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BRITISH MEDICAL ASSOCIATION.ANNUAL MEETING AT CARDIFF.

REPRESENTATIVE MEETING : JULY 20TH-23RD.THE annual Representative Meeting of the British

.Medical Association opened at the City Hall, Cardiff,,on Friday, July 20th, with Dr. C. 0. HAWTHORNE inthe chair. The representatives were officially welcomedby the Lord Mayor.

Mr. A. H. Burgess, professor of clinical surgery in- the Victoria University of Manchester, was electedPresident of the Association for 1929-30, and Dr.W. Harvey Smith, of Winnipeg, for 1930-31. Mr.R. G. Hogarth and Sir Robert Bolam were appointedVice-Presidents, in recognition of their services as

President and Chairman of Council respectively.International Obligations.

Much discussion arose on a proposal that theB.M.A. should become a full member of the AssociationProfessionelle Internationale des Medecins (A.P.I.M.),whose object it is to be an international union andbureau for the interchange of information and ideason the social and political aspects of medical practice.The proposal had been rejected by the Council onthe ground that membership would bring to theB.M.A. no advantages which would justify the annual.subscription (.S125) and the demands which would bemade on the time of the medical secretary and hisstaff. The Council expressed its willingness at alltimes to furnish medical associations, national or

international, with any information at its disposal,and several representatives said they thought thiswas sufficient evidence of the desire to help the profes-.sion in other countries. They pointed out that lackof funds already hampered expansion of the B.M.A.’sown work at home and that the expense of belongingto the A.P.I.M. might eventually reach 21000 a year,representing a very large capital sum. Medico-politicalproblems, unlike those of science, were purely national,and must be settled nationally. The A.P.I.M. wasyoung and had no prestige ; to join at this stagewould be a step in the dark. In answer to theseobjections it was argued that the purpose of joiningmight be to give rather than to receive. The new asso-ciation could not thrive unless it was supported, andthe B.M.A. had experience which would be really usefulabroad. Membership of the A.P.I.M. involved noobligation to abide by decisions taken on thecontinent, nor did it commit the B.M.A. to expenditurebeyond the subscription. The great need of the worldwas for international cooperation, and in point of factthere was much to be learnt from the ways in whichother countries dealt with such problems as healthinsurance and the certification of the insane.

These last arguments carried the day, and themeeting instructed the Council to take the stepsnecessary to secure full membership of the A.P.I.M.

Raddotherapy by the Unqualified.Mr. H. S. SOUTTAR,, Chairman of the Science

Committee, proposed :-That the Representative Body express the following

opinion, namely, that in view of the risks to the publicinvolved in the use of electricity and radiation as methods,of treatment by untrained and unqualified persons it is tobe desired (1) that suitable courses of training should beorganised under medical direction for persons who wish toadminister this form of treatment; (2) that persons whohave satisfactorily followed such a course should be entitledto have their names entered on an approved roll ; (3) thatone of the conditions attached to admission to, and main-tenance on, the approved roll should be abstention fromthe treatment of any patient except upon the responsibilityand under the general supervision of a registered medical- practitioner ; and (4) that patients who require electricalor radiation treatment should be referred only to thosepersons whose names are on the approved roll.

He put forward the motion because it was undesir-.able that the public should be misled by the absurdly

optimistic claims made by institutions providingtreatment by ultra-violet rays and electricity. On theother hand, medical men wanted to be able to sendtheir patients to places where suitable treatment ofthis kind could be skilfully given.

Dr. J. F. WALKER thought it unwise that theAssociation should set the seal of approval on anykind of unqualified practice. Could the line bedrawn at chiropodists or herbalists ?—Dr. H. B.BRACKENBURY, Chairman of Council, answered thatthere could be no objection to the establishment of aregister containing the names of persons competent todo certain things, so long as they were prepared todo these things only under the supervision anddirection of registered practitioners. The Associationwould never have opposed the registration of opticianshad they not asserted the right to act as independentpractitioners. The profession had to recognise atthis time of day that there were craftsmen capable ofdoing things that medical men were not prepared to dofor themselves.The motion was carried by a large majority.

Proprietary Medicines and Secret Remedies.The meeting approved a motion by Lancashire and

Cheshire that the Council should " consider theadvisability of resuming the investigation into thecomposition of secret remedies and the publication ofthe results." It was pointed out that a very largenumber of patients were misled by specious advertise-ments in the daily press, and that there was a constantstream of inquiries from doctors concerning the valueof the preparations recommended. The Chairman ofCouncil said that the matter had latelv been con-sidered, and it was thought that the cost might beprohibitive. The old publications could hardly bere-issued in their present form, but if they were revisedit must be done ab initio.The meeting was more impressed, however, by Dr.

J. D’EwART’s reminder that the expense of publica-tion, and even of actions at law, might easily bejustified by what the Association would gain in thepublic esteem by work so obviously useful.

The New National Health Insurance Act.Dr. H. G. DAIN, Chairman of the Insurance Acts

Committee, said that the Minister of Health hadinformed the profession that there was little in theInsurance Bill that concerned their interests, but thefew words affecting them had proved to be veryimportant. The Act of 1924 had said that additionalbenefits should be administered by approved societiesunless they were " in the nature of medical benefits."This clause was omitted from the new Act, and atthe same time new additional benefits had been intro-duced. He proposed the following resolution :—

That it is essential if the medical profession is to take partin the provision of additional (medical) treatment benefitsunder the National Health Insurance Acts that these, as inthe case of statutory medical benefit, shall be administeredin such fashion that the services of the medical profession,who elect to give advice and treatment in connexion there-with, shall not be under the control of any approved societyor societies.

This was passed nem. con., and it was agreed thatthe principle ought to receive statutory recognitionand definition.

Dr. BRACKENBURY said that the new Act gave theapproved societies dangerously wider powers, butthese could only be exercised with the Ministry ofHealth’s approval. The profession preferred protectionby legislation to protection by consultation. The newAct recognised two forms of additional benefit whichhad been separated by an unfortunate accident. Thefirst was payment to a practitioner for treatment oradvice outside the scope of any other additionalbenefit or of medical benefit, under a special schemeapproved by the Minister for the purpose. The secondwas payment to approved charitable institutions (e.g.,clinics) for similar forms of treatment. By law anapproved society could adopt the second of thesewithout adopting the first and thus the position of

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specialists or consultants would obviously be pre-judiced. The Minister had promised to do theutmost in his power to dissuade an approved societyfrom taking such action, but if societies provedrefractory a situation might arise in which theAssociation would have to advise consultants and

specialists to take no part in a particular schemes.Dr. E. R. FOTHERGILL (Brighton) expressed grave

fears that specialists and consultants would lose

practice because the approved societies would tendto make arrangements with hospitals and institutions,and after discussion the meeting unanimouslyaccepted his resolution instructing the C’ouncil to presson the llinistry " the necessity for the adoption orapproval of such regulations and schemes only as arein conformity with the appropriate fundamental

principles." and to take such steps as may becomenecessary to unite the profession against acceptingservice under any other conditions.

Periodical Examination of Iiisitred Persons.Dr. ELIZABETH CASSON, for Windsor, drew attention

to the value of regular medical examinations. Thepresent race of adolescents, who had been inspectedthroughout their school lives, were, she said, farhealthier than their predecessors, or than theircontemporaries from places where such examinationwas not done. A discussion followed in which onespeaker pointed out that regular examination—evenwithout fee-would profit panel practitioners bykeeping their patients away.Mr. E. B. TURNER wished that approved societies

could be induced to look at things in terms of healthand efficiencv instead of R. s. d., and the tendencv ofsome representatives to discuss the financial aspect’wasdiscouraged by others who wished the meeting toexpress a general opinion for the information of thepublic. The following motion was carried by a

large majority :-That in the opinion of the Representative Body the

establishment of periodical medical and dental examinationof all persons insured under the National Health InsuranceActs is urgently called for as an economic proposition, havingregard to the return so to be obtained in health and productiveefficiency ; that every such insured person, when acceptedas a patient on a doctor’s panel, should be by that doctormedically examined and the result of that examinationplaced on record : that preliminary examination shouldapply also to dental examination, when that additionalbenefit is included and avalable under the National HealthInsurance Acts’

Assistant Medical Officers in Mental Hospituls.Dr. J. W. BONE. chairman of the Medico Political

Committee, brought forward recommendations on thepayment of assistant medical officers in mental

hospitals, as set out in the Council’s report. These,he said, represented an attempt to bring the 1915scale up to date, and were submitted for generalapproval. The report received a good deal of criticism,especially from Dr. PETER MACDONALD, who said thatthe proposals had not been discussed with the RoyalMedico-Psychological Association, and might have anunfortunate effect on the present relations betweenthe governing bodies of mental hospitals and theirmedical staffs. They would be taken as interferenceby an outside organisation and if they were appliedmight have the effect of levelling down salaries ratherthan levelling them up.These views gained some support, but the Council

succeeded in getting the general approval it asked forthe proposals, on the understanding that the recom-mendations did not become part of the policy of theAssociation until there had been further negotiationswith the bodies concerned.

Paying Centres for Infant Hygiene.Dr. BONE reported that a deputation had waited

upon the Council from the Association of InfantWelfare and Maternity Centres, and the BabiesClub at Chelsea. The deputation said that there wasa strong feeling that the mothers of the middle-classpublic should be able to get that guidance andinstruction which is provided by the municipal and

child welfare clinics for poorer mothers. Manyprivate’ practitioners, it, was considered. were unableor unwilling to give the kind of instruction required-and there were advantages in having the instructiongiven at a centre by a doctor who had given specialattention to this branch of medical work. assisted bya fully trained nurse. The Council believed, saidDr. Bone, that the ideal was that mothers should beable to look with confidence to their own familydoctor for the guidance required, but he thought itwas no use to say that there ought to be no such centresas the one proposed. They already existed, and theywould be set up in increasing numbers. The Councilhad been asked to say what were the right lines fortheir conduct and therefore put forward a resolutionsaying that the education of mothers was desiiable,that there were already means bv which it could bepartially attained, that the further establishment ofpaying centres should be for the purpose of educationand health propaganda and not for treatment, andthat mothers preferring to avail themselves uf thecentres should do so with the knowledge of thefamily medical attendant.The Council made several other recommendations

on the subject, but opposition from representativesprevented their being considered.-Dr. FOTHERGILLand Mr. E. B. TURNER attacked the principle ofcountenancing clinics for people who could affoidto have a doctor of their own.-Dr. J. W. JOHNSONsaid that young mothers were more and more seekingthe aid of practitioners concerning the upbringingof children, and there was no excuse for lending aidto a misguided scheme of this kind.-Dr. E. A.STARLING deplored the extension of the "

wave ofclinics " from the poorer classes to the richen.—Dr.JOHN STEVENS thought that such a scheme mustlead to overlapping and friction between clinics andpractitioners, and Dr. A. B. MURRAY said that ‘’ ifwe’re not fit to look after the children it’s an end toprivate practice."The Council’s policy was supported by -Alr. BISHOP

HARMAN, Dr. DAIN, and Dr. BRACKENBURY.—Dr.C’HRISTIXE MURELL suggested that not very longago the proposal to establish infant welfare clinicsfor the poor had been looked at askance by theRepresentative Body; was there not a danger ofopposing anything new, because it was new ?

Dr. L. W’. BATTEN spoke convincingly on thedemerits of work at clinics, of which he claimedexperience, and amid enthusiasm the meetingpassed the following resolution, which representedthe view of the Council in 1917 :-That while it fully appreciates the value of any educa-

tional work proposed to be undertaken at paying centres formiddle-class mothers in the way of giving lectures on infantmanagement, it does not approve of these centres providingconsultations and advice in respect of mothers and youngchildren belonging to classes of the community who arequite able to consult their own family doctor.

Maternal Mortality and Morbidity.On a report brought forward by Sir Ew’EX MACLEAN,

as chairman of a special committee. Dr. DAIN saidhe was specially impressed by the fact that betterorganisation would bring about a big reduction ofpuerperal mortality and morbidity. The reportshowed that three-quarters of the mortality could bedone away with by measures of organisation alone,and the success being attained by certain workers inthe slums of large cities ought to be available for theordinary woman. The same view was reflected in

speeches by Dr. JAMES YOUNG (Edinburgh) and Dr.R. C. BuisT (Dundee) who proposed that the Council’srecommendations should be amended to include a

resolution-preceding the others because of its

importance-" that such immediate steps be taken aswill ensure full and cordial cooperation between doctorand midwife." This was approved by the meeting, inconjunction with the following recommendationscontained in the report :-

(2) That steps should be taken to determine by furtherexperimental research : (a) The factors which constituteand the conditions which vary resistance to disease, particu-

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larly as regards pregnancy and the puerperium. (b) The bestspecific prophylactic measure to employ for the preventionof infection by Streptococcus pyogenes. (c) The length oftime required to acquire such immunity and the degree andduration of such immunity. (d) The therapeutic value ofspecific as opposed to antiseptic measures in the treatmentof septicaemia caused by Streptococcus pyogenes.

(3) That increased facilities should be provided fortraining medical students with special reference to antenatalwork.

(4) That a condition of the payment of maternity benefitunder the National Health Insurance Acts should be that themother has had at least one antenatal examination by aqualified medical practitioner during her pregnancy.

(5) That members of the medical profesion should beencouraged to keep regular and careful records of theirmidwifery cases.

(6) That there is need for further provision of bedsspecially set aside for maternity cases in institutions. Thatevery maternity home should provide for the completeisolation of septic cases.

(7) That the Association should consider the allocationof additional grants to promote research into the problemsraised in this report, including especially the questionsraised in the first recommendation of this report.

(8) That a Committee with adequate representation ofpractitioners be set up to formulate measures designed tobring about reduction in puerperal morbidity and mortalityrates, to keep in touch with research work, and to assistdivisions and branches of the Association in arranging foreducation and propaganda with regard to the value ofantenatal service, the method of dealing with confinements,and the post-partum care of the mother and care of theinfant.

Dr. BRACKENBURY, as a Direct Representative onthe General Medical Council, said that the Councilhad been investigating allegations about the inade-quate training of medical students in midwifery.The replies received from teaching institutions hadalmost all been satisfactory. and neither the publicnor the profession need be under any anxiety. Allmedical students were having full opportunity fortraining in this sphere and were liable to a completeexamination. There was no excuse for saying that theregistered practitioner passing through the presentregime was not fully trained for undertaking antenatalwork, and there was no case for taking the matter out Iof the hands of the private practitioner. ,

In the consideration of this subject a certain amountof discussion arose between representatives whothought that the ideal midwifery service consisted ofmidwives assisted by specialists, and those whoregarded the general practitioner as the proper personfor the conduct of labour.

Puyment for Ambulance Lectures.Dr. PETER MACDONALD explained that at York the

profession tried to carry out the B.M.A.’s policy that.ambulance work is a matter of business and not ofphilanthropy. They had found, however, that else-where in the country medical men gave their servicesfor nothing or for an honorarium. This was confirmedby other representatives who told of " blacklegging "

by doctors. It was impossible, they said, to get thefee of one guinea for each lecture-a legitimate fee inview of the trouble involved in keeping up with thehandbooks-so long as medical men were willing toaccept presentation walking-sticks or railway vouchersinstead of their rights. Dr. MILNER MOORE, whoconfessed, at the age of 88, that he had never previouslyaddressed the Representative Body, strongly urgedthat the Association’s policy should be maintainedand observed, and this proved to be the opinion ofthe meeting as a whole.

Compulsion in the Treatment of Venereal Disease.Dr. DAVID LEES, for Edinburgh and Leith, proposed

a motion stating that it was essential that furtherpower should be given to practitioners and localauthorities " with a view to strengthening thevoluntary system by placing a compulsitor ’ on allpersons infected with venereal disease in order tosecure the submission to treatment and continuanceunder treatment of such persons until discharged bya registered medical practitioner." In England, heaid, 63 per cent. of the known cases of venereal diseasefailed to complete their treatment; in Wales the

percentage was 45 and in Scotland 51. In face of thiscould anyone say that the present schemes weresuccessful ? P Few clinicians would say that we werestamping out syphilis ; none would say that we werelessening gonorrhoea. The reasons were two-ignor-ance and carelessness. It was the duty of the profes-sion to dispel ignorance and the duty of the State todiscourage carelessness. The plan of a compulsitoras approved by every local authority and medicalofficer of health in Scotland did not infringe the libertyof any subject who deserved liberty. It only infringedthe liberty of the libertine.

Mr. BISHOP HARMAN thought that compulsionwould drive the disease underground where it wouldbe even more destructive than at present, but Mr.E. B. TURNER, who said he had spent a large part ofhis life in the fight against venereal disease, havingaddressed 987,000 people on the subject, commendedthe trial of a compulsitor in selected districts, as

proposed by Edinburgh, and recommended in theTrevethin Report. Dr. GRAHAM LITTLE, M.P., on theother hand, thought it useless to try compulsionlocally. People would change their place of residence,and in any case defaulting was the least important ofthe problems of syphilis. The wholly untreatedpatient was the real danger to the community, notthe patient whose infectivity had been reduced bybeginning a course of treatment. Dr. BRACKENBURYalso maintained that venereal disease could not possiblybe dealt with by local option ; he would rather seecompulsion over the whole country than in limitedareas, but Dr. LEES explained in his reply that thearea covered by the Edinburgh scheme extendedalmost from the Forth to the Border, which made achange of dwelling, especially in this time of housingshortage, an impossibility for most patients. Thepercentage of defaulters at his own clinic was only26—the lowest in Scotland and perhaps the lowestin the country as a whole. The Representative Body,by passing the resolution, would set a very necessaryexample to Parliament, some of whose medicalMembers had ideas on venereal disease some 20-30years out of date.The motion was lost by a considerable majority.

Miscellaneous Topics.An unsuccessful proposal by South-West Wales that

the Council should try to secure for the profession asupply of petrol (or its homologues) at commercial ratesled to the statement that many garages are willingto make this arrangement with practitioners. SirRICHARD LucE said that medical M.P.’s had decidedthat it would be undesirable to ask for privileges forthe profession as regards the new petrol tax.The Representative Body decided-" That it is undesirable that chiropodists should be

recognised in a special register as such register would conveyto the public that chiropodists were competent to undertakethe diagnosis and treatment of diseases of the feet."A suggestion was put forward that the annual

representative meeting should in future be held inLondon, to deal with medico-political questions so

that the business of the annual meeting held atvarious centres could be restricted to scientific andsocial work and enlarged in scope. But the motioninviting the Council to consider this plan was lost bya large majority. The same fate met proposals toreduce the annual subscription to two guineas, andto investigate the possibility of establishing a com-pulsory scheme of life insurance for all members ofthe Association.A further account of the deliberations of the

Representative Body will be published in a comingissue of THE LANCET. In the course of the proceedingsit was announced that Dr. Hawthorne had beenre-elected chairman for the coming year and that Dr.Arnold Lyndon had been elected deputy chairman.

QUEEN ALEXANDRA MEMORIAL.-It is announcedby the Queen Alexandra National Memorial Committeethat, when the fund was closed at the end of June, the totalamount received exceeded jE233,000.