985ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.

as the discharge has ceased to be purulent the packingmay be safely left in for two days, though a dailydressing is more comfortable. When the granulationsreach the surface a dressing of sterile vaseline spread ongauze is best.

(4) The " shirt button " abscess is recognised bymarked prominence of the breast with but slight signsof inflammation in the gland itself. An area offluctuation may be detected at the outer margin ofthe lower half of the gland. The best incision foropening this type of abscess is a semilunar one on themargin of the gland, and the pus will be found betweenthe breast and the pectoral fascia. When it has beenevacuated the finger should be inserted and a searchmade for the area of gland substance from which ithas arisen. It may be possible to open this adequatelyfrom the deep surface; if not, a small radially placedincision should be made over the affected lobe andcarried through to the posterior part of the breast.Tubes should be inserted in both incisions, but packingwill only be of use in the anterior one. The -tube onthe posterior aspect of the breast should not be eremoved for four or five days, being taken out when thedressing is done, boiled, and replaced. At the end ofthat time it may be removed altogether or a smallerone inserted for a few days more.The possibility of this being a retromammary

abscess arising from caries of a rib or from anempyema must be borne in mind. In both cases thebreast will be prominent, and one of these conditionsshould be suspected from the absence of signs in thebreast itself. An abscess from caries of a rib is themore common condition, and must be inferred whenexamination of both the chest and the breast isnegative. Both these abscesses will be beneath thepectoral fascia, and they tend to point a little furtherout towards the axilla.The subacute mammary abscess must be men-

tioned in passing as there is often some difficulty indifferentiating it from malignant disease. It presentsan oedematous indurated condition of the skin, oftenwith retraction of the nipple, which very closelyresembles carcinoma of the breast. However, thelength of history, the association with recent lactation,and the absence of a lump should help in the diagnosis.Enlarged axillary glands will be present in bothconditions.

Galactocele.

This condition is the only form of chronic breastabscess within the scope of this article, and mustbe mentioned in conclusion. Tuberculous mastitis,gumma, and actinomycosis are pathological rarities.It is a condition of retention of milk in a dilated duct,together with a mild degree of infection. It maybe readily recognised as a distinct elevation near thenipple produced by a round or pear-shaped tumour,in which fluctuation may be readily obtained. It ispainless, and firm pressure may produce a spurt ofmilky fluid from the nipple. In long-standing casescaseation of the contents takes place. It should beexcised when lactation is over, the usual radiatingincision being employed.

J. BASIL, HUME, F.R.C.S. Eng.,Chief Assistant, Surgical Unit, St. Bartholomew’s

Hospital.

Messrs. Watson and Sons (Electro-Medical), Ltd.,have devoted their Bulletin No. 73 to apparatus producingwhat is known as artificial sunlight. The description ofapparatus is prefaced by some general remarks on the nature,properties and biological significance of the part of thespectrum dealt with. Heliotherapy in medicine has cometo stay and there is now a wide choice in the apparatusavailable. The two chief sources of artificial sunlight areeither mercury-vapour lamps supplemented by some sourceto compensate for the lack of the longer wave-length, oropen arc lamps of the carbon or tungsten or tungsten-coredtype. There is a wide selection described and illustratedin this bulletin, and purchasers will do well not to forgetthat the best protective goggles are cheapest in the end andshould be purchased against their absorbing power. It isimpossible to tell by naked-eye inspection what is a goodgoggle and the spectrograph is necessary for this purpose.

Special Articles.PROCEEDINGS OF THE

ROYAL COMMISSION ON NATIONALHEALTH INSURANCE.*

(Continued from p. 829.)

THE evidence which is summarised below is thefinal instalment of the report of the proceedings priorto October. The Royal Commission resumed itsproceedings recently, and has been hearing furtherofficial evidence.

The National Council of Agriculture.(App. LXXXV. ; Q. 21051-21217.)

The National Council of Agriculture for England,represented by Mr. James Donaldson and Mr. DentonWoodhead, is strongly opposed to the pooling of thesurpluses of Approved Societies, on the ground that thepersons engaged in agriculture and other rural i ccupa-tions are as a class healthier than most other industrialclasses. The witnesses reminded the Commission thatagriculturists had objected from the outset to the flatrate of contribution, and they cited statements madeon behalf of the Government in 1911 to the effect thatApproved Societies would be allowed to use their ownfunds for their own members.

It was elicited from Mr. Woodhead in the course ofexamination that one reason why his Society had agood surplus was that, though a rural workers’ society,they excluded unhealthy members in the country.

* In previous articles the proceedings of the Commissionwere reported under the following headings: IntroductoryNote ; The Scope of the Insurance Scheme (see THE LANCET,Jan. 31st, pp. 247-8); The Provision of Medical Benefit (Feb. 7th,pp. 301-3 : Feb. 14th, pp. 355-6 ; Feb. 21st, pp. 403-5) :Financial Provisions of the Act (Feb. 28th, pp .454-7) ; MedicalCertification and the Regional Medical Staff (March 7th,pp. 508-9); The Approved Societies and the Money Benefits(March 14th, pp. 564-5 ; March 21st, pp. 623-4); Evidence ofthe Hearts of Oak Society (March 28th, pp. 677-9) ; Evidenceof the National Conference of Industrial Assurance ApprovedSocieties and of the Manchester Unity Approved Society(April 4th, pp. 731-3) ; Evidence of Independent Order ofRechabites, of Rational Association Friendly Society, and ofMiners’ Societies (April 11th, pp. 784-6); April 18th, p. 839 ;Evidence of Mr. Alban Gordon (April 18th, pp. 839-40 );Evidence of Joint Committee of Approved Societies, of StockExchange and Lloyds’ Health Insurance Societies, and ofGroup of Catholic Approved Societies (April 25th, pp. 889-91);Evidence of the National Insurance Beneficent Society(May 2nd, pp. 943-4); Evidence of the British Medical Asso-ciation (May 9th, pp. 993-5); Evidence of the British DentalAssociation and other Dental Organisations (May 16th,pp. 1044-6); Evidence of the Insurance Committees (May 23rd,pp. 1097-8); Evidence of Various Approved Societies (May 30th,pp. 1135-6); Evidence of the British Medical Association(June 6th, pp. 1184-6 ; June 13th, pp. 1248-50 ; June 20th,pp. 1315-6); Evidence of other Medical Bodies (June 20th,p. 1316 ; June 27th, p. 1348 ); Individual Evidence (June 27th,p. 1348); Medical Services in the Factory, Ministry of HealthInquiry Room, Evidence of National Sailors’ and Firemen’sUnion and of Loyal Order of Ancient Shepherds (July 4th,p. 36); Evidence of Friendly Societies’ Medical Alliance, SouthWales and Monmouthshire Alliance of Medical Aid Societies,Friendly Societies’ Medical Officers’ Union, Association ofApproved Societies, Standing Committee of Scottish InsuredWomen, and Society of Medical Officers of Health (July 11th,pp. 86-8); Evidence of the British Hospitals Association, theSheffield Joint Hospitals Council, and the Middlesex Hospital(July 25th, pp. 181-2); Evidence of Opticians’ Associations(August 1st, pp. 224-6); Evidence of Council of British Ophthal-mologists, of Ophthalmic Benefit Committee, of Chemists, andof Drug Store Proprietors (August 15th, pp. 348-50); Evidenceof Chartered Society of Massage and Medical Gymnastics, ofthe Ivory Cross, of Scottish Panel Chemists, Practice amongHighland Crofters, and of National Farmers’ Union of Scotland(August 22nd, pp. 402-3); Evidence of Nursing and otherWomen’s Organisations (Sept. 5th, pp. 519-20); Views of Trade-Unions, Evidence of Approved Societies (Sept. 19th, pp. 618-9);Evidence of Joint Tuberculosis Council, Cambridgeshire Tuber-culosis After-Care Association, London County Council on

Treatment of Tuberculosis, British Social Hygiene Council, andLondon Insurance Committee (Oct. 3rd, pp. 722-3); Evidenceof Society of Apothecaries of London, East of Scotland Dentists’Panel, Association of Poor-law Unions, Association of ParishCouncils of Scotland, and of Mr. W. J. Braithwaite (Oct. 17th,pp. 828-9).

References to the paragraphs in the printed statementsissued as appendices to the reports of the oral evidence aregiven thus: " App. X. 69," and references to the oral evidencethus-Q. 1369.

986 ROYAL COMMISSION ON NATIONAL HEALTH INSURANCE.

Evidence as to Casual Employees of Cou.ncil8.(App. LXXXVIII. and Q. 21317-21394.)

Mr. J. H. Barnby, of the Stepney Borough Council,stated that the Council employed persons on Sundaysfor the cleansing of the streets. He claimed that, asthis employment was purely casual and intermittent,the men should not be subject to deductions forNational Health Insurance contributions.

It was suggested to the witness that although thiswas part-time employment it was to some extentregular, and other types of casual employment werepointed out as having a better claim for freedom fromcontributions. It was also made clear to him thatthere was nothing in the Act to prevent the Councilpaying the whole contribution if, as appeared, theywere willing to do so.

Delay in Paying Sickness Benefit.(App. XCVII. and Q. 22731-22837.)

Miss M. A. Hilbery, who had at one time been asick visitor for the Prudential Approved Societies,gave evidence in which she suggested that sicknessbenefit was often withheld from insured persons forlong periods, and that this resulted either in return towork before recovery or actual hardship in regard toobtaining food.

National Insurance Audit Department.(App. CI. and Q. 23209-23289.)

Mr. W. A. Middleton, acting chief auditor, gavean account of the whole machinery of audit of theaccounts of Approved Societies. He pointed out thatan Interdepartmental Committee reported in 1912 infavour of the employment of a whole-time auditstaff, and said that their recommendations had beenfollowed.

The witness said that the auditors undertook a greatdeal of work not ordinarily falling within the scope ofan auditor’s duties, but that there was no precedentfor the working of such an enormous scheme as thatunder the National Health Insurance Acts, and a greatdeal of assistance had to be rendered to the societies.

Is it a fact that it is the smaller societies that cause yougreater trouble in your audit than the larger societies ?-There is no shadow of doubt about that. It is a question ofpart-time officials having these complicated Acts and regula-tions which are beyond their capacity-not beyond their zeal.With regard to the falsification of claims for benefit,

it was stated by way of illustration that sometimesthe dates were altered on medical certificates in orderto extend the benefit period, or such certificates werefabricated by copying a signature from a genuinecertificate.

Experience shows that there is a greater temptation toconstruct false maternity benefit claims because of the

comparatively large sums obtainable thereby-many suchcases are disclosed by discovery of a second claim purportingto be in a member’s name following at too short an intervalupon another in the same name, either or neither beinggenuine.

The cases of fraud or failure in Insurance Com-mittees’ accounts have been few in number, and theamounts involved comparatively small.

Chartered Accountants of Scotland.(App. LXXIX. and Q. 20342-20534.)

The evidence given on behalf of this body by Mr.John Reid was to the effect that the system of auditingby whole-time officials involved long delays and wasnot in the best interests of the successful working ofthe system, and that the multitude of duties whichthe auditors undertook showed a good deal of confusionas between auditing proper and actual supervision orinspection.

It was suggested that the auditing of the. accounts’of societies, both on the State side and the voluntaryside, should be entrusted to outside professionalauditors.

Evidence from the Department of Economics,University of Cambridge.

(App. LXXVI. and Q. 1979,1-19899.)Mr. Joseph L. Cohen, of the Department of

Economics of Cambridge University, criticised thepresent scheme of benefits as being wholly inadequate,and he advocated an extension of benefits all round.He stated that he could find no definite principle behindthe present rates of money benefits, which bore norelation to any significant fact in industrial life. Healso stated that-

Administration of insurance by the Approved Societycombines all the faults and none of the virtues of insuranceby industry or insurance by the State, or insurance by localauthorities. It cannot claim the virtues of being a democraticform of organisation.

Mr. Cohen advocated a system of health insuranceadministered by the Minister of Health, the benefitbeing paid through the Post Office and employmentexchanges with a State guarantee covering allemergencies in the life of a workman’s family.

The Actuarial Basis oj the Act.

(App. XCIV. and Q. 22252-22404.)Mr. Walter Farris, secretary of the Loyal Hearts

Friendly Society, questioned the necessity for thewhole actuarial basis of the Act. He said:-Under the National Health Insurance Act, spread over the

whole of the insured persons, there must always be a similarrange of ages and liability and the cost of benefits must remainfairly constant and proportionate to the number of insuredpersons, because the general public is forced to come under theAct at the age of 16 years and at the age of 70 ceases to beentitled to sickness benefits.

The witness suggested that there was no object inaccumulating enormous reserve funds for the benefitof a future generation, and he proposed that thereshould be a system by which Approved Societies shouldbe given credit from year to year for the expectedsickness of their members who are actually alive at thecommencement of each year, instead of the presentsystem, which credits societies at the commencementof membership with the present value of the expectedsickness of the member during the whole of the yearsthat the member is expected to live.

His proposals included provision for continuoussickness benefit, the abolition of the three days waitingperiod, and exemption from arrears. He estimatedthat there would be accumulations in about 30 years’time of a gigantic sum of 818,000,000, which wouldnever be wanted. It was suggested to the witness inexamination that the figure was much more likely tobe z200,000,000.

I want to know whether that trifling difference wouldmake any change in your point of view with regard to thepresent system ?-Even if I accepted that figure I shouldstill contend that the system that I suggest would be farpreferable and there would be greater benefits to the insuredperson.

Mr. Farris was reminded, with regard to reserves,that there was a process continually going on of eatingup existing reserves and replacing them by new ones.

The Government Actuary’s Evidence.

(App. LXXXVII. and Q. 21237-21316.)Mr. Henry, the Deputy Government Actuary, gave

evidence with regard to the 1922-23 valuations ofApproved Societies. He said that, with the exceptionof the disablement experience of women-the cost of benefits has been much below the provision madefor it, 38 per cent. of the surpluses being attributable to thissource. It should, however, be pointed out that the cost ofdisablement benefit in the case of both men and womenhas been constantly rising during the four years. Therelation of the average cost of the period to the corresponding" expectation " is not altogether, therefore, a satisfactoryindex to present and future conditions in regard to thisbenefit.

Roughly speaking, the surplus on the last valuationamounted to about three times as much as that in1918, but the surplus consists to quite a materialextent of monies carried forward from the earliervaluation.

987THE HEALTH OF THE NAVY IN 1922.

Since 1922 the sickness experience has been moreunfavourable and there has been a steady downwardcurve so far as surplus is concerned.The estimated total surplus of Approved Societies

on the results of the 1922-23 valuations, the last ofwhich will be published in 1926, is about 42,000,000,of which, said Mr. Henry, 14,000,000 must be

reserved, leaving 38,000,000 disposable, to whichhas to be added 8,000,000 from the earlier valuation.The total disposable surplus was thus estimated at36,000,000, or about .87,000,000 a year, to be spentover five years. _____________

THE HEALTH OF THE NAVY IN 1922.

THIS report gives a satisfactory account of thehealth of the Navy in 1922. Compared with thepreceding year, there were fewer cases of illness oraccidents, fewer deaths, fewer invalidings, and fewermen daily on the sick list. The table appended showsthe distribution of the casualties.For some reason the 4300 marines at headquarters

are separated off from the 96,560 other men in theService who are called the Total Force. In 1922, asagainst 1921, there was a reduction of about 16,000 inthe total naval establishment, which falls readilyinto three great groups-viz., the Atlantic Fleet, thefleets abroad, and the Home Station. The last accountsfor about half the establishment and the other two fora quarter each. The men on the Home Station includerecruits, men under training or in depots, and thoseawaiting discharge. The death-rate was 4-4 per 1000

on pp. 14-18 shows the number invalided for eachdisease group in each year of age or service. Invalid-ings are most frequent between 21 and 23 years of age,and about the fourth or fifth year of service. Deformi-ties of the limbs cause most discharges in the first yearof service ; eye diseases go on steadily all through ;ear diseases have their maximum in the first five years ;heart diseases in the first two years and again aftermen have re-engaged ; and tubercle has a maximumin the first five years and again, like organic heartdisease, after re-engagement. It would therefore seemto be acquired, in part, in the service period. At thehigher ages more men are discharged for tubercle thanfor venereal disease.

Of the vaccinations on entry only 8 per cent. (136)were primary. In 1921 28 per cent. of the new entrieshad to be vaccinated for the first time, and it looksalmost as though the public were vaccinating itselfas it should, but secretly. The Army has ceased topublish these vaccination statistics since the war, andno appeal to its experience can be made for confirma-tion or contradiction. Diphtheria and enteric fever hadonly half the incidence of 1921. Influenza was chieflyprevalent on the Home Station and in the AtlanticFleet, and there were 67 cases in the latter as against35 in 1921. The percentage case-mortality was 0-48in the Atlantic Fleet and 0-16 on the Home Station;no one died in the Mediterranean. There were twomeningococcus infections, of which one was at Harwich,where there had been no case for two and a half vears.The boy had not been on leave for six weeks, and theexamination of 456 contacts did not reveal any carrier.

HEALTH STATISTICS IN THE GROUPS, ROYAL NAVY, 1922.Figures for 1921 are in italics, on the left of columns.

in the fleets abroad and 2-7 on the Home Station ;there were 99 deaths from drowning (54: of them inships lost), 36 from tuberculosis, 32 from injuries, 25from pneumonia, 13 from diseases of the intestines (10from appendicitis), 12 from influenza, and 11 frommalignant disease. The invalidings were, in order ofmagnitude, as follows : For diseases of the eye, 348 ;diseases of the ear, 260 ; tubercle, 198 ; gonorrhoea, 178 ;organic heart disease, 146 ; deformities of the limbs,135 ; and neurasthenia, 111. Only 24 were invalidedfor syphilis, but there were three times as many inan average year before the war. A very valuable table

1 Statistical Report of the Health of the Navy for the year 1922.Published by H.M. Stationery Office, London, 1925. Pp. 176. 6s.

The other case, just as mysterious, was in a battleshipnear Constantinople, and neither was followed by anyother case. The percentage mortality of pneumoniawas 12 on the Home Station, 10 in the Atlantic Fleet,and 3 in the Mediterranean, which suggests that it isnot without good reason that elderly persons are sentto the Riviera in winter. Tubercle caused much thesame loss in 1922 as in 1921. Marines at headquartershad a liability, 1-16 per 1000, and for marines inships it rose to 1-57 ; this was, however, a great fallfrom that of 1921 (3-2). The sick-berth staff had aliability of 3-18, which was the lightest they havehad for years. The naval figures for venereal diseasesare particularly useful, for they distinguish first