256

for serious operative measures, there existed a large anc

rapidly increasing class of people who, though unable t<

afford the pure surgeon’s fees, could afford fees for surgerythat would be accepted by the general practitioner, ancwhose means and mode of life made possible the provisiorof a satisfactory environment and proper nursing. Bytheir resort to hospitals the hospitals are overcrowded and

compelled to spend at an unnecessarily high rate, the

honorary surgeons have more work to do from which

they receive no firancial return, while the general prac-

titioner is deprived of fees he might fairly enjoy for

work that compares favourably as to its responsibilitywith that entailed by a difficult confinement. There

can be no doubt that much of Mr. NORTH’S plea, in

which these things were put out, is sound. The highlevel to which medical education has been raised of late

years means that, in the case at any rate of the by nomeans insignificant number who have held good resident

appointments, satisfactory surgical work can be done if thelocal environment of the patient is suitable, and if intelligentassistance with trained surgical nursing can be got. The

extension of the cottage hospital system would do much tomeet the case. It would ensure the presence of adequatenursing in the locality, establish a sufficient amount of

proper assistance, including the development of a local semi-

professional anaesthetist, and might render available to all

local practitioners access to those special means of diagnosisand treatment which are too costly for him to invest in forhimself, having regard to his limited opportunities for usingthem. It would also afford shelter in cases where the

patient’s domestic arrangements could not suitably be madeto meet the case.

We agree with Mr. NORTH that the relations of consultingsurgeons and general practitioners would be greatly im-

proved by the extension of operating by competent generalpractitioners, and we think it possible, also, that the

consulting surgeon would really be the gainer financiallythrough the frequency with which he would be called in

for consultation upon patients who, if they came into hishands for operation, could not afford his fees, and must,therefore, be operated on by him in a hospital for nothing.Also the time at his disposal for the consideration and

development of original thought and procedure would be ,,

increased. The advantage to the public, too, would fre-

quently be great, for the patient would often gain byremaining at home and the avoiding increased nervous

dread. Moreover, as great surgical experience as possiblein the general practitioner is desirable in the interests

of all classes of the community alike; for persons of

no class are exempt from the danger of serious emer-

gencies involving immediate surgical intervention, and it isobvious that emergency operations are even more dangerousto life, and call for even greater surgical skill and resource-fulness than those for which adequate preparations can

be made, and time, place, and assistance carefully selected.We feel constrained, however, to demur to the individual

instance of what one must call malpractice on the part ofa hospital operating surgeon adduced by Mr. NORTH to

strengthen his argument in favour of the general practi-tioner-surgeon doing his own surgical work. It is obvious

I that no general conclusion can be drawn from such a case,D even though it be true, because it cannot rightly be allegedr that such a thing often happens. A like mode of argumenti might easily be made to favour the abolition of the entirei medical profession. But this is merely an instance of the7 all too common tendency to strain a point in favour of the1 thesis advocated. Mr. NORTH’S admirable paper is con-

vincing enough without it, and if read with a fair and openi mind should do much to arouse a sympathetic interest in the- subject.

The German Imperial InsuranceAct.

THERE has been presented to Parliament during this

! week a report dealing with medical benefit under the

! German Sickness Insurance legislation, which deserves the

study of all our readers, for any information upon the

administration of medical benefits under an insurance

system is extremely valuable to us. It cannot be too

often repeated that the Regulations under which our ownNational Insurance Act is being worked are provisionalin their nature, and it is certain that considerable

amendments must be made if the prognostications of

some of us prove unfortunately true, while the most

ardent supporters of the Act, those who appear to

consider that a noble object is a sufficient excuse for

any unfortunate coincident occurrences, admit that in so

elaborate and far-reaching a measure it is inevitable that

modifications will have to be made. Now it is an opensecret that much of our own legislation has been inspired bythe German pattern. It is, therefore, particularly interestingto look closely at that pattern, and the Commissioners

of the National Insurance Act have done well to publishthis report, and place the situation as they see it freelybefore the public.l As the German Insurance Consolidation

Act, though passed in 1911, will not come into full opera-tion until the beginning of next year, the report dealswith the statutory Sickness Insurance Organisations as theyexist and are working at the present time, but a note warnsthe reader that where the new law alters the constitution

of those organisations, or such of their duties, powers, ormethods of procedure as specially affect the administrationof medical benefit, the changes are indicated in the reportin brackets. The report is based upon inquiries made per-sonally in a number of towns in various parts of Germany,the towns being chosen with a view to ascertaining the

experience of important Sickness Insurance Organisationsdiffering in character and in methods by which the

medical service is organised and remunerated. Local

medical associations and representative local practitionershave been consulted, and, as a result, it is clear that thereare many points of difference between the insurance legis-lation of Germany and of England.For several years past THE LANCET has by articles under

various headings kept its readers informed with regard tothe progressive development of State insurance. in the

German Empire. By a coincidence in the same week

1 Medical Benefit under the German Sickness Insurance Legislation.His Majesty’s Stationery Office. Price 4&frac12;d.

257

that a report by our own Government on the subjectreaches us, we have also received two volumes in

which the provisions of the Imperial Insurance Act (Reichs-versicherungsordnung) are set forth. In view of the dissatis-

faction of so many British practitioners with the insurancestatutes which have become operative here, the books in

question deserve attention as showing what steps have beentaken by foreign medical men under similar circumstancesand as being illustrative also of the latest Government

report. The existence of considerable differences between

the British and German systems has been frequentlymentioned in our columns. For instance, under the British

system old-age pensions are granted without previous contri-butions by the pensioner, whereas in Germany they are

contributory, and the administrative body which grantsthem is also concerned with invalidity pensions, but

not with insurance against sickness. In Great Britain,moreover, no precise distinction is made between sick-

ness and invalidity. In the title of Dr. RUMPF’S

book R. V. O. stands for Reichsversicherungsordnung,and the work itself is divided into the three sections of

(1) Sickness Insurance, (2) Accident Insurance, and (3) In-

validity Insurance, with Old-age Pensions, and Assistancefor Widows and Orphans. Of these the first is no doubt

the most important to the medical practitioner. For many,

if not most, of the lower-paid occupations it is compulsory,while for others it is optional. Insurance is compulsory(1) for workmen in general (Arbeiter), assistants, apprentices,domestic servants, and home workers ; and (2) for the

following when their regular earnings do not exceed

2500 marks (.6125) per annum : the office staff of business

houses or manufactories, foremen, shop assistants and

apprentices, druggists’ assistants and apprentices, theatricaland orchestral employees, teachers and tutors, and the

crews of vessels, whether foreign-going or engaged in

inland navigation. Insurance is optional for (1) healthypersons belonging to the working-class, but for some

reason not coming under the compulsory law ; (2) membersof the family of an employer and engaged in his businesswithout remuneration ; and (3) tradesmen and other ownersof businesses not regularly employing more than two com-

pulsorily insured persons. These voluntary insurers, how-

ever, must not have an annual income exceeding 2500

marks, and are subject to certain restrictions as regardshealth and age.The administration of the sickness insurance, although

controlled by the State, is not in the hands of any

State-appointed individual or association, but is assignedto self-governing sick clubs (Krankenkassen), of which five

varieties are specified. The clubs decide what amount

shall be paid as the contributions of the insured persons,provided that it does not exceed 4 per cent. of the wages,except that in the so-called local sick club (Ortskrankenkasse)the contribution may, with the joint consent of the employerand the insured person, be as much as 6 per cent. of the

wages. Dr. RUMPF has a good deal to say about the

2 Arzt und R.V.O.: der Arzt und die deutsche Reichsversicherungs-ordnung. Von Dr. Th. Rumpf. Bonn: A. Marcus and E. WebersVerlag. 1912. Pp. 114. Price 3 marks.Der Gewerkschaftskampf der deutschen Aerzte. Von Dr. Theodor

Plaut. Karlsruhe: G. Braunsche. 1913. Pp. 246. Price 3 marks.

difficulties with which the club medical officers have to

contend, and Dr. PLAUT is particularly full on this

aspect of the question, his well-timed book being mainlyan account of the operations of the great medical protectionsociety, the Leipziger Verband, with whose operations ourreaders are familiar. Dr. PLAUT quotes freely from

official correspondence and gives particulars of negotia-tions brought to a successful issue against the strenuous

opposition of club committees who study economy without

considering the adequacy or otherwise of the remunera-

tion offered to their medical advisers. No one can read the

two books here noticed, side by side with the Report of theNational Insurance Commissioners, without feeling that wehave before us, and may have for some time, a great deal of

difficulty in the administration of medical benefits ; and alsothat the British service has to work out its own salvation, andcannot trust much to the German pattern, as in Germanydifferent conditions obtain.

Annotations.

BATH REDIVIVUS.

" Ne quid nimis."

THE discovery of the strongly radio-active properties ofthe Bath thermal waters opens up an obvious opportunityfor developing the resources of the city, and for this purposeit may be hoped that the authorities will receive unstintedand widespread support. The waters have been under the

careful observation, of course, of the medical man and thechemist for some time past, but while the former knew whatfavourable therapeutic results in many classes of cases the

waters, either by immersion or ingestion, were capable of pro-ducing, the latter could only supply a statement of analysis ofnegatively therapeutic constituents. As was pointed out someyears ago in these columns, the composition of the Bath watersdid not show any unique constituent present in importantquantity, and, in fact, resembled that of many of the ordinaryhard water drinking supplies in the country, which, of course,possess no special therapeutic value. It was concluded, apartfrom the reinforcements of treatment by diet, regularexercises, and so forth, that externally the waters wereeffective because they exercised a stimulating effect on thecirculatory and nervous systems, helping in this way the

absorption of chronic exudations, while internally their effectwas regarded as merely that due to the ingestion of regularquantities of warm water promoting the removal of wasteproducts, flushing the excretory organs, and tending to keep aregular state of the bowels. For a while our hydrothera-peutic authorities had to be content with some such explana-tion as this, though they had to admit that it was not a veryilluminating one, as in many cases the favourable resultsof treatment were definite enough to point to a specialtherapeutic property of an agent inherent in the water itself.It is highly probable that this agent in the case of the Baththermal waters has now been disclosed by the researches ofSir William Ramsay, who found that the waters showed anunusual degree of radio-activity due to the emanation ofradium called niton. It is true that, regarded from theordinary therapeutic standpoint, the quantity of emana-

tion is small, but as further researches have shown,it is endowed with enormous energy, and on this

account exerts intense effects which appear to be directed

chiefly to promoting healthy tissue activity. Already some