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be particularly useful in Grades 1 and 4, but it is adrawback to grading that these only include about10 per cent. of rectal cancers. The great majorityof malignant growths fall into Grade 2 or Grade 3.The significance of colloid or mucoid change has

been the subject of much speculation ; colloid carci-noma has generally been regarded as a type for which

the prognosis is bad, but there are some groundsfor believing that this is not necessarily so, and thatas in other types the depth of spread is the importantfactor.

W. B. GABRIEL, M.S., F.R.C.S.,Surgeon to St. Mark’s Hospital.

PANEL AND CONTRACT PRACTICE

THE PANEL CONFERENCE

THE annual conference of local medical and panelcommittee representatives was held on Oct. 22ndin the Great Hall of B.M.A. House, with Mr. D.ELLIOTT Dicxsorr, F.R.C.S. (Lochgelly, Fife), in thechair. Dr. Wm. C. Woodward, director of the Bureauof Legal Medicine of the American Medical Asso-ciation, was welcomed as a visitor. Dr. H. C. JONAS(Barnstaple), chairman of the Insurance Acts Com-mittee (I.A.C.), in moving the adoption of the report,said that the outstanding feature of the year wasDr. H. G. Dain’s retirement from the chair aftertwelve years’ service. He wondered how the con-ference would fare without Dr. Dain’s clarity of visionand facility of expression as the I.A.C.’s spokesman.He then spoke of Sir Henry Brackenbury’s decisionnot to seek re-election to the LA.C. Sir Henry, hesaid, had done extraordinary work for insurance

practitioners. There was no acuter mind than his,and he was the ideal public debater ; he fought hardfor his point of view and, when the fight was over,bore no rancour even if his view was not adopted.Dr. E. KAYE LE FLEMING added that they owed toSir Henry the foundation of their magnificent organisa-tion, and the conference passed with acclamation amotion recording grateful appreciation of his services.Sir HENRY BRACKENBURY said that, looking backover the 25 years since the introduction of theInsurance Act, two broad questions struck him

particularly : the increased value the nation placeson its health, and the enormously increased area ofmedical responsibility. Medical practitioners as a

body were sometimes reproached with the fact thatthe health of the nation was not better than it was ;the community and the individual lay person alsohad responsibilities. It was, he thought, not for

practitioners to reproach themselves for the imper-fections of the national health if the other partieswere not recognising and carrying out their responsi-bilities. There were four factors affecting the healthof the community which needed attention-noise,smoke, nutrition, and physical training.

Representation on the I.A.C.

At the 1935 conference the LA.C. were instructedto devise a scheme by which the various groups ofpractitioners in an electoral area should have a votingpower approximating to the numbers of insurancepractitioners in the groups, and to arrange for sucha scheme to be put into force for the LA.C. electionin 1936. The LA.C. decided on a scheme wherebythe individual members of the local medical andpanel committee should constitute the electorate,the vote of each member bearing a value equal tothe number of practitioners on the medical list at aspecified date divided by the number of members ofthe committee. An amendment by Dr. G. F. WHYTE(Dundee) to provide that an insurance practitionershould be regarded as included in the list of onlyone insurance committee was lost, and the conferenceapproved the action of the I.A.C.

Capitation FeeDr. JONAS (I.A.C.) moved :That the case for an increase in the capitation fee for

insurance practitioner is sound.

He stressed the importance of securing suitablerecruits to the medical profession ; the children ofmedical practitioners were among the best types ofrecruits. Since 1924 when the present capitation feewas awarded by a court of inquiry the cost ofmedical education had increased, the period for

qualification had been prolonged to six years, and thecurriculum had been stiffened. There were amplefigures available to demonstrate the increasingvolume of work in insurance practice ; moreover

the efforts of approved societies to reduce sicknessclaims had greatly increased the clerical work. Hedid not think there was much alteration in generalpractice expenses, but there was no doubt about theincrease in visits to and attendances by insured

persons. It was undeniable that the medical services

given under the N.H.I. Acts were considerably betterto-day than in 1924.

Dr. E. A. GREGG (London) expressed doubt aboutthe soundness of the case as submitted ; it wasunwise, he thought, to base it merely on post-1923conditions.-Dr. H. W. WALLACE (Lancashire) dis-agreed with Dr. Jonas about general practiceexpenses, mentioning the increased cost of assistants.- Dr. A. MCCARTHY (Birmingham) commented uponthe discrepancy between the increase of work andthe reduced cost of living index figure, but Dr.A. BENHAM STICH (Gateshead) would have likedexpert advice to be taken on the cost of living.-Dr. W. M. KNOx (Glasgow) wondered whether theLA.C. would be prepared to accept a reduced

capitation fee if the result of arbitration should beunfavourable.-Dr. P. MACDONALD (York), speakingas a hospital surgeon, said it was clear to him thatthe character of the work done by insurance prac-titioners had changed during the last 21 years, hadchanged since 1923, was still changing, and was

changing in the right direction. The case for theinsurance practitioner should, he felt, be based onthe quality of his work, and the responsibility heundertakes, rather than on the mere amount.-Dr.J. H. WARD (Lines, Lindsey) spoke against the

proposal on the grounds that the Government wouldnot agree to an increased fee.-Dr. A. BALDIE

(London) said no one present, and very few otherpractitioners, would think the case was not sound.But they might have to meet the argument that thecountry is initiating schemes of national defence andthat doctors should set an example at this juncture.He suggested this was an opportunity to appeal tothe Minister of Health to inquire into the allocationand distribution of surplus funds credited to approvedsocieties.-Dr. DAIN said that if the conference

thought the case was sound they must decide whatthey intended to do. If they went to arbitrationthey must be prepared to accept the award. TheLA.C. felt that the case was sound.

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The motion was put and carried unanimously.A resolution declaring that the time was now oppor-tune for action was carried by a large majority,as well as a third motion instructing the LA.C. toproceed with an application to the Minister of Healthfor an increase in the capitation fee. The threeresolutions were then put as a composite motion andwere carried with one dissentient.

Consultant and Specialist Services

The report of the LA.C. on this subject referredto the appointment of a joint committee repre-senting the British Medical Association, the NationalAssociation of Insurance Committees, and the NationalConference of Friendly Societies, to explore the possi-bility of securing the addition of consultant, specialist,and laboratory services to the benefits availableunder the N.H.I. Acts. Certain data are beingobtained so that the joint committee may form amore accurate estimate of the size of the problem,including some idea of the public demand for thesuggested extension of the present service. Mean-while a subcommittee of the LA.C. had preparedand the I.A.C. had approved a number of provisionsand safeguarding conditions as a basis of discussionby the joint committee. The principal items are :-

I. That consultant, specialist, and pathological servicesshould be available as an integral part of medical benefitfor all persons entitled to that benefit.

2. That such service should be available only on therecommendation of the general practitioner in attendance.

3. That there should be free choice of consultant,specialist, and pathologist by the general practitioner inattendance.

4. That the decision in regard to the eligibility of

practitioners for inclusion in, and continuance on, the listof available consultants formed in connexion with theprovision of the service, should rest with a properlyconstituted professional body.

5. That the organisation of such services should be onlines strictly comparable with those obtaining in privatepractice, the consultant receiving the patient in his ownconsulting-roòms or attending at the patient’s home, as

the case may be.

An amendment by Kent to provide alternativelyfor the consultant to attend at the consulting-roomof the general practitioner in attendance was carried.A motion by Lancashire that there should be no

extension of medical benefit unless and until the

capitation fee is considered adequate was carriedalmost unanimously.

Insured Persons in HospitalThe conference approved the action of the LA.C.

in agreeing to the inclusion in the regulations of aproviso laying it down that a practitioner shall notbe responsible for the treatment of his insured patientsin a hospital unless the hospital is one in whichpatients are entitled under the rules to secure treat-ment by their own medical attendants practising inthe district, whether or not such medical attendantsare on the hospital staff. This will not apply toconvalescent homes or institutions carried on for

profit.Convalescent Homes

The I.A.C. have been endeavouring to check thepractice which exists at some convalescent homes ofcollecting the medical cards of insured inmates onarrival and giving a temporary resident credit. Inthe autumn of 1935 inquiries were instituted and itwas found that of 48 insurance areas with con-

valescent homes situated in them only 11 had limited

payments from the local practitioners’ funds to theamount received from the central fund, whilst 8had such limitation under consideration. In 14 areas

payment was confined to those actually receivingtreatment and 6 areas had this point under con-

sideration. Pointing out that the payment out of alocal practitioners’ fund in respect of temporaryresidents of a sum greater than that received fromthe central fund means that the difference is borneby those practitioners who have not attended tem-porary residents, the LA.C. recommended that nodistribution scheme should contain any provisionpermitting a higher payment. This was agreed to.

Emergency Treatment

Dr. J. NELSON (Hull) moved : ,

That it be an instruction to the LA.C. to considerwhether any alterations should and could be made in theregulations dealing with emergency treatment to ensurethat payment for such service should not fall on either thedoctor or the practitioners’ fund where the circumstancesunder which the service was rendered do not comply withthe existing regulations.This, he said, was a small matter, but one which hadbeen causing a lot of trouble. He instanced the caseof a charwoman who, whilst working in the houseof her employer soon after 9 A.M., splashed ammoniainto her eyes. This he contended constituted anemergency. The mistress must have known thatthe employee was insured, but instead of sendingfor the patient’s doctor she called in her own medicalattendant. The practitioner giving the treatmentsent in a claim for emergency treatment. The twodoctors lived about the same distance from the

employer’s house. The employer was quite willingto pay the doctor who attended, but Dr. Nelson’scommittee took the view that the practitioner wasnot entitled to receive money either from or on behalfof an insured person.

Dr. J. SNEDDON (Manchester) said that in his areathe difficulty was overcome by practitioners doingone another’s emergency treatment. One type ofcase which was giving considerable trouble was thatof emergency treatment following extractions ofteeth.-Dr. C. L. BATTESON (London) said that in acase where the two doctors were equidistant therecould be no reason for sending for a practitionerother than the patient’s own doctor. In a case ofthis description his committee would disallow theclaim. The practitioner who was called in wouldhave a perfect right to charge a fee.-Dr. JONASsaid that on the facts of the case cited he agreedwith Dr. Batteson. He thought that areas finding-trouble with emergency cases might well look intothe Manchester method; it should be a case of" you do it for me to-day and I do it for youto-morrow."The motion was withdrawn.

Excessive PrescribingA motion by Essex that every effort should be

made to devise more efficient means for the examina-tion of the orders issued for the supply of drugs, &c.,the prevention of waste and extravagance, and forsafeguarding the limited funds available for the

provision of drugs was agreed to, and the LA.C.was asked to take steps towards this end.

Lancashire then asked the conference to agreethat the National Formulary is sufficiently compre-hensive to cover the medicinal treatment of the

majority of conditions with which the insurancepractitioner has to deal, and that its more general

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use would result in reduction of the cost of drugswithout loss of therapeutic efficiency.Both these motions were referred to the LA.C.

Other Motions

Dental Benefit.-Dr. J. W. E. CORY, at the sug-gestion of Dr. J. W. Bone (I.A.C.), amended a motionby West Suffolk to read as follows :That the adoption of the new scale in regard to adminis-

tration of anaesthetics under the dental benefit regulationswhereby an insured person may be deprived of theservices of a medical practitioner or even endanger hisright to medical benefit contravenes the principle that aninsured person is entitled to treatment not inferior to thatobtainable by a private patient and that steps be takento regularise the positionand the motion as amended was adopted.Dispensing Capitation Fee.-Dr. J. A. PRIDHAM

(Dorset) moved :That this conference instructs the I.A.C. to consider

the advisability of investigating the adequacy of thepresent dispensing capitation fee.

Dr. JONAS said the LA.C. would accept thereference provided it was left until the question ofthe capitation fee itself had been settled, and thiswas agreed to.

Range of Service.-A motion by Hampshire that theLA.C. should be instructed to press for the amend-ment of Clause 8 (3) of the terms of service so thatit should read :

Notwithstanding anything contained in the precedingparagraphs, the treatment which a practitioner is requiredto give does not include treatment in respect of a confine-ment, abortion, or threatened abortion

was rejected by a large majority as well as a motionby Lancashire to amend the same clause so that thelast two lines should read : " or attendance afterlabour in respect of any condition resulting there-from within ten days." Dr. Dain remarked that

practitioners had undertaken the obligation andshould carry it out.

Partial Incapacity for GPork.-Dr. J. S. MANSON(Warrington) moved :That this conference instructs the LA.C. to consider the

advisability of setting up a special committee to investigatethe problems of alternative or suitable occupations forinsured persons suffering from chronic disabilities whichcause such partial incapacitation as to prevent themfollowing their usual occupationBy changing their occupations persons suffering fromchronic disability might, he suggested, get a readjust-ment to life. But Dr. LE FLEMING rejoined thatthe problem of alternative work was an individualmatter and no one was better suited to help a

patient than his own doctor, and the motion was lost.

National Insurance Defence Trust

The statement submitted by the trustees showedthat of the 250,000 aimed at 207,295, or 82 per cent.,had been subscribed. England had subscribed 85 percent., Scotland 78 per cent., and Wales 55 per cent.of their quotas. At August 31st, 1936, the assets ofthe fund were 238,432. The excess of income overexpenditure for the past year was 5428. Mr. N. E.WATERFIELD (Surrey) moved :That this conference considers that the total sum

aimed at for the National Insurance Defence Trust is

inadequate and requests the LA.C. to consider and toput into force measures for the increase of this fund.

Either the fund was, he said, sufficiently large andshould be closed down or else efforts should be made

to stimulate it; in his view it was entirely inadequatefor a fight to a finish. He thought it unlikely thatthey would have to draw on the fund for a fight onthe capitation fee, but the terms of service mightcause such a fight. The feeling in Surrey was thatevery practitioner should contribute over a periodof ten years.-Dr. H. R. CRAN (Surrey) suggestedthat a fund of two or three million pounds should beraised.-The motion was carried by a large majority.At the conclusion of the conference Mr. Elliott

Dickson was re-elected chairman for next year.

THE SERVICES

ROYAL NAVAL MEDICAL SERVICE

Surg. Comdrs. J. R. Brennan and A. C. Anderson toDrake for R.N.B.

Surg. Comdr. C. R. Boland retires.Surg. Lt.-Comdr. E. V. Barnes to rank of Surg. Comdr.Surg. Lt.-Comdrs. W. P. E. McIntyre and T. C. Crean

to Pembroke for R.N.B., and J. Johnston to Victory forHaslar Hosp.

Surg. Lts. S. I. Ballard and M. G. Peever to Pembrokefor R.N.B. ; W. H. C. Watson to Queen Elizabeth; B. M.O’Sullivan to Drake for R.N.B. ; J. T. Wellwood toGrimsby; S. Miles to Cockchafer; and F. H. Williamsto Cicala.

ROYAL NAVAL VOLUNTEER RESERVE

Surg. Lts. F. W. Baskerville and P. G. Burgess, com-missions as Surg. Lts. terminated on entry into R.N. asSurg. Lt.

Surg. Lt. A. V. Griffiths transferred from list 2 ofSevern Division to list 2 of the London Division.

ROYAL ARMY MEDICAL CORPS

Capt. J. W. Eames to be Maj. (provisional).Short Service Commissions : Lts. G. C. Dansey-Browning

and A. Gleave to be Capts.Lt. (on prob.) A. B. Dempsey is restd. to the estabt.

REGULAR ARMY RESERVE OF OFFICERS

Lt.-Cols. R. J. Cahill, D.S.O., and E. B. Lathbury,O.B.E., having attained the age limit of liability to recall,cease to belong to the Res. of Off.

SUPPLEMENTARY RESERVE OF OFFICERS

Lts. to be Capts. : W. H. Young and H. D. K. Wright.

TERRITORIAL ARMY

Capt. T. F. Greenhill to be Maj.W. H. Wolstenholme (late Offr. Cadet, Manchester

Univ. Cóntgt., Sen. Div., O.T.C.) to be Lt.

TERRITORIAL ARMY RESERVE OF OFFICERS

Army Dental Corps.-E. T. B. Graham-Scott to be Lt.

ROYAL AIR FORCE

Flight Lt. R. G. James to R.A.F. Station, Turnhouse.J. H. Preston is granted a short service commission as

Flying Offr.

INSTITUTE FOR THE SCIENTIFIC TREATMENT OFDELINQUENCY.-Sixteen seminars for probation officersand social workers will be held at the West EndHospital for Nervous Diseases, Welbeck-street, London, W.Dr. T. Rowland Hill, on Oct. 22nd, gave the first offour weekly seminars on organic disease and delinquency,and on Monday, Nov. 16th, at .6.45 P.M., Dr. C. J. C.Earl will give the first of four lectures on mental defectand delinquency. In the spring the course will be con-cluded by a series of lectures on psychiatry and psycho-therapy of delinquency by Dr. Denis Carroll. Furtherinformation may be had from the secretary of the Institutefor the Scientific Treatment of Delinquency, 56, Grosvenor-street, W.l.