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tried for five years and that the results should then besubjected to review by Parliament.Two of the Commissioners whose views are bound to

have great weight with the medical profession - Sir W. iGuyer Hunter and Mr. -Jonathan Hutchinson - do not see

eye to eye with their colleagues as to the degree towhich the law should be relaxed. They propose instead" that in all cases in which a parent or guardian refuses toallow vaccination, the person so refusing should be summonedbefore a magistrate, as at present, and that the only changemade should be to permit the magistrate to accept asworn deposition of conscientious objection and to abstainfrom the infliction of a fine." In this connexion itmust be remembered that the Commission has already andunanimously reported in favour of the abolition of repeatedpenalties, so that the proposal refers only to a first penalty.Probably a compromise between the suggestion of the Com-mission and that of the two dissentients might retain thebest part of both proposals. The objection to the schemeof Sir W. Guyer Hunter and Mr. Hutchinson is that it leavestoo much to the choice of the magistrate. That functionaryis to be permitted to accept a declaration. It would thus

appear that if he pleased he could inflict a fine instead.There might be infinite diversity of practice in differentcourts. On the other hand, the citation to go before amagistrate at a fixed day and hour in a court of law, withall the forms and formalities that belong to legal pro-cedure in this country, might be more deterrent to an

indifferent parent than a mere call on a justice of peacein order to sign a declaration. Probably, therefore, theproposal of the two dissentients might be modified so thatthe magistrate could impose a fine only in the event of theparent’s refusal to make the necessary declaration, and withthis modification there would be practical agreement betweenthese dissentients and the majority of their fellow Com-missioners, so far as infantile vaccination is concerned.For our own part we are bound to say that we have

little fault to find with the scheme proposed by theCommissioners in this respect. It is their obvious desireto promote the practice of infantile vaccination, andthere is much to be said in favour of their view thatthe best way to accomplish this is to modify the lawso that the manufacture of anti-vaccination martyrsshall cease, and so that those who are merely indifferentshall not get the opportunity of neglecting vaccination as aresult of their indifference. In most communities whereBoards of Guardians have ceased to enforce the existing law,and where indifference is allowed to have its full effect, therecan be little doubt that a house-to-house offer of vaccinationunder the conditions set forth in the Report would result inthe protection of thousands of children who are at presentopen to attack by small-pox.

In another article we shall deal with the Commission’sviews and proposals as to re-vaccination.

THE APPLICATION OF COÖPERATION ANDMODIFIED TRADE-UNIONISM TO

MEDICINE.(BY A PRACTICAL MAN.)

WE have received the following outline of a scheme whichattempts to grapple with the financial depression under whichthe interests of the medical profession at large are at presentabiding. To many the bare idea of trying to cope with acondition of things regulated, they would say, by thelaws of supply and demand is ridiculous. To others,willing to admit possibilities of reform, this scheme willread as too drastic and too Utopian. :Some will see

in it practical possibilities. At this present juncture theproposals made in it are too crude for detailed comment, butany attempt at reform by deeds must be greeted with respectby all really concerned in the welfare of the profession asvery distinct from personal aggrandisement, and we desire toinvite comment upon the proposals of our anonymous corre-spondent, whose position, we may add, entitles him to

understand in a very practical way many sides of the subjecton which he writes

The spirit of reform is everywhere abroad among themembers of the medical profession. It would be well if theopportunity of its existence could be taken to put thefinancial arrangements between the public and the professionupon a satisfactory basis. The time is propitious, since itcannot be doubted that much of the discontent which is soevident is due to pecuniary difficulties. Underselling, adver-tisement, medical aid societies, and sixpenny dispensarieswould cease to be attractive, and the abuse of medicalcharity fail to cause so much heartburning if the struggle fora living among general practitioners were less acute.

Medical assistance is an absolute necessity for the majorityof mankind and the power of a united medical profession todictate its own terms is in consequence enormous. One isappalled at the suffering that might be entailed upon the poorerclasses by such a combination, actuated solely by greed,and efficiently protected against unqualified practitioners.The previous history of the medical profession, its willingcooperation with the charitable public in the administrationof hospitals, and the readiness of individual medical men toregulate their remuneration according to the poverty of theirpatients, may give an assurance that no bald attempt towrest more money from the public in return for medicalservices will receive the general approbation of the pro-fession.The scheme of financial reform outlined below repre-

sents a serious attempt to grapple with the difficulties of thepoorer members of the public in obtaining proper medicalattendance and of the poorer members of the profession inobtaining proper remuneration for their services, and at thesame time to deal in an effective manner with the abuse ofmedical charity.From the very earliest times it has been recognised that

the poorer classes of the community are unable to make anadequate return to their medical attendants for professionalservices. Ever since the practice of medicine has beenundertaken by a distinct profession this difficulty has beenmet by charity, at first dispensed by voluntary effort,more recently by the State. The dispensation of medicalcharity by both these methods in combination having provedinadequate to the need, the principle of cooperative insurancefor medical relief has in late years been introduced. As,however, practically no control has been exercised upon thedispensation of medical charity, and no serious organisationor compulsion used to extend the cooperative principle, thevery large class of improvident poor has naturally preferredcharity to cooperation. The proposal now submitted is tomake use of the great power possessed by a voluntary unionof medical men in order to set a reasonable limit to the dis-

pensation of charity and to compel those who are able todo so to make use of the cooperative principle for the

purpose of providing themselves with medical relief.For the profession to take up such a position as this is no

unkindness to the great body of the public who would becompelled to adopt the cooperative principle, so long as theperiodical contribution required from each person is one wellwithin his means. This action is really much more con-siderate than to leave such persons alone until, overtaken byserious illness, they find themselves obliged either to dissipateall their scanty earnings in paying the medical attendant or toappeal to the charitable public to provide them with medicalassistance. If it is a kindness to the public concerned it isalso undoubtedly an advantage to the medical practitioner.Not only would the actual sum of money to be divided amongthose medical men who attend this class of patient be muchlarger, but the hardening of the heart required beforeone can take money from a poor man incapacitated by illnesswould be rendered unnecessary. Thus would the professionbe better paid for its services with less hardship to the

patient, and thus would its members be enabled to retainthose higher qualities of mercy and compassion which areas valuable to the public as they are to the profession. Ifit be granted that on general principles the cooperativemethod of paying for medical services would be an

advantage both to the medical man and the patient, ithas still to be shown that the method can be

applied practically on such a large scale as would benecessitated by the united action of the profession on thelines now suggested. Not only is it believed that this canbe done, but that it can be further shown that the practicaldifficulties now met with in the working of isolated medicalclubs would be much lessened by the extension of the pro-vident system throughout the less wealthy classes of society.To turn now to some of the details of the scheme. In

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-the first place it must be distinctly understood that theobject of the union is solely to regulate the financialarrangements between the medical men and their patients.Indirectly, no doubt, it will tend to lessen many abusesin the profession, but directly the union must not

.attempt to take any active part in the repressionof unqualified practice, advertising, quackery, or anyother evils which are ur may become conspicuous. Everyqualified medical practitioner who is willing to undertake toadhere to certain simple rules with regard to the fees he will-charge his patients must be admitted to the union. Noconduct, however unprofessional, must render a member i

liable to expulsion, except the one unpardonable sin inthe eye of the union of accepting less than the fixedminimum rate of fee. Every medical man who joins theunion must, in return for his undertaking not to chargeless than the minimum fee to his private patients, beentitled to become a participator in the provident fund.He must, however, be absolutely free to refuse to attendprovident patients at all or any particular patient ofthe class. The remuneration that each medical man shallreceive from the provident fund must depend upon thenumber of provident patients actually attended by him.The duty of enrolling, registering, and expelling members,fixing the minimum fees and the scale of contributions to the,provident fund, would be entrusted to a central executive- council, while the detailed management of the provident Ifund would be undertaken by local committees. Thedistricts over which the local committees should presidewould most conveniently be determined by grouping togetherexisting Poor-law areas. In such a district a meeting of allthe medical men who were members of the union would’be summoned at stated intervals to elect from among theirnumber a small local committee. To this committeewould be entrusted the duty of providing offices, appointing.collectors, investigating claims of contributors to be.admitted under the different scales of payment, and’distributing among the members of the union their propershares of the balance of the fund remaining after expenseshad been met. Although the patients admitted to the

,privileges of the provident fund would be permitted tomake contributions of varying amounts based upon their.average earnings and the number of their families theywould be entitled to identical privileges. They should bepermitted to request the attendance of any practitioner intheir district who was a member of the union. The patienthaving chosen his attendant and the medical man having.accepted his patient, would each be bound to abide by hischoice until the expiration of some definite period deter-mined by the committee.

- .-. - ..

iu is naraiy necessary LO go more inco aeiiaii in explaining,the local organisation required to carry out the scheme.Excellent provident dispensaries are to be found inall parts of the country, where the system indicated isworked upon a small scale, and succeeds despite thecompetition of hospitals, "cheap" " medical men, andsixpenny dispensaries. The rules of such provident insti-,tutions, modified so as to considerably raise the wagelimit and to provide a more complete sliding scale of- contributions, might probably be adopted by the localcommittees. The two most frequent complaints broughtagainst club practice as at present carried on are

that the patients tend to become too exacting and that the,medical officers are tempted to be inattentive. Under the

suggested scheme inattention on the part of the medical- officer would be punished by the loss of his patient and acorresponding diminution in the share of the provident fund,while the too-exacting patient would be sent from one

,medical man to another until he mended his ways or foundthat such constant unnecessary attendance was only to beobtained by paying for it at the private practice rate of fee.

It still remains to be shown in what way such a unioncan be utilised to remove the most conspicuous abuses of-medical charity, and it is anticipated that no great-difficulty will be met. There is little doubt that the

managers and the medical staff of the hospitals are in earnestin their wish to find some way of ensuring that their

- charity shall be dispensed only to those who deserve or need it.The difficulty has hitherto been to find some satisfactorymethod of doing this. To set up a charity organisationdepartment at each hospital has been almost the onlypractical suggestion offered by those who are most activein their complaints. The managers of the hospitals havefor the most part rejected the proposal as both expensive

and ineffective. By the formation of the union we havenot only a simple method of identifying those whose financial

position renders them deserving of medical charity, butalso a means of bringing pressure to bear upon such hospitalsas might be indisposed to restrict their charity within properlimits.

It does not seem unreasonable to ask the hospitals, whenonce a universal system of provident medical assistance isestablished, to refuse to give their services to any person whois not either a contributor to the provident fund or a suit-able subject for Poor-law relief or who does not bringa certificate from a medical practitioner, stating that hisillness is of such a nature as to require hospital treat-ment. Thus would the great abuse of hospital charityby those well able to afford to pay private fees beabolished. Thus, too, would the overcrowding of the out-patient departments be lessened. The managers, knowingthat all patients of the poorer class could obtain medicalattendance at the hands of general practitioners through theprovident fund, would be quite willing to refuse hospitaltreatment to cases reported by their medical officers to beof a trivial description. The medical schools would espe-cially benefit by this arrangement, for the generalpractitioners, having nothing to lose by the proceeding,would willingly send the interesting cases amongtheir provident patients for consultation or for tem-

porary treatment at the out-patient department. Thedepartment, freed from the crowd of patients withtrivial ailments, and with the serious cases supplementedby patients sent for consultation, would be much improvedas a centre of medical education. The out-patient officers,relieved of much irksome routine work, would be able toexercise their proper function of consultants to the providentclass of patients, and would be able to spare time to forwardreports to the general practitioners upon the cases sent up fora second opinion.

Is it possible to doubt that the profession as a whole andthe vast majority of its units would benefit by the formationof such a union ? Is it possible to doubt that the public,and especially that portion of it who are financially unableto bear the strain of a long illness, would benefit by theinstitution of such a universal system of mutual medicalassurance ?

Is it not possible to hope that there is sufficient publicspirit to overcome the difficulties of bringing this reformabout ?The greatest difficulties to be overcome are those of fixing

the minimum fees for private patients and the sliding scale ofcontributions for the provident class. Fortunately suchsums once fixed would not be irrevocable. If they can befixed in the first instance so as to attract the majority of theprofession to join the union and to enable the majority ofthe less wealthy public to become contributors to the pro-vident fund the union would in a few years be powerfulenough to revise its pecuniary position.If the matter were of such a nature as to require Parlia-mentary action, which fortunately it is not, the first step in

the proceedings would be to appoint a Commission. Letthose members of the profession and of the general publicwho believe that the formation of a union on these lineswould tend towards the general good provide an inquiryfund and appoint a representative Commission to investigatethe subject. Such a commission, after hearing evidence,which would, no doubt, be willingly given by those interestedin provident dispensaries, hospitals, and friendly societies,as well as by representatives of all classes of general prac-titioners, would be able at least to report upon the feasibilityof the proposal, and if it appeared feasib!e would indicatethe methods by which such a union might be brought intoexistence. The position of the administration of medicalcharity is getting almost unbearable. Any way out would bewelcome. The present proposal is submitted to the profes-sion in the hope that it may be considered worthy of seriousconsideration.

DIRECT REPRESENTATION ON THE GENERALMEDICAL COUNCIL.-A meeting of Dr. Alderson’s supporterswill be held at 4 P.M. on Tuesday, Oct. 6th, at Bellvue House,299, Lavender-hill, S.W., by kind permission of Dr. Barkwell,to report progress of his candidature and to consider whatfurther steps shall be taken to ensure the election of Dr.Alderson as one of the direct members in the General MedicalCouncil.