BRITISH NATIONAL HEALTH INSURANCE
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760 PENICILLIN IN ACUTE NEPHRITIS THE generally accepted view of the lesion in acute glomerulonephritis-Ellis’s type 1 nephritis-does not encourage the hope that the condition would be benefited by sulphonamides or penicillin. The sulphonamides, despite enthusiastic early reports, have in fact provided no substantial advantage, and their toxic effects are often serious. The freedom of penicillin from this dis- ability, and the clinical impressions of benefit, such as that recorded by Moncrieff,l together with the observed relationship of infection to nephritis, call for further investigation of its effect. From experience with 25 cases, 10 of them afebrile, Sen 2 concludes that in children with febrile conditions associated with nephritis penicillin may minimise the illness by dealing with the focus of infection. Furthermore, even in afebrile cases he has noted a rapid increase in urinary output, and general clinical improvement ; and he suggests that penicillin has a direct influence on the kidney itself, whereby the illness is shortened. Unfortunately he has not been able to observe a control series, and the information he gives about the original infection and the clinical condition is incomplete. At present the claim must be regarded as unproved, but a carefully controlled assessment is clearly desirable. BRITISH NATIONAL HEALTH INSURANCE THOUGH compulsory insurance against sickness and accident was instituted in this country on a national scale at so comparatively recent a date as 1911, voluntary health insurance had by that time been operating for several centuries. The social guilds of the Middle Ages, whose records, collected in 1388-89, may be studied in the Public Record Office in London, provided cash benefits to their members in time of sickness ; ; and after the guilds had been suppressed by Henry VIII new agents of voluntary health insurance appeared in the friendly societies. Some steps had even been taken towards compulsory health insurance. In 1697 a scheme of health insurance on a compulsory basis was published by Daniel Defoe ; and in 1786 the Rev. John Acland, rector of Broad Clyst, Devon, worked out a scheme of compul- sory health insurance, which, embodied in a Bill, was introduced into the House of Commons in 1787 but failed to secure a second reading. In 1757 a statutory obligation to insure against sickness was imposed on coal-heavers working on the Thames, and in 1792 a similar scheme was applied in the coal trade on the Wear. Prince Bismarck was the first to cause a national scheme of compulsory health insurance to be enacted, though local schemes had then been long in operation in Germany. His scheme, which, it was said, was intro- duced to trump the long suit of the Social Democratic Party, became law on May 31, 1883, and came into operation on Dec. 1, 1884. In 1909 it was studied on the spot by Mr. Lloyd George, who, in his Budget speech of that year, spoke of it in glowing terms : " And a superb scheme it is. It has saved an incalculable amount of human misery to hundreds of thousands and possibly millions of people who never deserved it. Wherever I went in Germany ... men of all ranks, sections, and creeds of one accord joined in lauding the benefits which have been conferred upon Germany by this beneficent policy." Mr. Lloyd George added that the Government intended to bring in a scheme of national health insurance. It was brought in as part of the National Insurance Bill, which, introduced into the House of Commons on May 4, 1911, and, drastically amended to meet the criticisms of the medical profession, received the royal assent on Dec. 16, 1911. 1. Moncrieff, A. A. Lancet, 1944. ii, 706. 2. Sen, S. Amer. J. med. Sci. 1946, 211, 289; Indian Physician, 1346, 7, 151. The scheme as presented to Parliament was based on the German model, and contained provisions to which the medical profession strongly objected. At the insis- tence of the British Medical Association many amend- ments were made, the most important of which were : (1) the administration of medical benefit was transferred from the approved societies to specially created insurance committees containing representatives of the medical profession ; (2) all registered medical practitioners were given the statutory right to have their names placed on the list of doctors undertaking the medical care of insured persons ; (3) insured persons were given the statutory right to choose, and change, their insurance doctors subject to acceptance by the doctor ; (4) in every insurance-committee area a local medical com- mittee was to be formed, recognised by the Government as representing the medical profession of the area, and charged with certain important administrative functions. As a result of these provisions, which embodied principles for which the German doctors had long been contending, the medical profession has cooperated with the Govern- ment in the administration of the British system, whose operation has been free from the embittered disputes between the profession and the administrative authorities that had been not uncommon in Germany. The B.M.A., in their evidence submitted to the Royal Commission on National Health Insurance, not only recommended the continuance of the health-insurance system but urged that it should be extended to include the depen- dants of insured persons and to provide a wider range of service. The royal commission, reporting in 1926, recommended that such extensions should be made, " as and when opportunity offers and funds become available " ; but, being impressed with the difficulty of retaining the insurance principle in a service of wider scope, added : " The ultimate solution will lie, we think, in the direction of divorcing the medical service entirely from the insurance system and recognising it along with all the other public health activities as a service to be supported from the general public funds." The change foreseen by the royal commission is now on the eve of accomplishment. The Insurance Medical Service, as a separate service, will soon be a thing of the past ; it will be merged in a complete National Medical Service. The British health-insurance system is under- going a profound change. A new period in its history is opening, and the time is propitious for a comprehensive review of the system-a review that should include an account of the sources from which it sprang and of its actual working and development, and an appraisal of the measure of success it has achieved. Mr. R. W. Harris has presented such a review in his book National Health Insurance in Great Britain 1911-46,1 which will be found very useful by students of health insurance, whether in this country or abroad. Mr. Harris has unique qualifications for writing on the subject. As a civil servant he was associated with the late Mr. W. J. Braithwaite in helping Mr. Lloyd George to steer the National Insurance Bill through Parliament, a task involving preparations for the reception of innumerable deputations and the answering of innumerable inquiries. He was one of the first-appointed members of the staff of the English Health Insurance Commission, and became an assistant secretary in the Ministry of Health ; and since his retirement from the civil service he has been chairman of the medical service subcommittee of the London Insurance Committee. His book embodies an experience of health-insurance administration extending over 35 years and will be of permanent value. The narrative of events is not carried further than September, 1945, and no account is given of this year’s legislation, though the circumstances leading up to it are discussed 1. London: George Allen and Unwin. Pp. 224. 12s. 6d.
Transcript of BRITISH NATIONAL HEALTH INSURANCE
760
PENICILLIN IN ACUTE NEPHRITIS
THE generally accepted view of the lesion in acuteglomerulonephritis-Ellis’s type 1 nephritis-does notencourage the hope that the condition would be benefitedby sulphonamides or penicillin. The sulphonamides,despite enthusiastic early reports, have in fact providedno substantial advantage, and their toxic effects are
often serious. The freedom of penicillin from this dis-ability, and the clinical impressions of benefit, such asthat recorded by Moncrieff,l together with the observedrelationship of infection to nephritis, call for further
investigation of its effect. From experience with 25cases, 10 of them afebrile, Sen 2 concludes that inchildren with febrile conditions associated with nephritispenicillin may minimise the illness by dealing with thefocus of infection. Furthermore, even in afebrile caseshe has noted a rapid increase in urinary output, andgeneral clinical improvement ; and he suggests that
penicillin has a direct influence on the kidney itself,whereby the illness is shortened. Unfortunately hehas not been able to observe a control series, and theinformation he gives about the original infection and theclinical condition is incomplete. At present the claimmust be regarded as unproved, but a carefully controlledassessment is clearly desirable.
BRITISH NATIONAL HEALTH INSURANCE
THOUGH compulsory insurance against sickness andaccident was instituted in this country on a nationalscale at so comparatively recent a date as 1911, voluntaryhealth insurance had by that time been operating forseveral centuries. The social guilds of the Middle Ages,whose records, collected in 1388-89, may be studied inthe Public Record Office in London, provided cash benefitsto their members in time of sickness ; ; and after the
guilds had been suppressed by Henry VIII new agentsof voluntary health insurance appeared in the friendlysocieties. Some steps had even been taken towardscompulsory health insurance. In 1697 a scheme of healthinsurance on a compulsory basis was published byDaniel Defoe ; and in 1786 the Rev. John Acland, rectorof Broad Clyst, Devon, worked out a scheme of compul-sory health insurance, which, embodied in a Bill, wasintroduced into the House of Commons in 1787 but failedto secure a second reading. In 1757 a statutory obligationto insure against sickness was imposed on coal-heaversworking on the Thames, and in 1792 a similar schemewas applied in the coal trade on the Wear.
Prince Bismarck was the first to cause a nationalscheme of compulsory health insurance to be enacted,though local schemes had then been long in operationin Germany. His scheme, which, it was said, was intro-duced to trump the long suit of the Social DemocraticParty, became law on May 31, 1883, and came intooperation on Dec. 1, 1884. In 1909 it was studied onthe spot by Mr. Lloyd George, who, in his Budget speechof that year, spoke of it in glowing terms :
" And a superb scheme it is. It has saved an incalculableamount of human misery to hundreds of thousands andpossibly millions of people who never deserved it. WhereverI went in Germany ... men of all ranks, sections, andcreeds of one accord joined in lauding the benefits whichhave been conferred upon Germany by this beneficent
policy."Mr. Lloyd George added that the Government intendedto bring in a scheme of national health insurance. Itwas brought in as part of the National Insurance Bill,which, introduced into the House of Commons on May 4,1911, and, drastically amended to meet the criticismsof the medical profession, received the royal assent onDec. 16, 1911.
1. Moncrieff, A. A. Lancet, 1944. ii, 706.2. Sen, S. Amer. J. med. Sci. 1946, 211, 289; Indian Physician,
1346, 7, 151.
The scheme as presented to Parliament was based onthe German model, and contained provisions to whichthe medical profession strongly objected. At the insis-tence of the British Medical Association many amend-ments were made, the most important of which were :(1) the administration of medical benefit was transferredfrom the approved societies to specially created insurancecommittees containing representatives of the medicalprofession ; (2) all registered medical practitioners weregiven the statutory right to have their names placedon the list of doctors undertaking the medical care ofinsured persons ; (3) insured persons were given thestatutory right to choose, and change, their insurancedoctors subject to acceptance by the doctor ; (4) inevery insurance-committee area a local medical com-mittee was to be formed, recognised by the Governmentas representing the medical profession of the area, andcharged with certain important administrative functions.As a result of these provisions, which embodied principlesfor which the German doctors had long been contending,the medical profession has cooperated with the Govern-ment in the administration of the British system, whoseoperation has been free from the embittered disputesbetween the profession and the administrative authoritiesthat had been not uncommon in Germany. The B.M.A.,in their evidence submitted to the Royal Commissionon National Health Insurance, not only recommendedthe continuance of the health-insurance system but
urged that it should be extended to include the depen-dants of insured persons and to provide a wider rangeof service. The royal commission, reporting in 1926,recommended that such extensions should be made," as and when opportunity offers and funds becomeavailable " ; but, being impressed with the difficultyof retaining the insurance principle in a service of widerscope, added : " The ultimate solution will lie, we think,in the direction of divorcing the medical service entirelyfrom the insurance system and recognising it along withall the other public health activities as a service to besupported from the general public funds."The change foreseen by the royal commission is now
on the eve of accomplishment. The Insurance MedicalService, as a separate service, will soon be a thing of thepast ; it will be merged in a complete National MedicalService. The British health-insurance system is under-going a profound change. A new period in its historyis opening, and the time is propitious for a comprehensivereview of the system-a review that should include anaccount of the sources from which it sprang and of itsactual working and development, and an appraisal ofthe measure of success it has achieved. Mr. R. W.Harris has presented such a review in his book NationalHealth Insurance in Great Britain 1911-46,1 which willbe found very useful by students of health insurance,whether in this country or abroad. Mr. Harris has
unique qualifications for writing on the subject. As acivil servant he was associated with the late Mr. W. J.Braithwaite in helping Mr. Lloyd George to steer theNational Insurance Bill through Parliament, a taskinvolving preparations for the reception of innumerabledeputations and the answering of innumerable inquiries.He was one of the first-appointed members of the staffof the English Health Insurance Commission, and becamean assistant secretary in the Ministry of Health ; andsince his retirement from the civil service he has beenchairman of the medical service subcommittee of theLondon Insurance Committee. His book embodies anexperience of health-insurance administration extendingover 35 years and will be of permanent value. Thenarrative of events is not carried further than September,1945, and no account is given of this year’s legislation,though the circumstances leading up to it are discussed
1. London: George Allen and Unwin. Pp. 224. 12s. 6d.
761
in a way that throws light on present difficulties andcontroversies. There are, however, some curious omis-sions, including the lack of an index. No reference ismade to Henry Ratcliffe, who was the first to placefriendly-society finance on a sound actuarial basis, or toSir Robert Morant, without whose administrative geniusand immense driving power the health-insurance systemcould hardly have got under way in the short sevenmonths allotted for the purpose.
HOW LONG DEAD?
THE scientific aids towards identifying a person founddead have increased enormously in number and efficiencyin the last few decades, but Simpson 1 shows that theyhave not made easier the job of assessing the time ofdeath. X rays, blood-groups, dentition, estimation ofheight from a small piece of limb bone-all these areinvaluable in deciding on the victim’s identity, but tellus nothing about the hour of death. Simpson holds thatthe most reliable guide is the steady fall in temperaturewhich takes place up to twenty-four hours after death.Under average conditions about 25° F is lost each hourfor the first six hours, and 1-5°-2° F for each of the nextsix hours. Calculations based on these figures may behopelessly upset by extremes of temperature, the amountof clothing the man was wearing, ventilation, andenvironment-thus a body in a river will reach the
temperature of the surrounding atmosphere much morequickly than one on dry land. If parasites, such as fleasor body lice, are present, the entomologist may help byfinding out whether these creatures are still alive, and,if so, how long it takes to revive them. Adipocere mayhinder rather than help, for the hydrogenation of bodyfat is notoriously variable ; it may take place in threeor four weeks (with warmth), or may be delayed wellbeyond the four to five months which is the averagefor this country. The onset of rigor mortis and of post-mortem staining are of little use in placing the time ofdeath accurately. All in all, Simpson seems to placemost reliance on body temperature. " It is never toolate," he says,
" to measure the temperature in the hopethat, though the body is cold,’ it may still register afew degrees above that of the surroundings." He quotesas an example a murder at Hastings where the bodytemperature was still 7° F above air temperature, aftereighteen hours in the snow, and this made it possible tofix the time of death within an hour.
VARIOUS OPINIONS ON B.C.G.
SEVERAL months ago the Ministry of Health receivedfrom bodies interested in the prevention of tuberculosisa memorandum recommending the supply and use ofB.c.G. in this country 1; and the Minister has latelyannounced that B.C.G. is to be manufactured in this
country. This may make it possible to undertake thecontrolled investigation for which workers here have
hoped, and it will be well to take account of some ofthe pitfalls and possible disappointments indicated bya recent report from America. Levine and Sackett 2
vaccinated with B.c.G. a series of young children fromtuberculous families in New York City. No child abovethe age of one month was accepted unless the tuberculintest and radiological and clinical examinations were
negative ; with parenteral vaccination, 85% becametuberculin-positive. At first an attempt was madeto control the study by dividing the children into twoequal groups-those to be vaccinated and those to beused as controls-a physician being assigned to vaccinatehalf the cases ; and between 1927 and 1933 altogether990 children were studied in this way. The results were
impressive, for there were only 3 deaths from tuber-
1. Simpson, K. Science Progress, October, 1946, p. 713.
1. See Lancet, July 27, p. 138.2. Levine, M. I., Sackett, M. F. Amer. Rev. Tuberc. 1946, 53, 517.
culosis amongst the vaccinated compared with 18 amongthe controls ; in other words the number of deaths fromtuberculosis was four times greater (3-38%) in the controlgroup than in the vaccinated group (0-68%). Experienceshowed, however, that selection was taking place ; therewas a tendency to inoculate the children of the moreintelligent and cooperative parents and to keep thechildren of the uncooperative parents as controls.From 1933 onwards alternate children were vaccinated,
the selection being made before they were assigned topaediatricians. Since some children had to be with-drawn from the investigation, the number of controlsand vaccinated differed. Altogether 1094 children werestudied, of whom 566 were vaccinated (all intra-
cutaneously with 0-15 mg. B.C.G.) and 528 were controls.The tuberculosis deaths among the vaccinated were8 (1-41%) and among the unvaccinated controls also8 (1-51%). The possible effects of parental cooperation,economic conditions, racial distribution, exposure, lostcases, and percentage of autopsies were all assessed, butwithout the discovery of any factor vitiating the com-parison. It was found that, among the children segre-gated in hospital for three months before and threemonths after vaccination, there were among the 91vaccinated 1 death, and among the 96 controls 3 deaths,from tuberculosis ; in the former group the child whodied, though born of a mother who died of tuberculosis,was never exposed, whilst in the latter group one childwho died had not been exposed as far as was known.Levine and Sackett regard it as dangerous to takechildren into hospital during the first three months oflife ; but they consider that, when a child is admitted,B.C.G. may have some protective value. They concludethat B.C.G. must be judged by the results in childrenvaccinated at home ; and as a public-health measurethey rate it below removal of the tuberculous subjectfrom the home.The Scandinavian countries, on the other hand, from
long experience have no doubt of the value of B.C.G.,.which is being increasingly used. In Denmark, for
example, the number of vaccinations has crept up from82 in 1934 to 40,000 in each of the last two years. Thetuberculosis dispensaries are being overwhelmed bythis extra work ; and at a recent meeting of theDanish Association of Tuberculosis Doctors 3 it was
suggested that general practitioners, whose interest hashitherto been lukewarm, should be offered courses ofinstruction so as to win their active participation. Whilethe administration of the vaccine seems to be plainsailing, its production’ demands constant skill andattention. Dr. K. A. Jensen, who has been culturing thestrain since 1927, has found considerable difficulty inkeeping it on the narrow path of therapeutic rectitude." The ideal," he said, " is never reached. The man whois to cultivate the B.C.G. strain and keep it at a level ofsuitable virulence has a very responsible post. If thevirulence falls, so will the percentage of persons becomingtuberculin-positive after vaccination ... if the strainbecome too virulent, the number of complications willrise. Both events would be equally unfortunate, sinceeach would bring B.C.G. into disrepute." In Denmarkthe vaccine has been cultivated on Sauton medium, withsubcultivation about every two weeks.4 4 The slow lossof virulence after repeated subcultivation was formerlycorrected by several passages on bile-potato medium ;but of late years the same effect has been obtained bymore frequent transfers on the Sauton medium (every7-10 days), thus corroborating experimental evidencethat virulence depends essentially on the rate of growthon Sauton medium. Dr. Holm,4 who heads the tuber-culosis division of the State Serum Institute, is satisfiedwith the absolute safety of the vaccine. Its use is
3. See Nord. Med. Sept. 20, 1916, p. 2134.4. Holm, J. Publ. Hlth Rep., Wash. Sept 6, 1946, p. 1298.
