on questions of great importance to you and to me and to the general public. The whole thing seems wrong. How to solve it is the question.

In the first place, I would urge on every secretary and every state society to do his best to interest his delegate in the questions that are pertinent in his own state; instead of having messages brought from six or seven states in this Union, let every state have some message, and the delegate would then feel really obliged to take some active part and see that a thing was not smothered in committee or in a report subsequently adopted that meant nothing.

Then, again, in regard to the general procedure, I believe men who have been there for a few years as delegates could see that there should be some change made in the rulings. I believe there should be more of the open forum. We did have a committee of the whole once. It should be more than once, and there should be greater latitude given in debate. It has reached that point where our worthy Speaker suggested that there be an ad interim session of the House of Delegates. I think he is right in theory. It might be difficult and expensive to put into practice, but the same thing might be attained if we had longer sessions of the House of Delegates.

It is very evident to me now that Brother McCormack is, as usual, right when he states that at these sessions it might be well if some of our superior officers were present; even if they didn't receive instructions, they at least could hear what was said by some of the lesser lights.

We have the whole problem of medical matters resting in the hands of the House of Delegates. The profession of our states looks to us for their solution. I feel that not ample time is given for their solution, and it is for that that I would beg a full consideration at the hands of these secretaries, that they see to it that their societies do take an active live interest in all matters that concern the profession in their individual states.

DR. D. F. HARBRIDGE, Phoenix, Ariz.: As I hinted a few minutes ago, we are not of such great force in our neighborhood. We have but the one delegate, but we do feel a very serious handicap in the matter of appointing and having representation in the House of Delegates, in that being so far removed from the usual location of the meetings we have had to depend haphazardly on representation by a man who happened to be coming to the meeting.

We have talked this over on several occasions, and it does seem to me that if there was some method whereby the same delegate could repeat his visit a sufficient length of time to become familiar with the medical politics of the institution, we might get somewhere. I was delegate at the Boston meeting, and frankly confess I felt like an elephant in a china shop. I had no more idea of what was going on or what it meant than the man in the moon, but if we could in some way arrange to have a delegate to repeat his visits on several occasions (it might be the same obtains in other communities) it may be perchance that a little better understanding of the operation of this body might result.

DR. E. A. HINES, Seneca, S. C.: One reason for hasty action in the House of Delegates of the American Medical Association or of the state association, in some instances, is the failure of the proper elective bodies to provide for continuity of service on the part of the delegates. Wherever possible I believe the state association should send to the national body the secretary, and keep him there for a long term of years, as is the case with South Carolina. Not only is such service conducive to mature deliberations in the House of Delegates of the American Medical Association, but such a delegate is in position to interpret the action of the national legislative body in a highly intelligent manner to his constituents back home. Continuity of service assures the delegate of appointment on important committees, and thus he becomes intimately acquainted with all of the details of the organization.

Dr. Walter F. DONALDSON, Pittsburgh: I would just like to say that in the medical society of the state of Pennsylvania the only offices that are filled after action by a nominating committee are those of delegates and alternates to the American Medical Association. We have a committee that recommends to the House of Delegates at its session each year nominees for delegate and alternate, and it naturally follows that they attempt to send men of experience.

Some of you may have noticed that the delegation from Pennsylvania is usually composed of men whose faces have become more or less familiar to you.

DR. HOLMAN TAYLOR, Fort Worth, Texas: We will never properly handle the medical affairs of the American Medical Association until we do two things, first, abolish the distinction between membership and Fellowship in that Association, and, second, provide more continuous time for uninterrupted and uninterruptable transaction of the business of the organization by its legislative body, the House of Delegates. Just how we are going to accomplish these things, I am sure I do not know. If the matter were left entirely to

my judgment, I would be forced to confess my inability to give the answer, and I have been thinking along these lines for many years. The suggestion I have to make at this time is that we concentrate on these two problems and see if eventually we can not solve them satisfactorily.

DR. JOHN B. MORRISON, Newark, N. J.: We in New Jersey feel very strongly on this subject of representation in the House of Delegates. For 158 years, our delegates in the state have been permanent delegates. They are elected for a lifetime on good behavior. The only restriction put is that they must be morally upright and must attend two consecutive meetings. If they are absent more than two consecutive meetings, they are dropped. They are nominated by the county society and elected by the state society, and are permanently made delegates under the control of the state society. They come year in and year out, and they develop an interest in state medical matters that cannot possibly be obtained by annual delegates unless those annual delegates are elected again and again.

We find at our annual meetings that the largest proportion of attendance is made up of permanent delegates. We feel that representation in the House of Delegates of the A. M. A. should be along that line, not necessarily permanent but more than an annual delegate.

We in New Jersey have been in the habit of sending our delegates back time after time, in two or three instances, because they are valuable men.

If the proposition was made here that a man's membership as a delegate would be five or ten years, he would become of some value to us in the legislative halls of the A. M. A., just from the vast amount of experience he would obtain from contact and from study during those sessions.

Again we feel that the length of time allotted to discussion of political and medicolegal problems in the A. M. A. is not sufficient, and we have advocated again and again an ad interim session of the Trustees and of the House of Delegates.

DR. EARL WHEDON, Sheridan, Wyo.: I have been here for six or seven years after these gobblers to come out to Wyoming. We got one of the Trustees to come, and we made a Christian gentleman out of him. We can't keep him away from the Wyoming meeting next year, and we want more such men.

We, as secretaries, are not half cooperating among ourselves. We have an organization here. We come here and it looks as if we had to be about fifteen years in the secretary's organization before we were ever asked to bring up anything original or be put on a committee. I am not criticizing the man that made the program; it is our own fault because we don't try to bring out what our own problems are.

The last time I came here I picked up this program, and there were just four dates on the list as to when and where the state societies were going to meet. This year there are just two black sheep, Virginia and Illinois, in the matter of when they are going to have their meetings. That is a trivial thing to some of you, but it meant a lot to us in Wyoming. We haven't many doctors, and we stick them for $10 a year dues in our state society. We give them something. We have a medical defense, and we haven't had a law suit since it started. When you get an association working like Arizona does, you can't tell me that there isn't something in the binding together of men to make them understand that if they go around deliberately knocking the other fellow in order to get a little business for themselves, saying "Bum job! You ought to sue him," and so on, none of them will get anywhere. We are cutting those fellows out, and we are going to cut the lawyers out that start those things. We got the idea started at the last meeting of our state society, that none of us will doctor one of those rascals; they will have to go to some other state to get their medical advice, and it is working.

I say this is important. It is important for this reason-that we must cooperate in arranging our programs. We can cooperate. We have had a wonderfully fine session this last year. Dr. Mitchell got up and said he never listened to a better class of papers nor more intelligent discussion than he heard in a little town way off in Wyoming. That was from one of your members of the Board of Trustees, and he is going to be there next time.

We fellows ought to get together some way and cooperate so that we can arrange to have the same speakers, and place our times of meeting in adjacent states nearer together so that we can get the benefit of this outside help, because we have to depend on it. We can't do the original research work in the small community that you men in the larger cities can do, but if we can have the aid and cooperation of the American Medical Association, extended as Dr. Billings has suggested, I believe it will make a wonderful improvement in our meetings,

DR. FRANK BILLINGS, Chicago: Perhaps I would better speak ex officio. The procedure of the House of Delegates is so much better than the old method before reorganization that there is no comparison to be made between them. I have not been an official delegate of the American Medical Society since 1910, but I have sat in the House ex officio. I have always thought, as I stood before that body to say anything, that the majority of the delegates couldn't be fooled, that you couldn't put anything over on the House. I think any other man who has studied the House has felt that any nonsense could not be put over.

Our methods of procedure are like those of any other body of men who are not qualified in legislative matters. Doctors are notoriously not good at legislation. We have invariably, when we discussed things, talked of details; we don't get down enough to principles. For example, since 1919, the question of alcohol as a therapeutic agent has been before the House at times. This year in Chicago it was exactly where it was when it was brought up in 1919. In other words, the discussion of the subject was as to details, or this opinion or that opinion from this man or that man. No member of the House ever got up and said, "Isn't it time that we referred this question to the therapeutic section with funds enough to let them investigate and come back here with an official report to the medical profession of this country upon which the House can act?" Another example Dr. McCormack mentioned, the Sheppard-Towner bill, brought to the House every year since it was introduced into Congress had opinions expressed for and against, but the general principle of the federal government joining in with the several states on a fifty-fifty basis for health work has never been touched by a member of the House; never have any of the principles involved been discussed.

Until a member of the Board of Trustees presented it there was never an abstract of a report presented in the House, and I insisted three years ago that abstracts of all reports be made, and finally asked the Council on Medical Education and Hospitals to make an abstract report to the House, for inasmuch as the full report was in the Handbook and the Handbook in the hands of every delegate holdover or elect, each man could inform himself fully as to the report and then a short abstract was all that needed to be presented and then to go to the reference committee.

I think the House at its last meeting did order that hereafter abstracts of long reports should be made. What an enormous saving of the time of the House, for if you listen to officers' reports, to councillors' reports, you take one whole day and then they have to come back from the reference committee, and two days are taken up, Monday and Tuesday, with things that should be finished in much less time.

Even the President's address, the President-Elect's address, the Speaker's address, should be in the hands of every delegate to the House at least two weeks before the Annual Session in order that he may know what is going on, in other words, abbreviating the routine proceedings of the House, not in any way making them inferior.

It is in the hands of the House Delegates as to what may be done. The remainder of the time in the session of the House is taken up in resolutions and new business that is offered, but, if the state delegates were properly instructed by the state constituent associations on the character of resolutions coming, or if they got together in any one session and said, "Don't you think we should get a resolution before the House to change a certain policy?" and have it printed in advance before it goes, so that you have an understanding of the business to be considered and transacted.

DR. A. T. McCORMACK, Louisville, Ky.: I appreciate very much the discussion. I would like to move you that this body request the Speaker of the House of Delegates to appoint the reference commitees from the hold-over members of the House of Delegates for the next annual session at the earliest possible date, and that we request the Secretary of the American Medical Association to write to each delegate at least 100 days before the meeting, requesting him to send in for publication in The Journal or THE BULLETIN, at his pleasure under the instruction of the Board of Trustees, any important resolutions involving public policy that he may have to submit, so that they may be gotten before the entire membership of the American Medical Association.

We can try it out and see how it will work. I believe in everything I have heard said, by everybody I have heard say it, that this is one of the most important and interesting discussions throughout this whole day, excepting that it is a good deal like exploding a firecracker under an ash can (it doesn't get anywhere but it makes a nice lot of noise) to those of us who have heard and have discussed, we have gotten it out of our systems.

I suggest that those of you who have suggested this and talked this over talk it again. to the distinguished gentlemen who have just come into the room, and tell them what they

have missed, so when they get through with their transactions in the other room they will have something to work on.

THE STATE ASSOCIATIONS AND WORKMEN'S

COMPENSATION LAWS

W. C. WOODWARD, M.D.

CHICAGO

An understanding of the relations of our state medical associations and of the individual members of those associations to the workmen's compensation acts of our several states requires an understanding of the principles on which such acts are based. Formerly, the only redress the injured employee had was by suit in a court of law, which usually took much time and cost the employee much money, regardless of what he might recover. To remedy this, workmen's compensation acts were passed, based on the theory that losses due to injuries to employees arising out of any industry are proper charges on the cost of operating that industry. Such losses are to be charged up as a part of the cost of operation, and, as selling prices are fixed accordingly, are to be paid for in the end by the consuming public. Obviously, there are three parties to this arrangement: the employer, the employee and the consumer. Nowhere, however, does it imply any new obligation or special duty on the part of the medical profession.

The only obligations with respect to medical services imposed by workmen's compensation acts are such as they impose on the employer, and certain correlated obligations on the part of the employee. The employer must furnish free medical and surgical services to his injured employees under certain circumstances, and such employees must cooperate in the matter of treatment and must submit to examinations, if they would avail themselves of the benefit of such services. It is true that such laws do provide that in certain cases the fees charged by physicians shall be subject to review by the workmen's compensation board or by some similar body. This relates, however, solely to fees for such services as may be rendered within the purview of the law itself. Nowhere is there any provision denying the right of an employer or employee to make express contracts on his own account, to pay such reasonable fees as the physician may charge.

In New York, so far as the employer is concerned, the matter was settled by the New York Supreme Court, in a case an abstract of which was reported in The Journal, Oct. 1, 1921, page 1126 (Feldstein v. The Buick Motor Company, 187 N. Y. Supp. 417). In that case the employer had engaged a physician to treat his employees. The physician sent his bill to the employer, the employer refused to pay, and the physician sued. The defendant denied the jurisdiction of the court, claiming that the matter came within the jurisdiction of the workmen's compensation board. But the court held to the contrary, saying in effect that when an employer engages a physician to treat his employees, that employer was at liberty to make any agreement he saw fit with respect to payment, and that in the absence of an express agreement, the usual implied agreement to pay the reasonable value of the physician's services should be presumed.

In the case of the employee, the situation is somewhat different. Physicians have been so long accustomed to treating employees with the tacit understanding that their bills are subject to review by workmen's compensation boards that probably, in the absence of an express agreement to the contrary, the presumption would arise that the employment of the physician was based on that understanding. That, however, does not necessarily limit the right of the employee to contract for better services or for longer services than are provided for by the act, and to pay the difference himself. I doubt very much the right of Congress or of any legislature to deny or to limit the right of the workman to make such express con

tracts, but I know of no case in which this question has been passed on by the court.

Another matter of interest is the right of choice of the physician who is to treat the injured workman. There is something to be said in support of the claim of the employer to make such choice, and as much, and probably more, to be said in support of a similar claim by the employee. On behalf of the employer it may be said that he pays the bill-which, however, is really not the case, for he merely advances the money and collects the bill from the consumer. On behalf of the employee it may be said that it is he whose future physical welfare and whose very life is at stake, and that he can pass along no loss with respect to either of these matters to the consumer or to any one else. On behalf of the employer it is sometimes contended that he is better able to judge of the qualifications of the physician than is the employee. But the employee, it is contended, is better able to judge from day to day whether he is or is not getting satisfactory service. Before the enactment of workmen's compensation laws, an injured workman who could prove in court his right to damages on account of injuries suffered in the employer's service could select his own physician and collect from the employer the cost of that physician's services; and it certainly seems unreasonable to require such a workman to surrender such freedom of choice in order that he may reap the benefit of legislation passed supposedly in his interest. One state, Wisconsin, has straddled the situation and provided a panel system whereby the employer is required to submit to the employee a list of physicians from whom the employee may choose.

An employee who is being treated by a physician of his employer's choice has no adequate way of guarding himself against injury or wrong doing on the part of that physician. All he can do is to use his own untrained judgment with respect to the way he is being treated. If the employee should undertake to employ a consulting physician or a supervisor to see that he is being properly treated, he could in no way recover the costs of the physician's or supervisor's services. On the other hand, if an employee is being treated by a physician of his own choice, the employer can, and should be allowed to, make from time to time, if necessary, such investigations as will satisfy him as to the adequacy of the treatment and the progress of the case. And if the employer does employ a consultant to cooperate with the employee's attending physician or to investigate the progress of the case from time to time, the expense goes into the cost of carrying on his business and is ultimately recovered from the consuming public, as the workmen's compensation acts contemplate it should be.

There are two more elements involved in the matter of the choice of the attending physician. One of these is the possibility that if the physician is selected by the injured workman he may nurse the case along over too great a period, in order to satisfy his patient. The other is the possibility that if the physician is selected by the employer he will hurry the patient back to work sooner than the patient's condition justifies, in order to diminish the expense to the employer and to gain his good will with a view to future employment. There may be cases in which these charges on both sides are well founded, but I doubt very much whether there is any considerable imposition on either employer or employee with respect to such matters. It seems to me irrational to deny to an employee the right to choose his own physician when he suffers from an industrial accident for fear that he may choose one who is morally or professionally unfit. If a physician is morally and professionally unfit to treat an injured workman, then he is morally and professionally unfit to treat other persons. If he is not competent to treat a workman when that workman is injured in the course of industry, he is not competent to treat an injured workman at any other time. If such moral and professional unfitness prevails. among the physicians of a community, the state board of medical examiners should act to protect the people by revoking the licenses of such incompetents and