where the services are sold at a profit; and the men who accept these positions put themselves on a par with mechanics who punch the time clock. It is high time that we recog. nize the possibilities of this growing evil, and a discussion of the dangers that threaten, and how to obviate them is quite appropriate in the American Medical Association for the purpose of getting nation-wide action in an effort to avoid the pitfalls that are threatening. The first consideration is to protect the individuality of the physician, and the A. M. A. should take the lead in attempts to thwart all efforts to destroy that individuality.

PROCEDURE IN THE HOUSE OF DELEGATES

A. T. McCORMACK, M.D.

LOUISVILLE, KY.

Before I start making the very brief talk that I propose to make to you, I want to make two suggestions about the procedure in this body. First, I think it is very important that we make such representation to the Board of Trustees that there will not be meetings of the Board of Trustees during this meeting of the state secretaries. All this business we have been talking about is interesting to us and will educate us some, but they don't know what we are doing; and unless they hear what we say, as the representatives of the constituent associations, we might as well be talking down home or listening to the radio.

The most important question raised here today has been raised by Dr. Bryant, who wants to know what we are going to do for the state societies that need help. This big organization, composed of many wealthy, large states, ought to lend its helping hand to our brethren in those states that need help. It is up to us to do it, and nobody is going to do that unless we get it before the authorities that must initiate such action.

THE CHANGING MEMBERSHIP OF THE HOUSE OF DELEGATES

Several months ago, in a very brief statement, Dr. West raised the point as to procedure in the House of Delegates of the American Medical Association. I realize that I am talking to my peers and not to tyros in the subject of procedure in Houses of Delegates, bodies whose membership changes about two-thirds each year. The membership, therefore, is not familiar with the problems that will be presented to them. As a rule, the work is done, and has to be done, practically entirely, by committees, and the reports of the committees are practically always approved unanimously, after a more or less explosive discussion. But the work of the committees has been so remarkable in its character that we have had relatively little harm done us from the procedures of the House of Delegates except in the passage of ill-considered and ill-timed resolutions.

I am always reminded, in regard to the passage of resolutions, of that familiar hymn:

"Resolutions, yes, we make them,

Not to keep them, but to break them,

For we are only poor weak mortals after all."

Most of such resolutions are relatively harmless because nobody but the author reads them, except the committee that has to consider them.

ILL CONSIDERED RESOLUTIONS

We sometimes do a good deal of harm by an explosive resolution, ill considered, considered too short a time. We pass a resolution on the whiskey question, for example, without considering its verbiage; and we give help and comfort to the enemies of the profession, and slap in the face our strongest supporters in the legislatures and in public health.

We come along and read the Sheppard-Towner bill as it was originally presented to Congress, and very few of us have ever found out that that bill was

never passed, and we are still fulminating against it in resolutions. Practically every state in the Union has adopted the Sheppard-Towner law, and it is in successful operation with the thorough approval of the medical profession, not only approval, but the cooperative approval of almost every state; yet we are still fulminating against it in our editorials and in our resolutions, because we still think that the original bill was passed and don't know that the bill that was finally passed was with the concurrence of every organized body of medicine that had anything to do with it, and the money that is being expended under the SheppardTowner bill is being expended as distinctly for the advancement and the advantage of public health through the medical profession as the money that is being expended by the American Medical Association itself. We all know those facts in the field.

APPOINTMENT OF REFERENCE COMMITTEES

It has occurred to many that it would be an excellent plan if the reference committees could be appointed from the hold-over members of the House of Delegates at the conclusion of each annual session, so that the members of the committee would know a year in advance that they were to be members of a reference committee at the next House of Delegates, and so they would make special studies of the sort of problems that will come to them at that House of Delegates.

NOTIFICATION

Then, if, in addition, an amendment to the by-laws could be enacted providing that resolutions covering questions of policy shall be presented through The Journal, THE BULLETIN, or both, some sixty or ninety days before the annual session, so they could get out to the state and county society meetings, so that the members back home, the real fellows, could know what was proposed, and could express to their delegates, and through their delegates to the American Medical Association and to the people of the United States the accumulated and considered wisdom of the entire profession.

AROUSE THE GENERAL MEMBERSHIP

Those of us who attend these meetings realize our tremendous responsibility. We try to do the best we can, but the important thing, it seems to me, always is that in doing that best we interest and arouse the man in the trenches, the doctor that is practicing medicine, whether it is in the country or the city--the fellow that hasn't taken any particular part in our proceedings; we must arouse him and get him to believe what we are doing is representative of what he would do if he were here, and the more we can get him to consider it, the more we can bring it before him, the better off we will all be.

INITIATIVE OF THE DELEGATES TO BE PRESERVED

Of course, it is extremely important that initiative shall not be destroyed; it is important that the House of Delegates should not merely meet to register its approval of formal set resolutions that are put up before it. I think sympathetically of the boy in my class in school when our old Episcopal teacher read the prayers one morning. Looking over his spectacles, he saw this boy's lips moving. When the prayer was over he looked back at him and said, “William, you were talking during prayer."

"No, sir, I never said a word."

"But I saw your lips moving."

"I was just saying my own prayers. I don't believe in those ready-made, second-hand prayers."

I wouldn't want the House of Delegates to be put in the position where it had to be merely mulling over carefully considered forms that had been prepared long before hand, but put in the position where it can really have the menu spread and not the appetizers that come alone, and where it can really come to the meeting armed with the aroused opinion of the states on the problems that are involved,

and make this great American Medical Association the responsible leader of medical and health opinion in America.

I believe in all these changes that are going on, but I am getting to be an elderly man, and I listen with the conservatism of an older man to many of the suggestions that I hear. I wonder sometimes as I listen to the statements that roentgen-ray work could be much better done by nurses than by doctors, that laboratory technicians are far better qualified to do laboratory work than physicians, and that the lay clerks in the hospitals are more effective and better trained than the interns, that the lay secretaries are going to be far better and more effective (and I see demonstrations of that constantly) than their medical confreres. I am wondering eventually when this thing is led to its logical conclusion what is going to be exactly the function of the physician. We are going to have corporations make our systematic examinations of the well, and groups of men do the various things that were formerly done by individuals, and are going to give up individual things, and all that sort of thing. I am wondering what is going to happen to us if we do that.

It seems to me that this group of men here have the leadership, but they are a good deal like the Confederate Army. We would have licked the stuffin's out of them if they hadn't had a lot of privates as well as officers. We had a lot of officers, but we didn't have enough privates to go around. That is the only thing in the world that handicapped us. We can furnish all the leadership we please and get up and exploit it and explode it, but it doesn't do a particle of good in the world unless we get to every single doctor in Kentucky and New Hampshire and Oregon and everywhere else and get every one of them galvanized and stimulated so that they feel they are part of this show and they are the biggest part of it; because they are the maintenance of it; they are the brawn of it; and we can say what we please, the medical profession of America is just as good as its practitioners and not one whit better; and until they are making systematic physical examinations of the apparently well and until they are making real examinations of the siek, and until they are doing the things that will develop for them the confidence of the public, I don't care what our leadership is we can't go before the people and expect them to give us any more consideration than they do the chiropractors or the naturopaths or any of the other paths or cults.

It seems to me to be a matter of great importance that we put some weight here that will dam back the stream of medical opinion so that it must originate and get its head back home, so that the whole profession is considering our problems and so that we are merely responsive to an aroused, intelligent public opinion.

I like to talk about Kentucky, because we have a wonderful lot of faults and foibles down there. We don't talk much about them away from home, but every now and then we have something good to happen in Kentucky, and I like to tell about that when I get away.

At the last session of the legislature, the medical profession came before the general assembly and the people of Kentucky with the proposition that we are responsible for public health and medical legislation in Kentucky, we are responsible for the operation of its health laws.

When we have a high death rate from a preventable disease that the medical profession has the knowledge to lower, we are the fellows that are responsible because we are the ones that have got the fire in our hands that can destroy that disease, and we are the only ones that have that knowledge. The legislature had many years before put the responsibility on us of nominating the state board of health and of being responsible for its policy. An attempt was made to take that board from the control of the profession and put it under the control of politicians, and by a practically unanimous vote of both houses of the legislature, in spite of the fact that it was supported under a misapprehension by powerful political machinery, the medical profession was told to continue the job because they were willing to undertake it and accept the responsibility, and we were given increased appropriations to carry out the work.

I believe we did that because we went before the public and told them we intended to do the job, and we had demonstrated that while we were not doing it as ideally as it is done in the wealthier states, we were doing it the best we could. I believe it is important that we have the aroused opinion of the medical profession of America, especially the boys in the trenches, to come through the American Medical Association, so that we will have medical education.

We talk about getting systematic physical examination of the well. There is hardly a medical school in the United States that has its students systematically examined. There are a few, but practically none. They are not taught it in the medical school. Until we can put the force of public opinion down home back here amongst them in our Council on Medical Education, they are not going to be taught physical examination of the apparently well, and we know they are not. This is the crowd that is going to make all the progress. We are going to eliminate the things that are being taught in medical education that are uesless. We are going to make progress because we are representative of the medical profession.

If we are going to get anywhere with the American Medical Association, we are not simply going to get up and pass fulminating resolutions condemning this or commending that; we are going to take such constructive criticisms as were presented here this morning by Dr. Bulson-such suggestions as are dropped somewhat haphazardly by various members of this organization that are out working like the very devil in the field, in all sorts of weather and in all sorts of conditions and with all sorts of adversities and without remuneration other than the sense of duty done. The things that they have dropped from their hard work have got to be heard by the big men at the top, and they can't hear them if they are meeting somewhere else and discussing. However important those problems are, they ought to be here in this room now and during every meeting of the House of Delegates; and the men who are responsible for carrying out our work, our generals, ought to be hearing some of the things we are saying as well as us lieutenants; and we must hear from the privates back home if we are really going to accomplish anything in the American Medical Association.

DISCUSSION

DR. WALTER F. DONALDSON, Pittsburgh: I don't believe I can add a single word to Dr. McCormack's presentation except to say that it has been my experience not infrequently in the House of Delegates of the A. M. A. to see much good, hard work done by officers and committees passed over lightly, and I have witnessed it many times in our own state medical society. We have committees that work many, many hours throughout the year and spend a great deal of money in traveling expenses in the investigation of topics that have been assigned to them; and just as Dr. McCormack pointed out, their reports are printed in advance, are read by practically no one, and referred in a meeting of the House of Delegates to a reference committee, and after being mulled over by a committee more or less intelligently, are brought back and approved without discussion or question. The system seems to be entirely wrong. I am sorry I don't have any constructive suggestion to offer that would correct it; but it must be wrong. Our members depend on their chosen representatives, and we fall short because we don't go ahead and do things as approved when the power has once been put in our hands. Undoubtedly many valuable recommendations made by good committees fail because nobody continues the work.

I believe that if we gain nothing else from this discussion as presented by Dr. McCormack, some of us should make up our minds that we are going to go ahead and see that a few of these recommendations are enforced, no matter what they may be; and it may be that we will some time put over something that doesn't meet with the approval of the organization at large, and, receiving some destructive criticism afterwards, we can then call attention to the fact that there is too much carelessness in many important procedures of the House.

Dr. W. G. RICKER, St. Johnsbury, Vt.: There has been running all through this discussion today, to my mind, an underlying thought, and that is the big, big gap between the upper and lower levels, or between the officers of the national organization, including in that the state officers on the one hand and the membership on the other.

We are the secretaries, and as such are largely responsible for the program of the annual meeting. I wonder how thoroughly it has occurred to each of you that after all is said and done really the only contact between officers and members is the annual meeting. We write letters back and forth; and there is an occasional, very occasional, visit, either on the part of a secretary if the roads are good and the weather is fine, or possibly you may get a councillor to go and make a visit, but those are the exceptions except with the full-time secretaries.

The annual meeting, then, is the contact between officers and members. Why don't we make a little bit more of it than we do? To be sure, the time allotted at the annual session is limited. You can't talk over everything every year, and men are interested in this, they are interested in that; they want a symposium on goiter or cancer or carbuncles or something; they want a program of scientific papers, so-called, and some of them are pretty unscientific at that—you know that as well as I do. I believe it is not only a legitimate part of the program but one of the most valuable things that we can introduce into our program is to lay these association questions before the members at large.

The members of the states of Vermont and Iowa and all the rest of them have no idea of the House of Delegates or of this Association headquarters here. Ask them about it if you don't believe what I say. You know they don't have any idea of it.

A talk like Dr. Brown of the Trustees gave to my state society last year did more than anything to bring them together. Let us not leave it entirely for a visiting delegate from the national organization. This last October I had no hesitation, I had some things to say, and I put myself on the program; I put myself on at an advantageous hour, one of those times during the session when I was sure of an audience. You know how they kind of peter out at the tail end, or string in kind of slow at the beginning. I had some things to say. Every secretary has a right to put himself on the program now and then and say the things that ought to be said. You can't write it into your writtten report. Look how many times the remark has been passed to the effect, "Written and not read." What you write is buried. Let us be a little bit more aggressive in utilizing the knowledge and contact which we gain by these annual opportunities, and take it back to the state societies. Take this matter of the periodic health examinations. Get the literature from Dearborn Street here, circulate it over the state of Vermont. What does it amount to? Nothing at all; not one sheet out of a thousand that are sent out of that matter is read. THE BULLETIN is a good thing; it isn't read-of course it isn't.

Let us who are acquainted with these things read THE BULLETIN ourselves, if we choose, listen to these discussions, get these impressions, take advantage of our contact with trustees and our President-Elect, and then, either on the program or off of the program, but in any case at some time during the state meeting as opportunity arises, get up and put this thing before the rank and file.

You never will get this thing to the members, to the individual members of the county society, the man in the field, unless you stand up and talk it to them. Gentlemen, there is no bunch of fellows in the whole United States in a position to do it the way we few men are that are gathered here this afternoon.

DR. D. E. SULLIVAN, Concord, N. H.: I have had the honor and the pleasure of sitting in at the House of Delegates of this Association for a number of years, and no man could have that experience without coming away with some very definite impressions, and to me one of the strongest impressions has been this: that our societies send delegates there wild, loose and ininstructed, without any definite message to convey. Very few of the states send their delegates with resolutions pledged to urge their adoption.

In the number of years that I served, only once was I given a message, and that was on the very important question of "state medicine." That was referred to a committee and hearings were held. The report was nothing but a straddle, like a political platform, something built to let everybody in on and please nobody, and was adopted without any discussion. Some amendments have been made to it during these succeeding years. That is no way to do business. I think there are sad errors prevailing through the procedures of the national House of Delegates; and it is up to us as secretaries of these forty-eight states to see to it that our delegates are instructed by vote of our state house of delegates, or, if it be too late for that to be done, either through information conveyed by individual members or by the president and officers of the society, telling the delegates their opinions on certain fundamental questions. There are always those questions, and for years many of them have cried out in vain for solution at this House of Delegates. Most of the time is consumed in reading very voluminous reports that have been printed already and in the election of officers. Almost arbitrarily, summarily without any right at all to discuss a question, it is referred at once to some reference committee. Then, as I stated a moment ago, when that report is made, most likely there is no discussion, or very little,