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SPECIAL ARTICLES

BRITISH MEDICAL ASSOCIATION.

ANNUAL MEETING IN LONDON.

PROCEEDINGS OF THE REPRESENTATIVE BODY.

(Concluded from p. 209.)

Dr. H. B. BRACKENBURY put four points before themeeting, having reference to conditions under thenew Local Government Act.

Effects of Local Government Act.

First, he asked, what could the local authorities doto further the Association’s policy of unification ofhealth services ’? On April 1st the vaccination andinfant life protection services had been handed overby the poor-law authorities to the care of the publichealth authorities. Certain services had receivedpermission from the new authorities for administrationunder other Acts than the poor-law; for example,some pauper children would be dealt with under theEducation Act, and others, who were blind, under theBlind Persons Act. The new authorities were alsoat liberty to appropriate poor-law institutions forpublic health purposes. In addition, every local Iauthority had appointed a public assistance committee, iand could delegate to this committee its poor-lawfunctions, both advisory and executive. The publichealth committee might in turn delegate part of itswork to other committees ; pauper mentally deficientchildren, for example, could be handed over to thecommittee for mental deficients. Dr. Brackenburynext spoke of the position of district medical officers.It was proposed that the Association should ask thatwhole-time officers, apart from exceptional circum- i

stances, should not be engaged in domiciliaryattendance on the indigent poor. These patients,it was felt, should come under the care of generalpractitioners, or part-time officers, for two reasons :in order that the patient might have the advantageof a free choice of practitioner, and so that no oneneed be under the stigma of " having to have the

Ipoor-law doctor." IThe third subject raised was representation on

local authorities. The law prohibited any person inthe employment of a local authority from being amember of that authority. The result of this wasthat it was gradually becoming more and moredifficult for any member of the medical professionto be engaged in public work, and this was not anadvantage from the point of view of the community.Some arrangement should be sought with the Ministryof Health to effect a change in the law.The speaker’s fourth point concerned the super-

annuation of those poor-law medical officers who lefttheir posts on April lst. Up till that time many ofthem had been members of their local authorities,but under the new Act they were forced to resigneither their membership or their office. Thosewho had chosen to continue their public work, andto leave their medical post, lost all their savingsunder the superannuation scheme to which they hadbeen contributing compulsorily for years. Yet, hadthey been dismissed for misconduct, their moneywould have been refunded to them. The numbers iwho had suffered in this way were few, but theinjustice was a striking one. The Association hadsucceeded in placing a one-clause Bill before Parlia-

ment, but it had not been pushed. It was desirable-that public opinion should be brought to bear to getthe Bill passed.

Dr. H. KERR expressed the thanks of whole-time medical officers to the Association for opposingthe first draft of the poor-law order. Under thisdraft the medical profession had been subordinate tothe public assistance officer. The recall oi thisclause, and substitution of less objectionable terms,had been due to the Association.

Medical Patents.

In the absence of Dr. ARNOLD LYNDON, Dr.R. LANGnor-Dowrr introduced the subject of patentshis motion being that it was ethically undesirable fora registered medical practitioner to derive financial1benefit from the sale of the rights or from royalties.for any invention or discovery in the medical fieldwhich he might make. The Council had beenapproached by two outside bodies for a ruling onthis point. One of these, an industrial body, theAssociation of British Chemical Manufacturers, wasanxious to know whether the attitude of the medicalprofession had changed ; it had always been taken

I for granted that medical practitioners were opposedto any monopoly implied in patenting. In 1927 an

opportunity had occurred for testing this attitudewhen insulin was patented and handed over to thecontrol of the Medical Research Council. Theprofession had always used strong expressions againstprivate patenting in the past, and would doubtlessstill object to monopoly, secrecy, and hindrance toresearch. On the other hand, practitioners wouldbe equally anxious to be free of any charge of hindranceto industry or commercial research. It t wouldprobably be possible to dedicate a patent compulsorilyto a public patents trustee. Practitioners mightconsider that the time had come to sweep away allrestrictions on private patenting, but if it was feltto be undesirable to abolish this 300 year-old principle,an amendment on the lines indicated might beconsidered. This was a matter for the profession asa whole ; the General Medical Council was concernedwith medical education, the maintenance of theRegister, and the indication of the low line of medicalconduct.

Patenting tended to produce secrecy in the worker,it did not encourage the early publication of results,and it fostered haste and rivalry of an undesirablekind, rather than the scientific detachment requiredfor research. Moreover, it gave the great reward tdthe man who laid the last brick on an edifice whichmight be the work of many. Though intended to-

safeguard the public from the dangers of monopoly,the approach for the removal of an abused patent,could not be made for three years. It was unlikelythat anyone would wish to patent a discovery of aclinical nature, but a person working in the chemicalor biological world could scarcely occupy the clinicalfield as well, and his discoveries would verge on thecommercial. There was now an opportunity forrelaxation and adjustment so as to give some freedomof patenting and to safeguard against undue monopoly..

Dr. E. GRAHAM LITTLE proposed that the motionshould be referred back to the Council for further-consideration. The Council appeared to agree thatsome form of patenting must be considered, and to beinquiring, merely, into the best way to do it. Th&

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Association could not direct the attitude of the

profession, but could only lay down rules for members.In answer to a private inquirer, the President of theGeneral Medical Council had expressed the view that.a discovery or invention should be made availablefor the public good, and that the name of the discoverer- or inventor should not be associated with it in orderto acquire patients. But it seemed unfortunate tomake a separation between the medical professionand other men, and to rob the doctor of a right which.any other member of the community was in a positionto demand.

Mr. H. S. SOUTTAR seconded the proposal to referthematter back to the Council. A new situation hadarisen, he said, requiring consideration. There wasno question but that patents must be taken out ; thequestion was who should take them out. At presentpatents could be taken out in Germany for chemical-preparations invented in England, with the result thatEnglish manufacturers could not use them. Thechief value of patents would be to protect this countryagainst a foreign monopoly. A patent did notmean secrecy ; indeed the condition on which itwas granted was that the inventor should publishthe method of production in detail. It was, in fact,a guarantee against monopoly, secrecy, and hindrance,to research. He had himself never taken out patentsfor the plain reason that there was nothing to begained by it as far as he was concerned. But he had- consulted two medical men of first-class ability,researchers on certain organic chemical compounds.One had produced hundreds of preparations for thetreatment of a tropical disease ; but without theopportunity to patent them he gained no financialrecompense for his labours. In these circumstancesit was impossible to find a manufacturer to take upthe production of preparations which might becomethe monopoly of foreign firms. This type of workdeserved recompense-it required a very highstandard of ability. He dissociated himself from theidea that these men should not engage in clinicalwork for contact between clinical and laboratorywork should be encouraged, nor should the professiondisparage the man who tried to make a living fromlaboratory work. Dedicated patents had been

suggested to solve this problem ; these were excellentfrom the point of view of the manufacturer, but lesssatisfactory to the medical man, who would receiveback what the public trustee thought fit-a doubtfulprivilege. As an example of the possible results hecited the case of the inventor of the trench mortar

during the late war, who spent f:l4,000 on its

production ; this sum he recovered from the nationafter much litigation, but 18 per cent. of it was

immediately reclaimed in income-tax. He endedwith a loss of several thousands of pounds. The

point was of great importance to the individualmedical man, and should be referred back to theCouncil.

Dr. F. TEMPLE GREY suggested that as there hadbeen an unwritten law on this point for 300 years it

might as well remain unwritten. Why should notthe matter of patents be left to each man’s judgmentand taste ? z? Many of the points put forward againstpatents were covered by Act of Parliament ; it wasrequired that preparations should be put on the marketat the lowest possible price, and that the inventorshould receive due reward. There was nothingdisgraceful in a patent, and no one ought to be removedfrom the Register for taking one out. The term had’been confused by the issue of so-called " patentmedicines," which, in fact, were never patented, andof which the composition was kept a secret. The

proposal to refer the matter back to Council receivedfurther support from Dr. NOEL WATERFiELD, andthis course was approved by the meeting. A furthermotion to refer back to the Council a section ondedicated patents was also carried.

’, Fees for Midwifery.I Dr. J. W. BONE introduced the Council’s proposalsfor changes in the existing scale of fees paid by localsupervising authorities in cases where medical

practitioners are called in on the advice of midwives.The present scale, he said, came into force on Jan. 1st,1923 ; all the fees were inadequate, but in the pasthe had been unable to persuade the RepresentativeBody to do more than say so. The departmentalcommittee had now thought it time to revise the fees,and the Council had asked for certain alterations.These were : that the fee of the doctor for attendingparturition should be raised from f:2 2s. to f:3 3s. ; ;that the fee for attendance of mother and child at thedoctor’s surgery should be raised from 2s. 6d. to3s. 6d. that there should be no payment of -a fee forservices performed by the doctor after the tenth dayfrom his first visit unless he had reported to the localauthority that he considered, for reasons stated, thatfurther attendance was necessary, or unless he wascalled in by the midwife under her statutory rule; and,finally, that the provisions for payment of a fee forvisits to the mother other than attendance at labouror miscarriage, for mileage, and for attendance ofthe mother at the surgery, should also cover ante-natal examinations. The Council had asked for asmuch as was deemed advisable, and it would beunwise to go beyond a scale which the Associationmight reasonably expect to obtain.

In the discussion which followed the inadequacy ofthe old, and even of the revised scale, was stressed.

Dr. H. W. POOLER, speaking of post-partumhaemorrhage, said that no doubt the local authoritiescould find practitioners to attend cases for a guinea,but that no doctor went to such a case because of thefee. The reasons for his attendance could not beassessed in money. A differentiation between thefee for adherent and the fee for retained placenta hadbeen discussed in his division, but it was felt that itwas not easy to draw a dividing line which wouldsatisfy public opinion.-Dr. BONE, in answering thesecond point, said if the onus of the decision werethrown on the practitioner, the adherent placentarate would go up.Amendments to the scale of fees followed each other

with such rapidity that they had almost the air ofbeing auctioned from the chair.-An amendmentproposed by Dr. C. H. PANTING for South-WestEssex finally carried the day in a slightly modifiedform, as follows :-Fee for removal of adherent placenta involving exploration

of the uterus, including all subsequent necessary visitsduring the first ten days, inclusive of the day of birth,22 2s.

This fee not to be payable when the fee of 23 3s., for attend-ance at parturition and subsequent visits during the firstten days, is payable.Fee for suturing the perineum, for the treatment of post-

partum haemorrhage, for removal of retained placenta,or for any other operative procedure arising directly fromparturition, including all subsequent necessary visits duringthe first ten days, inclusive of the day of birth, 21 Is.

This fee not to be payable when either the 22 2s. fee orthe .S3 3s. fee already mentioned in the amendment werepayable.

Another proposal was made by Dr. A. S. WILSON(for Holland, Lines.) providing that the fee forattendance at or in connexion with an abortion or

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miscarriage, including all subsequent visits during theten days from and including the first visit, should beraised from 1 Is. to E2 2s., and this was also carried.The other suggestions put forward by the Council

were allowed to stand.

Birth Control.A motion was introduced by Dr. BoE, that in the

opinion of the Representative Body, where advice onbirth control was given at any maternity and childwelfare centre (voluntary or municipal) it should begiven on medical grounds only, and at the discretionof the medical officer in connexion with any individualcase, and not merely because it was asked for by thepatient.-This met with disapprobation from Dr.

LANGDON-DowN, who thought it a gratuitous andpernicious invasion of medical liberty. The phrasing,moreover, was ambiguous ; what was the meaning of" medical grounds," and did " advice " mean adviceon principle or method The doctor should haveabsolute liberty to dissuade the patient, or to urgebirth control, and to suggest the method he thoughtbest when necessary.-Dr. FOTHERGILL said that inHove the Labour Party had been trying to establishthat every woman who desired knowledge of contra-ception should have right to attend maternitycentres ; this would include single women. He agreedthat the patient should not determine whether shewas to receive information. It was not fitting thatanyone should have the right to dictate to membersof the medical profession what advice they shouldgive to their patients.

Dr. G. JONES (Lewisham) considered that theunmarried woman had every right to receive infor-mation if she desired it. To withhold informationwould not make her chaste, and if she was determinedto practise contraception she should be taught thebest and safest methods. The alternatives to

contraception were the infinitely greater evils ofchild murder and abortion. An altered form of theamendment, proposed by Dr. LA-N&DON-DowN, was

finally carried, and ran as follows :-In the opinion of the Representative Body the medical

officer at any maternity and child welfare centre (voluntaryor municipal) equally with any other medical practitioner,has the right to advise either for or against contraceptionby methods in accord with his individual judgment andresponsibility, and should not be subject to dictation fromthe patient or her employer in this matter.

Anaesthetics in Midwifery.Dr. J. YOUNG, speaking of the report of a com-

mittee on anaesthetics in midwifery, said that thedanger in anaesthesia was due to the toxic effects ofprolonged administration. There had been muchpropaganda in the press during the past year to make Ianaesthesia available for every woman. There was

undoubtedly a risk that if this were made a right,women would be tempted to call for it at an unsuitablestage in labour and the dangers of childbirth wouldbe increased. He asked that the following statementshould be incorporated in the report : In thisconnexion it is important to emphasise the fact

‘

that, unless widely guarded, efforts to extend theemployment of general anaesthesia in labour may,by increasing the risk of instrumental delivery at too Jearly a stage, tend to increase maternal mortalityand morbidity." jDr. CHRISTINE MURRELL said that the committee (

had covered the point freely in the following paragraph i

of the report : " The common form of anaesthetic iused in midwifery in this country is chloroform, or i

a mixture containing chloroform. Chloroform given tduring labour diminishes the strength and frequency 1

of the uterine contractions, and the semi-voluntarybearing-down efforts of the mother ; it thereforeprolongs the labour and increases the use of forcepswith the risks that this entails."

Though Dr. YouNG considered this paragraph tobe inadequate, the meeting felt that it should not beasked to incorporate a fresh opinion without moreconsideration, and passed to the next business.

Ophthalmic Benefit.Mr. BISHOP HARMAN described the work of the

National Ophthalmic Treatment Board, which hasnow been in operation for a little over a year. TheBoard is a limited company, and composed of fourmembers appointed from the British Medical Associa-tion, and.four members of the Association of DispensingOpticians. The members from each of the bodieshave an equal voice on the Board, except on medicalmatters which are the concern of the medical membersonly. All expenses for the first year were borne bythe Opticians’ Association, but at the end of thattime it was decided that the British Medical Associationshould give an equal guarantee, and for this purposethe sum of ;E1000 was voted. The scheme, Mr.Bishop Harman said, was now in vigorous workingorder. During the first three months of this yearmore cases had been treated than in the whole oflast year, and during the fourth month the numbertreated had exceeded all those in the first three months.The value of the scheme lay in the opportunity itgave for the doctor to insist on the examination ofhis patient by an ophthalmologist. It was importantthat the profession should have information on thescheme, and its regulations put before it at once.

Dr. D. F. TODD proposed an amendment, for

Sunderland, that the action of the Council in votingthe sum of f:l000 to a commercial optical companybe disapproved. He thought the Association was

creating a precedent of a serious nature if it steppedinto business concerns. The result would be thatopticians would again begin to treat without referenceto an ophthalmic surgeon.

Dr. HELEN LUKIS opposed Dr. Todd ; she thoughtthat time was wasted and much harm done by theoptician, who would provide a patient with glasseswhen the eye condition was referable to a generaliseddisease like nephritis. The eye was not in a water-

tight compartment, and could not be treated withouta knowledge of medicine, anatomy, physiology, andpathology. Her only complaint against the newBoard was that it was insufficiently advertised.

Dr. PETER MACDONALD pointed out the inaccuraciesin the Sunderland amendment. The NationalOphthalmic Treatment Board was not an opticalcompany, and the Council had not voted a sum, buthad put up a guarantee.-Dr. POOLER was anxious toknow how soon the scheme would apply in a practicalmanner to the rural areas.—Mr. BISHOP HARMAN

replied that the Council would consider sending acircular to members of the Association.-Dr. ToDD’samendment was lost.

Lunacy and Mental Disorder.In moving the annual report under " Lunacy and

Mental Disorder," Dr. LANGDON-DowN mentionedthat the Mental Treatment Bill had largely followedthe recommendations of the Association to the RoyalCommission, and on one point-that relating tonon-volitional patients-had adopted the advice ofthe Association in preference to that of the Com-mission. The Government had been urged to givethe doctor signing documents the status of a witness,but the inclusion of this had not been granted. An

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important change of onus had been introduced intothe protection clause that no civil or criminal pro-ceedings could be brought against a practitionerwithout the consent of the High Court, and that thisshould not be granted unless there was substantialreason to think he had acted in bad faith or withoutreasonable care.

Dr. D. ROXBURGH said that the Council had failedto obtain that immunity for the doctor which theRepresentative Body had laid down as a minimum.The profession believed that no doctor would sign acertificate without just cause, and it was no longernecessary to protect the lunatic from cruelty by law.The serious responsibility of giving certificates forlunacy was thrown on those members of the professionwho probably had least knowledge of nervous diseases-the general practitioners. It should be laid onthose who had the greatest knowledge of the subject.The protective clause was insufficient ; how coulda high court judge form an opinion without holdingan inquiry ?-Dr. LANGDON-DowN demurred; ifDr. Roxburgh wanted the medical profession to beentirely free from risks, he wanted a world at presentunattainable. The committee had been chieflyconcerned for the welfare of lunatics, whose positionwas materially improved under the Bill. The reportwas adopted.

Vaccination.Dr. E. LEwYS-LLOYD, in moving the adoption of

the Public Health Report, asked that the paragraphson vaccination should be left unaltered.-An amend-ment, however, was introduced by Sir ROBERT BOLAM,for Newcastle-on-Tyne, suggesting that Governmentlymph should be made available for generalpractitioners, and that every practitioner shouldreceive the same remuneration from the Governmentas the public vaccinator.

Dr. H. KERR removed some misconceptionsmanifest in this amendment. It had been stated ona previous occasion that Government lymph was themost reliable variety, on the basis of the experienceof public vaccinators. But it must be rememberedthat public vaccinators dealt almost entirely withinfants, the reaction of whose skin was slighter.Hence the small incidence of " bad arms." Otherproducers of lymph had been compelled by theGovernment to standardise their products, and itwas not likely that after enforcing this order theGovernment would be ready to step into the marketas competitors of these manufacturers. Besides, ifthe Government lymph were made public how couldthe Ministry of Health control results or collectstatistics ? Communisation of Government lymphwould, in any case, require special legislation. Theamendment was also opposed by Dr. Temple Greyand by Dr. Lewys-Lloyd, who pointed out that thewording was not clear. The Government remunera-tion for vaccination was Is. it was the local authoritieswho paid a higher fee. The Newcastle proposal wasnot accepted by the meeting.

Motor Drivers.Dr. R. G. GORDON said that the committee on

tests for motor drivers was fortunate in havingProf. Joseph Barcroft, of Cambridge, as chairman.The Traffic Bill had now been passed and wouldprobably reach the statute book at the end of thesession. This provided for a declaration of fitness onapplication for a licence, and certain disorders hadbeen made either conditional or absolute bars to

driving. The age-limit for motor-cycle riding wasto be raised from 14 to 16 years, and for drivingpublic vehicles to 21. No public vehicle was to

be driven for more than 11 hours in the 24, or formore than five and a half hours at a stretch.

Dr. C. E. DouGLAS (Fife) said that the problemhad been before the law courts for many years ofdeciding at what point the driver who had takenalcohol was safe, and at what point he became adanger. A definition of drunkenness publishedseveral years ago read to the effect that a man wasdrunk when he had lost control of his actions to suchan extent as to be prevented from being able toexecute carefully the work on which he was engaged.But it must be agreed that the point at which hebecame a danger was the point when he took alcoholinto his system. From the beginning alcohol hada sedative effect on some of the higher centres, andwork deteriorated in spite of the fact that the subjectthought he was doing better. This was a point inpreventive rather than forensic medicine. Therewere times when we were better without alcohol, andone of them was before driving a car. The meetingwas unwilling to give a ruling on the subject, andproceeded to the next business.

Public Medical Services.Dr. H. M. STRATFORD described the poor area of

Kensington in which the London Public MedicalService was active. The younger doctors hadconsiderable interest in the scheme, and found it

satisfactory and useful. They were not in any senseantagonistic to the Association’s scheme, but wishedto propose that until that scheme was in workingorder the Association should support and encouragethe London Public Medical Service.-Dr. BRACKEN-BURY said that the original scheme of this kindwhich had been put into practice had been initiatedand supported by the Association. To encouragesuch schemes had always been the accepted policy.

Dr. FOTHERGILL said that since the beginning ofthe century the State had been initiating healthservices, which were now encroaching on privatepractice. An effective general medical service hadbeen outlined in the proposals of the Council, but tobring the scheme into action the local authorities andvoluntary bodies must share the principles involved.He therefore introduced a motion to suggest thatthe Council should make every endeavour to securethe acceptance by the central and local healthauthorities, voluntary bodies (hospitals contributoryscheme committees, approved societies and employees’associations), as well as by all groups in the medicalprofession, of the principles advocated in their

proposals. This was carried.

Annual General Meeting.Prof. A. H. BuRGESS, the President of the

Association, took the chair at the annual generalmeeting. In announcing that Dr. W. G. Willoughbyhad been elected president for the year 1931-32,he said that this was the first occasion on which amedical officer of health had been chosen for thepresidency.-Dr. WILLOUGHBY said that Eastbournewas preparing an enthusiastic welcome for theRepresentative Body in 1932.

WORK OF THE LONDON HOSPITAL.-Last vearthe 13,992 in-patients (839 beds) stayed an averageof 18-55 days; the 645 deaths were a percentage of4-83. The 89,972 out-patients made 461,297 attendances.The average total cost of each in-patient was :B14 4s. 9d.and of each out-patient attendance 2s. 7d. At z265,311,the expenditure left a surplus of jE19,043, but this satis-factory pecuniary position was due to legacies, whichproduced z68,840. Whereas 20 years ago the income frominvestments was only 20,810, it is now 53,117.