became the centre of medical criticism. Publication followed publication in demanding reform from the medical standpoint. Seeing that a mental disease was spreading like an epidemic through the land, Professor H. Quincke, who never enters lightly into controversy, joined in making this demand for reform. In 1905 he wrote: 'If the chief purpose and ultimate aim in introducing conscription was the defence of the country, it nevertheless has an educative effect on the individual, principally because it teaches him not to notice discomforts, to put self in the background, and to strive to attain the common goal as a member of a greater entity. It suppresses egotism; our accident insurance breeds it, in the care of the beloved "Ego." General conscription lays a stress on duty; our accident insurance on the rights of the individual. It has taken many decades to bring the educative influence of the former to its fullest result on the character of the nation; the depraving influence of the accident insurance law is already noticeable, in the course of years it will appear even plainer.' In the same spirit in 1910 the great psychologist Hoche, in his first address as Rector of the University of Freiburg, speaking on mental disease and culture, said: 'Thirty years ago an unknown conception, to-day a disease which as a veritable cancer in the organism of our entire working population, is rightly the subject of deep anxiety. This national epidemic has not only begun contemporaneously with the coming into force of the accident legislation, but also as the direct result and dependence of it. Indubitably the law has engendered the disease.' There is no reason to believe that these views are exaggerated. The elementary notions of right and wrong and the general vision have become so distorted in Germany that drawing a statutory allowance is looked upon by certain classes as a positive honour. At the Congress of south-western German neurologists and doctors in lunacy in 1907, Weygandt stated that many people actually have 'Rentenempfänger' (receiver of insurance pay) printed on their cards. At the same congress Dr. Cramer declared that 'the idea of exploiting an accident 'to the benefit of one's purse was so human and so easy to ' understand that it was quite a normal psychical proceeding.' But although the existence of fraud is so notorious, the difficulty of penalising fraudulent claims has been found to be very great. Cases of pure simulation appear to be rare; for there is nearly always some ground for making a claim. The serious fact is that even when cases of gross abuse are discovered the laugh is frequently on the side of the man who has successfully hoodwinked the authorities-as, for instance, when a workman who drew a 50 per cent. pension in Berlin on account of pains when he moved' was accidentally discovered appearing as an acrobat in Alsace; or when another who was pensioned for inability to move his elbow, defeated a celebrity of the ring in open combat! A widespread difference of feeling appears to exist, in Germany as elsewhere, on the question of robbing an individual as opposed to robbing the State or a company. A person who would not think of stealing a sixpence would be quite capable of evading some tax or overstating a claim upon an insurance company, and even of boasting of his deed. Consequently the fear of being detected when making a false or an exaggerated claim for compensation is very small, as it carries with it practically no social degradation. Indeed a considerable feeling of esprit de corps has been found to exist among those who practise deception in their applications for sick or accident pay. Advice is given as to the best way of attaining the goal, which not infrequently entails deceiving the doctor; the applicant is cautioned as to where he is likely to give his case away, warned as to the peculiarities of each doctor, and instructed as to where and how he can best succeed in getting his claim certified. Professor Bernhard tells us that in Silesia there are experienced pensioners who positively give instruction in neurasthenia; and everywhere in Germany the workman has ample opportunities for informing himself' and learning up any symptoms he wishes to assume. The waiting-rooms of general hospitals appear to be centres of corrupting influence. Old hands initiate novices into all the dodges and devices and put them up to every subterfuge. We are told that these waiting-rooms are called the high schools of simulation.' The advice there given is probably far more subtle than the naïve 'When yer 'get 'urt say it's yer back; the doctors can't never get round yer back.'* As the result of these experiences the former views as to the duration of invalidity after an accident have had to be *Sir J. Collie on ' Malingering,' p. 133. entirely revised where insured persons are concerned, and this in spite of the enormous advance in the methods of treatment, of surgical science, and of hygienic and sanitary conditions generally. The most striking contrast has been observed between the short period required for recovery from accidents received in the riding-school or in sports, and the much longer period of incapacity when a man who is entitled to accident pay suffers similar injury. It has been found that the collaboration of the patient is frequently absent; and where moving a stiff limb or muscle is concerned, it is practically necessary for the patient to assist before a complete cure can be made. It is also obvious that the condition of muscular debility of a patient who has been some weeks in bed can easily be prolonged if he makes no effort and desires a long convalescence. Statistics in regard to injuries which admit of comparison show that not only has the period of incapacity become much longer in Germany than it formerly was, but also that it is longer in Germany than in countries where the workmen are not permeated with the consciousness of their power to claim support by the State. For example, the average period of invalidity connected with a broken collar-bone among insured persons in Germany had grown, as far back as 1896, to eight months. Formerly the time was, with the young, fifteen to twenty days; with older persons, twenty to forty days. This example is very suggestive, for a broken collar-bone is a very common accident which seldom produces complications. It would be hard to imagine a hunting man being kept out of the field for many weeks, to say nothing of months, by such a thing as a broken collar-bone. Quite serious injuries are treated lightly when there is an urgent desire to be restored to health. In the same way German experience shows what an enormous bearing the mental condition following on accidents has on the probable time of healing. Whereas in cases where no allowance is attached the patient welcomes any suggestion that his condition is improving, and faithfully carries out his doctor's instructions in the hope of hastening his recovery, the mental attitude alters entirely when restored health means Archiv für Unfallheilkunde, etc., 1896, p. 177. the stopping of an allowance. The doctor who reports cheerfully and hopefully is now regarded with suspicion and is considered more or less as an enemy. Is he not detracting from the commercial value of a good accident? Naturally the doctor's suggestions and treatment are not carried out with much alacrity, and every symptom is enumerated, pondered and made much of, for it may have a money value. This mental condition, even if not positively hostile, is certainly not favourable to recovery, and the little efforts which assist so materially in hastening restoration to health are not made. German medical literature provides a powerful warning as to the danger of legislating in a way that leaves wide openings for human frailties to enter in, and of forcing many millions of people into a form of insurance that positively challenges abuse. When millions are insured in a uniform way countless eyes are focussed on the money-dispensing arrangements. Any weak points in the defences are soon spied out and systematically exploited every method is employed in the attempt to secure benefits. It must not be imagined for a moment that only the public exchequer suffers from these abuses. It is the working classes themselves who suffer most seriously from the long duration of incapacity after simple accidents and from the increase of cases of nerve trouble. Workmen's Insurance in Germany has been cruel to the working classes in the most dangerous, because the most insidious, way. It has begun to sap the energy and the self-respect of working people. It hits them when they are down. When a man's vitality and love of activity are low, and he is forced by the conditions surrounding him to worry and fret over himself, the tempting possibilities held out by the law come into his mind and suggest that if only he did not make a complete recovery the State would see to it that he was cared for. And so it comes about that the paradoxical suggestion that Workmen's Insurance is a positive danger to the public health no longer makes any student of the subject smile. The evil is fully recognised by the officials whose duty it is to administer the law. If we turn to the official reports of the National Insurance Bureau in Germany we read : 'In the urgent interests of the working classes as well as of the entire nation, it is the pressing duty of the administrators of justice to use every possible means of checking the evil influences of covetousness for insurance pay. The neglect of this duty would necessarily lead to a diminution of the pleasure in work and of the decent feeling of responsibility among those insured persons who are no longer full-wage earners, and it would tend at the same time to damage the power of the nation.' * Dr. L. Laquer says 'The opinion that every accident carries ' with it a right to the highest compensation has become a 'dogma in the soul of the people, the common property of 'the masses.'t Ernest Schultze writes to the same effect: The 'mania for insurance pay, which has been created by the law, has taken deep root in the working classes.'‡ Professor Bernhard goes so far as to say that to-day many experts doubt if it is any longer possible to check this influence which is so injurious to the strength of the nation. Again and again sociologists and other experts on the Continent have urged amendment in the interests of the working classes, and have denounced the wickedness of using an effective bit of rhetoric or sentimental pleading as a political lever when such weighty issues are at stake. How can money compensate for taking away or undermining a man's love of work, and his interest in it, and what compensation can be offered for destroying the feeling of individual responsibility? We have said enough to prove that the troubles arising from the German insurance laws are very serious; yet we know that these laws were introduced in all good faith and with high hopes. Let us turn to the experience of England. Long before Germany began to gain this disastrous experience, equal or greater support had been claimable under voluntary arrangements by English working people in respect of much the greater part of the sickness, accident, or invalidity occurring in this country. This voluntary system included arrangements made with employers, friendly societies, trade unions, and sick-clubs; and yet it is only during the last few years that our medical literature has sounded such warnings as those long heard on all sides in Germany. It is difficult to avoid the inference. Our first experiment with State-regulated allowances dates from the Workmen's Compensation Act of 1897. This Act * Official Reports, vol. xxiii. Die Heilbarkeit nervöser Unfallfolgen, p. 99. |