experience in this way, principally because a large amount of valuable time is required, with no money remuneration, the latter being to them often an urgent necessity in the first years after graduation. In consequence the clinics lose what might prove to be valuable men and they are forced out into private practice improperly equipped. On the other hand, incompetent men many times with no proper instinct to make of themselves good clinicians but with a self-supporting income from some source, make up a large proportion of our clinical staffs. Bureaus of health would in a measure obviate this. Each bureau with its own building and its corps of physicians would be the administrative health bureau for the particular neighborhood in which it was located. One or more experienced physicians would be in charge with a dozen or more assistants according to the needs of the locality. These all to be under municipal pay as the whole system would be under the municipal control and supported from the city's funds. The duties of the assistant municipal physicians would be to visit from time to time daily or tri-weekly every family within their district, attend cases of illness where needed, advise regarding sanitation and infection, report cases of violation of law. Conditions and circumstances or cases of illness which they were incompetent to handle would be reported to their superior officers whose duty it would then be to direct and take charge of. A system of promotion according to time of service and ability would also be a part of the system. The admission into the ranks of the physicians attached to the Bureau of Public Health would be by competitive examination. The whole system would be a valuable clinic for the physician before entering private practice, for he would get actual experience in visiting families in their homes which is never gotten in either the dispensary or the hospital. This would in no wise affect the private practitioner or his livelihood. There would always be a demand for the private physician by the better classes the same as we have private tutors although there is a public school system, or that we have private detective agencies as well as a public police system. The whole system would tend to elevate private practice rather than to do it harm. For instance, although the people at large would have a perfect right to apply at a public health station to have a doctor sent to them, the tendency of the people at large would be to seek the services of the private physician if they could afford it. If it were not within their means, then the private physician would not be anxious to have them for a patron. As an embellishment to a public health system such as this, it should be made a misdemeanor not to pay the private doctor since the municipality had provided a means by which medical attendance could be had without pay, just as the state at the present time assigns legal aid to the person without funds, so would the municipality honor the bill of a doctor who had been imposed upon by persons who if they had chosen could have gotten free medical services. The local public health bureaus could also appropriately maintain supervision over practitioners in general, so far as irregular practices and unsanitary septic methods are concerned. It is a lamentable fact that such supervision should be necessary over an honored profession, but when we consider the rank injustices perpetrated by men holding medical diplomas from reputable schools, and licensed by the state, and languishing snugly behind the protecting arm of membership in their county medical societies, then the need of some sort of supervision seems entirely in place. The medical profession should be eager to aid in its own housecleaning. Revocation of licenses similar to disbarment proceedings in the profession of law would seem to be the only practical way to keep the medical profession at the high level it was intended to occupy. Young physicians upon graduating would elect whether they should wish to enter upon private practice at once or enter the ranks of municipal health officers. The advantages to be derived from a system of this kind are so varied and will multiply so fast as the system is elaborated that it is impossible to recapitulate them all. It is said that one of our largest life insurance companies would be willing to pay $10,000,000 if the government would permit them to have in their employ doctors whose sole duties would be to medically supervise the lives of the policy holders, not only in times of sickness but in times of health, prolonging their lives by keeping their healths up to concert pitch, so to speak. If this be good for insurance companies, why would not a similar policy be good for the commonwealth? Only by constant supervision in the home, by studying the needs of the people as to their daily work, their ignorance or their poverty, can the greatest good be accomplished. To get behind the symptoms of disease to the root of all the trouble should be the physician's ideal. Definite aid is given and the patient started on the right track. The immoral are given a new view of life, often the first step in moral reclamation. In the foregoing I have tried to state the case for a national department of health and its subsidiary bodies. The great underlying objection to such a system rests in fear of its power. However simple and unpretentious it starts, there is widespread concern lest once given life it will grow in function and power until it interferes with the liberties of the people. But in its simplest form as a guardian of the public welfare it involves none of these things but gives the fullest measure of protection to the people of the United States, the greatest country in the world. 46 W. 48th St., New York City. AN INTERESTING CASE OF FRIED- BY MARCUS NEUSTAEDTER, M. D., Ph. D. Attending Neurologist to New York University and Bellevue Clinic; and Out-Patient Department of Bellevue Hospital, New York City. There are a number of diseases of the central nervous system whose cause is congenital hypoplasia of certain parts of the 'Presented before the Eastern Medical Society, June 10th, 1910. brain or spinal cord, and one of these diseases, in accordance with modern experience, is the group of hereditary or family ataxias. The Friedreich was the first to recognize a certain form of tabes of an hereditary nature. Two years after Duchenne gave a classical description of locomotor ataxia, Brousse called the congenital or hereditary form of tabes Friedreich's ataxia. main symptom of this disease is an insidious onset of ataxia, that is, starting in the lower extremities and progressing up into the upper extremities, coupled with a loss of patellar reflexes and the absence of sensory and sphincter disturbances. Pathologically Friedreich himself, and according to the investigations of Schultze, found that there was a great degeneration of the posterior columns of the cord. Following Friedreich's exposition of this disease there were reports of other investigators supporting his findings and giving other details of the pathology of this dis ease. In the course of these reports we find cases analogous in the onset and symptomatology to Friedreich's, yet differing from the pathology of that disease in very important points. Nonne reported hereditary ataxias whose pathological condition was congenital hypoplasia of the cells of the cerebellum, and his cases as well as others that came under the observation of P. Marie, were grouped by the latter author, as a special group of the so-called Hérédo-Ataxie-Cerebelleuse. The main symptom of these cases was a progressive ataxia of a cerebellar nature. occurring in families in which the patellar reflexes were rather exaggerated and not absent as in pure cases described by Friedreich. Alongside of that symptom |