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redress, and partly because the person-sometimes a fellow workman-responsible for the accident was often unable to pay damages. Moreover, this law did not provide for accidents caused by chance or by the fault of the workman himself.
The present system of insurance against accidents is carried out under the guarantee of the empire, on the mutual system, by the employers united in trade associations, which may embrace the different branches of industry in certain districts or in the whole empire.
The object of the insurance arrangements is to secure compensation for bodily injury or for death, in consequence of an accident to the workman whilst working for his employer, injuries sustained on other occasions being excluded. As a matter of course the injured man must not have brought about the accident purposely, though the injury may be due to his own fault. The compensation includes the cost of the cure, and in addition a fixed allowance during the period of incapacity for work, or in fatal cases burial money and an allowance to the survivors (widows, children, parents) from the day of death. When the injured person is totally disabled the compensation amounts to two-thirds of his average year's earnings; if only partially incapacitated for work a fraction of this amount will be granted. For the first thirteen weeks after the accident the associations for insurance against sickness (or, in their absence, the employers) have to step in.
In the interest of a fair and suitable treatment of sufferers from accidents the trade associations are, however, legally authorized either to commit at their own costs the care of the injured to the associations for insurance against sickness beyond the thirteenth week, until a complete cure is effected, or they may themselves undertake the charge of the patients at any time during the first thirteen weeks, with the understanding that their outlays of sick pay shall be refunded by the associations for insurance against sickness.
The amount of the compensation is fixed, after a police investigation, by the organs of that trade association in whose district the accident happened. Against this decision an appeal may be made to an arbitration court, composed of two members of the trade association, two representatives of the insured workmen, and a presiding magistrate. This court is invested with the character of a special court of law; in more complicated cases an appeal from its verdict may be made to the Reichs-Ver-sicherungsamt.
Every employer contributes to the burdens of the year in proportion to the risks to which he exposes his association.
As it is evident that both the trade associations and their individual members have a
strong interest in diminishing the chances of accidents, the law confers on the associations the important prerogative of prescribing regulations for the prevention of accidents. Through these regulations the employers can be compelled, under penalty of higher assessments, to adopt the necessary measures for safety; the workmen also may be forced by fines to follow the rules.
As regards the participation of the insured workmen in the organization of the trade associations, they are neither members of the associations nor have they to bear any of the corporate burdens. They have, however, to take on themselves a portion of the aggregated liabilities caused by accidents, in so far as, together with the employers, they contribute to the associations for insurance against sickness, to which, as already stated, for practical reasons, the care of patients during the first thirteen. weeks of the illness is left.
Accordingly the law permits representatives of the working men (chosen by the directing boards of the associations for insurance against sickness) to take part in the police investigation of accident cases, and in the discussions of preventive regulations, as well as in the proceedings of the arbitration courts and of the Reichs-Versicherungsamt; on all these occasions the workmen enjoy the same rights as the representatives of the employers.
The Reichs-Versicherungsamt (Imperial Insurance Department) is the supreme court for all that has reference to organization, administration and judicature. It is composed of permanent members a president appointed for life by the Emperor on recommendation of the Bundesrath, and several higher officers similarly appointed; and of temporary membersnamely, four delegates of the Bundesrath, and representatives of the employers and employed in equal numbers. Two judiciary officers are added to decide the more important cases, such as appeals to the Reichs-Versicherungamt and the settlements or adjustments of claims in the case of changes in the composition of trade associations. For some of the federal states, special state insurance offices have been established.
INSURANCE AGAINST INVALIDITY AND OLD AGE.
The money to pay the invalidity and old age pensions is furnished jointly by the empire, the employers and the employed. The empire contributes to each annuity the fixed amount of 50 marks per annum, and pays the contributions of the workmen while serving in the army or navy. It defrays the expenses also of the Reichs-Versicherungsamt, and effects gratuitously, as in the case of the accident insurance, the payment of pensions through the postoffices. All other expenses are borne in equal shares by the insured and their employers, and are raised by current-contributions.
It can hardly be doubted that a general system of insurance of the laboring classes, rendered compulsory by law (such as the German system) must exercise a beneficial effect on the mass of the poor people, and through them on the whole nation. By such a system every laborer is assured of a certain amount of support in case of illness, accident or infirmity. The insurance subscriptions (paid partly by the empire, partly by the workmen themselves, and partly by their employers) are reduced to a minimum owing to the immense number of individuals thus clubbed together. Some, indeed, may object that a state institution of this kind is "too paternal," or rather "too socialistic," but such terms mean little in themselves. A system which gives the poor workman a certain just sense of security, and, when sick, the feeling that he has contributed something to his medical treatment, must deserve attention. Moreover, it doubtless reduces in number those who, having lost employment by illness of various kinds, become paupers.
An insurance system of this kind presents special points of interest in regard to medicine and the medical profession. The mutual obligation of the different parties concerned in such a system must help towards the proper carrying out of sanitary regulations. It becomes at once the duty of an employer, not only towards his workmen but towards other employers, to see that his workmen do their work under the most hygienic conditions possible. The workmen, moreover, are bound to carry out directions as to personal hygiene, etc., and when ill or injured must submit to be treated by the approved methods, and cannot so easily go wandering about from one hospital to another, as they sometimes do in England.*
It is obvious that the collection of statistics of medical importance must be greatly furthered by an insurance system of this kind. By the necessary registration of cases knowledge must be gained as to the exact relative frequency of various illnesses and injuries. amongst workmen employed in different kinds of work, and living in different places.
The statistics must also help in deciding which methods of treatment, at least which practical methods, give the best results when employed on a large scale. By the aid of the insurance associations more hospitals and sanitoria for treatment of the consumptive poor could be erected, both in suitable parts of the country, somewhat after the model of the new sanatorium for poor consumptives at Rupertshain in the Taunus, and in towns, like the hospitals for consumption at London, Frankfurt, etc. In fact, not only sanatoria for consumption, but sanatoria for various classes of convalescents might be profitably established by such an insurance system. Similarly, institutions for Swedish gymnastics and massage might be instituted (or, as in some German towns, private ones might be hired by contract during certain hours of the day) for the use of working men, considered by the insurance doctors likely to be benefited (for example, after injuries to joints, etc.) by such means.
These are some of the advantages which might accrue from such a general system of working men's insurance. On the other hand, it must be acknowledged that medical men are not likely to be well remunerated for their most important share in the work. Medical men would naturally, as in Germany, be found to do the work for very little, partly to have a share in the great undertaking, and partly, doubtless, for the sake of the experience to be gained. After all, however, the medical clubs. in England are probably just as bad for the doctor's pockets, do less good to the working classes, and are more liable to be abused by those who could quite well pay the ordinary medical fees.-British Medical Journal.
The Present and Future of Skiagraphy.
BY OTTO L. SCHMIDT, M. D., Professor of Medicine, Chicago Policlinic; Instructor in Practical Medicine, Northwestern University Medical School, Chicago.
The intense interest aroused by Professor Roentgen's first report on a new method of differentiating the internal structure of opaque bodies was due not alone to its novelty, and the incredulity which it met with, but in a greater degree to the services it promised to render in the healing art. The discovery has proved to be eminently "practical" in its ap
* New edition, published by A. Asher & Co., Berlin and London, 1896. See also Die Arbeiterversicherung in den Europäischen Staaten (Leipzig, 1895), by Dr. T. Bödiker, president of the Reichs-Versicherungsamt; and Les Assurances Ouvrières en Allemagne (Paris, 1895), by Maurice Block.
*I do not mean that poor patients should necessarily be prevented from changing hospitals when they really fancy themselves badly treated; it would be sufficient if those who now change hospitals for some trivial question of convenience, should have a practical inducement not to do so. Knowledge as to the sequela of disease, ultimate results of operations (such as radical cure of hernia, etc.), recurrence of tumors, etc., would be thus facilitated. Certain classes of patients would probably continue to wander, for instance, many neurasthenics, including the malades imaginaires of the poor.
plication, the results achieved being not only definite, but at times so startling as to attract the attention of the world.
Shorly after Professor Roentgen made his discovery he noted the difference in penetrating power of the x-ray through his own hand, bringing out all the bony details, in a way that had not been possible before. With a fine spirit of deference to science, which he was to advance materially, he chose for his first human skiagraph the hand of Professor Köllicker, one of the greatest living anatomists. To Roentgen's reasonable claims for the future of the x-ray were at once added the wildest speculations, some of which were advanced with every semblance of complete verification. Stones of the gall-bladder and renal calculi were placed on sensitized plates and shadows obtained, which were described and published in such a way as to lead the readers to believe that they had been obtained while the objects were in situ in the human body. With the improved technique of the last few months but few stones have been demonstrated in the cavities of the body. While our too sanguine hopes were not realized, with improved methods and a better understanding of the scope of the x-ray have come many happy surprises which have been some compensation for our unrealized hopes.
The term "skiagraph" was introduced in English and American literature by Professor Stine, to designate the x-ray picture. Radiograph is also employed, but not so frequently as the other.
For medical work we use both fluoroscopy and skiagraphy, the latter being preferred when it is possible to use it. The sensitive. plate will give minutiæ that the retina cannot perceive, and we have the additional advantage of a permanent record for future use. It was thought that the fluoroscope would supplant that skiagraph, but in most cases the plate will catch the details of a picture in less time. that it takes to do so with the fluoroscope. A method of photographing the fluoroscopic shadow has been introduced, with the idea of lessening the length of exposure. This has not given pictures with as good definition as the direct method, and it has been but little used. For the detection of foreign bodies in certain localities the fluoroscope is sufficient, but as their removal is often difficult the surgeon usually prefers a picture to which frequent reference can be made; for the observation of moving objects, such as the heart and diaphragm, the fluoroscope alone is serviceable.
The importance of skiagraphy in anatomical study cannot be overestimated. The gross anatomy of the body is fairly well understood; still the accurate delineation of the bones, and especially of joints, is necessarily schematic,
as drawings can only be made after a partial or even complete dissection, which must alter to come extent their normal relations. Skiagraphs show with great accuracy the normal positions of bones in the formation of joints; as they are true representations of undisturbed relations, they should be extensively adopted in illustrating anatomical works in place of the schematic pictures now employed. Although the additional information to be obtained in this way cannot be great, that which is gained is of the utmost importance; particularly is it of value in the examination of bones and joints during growth. The ossification of bones has a fairly uniform rate, and text-books give the time when the centers of ossification first appear and approximately the time when it is completed. This process is subject to wide variation in individual cases. The x-ray furnishes us with definite information regarding the ossification of bone, and we are able by this means to note any departure from the normal. We are thus placed in possession of an important diagnostic aid, and one which gives us information not heretofore obtainable. It is possible that we may be able to recognize with greater certainty that protean disorder, rickets, having as its most characteristic feature delay in the ossification of the bone. The opposite condition, of too early union of central and distal ossification, resulting in the early stoppage of growth, will be revealed by the skiagraph. In short, we may confidently look for a flood of light to be thrown on all anomalies of bone nutrition.
One of the earliest applications of the x-ray was to the detection of foreign bodies. It is in these cases that some of the most brilliant achievements have been reached. The power of the ray in depicting a foreign body imbedded in the tissues depends upon the greater density of the former. The general rule is that the greater the specific gravity of an object the more marked the shadow-or stated in other words, the higher the specific gravity, the greater the absorption. This rule has some exceptions. The heavy metals and their salts give dense shadows. Iron, glass and stones are the substances most commonly introduced into the body which are detectable by the x-ray. In a large proportion of cases the foreign bodies become encapsulated, and cease to be a source of danger. In all recent cases, however, where a foreign body can be accurately located in an accessible portion of the body, it should be removed. If the foreign substance causes pain, interferes with locomotion, or leads to suppuration, it should be removed, even though an extensive operation is required.
Fractures and dislocations offer a wide and brilliant field for investigation. By this means we may study a fracture before it is reduced,
and afterward we can see how perfectly it has been done. The latter will often surprise the surgeon. In many cases where there is every appearance of perfect reduction the fluoroscope or skiagraph will reveal marked discrepancies in the apposition. It is needless to comment on the importance of early and correct knowledge of the position of fragments after fracture. In addition, there are fractures in the long diameter of bones and near joints, in which the most experienced surgeons may err, and which are at once revealed by the skiagraph. In many dislocations the value of this method is very great. Especially is this true in dislocations of the knee. These are often attended by so much inflammation and swelling that it is practically impossible to say when perfect reduction has been secured. In these cases a skiagraph can be made which will give accurate information without pain or special inconvenience to the patient.
Skiagraphy will undoubtedly develop important forensic relations. The value of the skiagraph in evidence has not yet been determined, but as the method is based on rigid principles of physics, there can be no question of its ultimate recognition in our courts. Especially will this prove to be the case in the treatment of fractures and dislocations which furnish the basis of the larger number of malpractice suits. We feel safe in predicting that it is only a matter of time until the treatment of most fractures of the extremities will be guided and controlled by the skiagraph.
An important field for the x-ray is in the diagnosis of diseases of bone. Tuberculosis and other diseases alter the normal lines and the density of these structures so that we can often determine the extent and character of the disease. A bone tumor, being of less density than the surrounding tissues, would present less resistance to the passage of the rays, and in consequence could be recognized. Chronic inflammation with its consequent structural alteration can easily be recognized. Osseous deformities, both congenital and acquired, will furnish an important field of investigation.
Thus far we have considered mostly surgical affections, but it is reasonable to suppose that valuable data may be obtained by the x-ray in internal medicine. As tissues differ in structure and chemical composition, a certain limited differentiation is obtained in the skiagraph. The lungs, for example, because of their contained air allow the rays to pass readily, consequently they are shown as light shadows, and can be differentiated from the heart, diaphragm, and liver. The heart with its dense muscular structure, rich in salts, throws a dark shadow by which its border is easily recognized. Aneurisms and tumors containing blood are easily identified when situated in less
absorbent tissues like the lungs. Skiagraphs often show the skin and fatty tissues, and occasionally muscles may be outlined. These details are usually more apparent in the negative than in the print. These facts lead us to hope for great advances, that will come in the future with a better understanding of the process, and improved technique. At present the practical range of application seems to be limited to a differentiation of bony structure, calculous deposit, solid tumors, and foreign bodies.
With perfection of technique a skiagraph ought to reveal everything visible with the flouroscope, except in the case of movable shadows, as of the heart and diaphragm. Fluroscopy requires much less time, but an exceedingly practiced eye. Therefore some observers prefer and have been much more successful with the screen than others.
The left border of the heart, the diaphragm and the liver can be readily seen, also moderately extensive consolidations in the lungs, pleuritic exudations and aneurisms; but as to the diagnosis of atheromatous cardiac arteries, mere pleuritic adhesions, the accurate size of the kidneys, and many similar complicated conditions, proof must be brought before these statements can be accepted as of positive diagnostic value.
The great drawback to the screen is its phosphorescence; this blurs outlines and produces false shadows. Mr. Edison is recently quoted as having removed this fault in part.
Skiagraphy is much more difficult and subtile in its medical than in its surgical application. The latter has been fairly well exploited in the short time since the discovery of the Roentgen ray, while at present more attention is being paid to the medical possibilities.Medicine.
BOOKS AND PAMPHLETS RECEIVED.
"Contribution to Traumatic Abdominal Surgery," by Thomas H. Manley, M. D. Reprinted from the Annals of Surgery.
"Results of (Chemical) Electrolysis versus Divulsion or Cutting of the Treatment of Urethal Strictures,' by Robert Newman. M. D. Reprinted from the Medical Record, March 27, 1897.
"Functional Indigestion, Its Causes and Treatment," by J. M. G. Carter, M. D. Reprinted from the Medical News, October 24, 1896.
"The Prevention of Infectious Diseases," by J. M. G. Carter, M. D. Reprinted from the Journal of the American Medical Association, August 22, 1896.
"On the Treatment of Fractured Shafts of Bone in Children, Simple, Complicated and Compound," by Thomas H. Manley, M. D. Reprinted from the Journal of the American Medical Association, October 31, 1896.
Published in Honor of the Tenth Annual Convention of the National Association of Railway Surgeons.
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