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as a ground for divorce, not as a punishment, but in theinterests of the sane spouse and children and countless

generations to come. It matters not whether it was or wasnot the lunatic’s fault that he is insane ; in either case it isdeplorable, and should evoke our deepest sympathy for

everybody concerned; but we have to consider the spouseand family thus bereft of an important member and theillimitable suffering of future generations.

I am, Sir, yours faithfully,A. HAMILTON,

Organising Secretary, Divorce Law Reform Union.

THE MEDICAL PROFESSION AND THENATIONAL INSURANCE ACT.

To tAe Editor of THE LANCET.

SIR,-You kindly published recently a letter from theNational Medical Guild in which attention was called to thefact that treatment by quacks, herbalists, and others wasbeing permitted under the own arrangements clause ofthe National Insurance Act. May we be further permittedto state that the London Insurance Committee is prepared(on the evidence of its chairman given in the House ofCommons recently) to allow arrangements to be made with" homœopaths and herbalists," and this in spite of the factthat Form 43 1. C., on which application to make" ownarrangements " must be made, contains the statement that"the Committee will also require to be satisfied that thetreatment obtained will be of a nature, quality, and extent notinferior to that obtained under the panel system."The Parliamentary representative of the Insurance Com-

missioners-namely, Mr. Masterman-has made it clear thatthe matter is one for the discretion of the Committees, andone which he did not feel disposed to take up. Seeing thatthis has been a bone of contention in Germany and othercontinental countries, it is well that the profession in

England should take the matter in hand as early as possible,and the first step to this is to understand it fully. Wewould therefore ask you to be so good as to give publicity tothis letter. I am, Sir, yours faithfully,

GORDON R. WARD(for the National Medical Guild).

MEDICAL DEFENCE UNION.-The annual generalmeeting of the Union will be held on May 29th, at 4 P.M., at ’,New London Hotel, Exeter, when the usual statutory resolu-tions will be placed before the members, together with theannual report and balance sheet.

SWANSEA HOSPITAL.-The accommodation atthe Swansea General and Eye Hospital has been materiallyincreased by the completion of a new block which was

opened on May 3rd by Lady Mond. The building is threestoreys high, and on the ground floor there are a new dis-pensary and waiting-rooms and a large waiting hall, leadingout of which are four casualty wards, dressing-rooms, bath-rooms, and a porter’s room. On the first floor are a 12-bedward, to be called the Patti Ward, and a two-bed ward,the cost and maintenance of which are being borne byMr. Roger Beck. On the second floor there is accommo-dation for 14 patients. On each of the two upper floors arenurses’ kitchens, bathrooms, &c. The cost of this block is

about £13,000, and is the first instalment of a generalscheme of enlargement decided upon in 1911, which it wasestimated would entail an expenditure of .630,000. A legacyof 10,000 has justified the immediate building of wards toaccommodate 24 patients, when there will only remain theconstruction of additional wards in existing buildings for32 patients. The hospital was established as long ago as1817, but the first portion of the present buildings wasopened in 1869. Among the first subscribers was MissFlorence Nightingale who advised the promoters in thearrangement of the institution. In 1876 a second wing wascompleted, when the accommodation was raised to 130 beds.In 1889 the special eye department was provided, and otheradditions have been made from time to time, including anoperating theatre. That the present extension is necessarythere can be little doubt, for the population of Swansea hasincreased from 70,000 in 1879 to 115,000 at the present time.

MEDICAL PRACTICE UNDER THEINSURANCE ACT.

(BY OUR SPECIAL COMMISSIONER.)(Continued from p. 1270.)

IX.-RURAL PRACTICE IN SCOTLAND.

How the Act Assists the Well-to-do Resident.

MILNGAVIE, a village on the outskirts of Glasgow, with anestimated population of 3481 persons, is in the centre offarm-land. I went there to see how the Act worked in whatwas represented to me as being a typical rural centre, andfound three similar districts adjoining each other withseven practitioners between them. All seven practitionersare on the panel, and their work overlaps. They are, I wasinformed, on the panel not from choice but from necessity.It was, they considered, their only course in the circumstancein which they were placed. They were too-near to Glasgow,where there might be a large supply of medical men fromwhom assistance could have been obtained by the LocalCommittee if they had attempted any strenuous resistance.Moreover, they felt that they did not know how the new Actwould work. Thus a practitioner at Bearsden, one of thethree districts, did not imagine he would have more than adozen or two insured persons cn his list. To his greatsurprise he found something like 500 names; yet thisis a purely residential district, where everyone hithertohad paid the usual fees and there had been no clubsand no contract work. In such a neighbourhood itdid not seem possible that 500 persons would beinsured under the Act, and that no less than that numbershould appear on one practitioner’s list was entirely contraryto expectation. It was soon apparent that these insuredpersons were youths and young women, the grown-up childrenof his well-to-do patients, who were occupied as office boys,clerks, or typists in their father’s business or in the businessesof friends. Formerly, if any of these young folk fell ill,their parents paid full fees for medical attendance. Now theyare all insured, and the question is whether the 500 yearlypayments will represent a larger sum than the occasional butfull fees formerly received. This is a matter that concernsthe nation as well as the patients and their medicalattendants. It means that the community, by its repre-sentative the State, is now paying 2d. a week towards thecost of sick allowance, medicine, and medical attendance forthe children of well-to-do families, who formerly met thewhole of this outlay out of their own private resources. Inthe past such a call on their purses was considered no hard-ship, and the question arises whether it is right to tax thewhole community so as to provide 2d. a week for each ofthese sons and daughters of well-to-do families. Thoughthis matter was brought to my notice in regard to the resi-dential district of Bearsden it applies to the country at large.I am sure that the same point must arise in many districts,and when in the course of my tour my attention is againbrought to it I shall be able to deal with it in a few words,and avoid needless repetitions, if I refer my readers to theconditions at Bearsden.

How t7te Act Assists the Farmer.It is not only the children of prosperous business men

who profit by the Act to get a State contribution inthe event of illness. At the other end of the social scalethe agricultural labourers are also adding to public expendi-ture. Undoubtedly if the State should aid individuals toinsure against sickness none are more deserving of suchassistance than agricultural labourers. But the matter doesnot work out exactly in this way. It is the farmer whoreceives State aid, and however much the British farmermay require State subsidy in his present somewhat anxiousposition, it was not the intention of the National InsuranceAct to afford it. In Scotland there has been so much

emigration that agricultural labour is hard to obtain, and thewages paid are much higher than in England. A labourer

easily obtains 15s. a week besides his board and lodging onthe farm, and hitherto medical attendance has been included.The farmer paid for the medical attendance upon his men,and not only paid full fees, but, if he sold milk, he veryfrequently sent for the doctor. It is absolutely necessarythat the farmer should guard himself from the risk of

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spreading fever through selling infected milk, therefore thedairy farmer regularly sought medical advice in regard tothe men that were working for him, and full fees, in whichdistance was considered, were paid. Now this is all altered.The farm labourers have become insured persons. Theselabourers are not better off in regard to medical attendancethan before, but, together with the State, they have to paya part of the cost, while formerly the farmer paid the wholecost. Thus the Act becomes a measure to relieve the

employers who used to pay for the medical attendance of thosethey employed. Some employers paid very liberally, but nowthere is no natural opening for individual generosity, and alsomedical service is paid for in terms of the National InsuranceAct. At Milngavie one practitioner related to me that someof the surrounding county families might have as many asten indoor servants, and that he had often received his fee ofhalf a guinea per visit for attending one of these servants.Now they were all insured persons and this had not reducedthe amount of sickness prevalent nor the number of times thathe was summoned. In one wealthy household he had amongthe servants a case of influenza, in another one of measles, andhad paid one patient four, and the other eight visits, and hadnot finished with them yet. He could not but think that thehalf guinea per visit under the old system would be foundto pay him better than the 7s. a year under the new dispensa-tion, though, of course, a year’s accounts will be requiredbefore this point can be settled for certain.

Reduction of Income through the Act.There is a great difference between an urban and a rural

practice, and this difference, which has grown of late soas to be patent to all, has been accentuated by the Act asit works in Scotland. For example, ’’ The rural practitionercannot send minor operation cases to the hospitals of thenearest town," remarked one of the Milngavie doctors ; "weperform the operations ourselves." He told me that he hada patient with a fracture who at present needed constantattendance. This was a youth who lived in a villa, andformerly, when he required medical attendance, a fee of 3s.per visit was paid ; now the youth was an insured person.He informed me also that just as the Act came into force hehad a case of pneumonia and was obliged to visit the patienttwice a day. This meant travelling 12 miles every day toattend to one single insured person. Then he had two opera-tions to perform and an urgency case which compelled him tohire a carriage. Further, a patient suffering from epilepsyhad been dismissed from a neighbouring asylum since theAct came in force, and had now become an anxious chargeupon the panel doctor. There was one person whose name

appeared on my informant’s list whom he had a great mindto refuse as a patient, he told me. This was a young girlwho received 10s. a week pocket money from a well-to-dofather. On the plea that she had been typing businessletters this girl was insured as an employed person. Butshe was not keeping herself and she was not poor. He did

accept the shrewd young person as a panel patient, but it isclear that the Act was not intended to operate for the benefitof persons in this fortunate position. He attended also someformer parish patients, but believed that this would notrelieve the Poor-rates, as the 10s. sick allowance in manycases did not suffice, and insured persons would still applyfor poor relief. Again, they had no institution for the treat-ment of tuberculosis, there was no place where sputumcould be examined-everything was left to the panel doctorand his own unaided devices. Altogether, and looking overhis books, the first Milngavie practitioner on whom I calledfound that since Jan. 15th, when the Act came in force, hehad attended on an average a fraction over nine insuredpatients per day. This, multiplied by the 365 days of theyear, would make 3285 consultations per annum. Lookingcarefully over his accounts, making due allowance for baddebts and gratuitous work, he concluded that he used toreceive 2s., on an average, for every consultation. If,therefore, and according to the above calculation, hewill have to give advice 3285 times during the year heshould receive .6328 ; but as he has only 700 insured personson his list he would not receive more than £240. Thisseemed like a net loss of £88, or nearly a quarter of hisincome. Instead of 2s. he now expects to receive aboutIs. 5d. per attendance, and this is to cover everything-nightvisits, minor operations, and very long distances to travel.According to the above figures, we have the interesting fact

that each insured person requires an average of close upon4’7 attendances per annum.

Differences between Rural and Town Practice.The differences between rural and town practice to which

I have alluded will have to be dealt with in a serious spirit.Complaints were made to me that the Medical Committee atGlasgow could not be induced to take any interest in theposition of the surrounding country doctors. It was felt

by the latter that the Act might prove advantageous intowns where practitioners are able in the ordinary pursuitof their business to see many patients within a smallradius. But in the country to see two patients, livingin opposite directions, it was sometimes necessary totravel 10 or 12 miles without a mileage allowance. Thenas the rural practitioners did more operating than townpractitioners this meant devoting more time to some

of the patients. With regard to the number of patientswhom the doctors on the panels in erowded towns areexpected or prepared to treat, one of the Milngavie practi-tioners with whom I conversed said that he could notunderstand how his town colleagues managed to see scoresof patients in an hour or two. It was not right, he thought,to attempt to diagnose so quickly as was thus implied.Even the traditional 15 minutes was often insufficient tosettle the nature of a case. Whether in town or countryit is clear that where the Act has compelled practitioners todo their work too rapidly it must inevitably lower the toneof the medical profession.

’

I found the question of malingering had been very care-fully considered, and a view, new to me, was put forward,that it was beneath the dignity of the medical man to act as" Government or Inland Revenue spies " by denouncing casesof malingering. Any special activity in this line I was alsoinformed would soon render the panel doctor unpopular, hewould do no good, and lose his patients. Besides, it wasfelt to be a very unsafe thing to treat a patient as

a malingerer save upon the most unmistakeable evidence.The past history of the patient is probably the best guide toa decision in ordinary cases of malingering, but it is doubtfulwhether panel practice is likely to provide many oppor-tunities for going into these details.

Resentment against the Act.All the practitioners complained about the question of

mileage. One among them explained that he had to go15 miles in a day without any extra allowance. Formerlythere were a few Foresters and Gardeners. The members ofthese Friendly Societies only paid 3s. 6d. per annum, andthis included medicine. Now, as insured persons, 7s. werepaid on their behalf, and medicine was not included.

Undoubtedly this was a great improvement, but the oldclub patients either lived in the village itself, or if theylived at a distance they paid the usual fees. It is truethe panel doctor is allowed to dispense drugs to distant

patients and then receives 8s. 6d. a year instead of 7s. ;but this difference is not enough to pay for the longjourneys. Then they were constantly obliged to per-form minor operations for nothing, and there was noallowance for chloroform. The majority of the neighbouringpractitioners were opposed to the Act and did not go on thepanel till the very last minute. Being imbued with

antagonism and resentment, they have not the right feelingtowards their patients, and this cannot but affect the

practice. As one of them explained, they were coerced to goon the panel; they were threatened with the importation ofdoctors. Thus. the panel doctors feel they are acting undercompulsion. They try, nevertheless, to make no differencebetween private patients and insured persons, but this isoften materially impossible if for no other reason than thewant of time.

(To be continued.)

GLASGOW UNIVERSITY CLUB, LONDON.-Thesummer dinner of this club will be held at the TrocaderoRestaurant, Piccadilly-circus, W., on Friday, May 30th, at7.15 for 7.30 o’clock. The Right Hon. Augustine Birrell,K.C., M.P., Lord Rector of the University, will take thechair. Members intending to be present or to bring guestsshould give early notice to the honorary secretaries, Mr.W. Craig Henderson and Dr. David S. Roxburgh, 30,

Seymour-street, London, W.