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Hopkins University, Baltimore, delivered the address inmedicine, which was a lecture, illustrated on the screen,concerning the nerve-supply of the internal organs ofsecretion and of the smooth muscles. I was unable to take

any notes as the lights in the hall were turned out, butDr. Barker promised publication in the Journal of theCanadiot Medical Association of a written address on thesubject.

.Report on the Friedmann 01f,re.The report of the committee of five appointed about three

months ago by the Canadian Association for the Preventionof Tuberculosis to investigate the Friedmann remedy wasread. The committee had studied the 161 cases inoculated

by Dr. Friedmann in Montreal, Ottawa, Toronto, and

London, with the aid of those physicians who had had thecases treated in their respective cities under their observa-tion. The report of the committee, which was read byDr. George D. Porter (Toronto) stated that as a result ofthe committee’s observations from March llth to the presenttime it seemed justifiable to conclude: 1. That the inoculationshave neither constantly nor frequently been followed bymarked change in the clinical course of the disease. 2. Thatthe cure, or progress towards cure, claimed by Dr. Friedmannfor the treatment has neither constantly nor frequently takenplace in the time during which these cases have been underobservation. 3. That the results have been disappointing,that Dr. Friedmann’s claims for his remedy have notbeen proved, and that nothing has been found to

justify any confidence in it. The report was signed byProfessor J. George Adami, Professor J. J. Mackenzie, Dr.A. H. Caulfield, Dr. E. S. Harding, Dr. John W. S.McCullough, Dr. W. G. Ross, Dr. J. H. Elliott, and Dr.George D. Porter. Dr. Charles H. Hodgetts (Ottawa), a

member of the committee, refused to sign on the ground,it was stated, that Dr. Friedmann not having kept hispromise to divulge to the committee the exact compositionof his remedy, the investigation was worthless and anyreport must be equally so.

Address on Mental Hygiene.Dr. LEWELLYS F. BARKER gave an address on Mental

Hygiene, which meant making men think better, act better,and become better. The imbecile, the criminal, the prostitute,and the insane were so because they had to be ; their mindsworked in that direction. The majority had been born witha bad brain and acted as their brain directed, while others,though born with a good brain, acted wrongly or criminallybecause so influenced. The advocates of eugenics believedlargely in heredity, and urged the bringing into the worldof children equipped with good brains. A second schoolbelieved environment to play the greater part in the

development and expression of brain power, and devotedtheir attention to it. Both schools were of equal import-ance, and there should be no quarrel between them.Dr. Barker emphasised the benefit of institutional trainingfor the mentally unfit, and urged that psychiatric clinicsshould be held frequently and that school teachers should betaught to recognise abnormal children and to segregate themor have them placed in institutions. A campaign for thepromotion of mental hygiene in Canada similar to that inthe United States would be equally successful.

Scientific Proceedings.A symposium on Diseases of the Stomach was introduced

on June 26th by Dr. ALEXANDER MCPHEDRAN (Toronto),and one on Diseases of the Thyroid by Dr. A. J. OCHSNER(Chicago.)On June 27th Dr. FRANK BILLINGS (Chicago) gave a

clinical lecture in the morning, in the course of whichhe attacked the methods of handling vaccine in the UnitedStates. He said that drug firms manufactured vaccines fornearly every known disease, and even combined cultures ofvarious kinds to make a birdshot vaccine. Dr. Billingsbelieved in vaccines to a great extent, but the manufacturedvaccines were often entirely unsuited for their purpose andlikely to have serious effects on the patients.

Dr. JOHN B. MURPHY (Chicago) also held a surgical clinicin the afternoon.

St. John, New Brunswick, was chosen as the next place ofmeeting, and Dr. Murray Maclaren, of that city, was electedPresident for next year.London, Ontario.

MEDICAL PRACTICE UNDER THEINSURANCE ACT.

(BY OUR SPECIAL COMMISSIONER.)(Continued from p. 177.)

XVII.-MANCHESTER : OPPOSITION TO THE ACT ; THE’POOLING SYSTEM.

FOR a long time Manchester has been an active centre forthe organisation of medical men to resist hospital abuse andthe evils arising from club practice. Over and over againin the editorial columns of this paper, and through theletters of local correspondents, this has been made clear. InManchester was founded the Medical Guild, whose activitiesare surely well known to readers of THE LANCET. Whenthe new constitution of the British Medical Association cameinto being many smaller bodies like the Medical Guild wereto a great extent absorbed, their principal workers becoming.officers of the Association. In this way, for practical’and local purposes a joint committee of the Manchesterand Salford divisions of the British Medical Association,consisting of 25 members, became representative, more orless, of the locality. There are four divisions of theAssociation in Manchester and one in Salford, and eachelected five members on the joint committee. This com-mittee became the executive of the organised forces of themedical profession. There is no special resolution or statute’confirming any powers which this committee may require oract upon, but by the force of circumstances its vote became-influential if not authoritative. The joint committee came-into existence before the question of compulsory insurance-was before the public. The object then in view wasa proposal to appoint whole-time midwifery surgeons forthe purpose of attending on the poor. The joint com-mittee combated this project and helped the city council to’establish a tariff for such work. The attending surgeons-under this tariff were to be paid according to work done and]the appointment of whole-time officers was avoided. The-tariff for such payments- was- to be based on the total’

earnings of the family, who’ were free’ to select their own.’medical attendant. It will be seen, that the principleestablished in regard to midwifery cases amoag- the poor was-quite opposed to the contract system and to,the capitation.fees that form the basis upon which the administration of!medical benefits under the National Insurance Act is-founded. By reason of their previous experience the

majority of the Manchester and Salford practitioners-werequite disposed to resist the National Insurance Bill as-soon’as it appeared on the tapis, and circulars were sent round as-late as December, 1912, calling upon all local practitioners-not to accept service under a measure with such provisions.At the same time, if the cardinal points brought forward bythe British Medical Association had been granted, there would’have been no opposition to the Act on the part of the practi-tioner. Of these points the establishing of a wage limit wasconsidered in Manchester to be by far and away the mostimportant. The general and correct impression that the Actmeant an extension of club practice prevailed, and resistancewas threatened largely on the score of the old and greatgrievance against the Friendly and other Societies that

they accepted as members persons who could well affordto pay medical fees. Much bitterness was displayed overthe question of a wage limit, and the proposal to limitmedical benefits to the R2 a week income was twice broughtforward at the instance of influential Manchester men. Oneach occasion it was defeated, but it is important to notethat there was a good minority in its favour. In this respectManchester differs from the majority of other places, for,.curiously enough in my opinion, the proposal to establish a,

wage limit was little discussed in many localities where

opposition to the measure was keen. In Manchester I found.the opinion prevailed that there was no other solution than,that of establishing the income limit if the profession were towork the Act with pleasure.

Abuses continued under the Pooling System.It was the Salford practitioners who first formed a scheme

for working the Act without applying the contract system.Manchester promptly agreed that they would also adoptthe Salford scheme, and an official came from London

to inquire into an interesting and serious position. The;

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result of this inquiry was that consent was given on behalfof the Government to the local scheme, and thus what isknown as the pooling system came into existence. The

payment was to be for attendance under the supervision ofthe Local Medical Committee, and doctors on the list" "took the place of panel doctors. The pooling scheme wasadopted on Jan. 5th, 1913. This system, while ithas brought into existence special grievances of itsown, has not done away in any notable manner with

objections to the Act where it is worked in the usual way.The trouble about contracting out still remains. The newrule in this respect means that the medical attendant goes onthe panel for the limited number of patients who are definedas having contracted out, and that the patient is liable forthe balance of his account. Again, we have to rote atManchester the same grievance as elsewhere-namely, thatwealthy men insist on insuring their grown-up sons and

daughters on the pretext that they are employed personsearning less than £160 a year. According to one of thelocal practitioners who has done much to organise the pro-fession, at least a quarter of the persons at Manchester whoare now insured under the Act were paying medical feesbefore the Act came into force. He told me of a panel chemistwho had made up prescriptions under the Act for threeinsured persons each belonging to families earning in theaggregate more than 700 a year, though the earnings of noone member might be over £160 per annum. ’’ The factthat many persons who used to pay fees are now insuredmeans that many practitioners who were doing honourablework are now degraded to contract work," remarked anotherwell-known practitioner. ’’ They feel they are driven into acorner, that they must live and must earn their livingaccording to the ways and means given them." Iderived the general impression that if a wage limit were

imposed on patients and the number of insured personsinscribed on the lists of the panel doctors limited, the

capitation system could be accepted in Manchester and thewhole difficulty of working the Act removed.

Detczils of Application of the Pooling System.The pooling system is probably well enough known to

readers of THE LANCET not to need lengthy explanation.Under it insured persons do not inscribe their names on the listof a panel doctor, but send when illness occurs for any prac-titioner whose name is on the list. The insured are at libertyto change their medical attendant as often as they choose.The practitioner on his side sends in the bill to the InsuranceCommittee. The fees claimed must be according to thetariff agreed upon-namely, 2s. if the patient calls on thedoctor, and 2s. 6d. if the doctor calls on the patient. Specialvisits-namely, those paid the same day in response to a callreceived after 10 A.M.-3s. 6d., and night visits 5s. Surgicaloperations requiring local anaesthesia (other than incision ofabscess), 10s. 6d. Abortions and miscarriages are to betreated at the ordinary rates; administration of generalanaesthetics, f.1 11s.; setting of fracture or reduction of dis-location, 10s. 6d. and sanatorium benefit report, Med. 2,5s. ordinary fees for succeeding visits or consultations. Atthese rates, however, it soon became evident that the 7s.contributed yearly by every insured person would not sufficeto pay the bills sent in. Yet this tariff is below that paidbefore the Act by a large proportion of the persons who arenow under the Act. As there is not money enough to goround, a system had to be devised as a basis for cuttingdown the bills sent in. Therefore a case average wascalculated, and if attendances in any one case exceed theaverage some explanation is required, or the sum claimed isreduced to the average.

Financial Results of the Pooling System.As the Act came into operation during the worst part

of the year, the amount available for the first six weekswas equal to only 12s. 6d. for every f.1 charged. AtManchester up to March 31st, 1913, there had been 247,799attendances at the house or surgery of the doctors on thelist," and the latter had paid 68,685 visits, 1351 specialvisits, and 498 night visits. Then they undertook 426

operations, for which a fee of 10s. 6d. is allowed ; had anæs-thetics administered 20 times, and attended to 45 fracturesor dislocations. The total charges for all this work were

f.33,994 14s. 6d., and this covers the period from Jan. 15thto March 31st, 1913. The accounts are made up separatelyby the Insurance Committee for each practitioner, and

the latter is charged 5s. annually to cover the workingexpenses. The Insurance Committee is not paid for thiscontrol work, but the clerks are familiar with it and it doesnot take up much of their time. Every doctor on the list hasto send in his day book sheets. Their calculations andadditions are so often wrong that they must all be carefullychecked. The same accounts are submitted to the LocalMedical Committee and the latter, acting on the average costof each case, reduced the charges made by the medicalpractitioners from .833,994 to .631,477, and of this latter sum.f:.20,929 have been paid on account. Thus the doctors onthe list have received about two-thirds of what they claimed;but this is only a payment on account. Each practitioner iscredited with the full amount, though during the year onlypayments on account will be made. When the total amountof the pool at the end of the year is ascertained, the balanceremaining in the pool will be divided pro rata. The pay.ments effected by insured persons vary constantly. Somedie, some go away, and others simply refuse to pay. In thesame manner, the incidence of sickness changes according tothe season and the weather, not to mention occasional

epidemics. If in the worst part of the year the doctorsobtained 12s. 6d. in the E, the yearly average is likelyto be much above that figure. On the first publishedlist there were 309 practitioners working the Act; sincethen there have been a few additions and a few with.drawals. The second list published at the end of May,1913, shows that for the second quarter 284 practitionersaccepted service, a net reduction of 25. The explanationgiven is that many of the latter reside outside Manchester,but having a few patients in Manchester they put their namesdown presuming that it might be of some advantage to them.Experience, however, has shown them it was not worthwhile doing so. While these practitioners have not hadenough work to induce them to continue service, others havehad too much to do. The accounts sent in show that some

practitioners have treated from 400 to 500 different patientsin one month. Some of these practitioners have assistants,though the names of their assistants do not appear on thelist. One or two practitioners have treated even more than500 different persons in the course of a single month. Asthe average number of different persons treated by any onepractitioner in a month varies from 100 to 200, it will beeasily understood that the figures given above are taken asevidence of a very serious abuse. The total number ofdifferent persons treated was 24,660 in January, 39,598 inFebruary, and 40,250 in March.

Further Results of the Pooling System.The Manchester Medical Committee, in a circular dealing

with the earliest of the figures given above, points outthat the daily average of cases was 1451 in January and1414 in February; and as this is practically no change,it disposes of the idea that there was a considerablerush in the early days of the medical benefit. Thecircular further urges that the figures strongly supportthe assertions made by the profession as to the incidenceof disease, and show that Mr. Masterman was too optimisticwhen dealing with the amount of sickness to be anticipated.The average cost of each patient is estimated at 5s. 4d.

in January and 6s. 9d. in February. ’’ Each account

above these averages was scrutinisect twice by two differentpairs of members of the Subcommittee and reduced eitherto the average or an allowance made when satisfactoryexplanations were given for the excess by the practitioner.The accounts above the average, for which no explanationswere forthcoming, were then reduced to a general average."These accounts, the Medical Committee in their circular justquoted, show "how much more accurate was the profes-sion’s estimate of 8s. 6d. as the minimum amount per caputon which the scheme could efficiently be worked than theestimate of 6s. 6d. of the Chancellor of the Exchequer. Ifthe 8s. 6d. had been granted it is probable that, for work onthe lines of ordinary private practice, approximately 20s. inthe .f:. would have been paid."

Actually the number of persons insured at Manchesteramounts to 254,000, and after much toil the distribution ofbenefits among those who fall ill is working much better.There are less delay and fewer complaints. At the InsuranceCommittee no serious complaints as to unsatisfactory attend-ance or neglect on the part of medical men have beenreceived. Such slight complaints as have been made wereso trivial that not one of them was of suffiçient importance

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to bring it before the notice of the medical superintendent.This, of course, is one of the advantages of the poolingsystem. As the medical practitioner is never certain of

keeping his patient he has to show him every attention ; andthe oftener the patient comes or requests a visit the better.But under the capitation system it is just the reverse.

Some indelicate practitioners, I am assured, have been

encouraging their patients to call often ; but they will findthemselves in an awkward position if, at Manchester as at

Salford, the pool is abolished and the capitation systemestablished. The people who have been taught to calloften will have to unlearn the lesson given and some pretextmust be found for telling them not to call so frequently.

(To be continued.)

BIRMINGHAM.

(FROM OUR OWN CORRESPONDENT.)

The Midwives Act.THE official cards of the Birmingham union used by

certified midwives for the purpose of obtaining the assistanceof a medical man in a case of emergency have in practice ledto difficulties. The guardians have now withdrawn them andthey will not in future be used. It is recognised that there I

may be some cases among persons not entitled to maternitybenefit under the Insurance Act in which a medical practi-tioner cannot obtain his fees. In such cases when a doctoris called in by a certified midwife the guardians will pay areasonable fee subject to their being satisfied (a) thatmaternity benefit is not payable in the case; (b) that themedical practitioner has made reasonable efforts to securepayment; and (0) that the head of the family is too poor topay the fee.

Birmingham and Midland Hospital for Women.

Birmingham was the first authority to make puerperalfever a notifiable disease. A further step has now beentaken in the opening of a special ward for these cases at theWomen’s Hospital at Sparkhill. Two years ago, under an

arrangement with the city council, two beds were reserved forpuerperal fever cases, but this number was soon increased toseven. These proved inadequate, and a new building hasbeen erected costing .E6000. This sum has been given byfriends of the hospital, with the exception of Z600 still

required. The city has contributed nothing to the capitalexpenditure, but agrees to give three-fifths of the annual costof maintenance. The new ward is isolated and self-contained,and will accommodate 25 patients. It has a sheltered southverandah with six beds for open-air treatment.July 22nd.

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SCOTLAND.

(FROM OUR OWN CORRESPONDENTS.)

Appointments at the University of L’dinb2cryh.THE Edinburgh University Court on July 14th elected

Charles Glover Barkla, M.A.. D.Sc., F.R.S., Wheat-stone professor of physics in King’s College, London, tobe professor of natural philosophy in the University of

Edinburgh, in succession to the late Professor MacGregor.Dr. James Ritchie, superintendent of the laboratory of theRoyal College of Physicians, Edinburgh, was appointed tothe chair of bacteriology recently instituted in the

University.The University and the Royal Infirniary.

An agreement between the University Court and the boardof managers of the Royal Infirmary establishing a close andintimate relationship between the University and the RoyalInfirmary in respect of the work of the pathological depart-ment, and also regarding clinical arrangements in medicine,surgery, and gynxcology, was considered at the same courtand approved, with a view to bringing the provisions ofcertain sections into effect as from next October. An appli-cation was also granted on behalf of the teachers for themedical education of women in Edinburgh for recognitionfor the next academical year, and the appointments of

University assistants and lecturers were made for the sameperiod.Assistant Medical Officer (Tuberculosis Officer) for Edinburgh.At a joint meeting of the sanatorium subcommittee of the

Edinburgh Insurance Committee and a subcommittee of thepublic health committee of the town council it was unani-

mously agreed to recommend the appointment of Dr. JohnGuy as assistant medical officer of health for the town andalso to act as tuberculosis officer. The salary is 500 perannum, and there were three applications for the post. Forthe last six months Dr. Guy has been acting as tuberculosisofficer for the county of Gloucester and expert adviser tothe County Insurance Committee there.

Honollr to Sir Claccrles Bedford.The University of St. Andrews has recently conferred the

degree of Doctor of Laws (LL.D.). honoris causâ, on Lieu-tenant-Colonel Sir Charles H. Bedford, D.Sc., M.D. Edin.,I.M.S. (retired), in recognition of his researches andadministrative work in India, more especially relating toexcise and customs’ questions. Sir Charles Bedford retiredfrom the Indian Medical Service, after 22 years’ service, in1911, and was knighted the same year.July 22nd.

IRELAND.

(FROM OUR OWN CORRESPONDENTS.)

The Delegates’ Meeting.A MEETING of delegates representative of the medical

profession of Ireland was held at the Royal College of

Surgeons on July 17th, Dr. P. J. MacNamara, of Kilmallock,in the chair. The meeting was well attended, and though anunnecessary amount of temper appeared at times, a greatdeal of useful business was got through. In the first place,the question of organisation was discussed. The agendacommittee had suggested that the new executive committee.should have as its nucleus the old conjoint committee,but should be strengthened by the addition of direct

representatives of each insurance area. The principle ofthis suggestion was adopted, but an important modi-fication was made. Instead of the entire body of theIrish Committee of the British Medical Association,some 15 or more in number, with an equal numberfrom the Irish Medical Association, being included in theexecutive committee, the representation of these bodies iscut down to one member each. At first sight this has merelythe effect of making the committee less unwieldy, but it hasalso the important result that it deprives the executiveof what has been up to the present its only certainincome. Hitherto the British Medical Association has con-tributed .E200 a year and the Irish Medical Association 100a year to the conjoint committee, and this has constitutedits entire income, except £90 received as a subscription of10s. per head from 180 medical practitioners. Unless, there-fore, members of the profession are willing to contributedirectly for the support of the professional organisation,the step taken may prove a very serious one. Themeeting authorised the new committee to levy a sub-

scription of .61 per head on all medical men in Ireland.The new committee is to be called the Irish Medical Com-mittee, and the constitution will be as follows :-(1) Onemember elected by the medical men of each insurance area;(2) three members elected each by Belfast, Cork, andDublin, and one by Londonderry, Waterford, Limerick, andGalway; (3) one representative of each of the followingbodies-the University of Dublin Medical School, UniversityCollege Medical School, the Queen’s University MedicalSchool, the Royal College of Physicians, the Royal College ofSurgeons, the Apothecaries’ Hall, the Medical School of

University College, Cork, and of Galway, the RoyalAcademy of Medicine, the Ulster Medical Society, theCork Medical Society, and the Belfast Medical Guild ;(4) two representatives appointed by the medical womenof Ireland. This committee is to replace the former

conjoint committee of the Irish Medical and theBritish Medical Associations, and no representatives are tobe elected by any branch of the Irish Medical or of theBritish Medical Associations in Ireland. The first meeting of