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THE

ORGANISATION OF THE PROFESSION.

(FROM OUR SPECIAL COMMISSIONER.)(Continued from p. 911.)

The Manchester Medical Guild.-A History of Five 1ears’Work.-Advertising and Quackery Checked.-The Pro-fession Pledge Themselves not to Compete for ContractWork.-An Object Lesson.

THE Manchester Medical Guild was formally established inOctober, 1894. Dr. Henry Simpson was its first President andwas well fitted, by reason of the high position he had acquired,his tact and authority, to hold this post. Many contentiousdiscussions were brought to an harmonious conclusion by theskilful manner in which he conducted the debates. But

previously to the creation of this Guild there existed the

Manchester Medico-Ethical Association. This was not a

numerous body, but it rendered good service in affording anopportunity for the discussion of economical questions. Herein February, 1894, Dr. Alexander Stewart read an importantpaper (which was published and circulated among membersof the profession) dealing with the economic side of the pro-vident dispensary system. After exposing the abuse and theunderpay he concluded that the fault was not in the systemitself but in the method of application. Then he insistedthat the remedy for these evils was to be found in union,organisation, and cooperation, and said :-

" The ideal, to my mind, would be one large powerfulassociation for the whole of Manchester and Salford withdistrict branches, one for each Parliamentary division or

other suitable area. Call it a Guild-a good old name andshort. The objects of the Guild would be to promote mutualcounsel and support by regular meetings and other means.The branches should enjoy a certain degree of autonomy, but

- subject to the control of the parent stem in order to securecontinuity of life and uniformity of action as far as wise andneedful. Thus organised, the question of providing medicalattendance for the working classes could be taken up-howbest to procure medical attendance for the poor and for allwho are not able to pay the usual private fees."

It was not long before this proposal was realised and to-dayDr. Stewart is the honorary secretary of the Guild which hewas desirous to see established. The first annual report pub.lished by this organisation deals with the work done in 1895.One of the earliest questions discussed was that of providentmedical aid, which was considered a good thing in itself,but so abused in practice that it often became "a grindingtyranny." It was found that in the Manchester district the

friendly societies rarely paid more than 3s. per annum permember for medical aid and in some societies the paymentwas only 2s. 6d. That this was considered insufficient by atleast some of the members of the friendly societies is provedby the fact that though subscribing to their club doctor"they frequently consulted a " private doctor and paid theusual fees. Of late years, however, this habit was on thedecrease, and the practice of employing the club doctor " asthe "family doctor " to attend to the wife of the memberis not so general. Thus the "club doctor" found that hiswork increased and his income decre2sed. Such appoint-ments, therefore, must be judged on their own merits and noton the indirect advantages which were supposed to accruebut which experience showed are rarely realised. Thequestion therefore now arose whether a medical man couldlive by club appointments alone and the council of theGuild after due investigation concluded that he could not.They therefore urged that the minimum rate of paymentshould be raised to 4s. per annum for those who lived withina radius of one mile from their medical officer’s residence.Further, no one should be admitted to membership withoutfirst undergoing a medical examination, and a fee of 2s. 6d.should be paid for this examination ; certificates of sicknessshould be charged for at the rate of Is. each ; ordinary medicalfees should be claimed for all cases coming under the

Employers’ Liability and Lunacy Acts; and the governingbodies of the friendly societies should aid the membersof the profession in the detection and prevention of abuse.These rules are to apply only to clubs composed of healthymen.

The provident dispensaries at Manchester and Salford weresupposed to provide for the class which is too well off toattend as out-patients at the hospitals and yet not able topay the usual medical fees. The council of the Guild on

investigating this matter reported that, in their opinion, themedical officers of these provident dispensaries were insuffi-ciently paid. In many instances they did not receive moreon an average than 3d. per consultation, and the highest sumever attained was 7½d. In 1894 the medical officers hadreceived f.2600 from 26,007 subscribers, or about 2s. permember per annum. Then, as these provident dispensariesare not under medical control, there is no wage limit enforcedand it is claimed that the medical officers should be ableto decide who should be admitted. While the medicalofficers were underpaid, receiving but E2600 out of .E439&paid in weekly subscriptions, the reserve funds amountedto E1419 19s. 9d. This state of affairs was, however, sowidespread that it could not be easily altered, and beforeany serious attempt could be made the members of the pro-fession must be organised in a more effective and widespreadmanner.

The council of the Guild in its annual report then pro-ceeded to discuss and denounce the Medical Aid Associationsestablished by industrial insurance companies. One of these

companies had boasted that it employed in different parts ofthe country about 1000 medical officers. This more modern

development excited the surprise of the Guild. During thelast quarter of a century the cost of commodities has greatlydecreased and the earnings of the industrial portion ofthe population have increased. On the other hand, medicaleducation now costs more in time and money than formerly;why, therefore, should medical men be paid less The onlyexplanation given is the general tendency to try to geteverything at the very cheapest possible price and theskill of the paid agents of these companies who are ableto inveigle both the members of the profession and thepublic. After quoting the conclusions of the report ofthe committee appointed to consider the question ofmedical aid associations by the General Medical Counciland published in 1893, the Guild expressed its regretthat no attempt was made to find a remedy forevils which were acknowledged to be in existence.The whole question had been dismissed because the com-mittee had "not disclosed the prevalence of any offenceswith which it falls within the statutory province of theCouncil to deal." The Guild in the face of thatdeclaration urged that members of the General MedicalCouncil should be made directly responsible to theopinion of the profession. It was not desirable that medicalmen should be the paid servants of lay committees andshould be sweated by commercial enterprises. The councilof the Guild was, however, of opinion that the Medical Actsunder which the General Medical Council hold their discip-linary powers are capable of a very different interpretationfrom that officially given as a reason for their inaction, TheGuild urged that the ethical law against canvassing and ad-vertising, personally or by an agent, could with advantage beconverted into a penal enactment. This would not interferewith the legitimate work of the friendly societies and wouldbe welcomed by the profession. The Guild also laid downthe principles that should govern all contract work-namely,a wage limit ; no profits or reserve fund to be built up out ofthe subscriptions paid for medical attendance ; the medicalofficers to be controlled only by a medical committee; no,canvassing or advertising to be allowed; no one medicalofficer to have more than 1500 members on his list livingwithin two miles of his residence, &c. But all these reformscan only be brought about by combined action on the partof the profession and therefore the work of organisation wasthe first of all necessities. Such, briefly, were the results ofthe investigations made by the Manchester Medical Guildduring the first year of its existence.

L With regard to the action taken, practitioners were warned. by circular against a new Medical Aid " about to be estab-

lished, resolutions were passed against a provident dis-, pensary for ° touting," and copies were sent to the General

Medical Council. A "private dispensary" advertised byl printed leaflets was denounced. The medical officers of a, dispensary were assisted to obtain some reforms. A branch of the Guild was established at Accrington. A remonstrance

was sent to the Manchester and Salford Provident Dis-. pensaries for advertising and two cases of advertising inr newspapers were reported to the General Medical Council.A case of advertising cards was brought to the notice of the

981

licensing authority. A resolution was passed that patientlin rate-supported hospitals and fever hospitals should bEallowed to send for outside practitioners at their own expense.Communications were opened with the Members of Parlia-ment in charge of the Bill on insurance of children, as itaffected the duties of certifying medical officers. A case of

personation and advertising was reported to the GeneralMedical Council and a case of "covering" was also dealtwith. Finally, a report was drawn up concerning the Mid-wifery Nurses’ Bill.On Jan. 30th, 1896, the second annual meeting was held

and the next month a case of "covering" was stopped bythe action of the Guild. A report on Provident Medical Aid,which had been a subject of constant discussion during theprevious five months, was adopted. The Guild now proceededto discuss the registration of midwives. In March a friendof a member of the council of the Guild was accused ofimproper conduct. The matter was carefully investigatedand the accusation proved to be false. An advertisingM.R.C.S.Eng. was reported to the General Medical Counciland an investigation was instituted in regard to a notoriousquack. Aid was promised to a practitioner so that he mightprosecute a medical aid society which was alleged to havecanvassed in his name though he was not connected with thesociety. Then a business firm had issued to the public alist of the names and hours of the " consulting physiciansand surgeons of Manchester." A circular on this matter wassent to the gentlemen whose names were thus adver-tised in many cases without their knowledge andconsent. A charge of I underselling was brought againsta member of the council, investigated, and settledby the member honourably withdrawing from the contract.The scale of fees for certifying lunacy paid by a certainboard of guardians was discussed and circulars were sent toall the practitioners of the district. Measures were taken in

regard to a district nurse who had attended a case of injurywithout the supervision of a medical man and measures weretaken so that she should not act in this manner again. Anew propaganda by the Provident Dispensary was inquiredinto and representations were made, so that this also wasstopped.

In January, 1897, the Salford Board of Guardians wereapproached in regard to the appointment of a certifyingsurgeon for lunacy cases and were persuaded to advertisethe appointment and throw it open to the local members ofthe profession. At the same time assistance was given tothe practitioners of Wigan to establish a medical guild inthat town. It was on Jan. 27th that the third annual

meeting was held. The next month the case of an

unqualified person practising medicine was taken intoconsideration and a case against "a midwife and hercordials" was reported to the authorities that had grantedher certificate. In March the Apothecaries’ Society wasinduced to move against a quack calling himself "professor."The question of consultants meeting "sixpenny doctors" wasdiscussed but no conclusions were adopted. In June

complaints were made against a well-known agency for

assisting a medical aid society in obtaining medical officersand locum-tenents. The steps taken by the Guild will, it isbelieved, prevent this recurring. During the same month apractitioner had accepted office under a medical aid societywhose previous medical officers were endeavouring toobtain certain reforms. This action was strongly con-

condemned by a special resolution. The next month thedean of the Manchester Medical Department of Owens

College was communicated with, suggesting that thestudents be addressed on the ethical side of their duties.A sympathetic reply was received. In August the Regis-trar of the Royal College of Physicians of London wrotethat the Censors’ Board had condemned the action ofan advertiser about whom the Guild had sent up a com-plaint. During the following months long discussions wereheld on the questions of a minimum tariff of fees and onhospital reform, and the charging of fees to hospital patientswas condemned. The profession was warned against a new " Friendly Society and Medical Aid Club " with the result that eventually this new venture was abandoned. InNovember a branch of the Guild was established at Middleton. lAt the same time an attempt was made by the ministerof a chapel to set up several medical aid societies. He had secured the services of a well-known local practitioner. The Guild, however, at once took steps to prevent this and were E

successful, for the practitioner concerned, when the matter was fully explained to him, readily and honourably withdrew t

9 his connexion with these societies. In December action wastaken in regard to an advertising ’’ private club " and against

, the Medical Aid Department of the Manchester Warehouse-. men and Clerks’ Provident Association. Measures were also

adopted to raise the scale of fees paid by a certain life, assurance company.

During the year 1898 many discussions were held on quack! practice in various forms, medical aid associations, mid-

wives, provident dispensaries, club and allied practices, con-sultations with "cheap doctors," a tariff of fees, unprofes-.-sional advertising, hospital reform, guild extension, &c.In regard to the latter seven meetings were held indifferent parts of Manchester and Salford. A convener was

appointed for each district so as to call the profession togetherwhenever occasion might arise for united action. In

May meetings were held at Manchester to consider hospitalreform. A committee was appointed which brought aboutthe election of a joint committee representing the hospitalson one side and the medical societies of Manchester on theother, both desiring to deal with the question of hospitalreform. Appeals were made to all practitioners to bring,forward evidence on the prevalence of hospital abuse and a.proposition was carried condemning the exaction of fees frompatients treated in charitable institutions that are supportedby voluntary contributions. In regard to the tariff of fees-.it was found that the fees of reputable practitioners varied so.greatly that it was very difficult to establish a uniform rate.But the Manchester Medico-Ethical Association had pro-claimed that 2s. 6d. should be the standard minimum fee ofthe district and the Manchester Medical Guild did not think:it expedient to interfere with this decision. The Medico-Ethical Association, together with the Medical Guild, madea further investigation into the question of " Club andAllied Practices," and a joint report was issued, but no actionwas taken except by the Middleton Medical Guild, and thereall the members formally resolved not to accept any clubs infuture for less than 4s. per head per annum. This was con-sidered a practical but not an ideal solution of the difficulty.The Guild, by appealing to the Royal College of Physiciansof London, succeeded in stopping the issue of handbills by aLicentiate advertising his hours of consultation, &c. Theexploitation of medical men by laymen was to some extentrestricted by the adoption and the publicity given to the-following resolution :-With reference to the promotion of provident medical aid clubs by

laymen the Council of the Medical Guild strongly deprecates the action.of any medical man who, by giving such aid as permits the interven-tion of any third party between medical practitioners and their patients.-deals a severe blow at the best interests of the profession as a whole.

During the year 1897 the subscription of 5s. per head permember of the Guild amounted to £49, so that there were 196-members. At the present time the membership slightlyexceeds 200. In 1898 the council of the Guild held 16 meet-ings and there were numerous meetings of the committees onhospital reform, on club practice, on the Midwives Bill, the-Vaccination Bill, &c. All these questions were also fullydiscussed at the quarterly meetings of the entire Guild.Memoranda were drawn up on the Midwives and Vaccination,Bills and sent to the local Members of Parliament and to the-Members in charge of these Bills. Great regret was-

expressed that the Legislature had rendered vaccination’optional, thus overlooking the fact that all sanitarylegislation is based on compulsion. It was thought,however, that the wiser sections of the population would’continue to avail themselves of the proved protection whichefficient vaccination affords. The old-standing grievanceagainst the Manchester Warehousemen and Clerks’ ProvidentAssociation was partially settled this year. The prospectusesand reports of this association advertised, it was said, the-names of the medical officers and consultants and wereused for canvassing purposes. This practice has now been-abandoned. On the other hand, the Guild failed in its efforts-to make the association impose a wage-limit. The opinion ofthe council of the Guild was asked as to whether practitionersshould stamp their names on the printed labels of theirmedicine bottles and the council decided that this was-

inexpedient. The question was also raised of boycotting " six-penny doctors," but the Guild concluded that they were notyet strong enough to carry out efficaciously such a measureand that for the moment they must content themselveswith bringing moral pressure to bear. A great deal ofeducational work has been accomplished in this and in otherespects. These efforts have met with considerable encourage-nent and the improvements already realised give fair promise

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of greater progress in the near future. During the course of theyear a deputation of the Manchester Medical Guild was sentto Cardiff to aid the local practitioners in that town to forma similar association. Also on July lst the Guild started anorgan of its own called the liledicaL Guild Quarterly, whichwas at first sold for ld., but the price has now been raisedto 2d. By this means those members who have failed toattend the quarterly and other meetings are informed as tothe questions at issue and the local practitioners are nowable to place on record their views. In an editorial articlein its first number this organ of the Guild states that :-

"Whilst on every side unity and organisation are beingused to obtain for various divisions of labour the best con-ditions possible the medical profession alone remains dis-united, disorganised, and without effective power. Incommercial acumen far behind the individuals with whom ithas to deal, the profession offers a weak and vulnerable frontto the exploiting forces constantly arrayed against it."

Then Dr. Alexander Stewart points out that :-" The tradition of the profession is in danger of being lost

because so many young practitioners swell the ranks everyyear without the previous training in the minutiae of generalpractice which the old system of apprenticeship preserved.Few practitioners nowadays keep assistants, so keen is thecompetition and so low the general run of fees in privatepractice. There are thus within the profession itself theelements of a struggle for existence which intensifies thestress of competition."

Dr. Henry Simpson, after describing the difficulties thatbeset the young practitioner, maintains that unless he is ina position of pecuniary independence it is difficult to seehow the struggle for maintenance is to be kept up and how hecan avoid being drawn into the vortex of the submerged andsweated. In spite, therefore, of nonsensical talk abouttrade unionism it is clear that, in the face of combination onevery side, the great body of our profession must combine inself-defence against the various agencies bent on farming the.doctors for their own profit."

Dr. J. Dixon Mann insists on the necessity of focussingthat most potent abstraction-professional opinion-so as tomaintain a high standard of medical ethics. Many men arecompelled by economical forces to act against their own.ethical conceptions, but he also observes that " others

similarly placed are lacking in that innate impulse to dealhonourably with their fellows and succumb to temptationand conduct their practices on lines more mercantile andcompetitive than ethical and professional. Nor are alloffenders the victims of circumstances ; some take a wrongcourse, not in consequence of their surroundings but from atotal and callous disregard of professional obligations. Itus to such as these that the second of the two chief functionsof the Guild applies. - The individual expression of opinionby a brother practitioner would probably be lightly esteemedby the offender ; but when a body of men, representing the,profession of the district, speaks its words carry weight andcannot well be neglected."

Mr. R. Hanson Wolstenholme, one of the most active.and enthusiastic members of the Guild, points out that

though the number of practitioners has increased the popula-tion has never been so numerous or the wealth of thecountry so well distributed and the demand for medicalservices so imperious, yet "the fourpenny physician,’ the’ sixpenny doctor,’ the penny a week club,’ the medicalaid association,’ et 7too genus omne, together with the

advertising terror who announces himself by means of hand-bills pushed under the doors of people’s houses, constitutean opprobrium to the profession. These excrescences havedeveloped along with the largest and most influentialmedical association in the world ’ and no persistent attempthas been made by it to remove them. To appoint an ethical- section once or twice at its annual meetings during thecourse of 60 years is merely to toy with a question whichwill require continuous and united effort to solve."

Like their colleagues at Middleton the members of theManchester Medical Guild have now signed a pledge under-taking not to accept any new club at less than 4s. per annumper member plus a 2; . 6d. examination fee for all newmembers. The term "new club" does not mean a recentlycreated club but a club which is new to the medical officer.So that all medical officers who are actually serving for lessthan this cannot be replaced unless the 4s. are paid to themew comer. The pledge does not call upon club medical

fficers to resign or to attempt to raise their fees, but it giveshem an absolute guarantee that if they do so no co-signa-ories will compete against them. Thus Mr. Wolstenholmenforms me that a medical otricer of a small club in Salfordvas dismissed three months ago because he attempted toaise the subscription paid by the members to the standardf 4s. During these three months the club has sought,ctively to secure the services of some other local practi-ioner but has utterly failed. The pledge has been signed)y all the 53 practitioners in Salford, by the whole professionn Eccles and Levenshulme, by practically all the medicalnen in ordinary practice in Beswick, Harpurhey, Hightown,torton, and Openshaw. Each of the other districts of Man-:hester except Hulme is in need of an earnest, active local)ractitioner who will take upon himself the work of canvassingiis colleagues and convoking them to meet. When this has)een done all the clubs will be requested to raise their sub.criptions to 4s. From this it will be seen that, though theaumber of medical men who according to the accounts have)aid their 5s. annual subscription as members of the Man-tester Medical Guild barely exceeds 200, the action of theGuild is supported by a much larger number of practitioners.,orne 60 per cent. of the practitioners are formally enrolledand many of the consultants have also joined. TheManchester Medical Guild extends over a radius of fourniles. The Medical Guilds of Wigan, Bolton, Ashton,Middleton, and Stockport are not affiliated, but some oftheir members also belong to the Manchester Medical Guild,and applications have been received from all parts of

England for copies of the rules together with other informa-tion. Manchester and Salford are divided by the Guild intojen sub-districts. When a meeting is held in any one of theselistricts for the purpose of discussing questions interestingthe profession generally the invitations sent out are notjmited to the members of the Guild but all the local practi-tioners are invited to attend. Thus a great deal of outsidesupport has been secured and the action of the Guild hasbeen strengthened by the approval of those who have not yetbeen enrolled formally as members. Also a great benefit hasresulted from the fact that now when a medical man has agrievance against any one of his colleagues he at once appliesto the Guild for redress. The matter is then investigatedand a sort of arbitration established. Thus personal disputesare avoided and the contending parties reconciled. Inthis manner a feeling of friendliness and harmony has beenengendered between the members of the profession. A

higher sense of dignity has been developed; the "shoppy"class is being gradually eliminated or is dying out and isbeing replaced by a more worthy and professional feeling.Even the "sixpenny doctors " have been induced to sign thepledge undertaking not to accept clubs at less than 4s., andthere is a tendency even among the lowest sections of theprofession to seek admission to the Guild.

This necessarily is but an imperfect and brief summary ofthe work achieved by the Manchester Medical Guild duringthe last five years. Nevertheless, it will serve to show howextensive and various is the work that has to be done. Noone can read through all the items mentioned above withoutrealising that it would be absolutely impossible for an

individual practitioner to deal with them if he was unaidedand alone. The necessity of union thus stands clearlyrevealed, and it will be seen that the practitioners in manyof the numerous towns by which Manchester is surroundedhave fully appreciated the object-lesson thus given, for theyhave also formed medical guilds. The movement is growingbut it lacks uniformity and the time is approaching whenthese various local medical unions should be brought togetherso as to establish a common understanding.

NOTES FROM INDIA.(FROM OUR SPECIAL CORRESPONDENT.)

Plague and War and the ,Serviccs.-A Sacrifice to Duty.-The Course of the Epidemic.-Inoculation in BombayC,ity.-8hi,vments of Plague Prophylactic Fluid.

IT has been an extraordinary feature of plague administra-tion in India that civilians or military men should always havebeen placed in the highest positions of authority, whilemedical men have been practically left to carry out theirregular executive duties. The anomaly seems all the greater