304

in the view that the money spent on health insuranceimproves the health of the worker, they thought itquite a matter of speculation whether the exp.mditurewas repaid by the greater efficiency, wage-earningcapacity, and general contentment of the workers.The first consideration was the fullest possible measureof employment, and if more money was being takenout of industry than was essential for the existingstatutory benefits, the view of the employers wasthat this was harmful to industry and therefore to theworkers. They were not prepared to say by exactlyhow much the contributions could be reduced, butthought that the Government actuary might bea little more optimistic in his views, and in any casethey suggested that the burden would be more

equitably distributed if the taxpayer paid a highershare, and the employer, as such, a smaller shareas the counting of heads of the numbers employeddid not give the most equitable distribution of theburden.

In provnua articles the proceedings of the Commissionwere reported under the following headings : IntroductoryNote ; The Scope of the Insurance Scheme (see THE LANCET,Jan. 31st, 1925, pp. 247-8) ; The Provision of Medical Benefit(Feb. 7th, pp. 301-3 ; Feb. 14th, pp. 355-6 ; Feb. 21st, pp. 403-5) .Financial Provisions of the Act (Feb. 28th, pp. 454-7); MedicalCertification and the Regional Medical Staff (March 7th,pp. 508-9) ; The Approved Societies and the Money Benefits(March 14th, pp. 564-5 ; March 21st, pp. 623-4) ; Evidence ofthe Hearts of Oak Society (March 28th, pp. 677-9); Evidenceof the National Conference of Industrial Assurance ApprovedSocieties and of the Manchester Unity Approved Society(April 4th, pp. 731-3) ; Evidence of Independent Order ofRechabites, of Rational Association Friendly Society, and ofMiners’ Societies (April llth, pp. 784-6) ; April 18th, p. 839 ;Evidence of Mr. Alban Gordon (April 18th, pp. 839-40) ;Evidence of Joint Committee of Approved Societies, of StockExchange and Lloyds’ Health Insurance Societies, and ofGroup of Catholic Approved Societies (April 25th, pp. 889-91) ;Evidence of the National Insurance Beneficent Society(May 2nd, pp. 943-4); Evidence of the British Medical Asso-ciation (May 9th, pp. 993-5) ; Evidence of the British DentalAssociation and other Dental Organisations (May 16th,pp. 1044-6); Evidence of the Insurance Committees (May 23rd,pp. 1097-8) ; Evidence of Various Approved Societies (May 30th,pp. 1135-6) ; Evidence of the British Medical Association(June 6th, pp. 1184-6 ; June 13th, pp. 1248-50 ; June 20th,pp. 1315-6) ; Evidence of other Medical Bodies (June 20th,p. 1316 ; June 27th, p. 1348) ; Individual Evidence (June 27th,p. 1348) ; Medical Services in the Factory, Ministry of HealthInquiry Room, Evidence of National Sailors’ and Firemen’sUnion and of Loyal Order of Ancient Shepherds (July 4th,p. 36); Evidence of Friendly Societies’ Medical Alliance, SouthWales and Monmouthshire Alliance of Medical Aid Societies,Friendly Societies’ Medical Officers’ Union, Association ofApproved Societies, Standing Committee of Scottish InsuredWomen, and Society of Medical Officers of Health (July llth,pp. 86-8) ; Evidence of the British Hospitals Association, theSheffield Joint Hospitals Council, and the Middlesex Hospital(July 25th, pp. 181-2); Evidence of Opticians’ Associations(August 1st, pp. 224-6) ; Evidence of Council of British Ophthal-mologists, of Ophthalmic Benefit Committee, of Chemists, andof Drug Store Proprietors (August 15th, pp. 348-50) ; Evidenceof Chartered Society of Massage and Medical Gymnastics, ofthe Ivory Cross, of Scottish Panel Chemists, Practice amongHighland Crofters, and of National Farmers’ Union of Scotland(August 22nd, pp. 402-3) ; Evidence of Nursing and otherWomen’s Organisations (Sept. 5th, pp. 519-20) ; Views of Trade-Unions, Evidence of Approved Societies (Sept. 19th, pp. 618-9) ;Evidence of Joint Tuberculosis Council, Cambridgeshire Tuber-culosis After-Care Association, London County Council on

Treatment of Tuberculosis, British Social Hygiene Council, andLondon Insurance Committee (Oct. 3rd, pp. 722-3) ; Evidenceof Society of Apothecaries of London, East of Scotland Dentists’Panel, Association of Poor-law Unions, Association of ParishCouncils of Scotland, and of Mr. W. J. Braithwaite (Oct. 17th,pp. 828-9) ; Evidence of National Council of Agriculture, as toCasual Employees of Councils and Delay in Paying SicknessBenefit, of National Insurance Audit Department, CharteredAccountants of Scotland, Department of Economics (Cam-bridge), the Actuarial Basis of the Act, and of the GovernmentActuary (Nov. 7th, pp. 985-7) ; Provision of Extended Medicaland Allied Services, Specialist and Consultant Services, Treatmentof Dependants, Income Limit of Manual Workers, and HospitalProvision (Nov. 28th, pp. 1123-4) ; Official Evidence (Dec. 12th,pp. 1247-8) ; Evidence as to Question of Proof of Unemploy-ment, and of Sir Walter Kinnear (Dec. 26th, pp. 1355-6).

PEOPLE’S LEAGUE OF HFALTH.--A series of eightlectures on the Mind and What We Ought to Know About Itis being delivered by medical men on Mondays at 0 P.M.,from Feb. 1st to March 22nd, at the house of the MedicalSociety of London, 11, Chandos-street, W. Furtherinformation and tickets for the course, price 10s., may beobtained from the hon. organiser, People’s League of Health,12, Stratford-place, London, W. 1.

THE GENERAL MEDICAL COUNCIL.MEMORANDUM AS TO THE CONSTITUTION,

FUNCTIONS, AND PROCEDURE.BY THE REGISTRAR.

THERE is so much misconception at the presentmoment in regard to the General Medical Council,not only amongst journalists and the public, butamongst members of the medical profession them-selves, that it seems advisable to give accurateinformation on the subject, in order that it may bemore widely known how the Council is composed,what are its duties, and how these are carried out.What follows may be found in the documents prefixedto the Medical Register, in the published minutes andstanding orders of the Council, in the public addressesof the President, and in Harper’s " Legal Decisionsupon the Medical and Dentists Acts " (Constableand Co.).

Constitution.

The Council was constituted under the MedicalAct, 1858, and its composition was somewhat alteredby the Act of 1886. It now consists of 18 membersappointed by the universities in the United Kingdomhaving medical faculties ; of 9 members appointedby the medical corporations, such as the RoyalColleges of Physicians and Surgeons ; of 5 membersappointed by His Majesty in Council; and of 6members directly elected by members of the professionas a whole-a total of 38. To these are added 3dentists who are members of the Dental Board andare appointed for dental business. The universitiesmay appoint either medical men or laymen ; generallyit is not the medical faculty of the university thatappoints the member, but the academic governingbody, whatever that may be. In Cambridge, forexample, he is elected by the members of the Senate,in the same way as the representatives in Parliament.The representatives of the medical corporations mustbe members of these bodies, and consequently mustbe registered practitioners. The representativesnominated by His Majesty in Council are generallyappointed for special reasons, relating to departmentsof the public medical service. For instance, thechief medical officers of the public health departmentsin England, Scotland, and Ireland have been or are

among them; the medical editor of the BritishPharmacopoeia, 1914, was recently appointed by theCrown with reference to his special knowledge ofthis department ; for many years before the formationof the Dental Board, Sir Charles Tomes was appointedto represent dentistry ; Sir Francis Champneys, thechairman of the Central Midwives’ Board for England,was appointed soon after that body came into being,when the rules of the Board became subject to theapproval of the Council; and so on. The directrepresentatives are practitioners elected, four fromEngland, one from Scotland, and one from Ireland,by ballot of all the members of the profession havingregistered addresses in these countries respectively.The nominees of the Privy Council and the directrepresentatives of the profession are ’appointed forfive years. The representatives of the universitiesand medical corporations may be appointed for fiveyears or less.

It will thus be observed that the 18 membersappointed by the universities, and the five membersappointed by His Majesty in Council, may all belaymen ; but so far no laymen have been appointed.As will be seen later, the functions of the Councilare largely concerned with medical education, andconsequently the universities have found it expedientto appoint members of their body conversant withthis subject, and the Privy Council have found itdesirable to appoint persons having special knowledgeof certain subjects of public importance, whichmight not otherwise be represented.

It is important that the constitution of the Councilshould not vary too quickly, because the Council

305

meets only twice a year, and its executive committeeonly three or four times. It naturally takes sometime for members to become acquainted with theirduties. Moreover, it is important that membersshould have some knowledge of precedents in regardto education and to judicial decisions. And again,when applications are received from practitionerswhose names have been erased from the Register fortheir restoration thereto, it is desirable that thereshould be members present who were in attendancewhen the case was originally heard, and thereforehave the circumstances in their personal recollection.

Functions.Sins of commission-more often sins of omission-

are freely laid to the Council’s account, of which,from its very nature and constitution, it cannot beotherwise than guiltless. It is reprimanded for doingwhat the law says it shall do. It is bitterly reproachedfor leaving undone what the law gives it neitherpower nor means to do. It is spoken of at one timeas the " Parliament of the profession," yet it has noauthority to legislate for anybody, and it cannot makeeven a by-law for any but its own proceedings. Atanother time it is scornfully described as a " doctors’trade-union " ; yet it cannot legally levy an annualsubscription, or say a word on the matter of ratesof pay, or hours of work, or disputes with employers,or theories of practice ; it offers no pecuniary benefitsor strike-pay ; and it can be sued in the courts likeany other corporation. It exists, in fact, for theprotection of the public, not of the profession.The Council is, in fact, neither a parliament for

making professional laws nor a union for protectingprofessional interests.When the Council was created nearly 70 years

ago, the declared purpose of the legislature was notto promote the welfare of professional men or pro-fessional corporations-it was not to " put downquackery," or even to advance medical science. Theobject in view was simply the interest of the public.The preamble of the Act of 1858 consists of two linesonly :-

" Whereas it is expedient that persons requiring medicalaid should be enabled to distinguish qualified from un-qualified practitioners : Be it therefore enacted...."’

The preamble, as will be seen, recognises two kindsof practitioners : the " qualified " and the " un-qualified." Up to that time (1858) no easily-under-stood line was drawn between the two, and whenthe public desired to make a choice, they werefrequently at a loss. The Act set up machinery for,as it were,

" hall-marking " the qualified practitioner,so that he might easily be recognised when his services Iwere required. But the public were left free then,as they are free now, to seek " medical aid " from theunqualified practitioner if they like. And theunqualified practitioner was left free then, as he isfree now, to practise for gain among those who chooseto employ and pay him. He was forbidden, underpenalties, to pretend that he was qualified, by takinga title he did not possess ; he might not use the courtsfor the recovery of his charges ; he could not give avalid certificate of sickness or death ; and now bythe Regulations made under the Dangerous DrugsAct he cannot prescribe certain dangerous drugs, likecocaine or morphine ; but except for these and a fewother not very inconvenient disabilities, he was

untouched by the law.On the other hand, the " qualified " men, as a

set-off to their new legal status and official recognition,were subjected to a new central control, educationaland disciplinary. They obtained no monopoly ofpractice among the public in general. They wereafforded no special " protection " against the- com-petition, not always scrupulous or insignificant, ofthe uncontrolled unqualified practitioner.The qualified practitioners might fairly have claimed

that it would be good for the public, as well as forthemselves, if monopoly of practice, and protectionagainst the competition of the untrained, had been

conferred upon them. In other countries, and in otherparts of the King’s dominions, the restriction ofpractice to the qualified is with general consent andapproval enforced by law. There, any unqualifiedperson who habitually and for gain practises or holdshimself out as practising any branch of medicine orsurgery is liable to severe penalties. In this country,indeed, the practice of dentistry and the practice ofmidivifery have been by law restricted to qualifiedpersons. But in these days it requires some resoluteignoring of the signs of the times to believe that, inthis free country, legislation restricting the practice ofmedicine and surgery to qualified persons only iseither probable or possible in the near future.

In one significant respect, however, the Councilis empowered to " protect " the aspirant to qualifica-tion-not against the competition of the unqualified,but against the possible action of the licensing bodiesin restricting his freedom when qualified. Section 23of the Medical Act, 1858, reads thus :-

" 23. Privy Council may prohibit attempts to impose restric-tion as to any theory of medicine or surgery by Bodies entitledto grant certificates.-In case it shall appear to the GeneralCouncil that an attempt has been made by any body,entitled under this Act to grant qualifications, to imposeupon any candidate offering himself for examination anobligation to adopt or refrain from adopting the practiceof any particular theory of medicine or surgery, as a test orcondition of admitting him to examination or of grantinga certificate, it shall be lawful for the said Council to repre-sent the same to His Majesty’s Most Honourable PrivyCouncil, and the said Privy Council may thereupon issue aninjunction to such body so acting, directing them to desistfrom such practice ; and in the event of their not complyingtherewith, then to order that such body shall cease to havethe power of conferring any right to be registered under thisAct so long as they shall continue such practice."

Once a practitioner has been trained and testedin the knowledge essential for public safety, he mayadopt any " theory " of medicine or surgery in whichhe honestly believes.The instrument which Parliament set up for the

purpose of marking the distinction between qualifiedand unqualified persons is called the Medical Register.And the making and keeping of this Register isentrusted to the Medical Council. On the Registerare placed the names of those who have passed certaintests of professional fitness. These are called registeredpractitioners, and these alone the law declares to beduly or legally qualified. The Council has to see

that the tests of professional fitness actually appliedby the examining bodies to aspirants for registrationare

" sufficient." The tests must ensure that allthose who pass them possess " the knowledge and skillrequisite for the efficient practice of medicine, surgery,and midwifery." The Council has also to see that noregistered person, who by crime or misconduct hasbecome unworthy of the legal status which registrationconfers, shall remain on the Register. In other words,the two great functions which the Council in thepublic interest discharges are, first, to prevent theunfit from gaining access to the Register; and,secondly, to remove the unworthy from it. Exceptas to a few subsidiary matters, such as the preparationand issue of the British Pharmacopoeia, the controlof diplomas in public health, the scrutiny of themidwives’ rules, and the like, all its powers and allits work in relation to the medical profession havereference to these two functions. It is a council ofeducation and a board of registration, under thesupervision of the Privy Council, which may directit to amend its errors, if any, or supersede it if itpersists in them.The performance by the Council of its duties in

regard to education are not at present in question,and it is therefore not necessary to enlarge upon thisaspect of its work ; but it has been necessary to setdown the foregoing in order to show how large apart of its duties are connected with education, andwhy the members elected by the universities andappointed by the Crown have hitherto been membersof the medical profession rather than laymen.

306

The Medical Council is also a Board of registration.In fulfilment of this function, partly by the force ofnecessity, and partly in virtue of the interpretationof the law by judges, it has become a professionalcourt of justice, a domestic forum for the trial anddetermination of grave charges brought againstregistered practitioners in their professional capacity.By successive judicial decisions of the High Courtand Court of Appeal, it has been laid down that inits procedure the Council, sitting as a tribunal, mustas nearly as possible follow the forms and rulescustomary in other courts. But it has no authorityto compel the attendance of witnesses, to administeroaths, or to call for the production of documents.It has only one judgment to give when a charge ofmisconduct is proved to its satisfaction-namely,"

guilty of infamous conduct in a professional respect" ;and only one sentence when judgment is given-namely, " erasure from the Register." From thissentence and judgment, given after proper inquiryand without malice, the High Court of Justice haspronounced that there is no appeal. In the earlieryears of the Council’s life, its decisions were frequentlycalled in question before the higher courts of law.The results were on the whole fortunate, for whileits actual findings as a professional tribunal werenever reversed, the judgments delivered on theseappeals not only defined, but in effect prescribed, thejurisdiction of the Council. They laid down its pro-cedure, they interpreted broadly the meagre languageof the Statute, and they settled beyond dispute thefinality of its judicial decisions in all causes withinits competence.

All the Act says is" If any registered medical practitioner shall be convicted

in England or Ireland of any Felony or Misdemeanour, orin Scotland of any Crime or Offence, or shall after due inquirybe judged by the General Council to have been guilty ofinfamous conduct in any professional respect, the GeneralCouncil may, if they see fit, direct the Registrar to erasethe name of such medical practitioner from the Register."

In 1863 the Lord Chief Justice and his colleaguesof the Queen’s Bench laid it down that this clause" makes the Medical Council sole judges of whether a

medical practitioner has been guilty of infamous conductin a professional respect; and this Court has no more powerto review their decision than they would have ... of deter-mining whether the facts had justified a conviction forfelony or misdemeanour under the first branch of the section.The Council is the tribunal to whom the Legislaturehas left the decision, as being the best judges in the matter,and this Court cannot interfere."

In another appeal Lord Justice Bowen declared that,provided " due inquiry" had been made by theCouncil-" the jurisdiction of the domestic tribunal, which has beenclothed by the Legislature with the duty of discipline inrespect of a great profession, must be left untouched byCourts of Law."

Referring to the language of the Statute, LordJustice Fry added :-

"’ Inquiry,’ and judgment,’ and guilt’ are all wordswhich express and which are relevant to a proper form ofjudicial proceedings, and, therefore, although this bodyproceeds by different rules of evidence from those on whichCourts of Law proceed, I cannot for a moment doubt thatthe Council were proceeding judicially, nor can I helpadding that the manner in which the Council has proceededon this inquiry, as on all other inquiries, shows that theCouncil are fully aware that they are performing judicialduties, and endeavour evidently to perform them in a veryadmirable manner."

These and like judgments settled the jurisdictionand the procedure of the Council sitting as a tribunal.The meaning and scope of the statutory verdict ofthe Council-" guilty of infamous conduct in a pro-fessional respect "-were given by the definition ofthe Court of Appeal in 1892.

" If it is shown that a medical man, in the pursuit of hisprofession, has done something with regard to it whichwould be reasonably regarded as disgraceful or dishonourableby his professional brethren of good repute and competency,then it is open to the Council to say that he has been guiltyof ’ infamous conduct in a professional respect.’ "

The words, " infamous conduct," in fact, constitute-a technical legal expression, defined by the Lords.Tustices to mean conduct " disgraceful or dishonour-able " in a qualified professional man acting as such..

.Pyocetrc.It will now be convenient to consider the way in

which the Council carries out the duties imposed uponit under Section 29 of the Act, quoted above. Itwill be seen that the inquiries take place under twoheads-viz., those relating to convictions, and thoserelating to " infamous conduct." To deal with allsuch cases, the Council has set up a special committeeof five, which, assisted by the judicial assessor andthe solicitor, acts the part of a grand jury, and con-siders whether there is prima facie evidence calling-for a formal inquiry by the Council, or whether thecircumstances suggest that a letter of warning maysuitably be sent, or whether in the absence of relevantevidence no further action is necessary.With regard to convictions, the Council, by th&

direction of the Home Office in England, and the-corresponding authorities in Scotland and Ireland,receives from the police all over the kingdom reportsof convictions of medical practitioners for any offence-whatsoever. Some of these are trivial, such, forinstance, as having the number-plate of a motor-carunlighted, or exceeding the speed limit. In thesecases the Council, as a rule, takes no action beyondrecording the fact of the conviction. Other cases.

may be those of convictions for drunkenness, andunless this conviction is for an offence committedwhen in attendance on a patient, or (say) when incharge of a motor-car, it is usual to issue a warningto the convicted practitioner. But should furtherconvictions of the same sort be reported, the com-mittee may think that they indicate a habit of £

intemperance which might be dangerous to thepractitioner as a professional man and to the patientsunder his charge ; in this case it might be decidedthat for the protection of the public the practitionershould be summoned to appear before the Council.There are other convictions of a still more seriousnature, such as those of felony, in which, obviously,the Council ought forthwith to consider the matterin relation to the practitioner’s professional status,and to the good repute of the Register.

If an allegation of " infamous conduct " is received,the Standing Orders, which are published by Messrs.Constable and Co., prescribe that the complaintmust be formulated in writing, stating the grounds of £complaint and accompanied by one or more statutorydeclarations as to the facts alleged. The practitioner,.if the complaint is relevant to his profession, is thenasked to give such explanation of the matter in writing:as he may think fit, and the complaint and the answerthereto are brought before the committee. If, intheir opinion, a prima facie case has been made outto justify an inquiry by the Council, the practitioneris in due course summoned to appear. In cases inwhich a practitioner has been under the censure ofa judicial or other competent authority in relationto his professional character, as the result, for instance,of an inquiry into professional conduct held underthe National Insurance Acts, or of a trial in the civilcourts, statutory declarations by the authority inquestion are not required ; but the depositions,judgments, and other relevant documents, are officiallysupplied, and in other respects the same procedure isfollowed by the Council.When the inquiry takes place, the complainant

or complainants may be represented by counsel orsolicitor, or in the event of there being no personalcomplainant or lawyer representing him, as forinstance in the case of a criminal conviction, the factsmay for convenience be laid before the Council by itsown solicitor, who formally proves the convictionand informs the Council of the circumstances as

reported. The practitioner is entitled to be, and asa rule is, present ; and he also may be represented bycounsel or solicitor. The hearing is in public, witnessesare called and examined and cross-examined, as in

307

the ordinary courts of law. Questions may also be Iput to witnesses by members through the chair.The judicial assessor is always present to assist theCouncil in regard to any points of law or procedurewhich may arise, and if there is a conflict of evidence,he, as a rule, sums up and indicates the legal weightto be attached to each part, in the same way as ajudge sums up for a jury. When a criminal convictionhas been proved, it has to be accepted as a fact, andthe Council does not

"

retry " the charge which led

to the conviction, any more than, according to LordChief Justice Cockburn, the High Court would do ;but it is willing to hear anything that the accusedpractitioner may have to say, or may desire to be saidon his behalf, in regard to the actual gravity of theoffence of which he was found guilty, and in particularto its relevance to his profession, as affecting hisposition on the Medical Register. At the conclusionof the hearing the public and the parties withdraw,including the Council’s solicitor, if he has been calledon to lay the actual facts before it, and the Councilthen deliberates upon the case in camera. It decidesfirst, whether sufficient evidence has been producedto enable it to come to a decision on the facts alleged ;secondly, whether the conviction or facts alleged inthe charge have been proved to its satisfaction ;thirdly, whether it will proceed to judgment at once,or postpone it to a future date ; and fourthly, if itdoes not postpone judgment, whether, on the factsproved, the name of the practitioner is to be erasedon the ground that he has been convicted of a graveoffence, or is guilty of " infamous conduct in a pro-fessional respect." A full shorthand note of the wholeproceedings is taken, and copies are accessible if theyare required, either by the Council itself or by anycompetent authority.The practice of suspending judgment to a laber

date is one which has been gradually evolved by theCouncil. The Act gives one penalty only-viz., thatof erasure-but there are cases in which, when apractitioner has, for instance, been repeatedly con-victed of drunkenness and promises amendment, theCouncil suspends judgment in order that he may havetime to show that his word is good, and in this eventthe practitioner is summoned to appear in 6 or

12 months’ time and to produce evidence as to hisgood conduct in the interval. At the adjournedhearing, if the evidence of conduct is satisfactory,the Council, although it may have found the con-viction or the facts, as the case may be, to have beenproved, does not deem it necessary to proceed tojudgment or to direct the erasure of the name fromthe Register, and the accused practitioner is " dis-charged with a caution." The minutes of the Councilrecord many examples of such " cautions."The Act gives the Council no explicit power of

suspension, nor, in view of the fact that practice byunregistered persons is not prohibited, would meresuspension from the Register be of any practicalvalue to him. A practitioner’s name is either on oroff the Register. If it is on the Register, he is entitledto all the privileges of registered persons, and thesecould not be suspended in the case of an individualwithout the actual erasure of his name. He musthave all or none.A practitioner whose name has been erased may,

under the conditions set forth in the Standing Orders.apply to have it restored ; and, if in the opinion ofthe Council it will not be prejudicial to the publicinterest to grant his request, his name is thereuponreplaced upon the Register. It may here be remarkedparenthetically that the Council has no jurisdictionover the licensing bodies in regard to the withdrawal,under their by-laws, of their qualification from oneof their own members or licentiates. Certain bodies,for instance many of the universities, have no statutorypower to withdraw their degrees once they have beenconferred. Others, such as the Royal Colleges ofPhysicians and Surgeons, have power, independentlyof any action by the Council, under their own by-lawsto suspend or expel their members for offencesinvolving a breach of their particular regulations or of

the practitioner’s declaration on admission. When apractitioner applies for restoration it is essential, inorder to conform to the law, that he should actuallybe in possession of at least one qualification, forrestoration is in effect re-registration. If he is not,the Council has no power to restore his name only,for he is, in fact, unqualified. He must therefore firstapply to the bodies whose qualifications he formerlyheld, asking to have at least one qualification restoredto him. In this matter the licensing bodies havenecessarily complete autonomy. They are not boundeither to await or to follow a decision by the Council.It is the custom of the Council from time to timeto issue warning notices to practitioners in regard topoints of professional conduct, and it has been thepractice not to issue such a warning until a number ofcases of a particular form of misconduct have beenbrought before the Council, so that it is clear that astate of things is becoming prevalent which is contraryto the public interest. For instance, in certain partsof the country it was formerly customary for a

qualified man in large general practice to employ anumber of unqualified persons as his assistants.These, as they acquired a certain amount of rule-cf-thumb experience, were gradually entrusted moreand more with the sole care of patients. The practi-tioner sometimes did not see the patient until it wastime to sign a death certificate in order to avert aninquest. Individual cases of gross abuse were oneby one brought before the Council and condemned.Others, in which serious forms of evasion of the lawwere attempted, followed upon these ; and as theyarose these ingenuities were severally met and dealtwith. At length it was made clear to those whoclung to the bad tradition that their practice was toodangerous to be profitable, and that the unqualifiedassistant " must go. Having accumulated a sufficientbody of experience regarding the mischief which hadto be remedied, the Council summed up all in a" warning notice " respecting the professional offenceof " covering." All qualified practitioners were

notified that the abuse of their qualifications, wherebyan unqualified person was enabled to mislead thepublic and to treat patients as if he were qualified,under " cover " of his qualified employer or employee,who might sign for him his medical certificates, andotherwise enable him to evade the law, was in itsnature fraudulent and dangerous to the public health,and that such an offence rendered them liable to bejudged guilty of " infamous conduct." The result.was remarkable. Unqualified assistants were dis-missed wholesale, often no doubt at the cost of somehardship to individuals, but in the end for the goodof the public and the profession alike. The evil,from being almost endemic in particular districts,became sporadic, and has now almost passed away.Other forms of " covering," such as those by whichuncertified women were enabled to practise as mid-wives, and other unqualified practitioners were

enabled to procure medical certificates from thequalified, were one by one dealt with as they arose.Private " interests " must not prevail against theinterest of the public.’, More recently the practice of advertising, whetherdirectly or indirectly, for the purpose of obtainingpatients or promoting a practitioner’s professionaladvantage, was brought before the Council in con-nexion with some particularly flagrant cases ; andeach case had to be judged on its merits-or demerits.The character of the advertising varied. In some-cases articles were inserted in the press, either bythe practitioner himself or through the medium ofcomplaisant journalists, affirming directly or byimplication the superior methods of treatment of apractitioner, who desired for gain to attract patientsto himself at the cost of his self-respect and therespect of others. If this procedure were unchecked,the practitioner who had fewest scruples, in praisinghimself and his wares, would reach the widest public,and extend his practice without any guarantee thathis merits were in fact superior. It was discreditableto his profession, and contrary to the public interest,

308

that a qualified man should thus adopt the methodsof the unqualified self-advertising and self-praisingpractitioner of medicine or surgery. Accordinglythe Council warned the profession against conductof that kind, and, where a formal and duly attestedcomplaint of such conduct is received, it holds aninquiry into the alleged facts. When the inquiryelicits evidence of deliberate bad faith, or of wilfulexploitation of the public for gain, the offence of" unprofessional advertising " is naturally held to beaggravated.To sum up, what has been written in regard to the

disciplinary procedure of the Council, it is clear, first,that the Council does not itself initiate proceedings,does not itself employ detective methods, and doesnot itself act as prosecutor, against registered practi-tioners. It is a statutory court of justice, andtakes action only in cases of criminal conviction, orof judicial censure, officially brought to its notice, orin cases of formal complaints, supported by primafacie evidence, brought before it by responsiblepersons or bodies. Secondly, its judicial procedureis based as nearly as may be on that obtaining in theLaw Courts. When a charge is made the practitionerhas every possible opportunity of defending himself ;and should his name be erased from the Register, itmay after a lapse of time be restored thereto, if thatcan be done with safety to the public. And thirdly,it is now unusual for complaints involving a chargeof " infamous conduct " to be lodged in regard toany matter on which the Council has not alreadyissued a general warning to the profession and to thepublic.

PARIS.

(FROM OUR OWN CORRESPONDENT.)

Proposed Insurance Legislation.A PREVIOUS letter outlined proposed French legis-

lation on obligatory insurance against sickness, oldage, and unemployment. The French medicalprofession has not been favourably impressed with thesocial insurance in vogue in England and in Alsaceand Lorraine. Objection is taken to the frequentdemands for needless consultations and the insufficientpayment of physicians. After making all necessaryallowances, the introducer of the new French lawassigns 1-20 per cent. of the basal workers’ salary of5000 francs per annum to cover pharmaceutical,hospital, and medical expenses. Jayle finds that ofthe 60 francs thus forthcoming the physician is toreceive 27 to 30 francs for seven days’ medical service,and considers that no country provides adequatecompensation for the physician, although the sumspaid in England are twice those proposed in France.Insurance practice must remain imperfect and poorunless physicians unite to exact a payment whichthey consider suitable. If their demands are not madeunitedly it may be that clinics will multiply, but theirmedical personnel will certainly be inferior. The resultwill be overloading of the free public hospital service,and the proposed law will not ameliorate presentconditions. If physicians’ unions, or syndicats,support what are considered just medical demands,the difficulty will be to compromise between thesedemands and the funds really available from theinsurance treasuries. The question is very difficultin all its aspects.

Tuberculosis in Bakehouses.In discussing night-work in bakehouses the

advocates of reform and their opponents haveadvanced all sorts of medical arguments, based forthe most part on statistics which are positivelyfantastic. Some have said that tuberculosis affects70 per cent. of workers in bakehouses, whereas othershave estimated the rate at only 5 per 1000. MM.Jacques Parisot and G. Richard have recently putbefore the Académie de Médecine some definitestatistics which are particularly interesting now that

the Senate is discussing a Bill for the suppression ofnight-work. From information collected in socialhygiene dispensaries from 1921 to 1925 they havecome to the conclusion that the mortality from tuber-culosis amongst workers in bakehouses at Nancy worksout at 10 per 1000, whilst the mortality for the restof the population of the town varies between 2’5 and3 per 1000. It is instructive to compare these figureswith those obtained in an allied trade-the pastry-cooks-in which there is said to be no mortality anda morbidity of less than 1 per cent. The reason forthe difference seems to be that bakehouse work liesoutside present social regulations (night-work, no

regular weekly day off), and that baking is done inunhygienic conditions which are often deplorable.These factors favour the onset of tuberculosis amongstthe workers. A significant fact is that two-thirdsof the people found suffering from tuberculosis

- many of them with extensive lesions and tuberclebacilli in the sputum-go on with their work as usual.Apart from any possible risk of contaminating breadbefore it is cooked, there is obviously a certaindanger from the inevitable soiling of bread as it istaken out of the oven into a dusty atmospheresaturated with bacilli. Mr. Cazeneuve, of Lyons, hasindicated another point of importance to the tradewhich has received insufficient attention. It is allvery well, he says, to take account of the suppressionof night-work and the eight-hour day, but it mustnot be forgotten that the substitution of mechanicalkneading for hand kneading would be a greatimprovement-an improvement as much in theinterests of the worker as in that of the consumer.

Fitness of Railway Employees.A report on the physical examination of railway

employees has been presented by Dr. Guillain, professorof neurology at the Salpetriere. Guillain suggests thatall French railway systems require a standard physicalexamination for the admission of employees to theservice. Each employee should be examined every fiveyears to the age of 50, and every three years after thatage ; vision should be examined every two years;cardiac patients should not be accepted for service;and employees addicted to alcohol should bedischarged.

New Technique in the Treatment of Lupus.Dr. Auregan, of Lannion, Brittany, has just

presented to the Société de Dermatologie et Syphilo-graphie a method for treating lupus which he has beentesting since 1904. The method is new mainly in itsspecial technique, but Prof. Sabouraud declaresthat it has been proved of great value. The lesions areanaesthetised and deeply curetted, and the wound isfilled with an ample supply of very finely powderedpotassium permangante crystals. The crust formedby the permanganate is removed in 15 to 20 days,cure being perfect in ideal cases. Uncured tracesremaining may be eliminated by repetition of thetreatment. All cases thus treated by Auregan haveremained cured and no case has needed more thanthree applications of the method, which is commendedfor its sureness, simplicity, and inexpensiveness.

Pain in the Hip.According to Dr. Calot, of Berck-sur-Mer, the cause

of pain in the hip, at all ages, is very often entirelymisunderstood. When it comes on in young childrenit is put down to coxalgia ; in adults and old peopleit is often attributed to sciatica, lumbago, rheumatism,rheumatoid arthritis, and the rest. This observer,however, claims to have demonstrated that 90 timesout of 100 above the age of 20, and in nearly 50 per cent.of cases below that age, the functional disturbancesnoticed are really due to a slight congenital abnormalityof the form and adjustment of the two bones of thehip-abnormalities which have been present withoutsign or symptoms for 10, 20, or 60 years. They remainlatent so long as there is no excessive strain, but iffunctional equilibrium is destroyed at any age by theeffects of fatigue or a fall or some debilitating diseasesymptoms such as pain and limping are the result.