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considerable importance to certification ; to signa false certificate was a very serious thing for amedical man ; neither did they wish to palliate laxcertification. They recognised their duty in thisrespect, but it was an oppressive duty and had beenplaced on them over and above their duties to their

, patients ; there was nothing comparable to it in

private practice ; and it must be taken into accountin deciding the amount of capitation fee.As regards the pre-insurance club practices, he

accepted the evidence of the insurance committeesthat the insurance scheme offered a better service.He could not admit that the contract rate of 4s. was adequate, but even accepting that, it was to be noted that a customarv service rate in those days was 1-25services per member per year. Assuming a presentday service rate of 3-77, even the 4s. rate would beequivalent to 12s. in insurance practice, less Is. fordrugs, but with an addition for certification, records,and increased range of service.

In conclusion, Dr. Brackenbury said that he couldnot believe that the approved societies seriouslysuggested that a reduction in the capitation fee wouldreally improve the service available to insuredpersons, neither did he think the societies woulddesire that the pay from insurance work should be solow that the doctor would devote most of his timeand interest to his private practice. The professionwholeheartedly desired that the insured personshould receive as complete a service as is given toprivate patients, but to secure that it was necessarythat the capitation fee should be comparable to theincome derived from private practice.

In concluding the sittings of the Court the Chairmanthanked all the parties for the excellent way in whichthey had presented their evidence. He hoped thatthe Court would be able to issue an early report.

PARIS.

(FROM OUR OWN CORRESPONDENT.)

The Projected Insurance Scheme and the 3ledicalProfession.

THE Chambre des Deputes has under discussion anew proposal with regard to an insurance scheme, asubject which is of topical interest to the Englishmedical world. Under the proposed scheme insur-ance will be of two kinds, compulsory and voluntary.The first category includes all those persons whoseincome is less than 10,000 francs per annum, allowinganother 2000 francs for each dependent child under16. A levy of 10 per cent. is made on the basis ofthe income, contributed partly by the employer andpartly by the employee, and in return the insuredperson may claim medical treatment and drugs forhimself, his wife (if not a separate wage-earner), andhis children. A daily- allowance amounting to halfthe regular salary is made in case of illness, and fordisablement a pension of 500 to 3000 francs, accord-ing to the scale of the contributions, is allowed. Afurther allowance is made to wives during the threemonths preceding and the three months followingchildbirth, while obstetric treatment is provided free.The number of wage-earners affected by the com-pulsory insurance is estimated at 12,000,000, includ-ing wives and children. In addition thereto farmers,artisans, small employers, and small merchants areeligible, provided that they are not more than 30 yearsof age and free from any chronic malady. It hasbeen decided to place the administration of the fundsin the hands of mutual benefit societies. Insurancesocieties are authorised to make contracts for medicalservice with the doctors, on condition that the follow-ing three principles are maintained : (1) free choiceof doctor by the insured party; (2) collective con-tract ; (3) adoption of part-payment coupons. Freechoice of doctor is, however, limited to such medicalmen as have signed a collective contract with a

society, and as the society will naturally endeavour

to contract at the lowest possible capitation figure,the contract doctor will be obliged to enrol a,clientele of unwieldy proportions. The part-pay-ment coupon is designed to circumvent abuses of thesociety’s funds by laying a small charge directly onthe insured person for all medical treatment hereceives, but it is doubtful if the object desired willbe achieved. The main objection to the working ofthe law is that the interests of the insurance societiesw-ilI be constantly opposed to the doctors’ profes-sional interests ; the detection of malingering willbe of greater moment from the society’s point ofview than careful ministration to the sick. In viewof the unanimous protests of the organised medicalprofession the Bill has been submitted for revision,but will shortly be laid before the Chambre, whichwill doubtless make it a plank in- the forthcomingelection platform. French medical opinion is notconcerned with the political aspect of the question.Its sole object is to consider the insurance schemefrom the point of view of the medical professionin maintaining a high standard of technique andefficiency.

Instruction in the Technique of Sanitation.As provision for practical training in sanitation

has hitherto been lacking in France, the UnderSecretary of State for Technical Education hasadded to the National Conservatory of Arts andCrafts an Institute of Sanitary Technique, open toall whose studies or whose profession demand a

scientific knowledge of sanitation. Duly matricu-lated pupils may obtain a diploma in sanitary tech-nique on satisfying a board of examiners. Non-matriculated pupils who do not wish to qualify mayattend the lecture courses on application to theDirector of the Conservatory. The training will befree, and the complete course will not exceed threemonths, in order to allow candidates who do notlive in Paris to complete their studies in the shortestpossible time. The course will include theoreticallectures, practical demonstrations, and visits whichwill occupy the whole of each day. At the openingof this institute, which took place recently, thedirector. Mr. F. Heim, outlined the purpose of thework. " The object of the institute," he said, "isto give engineers, architects, builders, and allothers who are concerned in matters of hygiene anopportunity to acquire knowledge which will enablethem to embody sound hygienic principles in theirconstructive work, and thus further the materialwelfare of the community."

Hygienic Measures following the Floods of Paris.During the recent floods the Parisiens suffered

more from apprehension than from the realisationof their fears. The waters of the Seine remained at25 cm. below the flood level of 1910, but these 25 cm.spared Paris the disasters of 14 years ago. Fromthe medical point of view, the unfortunate happen-ings which were recorded in THE LANCET of Feb. 5th,1910, have not been repeated on this occasion.Only a very circumscribed area of Paris, in theseventh arrondissement, was deprived of electricity,but no damage was caused either to hospitals or tohospital installations. Refugees who were forced toleave their dwellings were allocated to empty militarybuildings situated on the fortifications. The Ministerof Hygiene instituted a daily medical visit to eachof these buildings, and provided a staff of nurses tocare for the sick, the convalescent, the mothers, andthe children. The population of Paris was warned, bymeans of a circular, not to drink water from publicfountains or wells unless it had been boiled or other-wise purified. Other sanitary provisions were as

follows. Wells and cisterns must be cleaned anddisinfected (500 g. of calcium or potassium petiiian-ganate per cubic metre of water to be disinfected).Conduits must be examined, and where polluted byinfiltration they must be put in order and cleaned.The consumption of uncooked vegetables has beentemporarily proscribed ; all foodstuffs which might

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have been subjected to pollution must be cooked.Houses and outhouses are to be cleared of mud andfilth, which must be deposited at a safe distancefrom anv drinking water-supply. Plaster and lime,added to the mud, is recommended as a convenientdrying method. Disinfection is carried out bycarefully mixing about 5 kg. of quicklime with everycubic metre of mud. The floors of dwellings mustbe disinfected either bv whitewash in the case ofearth floors, or by thorough washing with an anti-septic solution (eau de javel, cresyl. warm lye,&c.) when the flooring is of,wood. The same pre-cautions must be taken with cellars and base-ments. Soiled mattresses must be burned and otherbedding washed and disinfected. Schools, workshops,factories, and shops may not be reoccupied untilsuch measures have been carried out. With theseprecautions no sudden epidemic or aggravation ofsanitary conditions have been provoked by the floods.

Public Health Services.SCHOOL-CHILDREN ON THE ISLAND OF

LEWIS.THAT conditions on the Island of Lewis are incredibly

hard at the moment is borne out in the reports for1922 and 1923 of the school medical officer, Dr. AgathaE. Miller. These islanders are always faced with theprimitive struggle of wresting a living from the naturalresources of their surroundings ; the last three yearshave been lean ones, and there is now a strenuousfight for existence. Children’s weight here fluctuatesaccording to whether the harvest be good or bad, andthere is an annual " spurt " in weight throughout theisland after harvest. A good harvest in 1920 meantan increased average weight in the summer of 1921.A poor harvest in 1921 resulted in a decreased averagein 1922. In 1922 the harvest was better again, andone would have expected improved weights in 1923.In this we are disappointed. The fishing and tweedfailures, with the consequent loss of employment,have told against the children. " The outlook,"writes Dr. Miller, "for the coming school year, withthe wet season, the failure of the harvest, and thecondition of the peat, is black indeed."On entering upon school life the physique of

these island children. who come of a noble, well-built race, gradually deteriorates. They enter schoolwell above the normal in every way; indeed, inprevious years the entrants have been very much abovethe average in weight, but as school years pass thechildren below the average increase in number. Indistricts specially dependent on the harvest thedeterioration is greatest. Feeding experiments duringthe last three years in one large school demonstratedthat this deterioration was dependent on want of foodalone. The result of the provision of merely a cup ofcocoa or soup at midday was that of 61 infants of5 and 6 years of age not one was below 40 lb. in weight.With the stoppage of this midday soup or cocoa

and failure of the harvest 13 per cent. fell below.Similarly, of 28 children of 12 years only 2 wereunder 70 lb. in weight and 50 per cent. fellbelow. The weight averages of boys of 5 fell from45-56 lb. to 41-40 lb., and for girls from 47-38 lb. to44-31 lb. Boys of 12 fell from 76-68 to 73-54, andgirls from 79-13 lb. to 71.62 lb. In 1922, owing to thelack of funds and the inability of the parents to paythe necessary penny, the provision of a cup of hotcocoa at midday was stopped. and so grave is thepresent outlook that teachers all over the island aretaking steps to raise the necessary funds for middaysoup or cocoa. The distress is so general that it isfeared that unless relief works of some kind are startedall over the district within the next week or two thechildren will have to be fed from outside sources.

The country children almost invariably belong tocrofter fishermen, who welcome whatever casual labour Ithey can get. Unfortunately there has been little

or no work available for the last two years. Thechildren of men who did not come back from thelate war are conspicuous by their good clothing andsuperior nutrition. The rural population here differsfrom that in southern areas inasmuch as, having ahereditary right to the soil it is stationary, andfundamentally the race is good, as is demonstrated bythe teeth. Two-thirds of the children examined hadperfectly sound teeth. The majority of defective teethwas accounted for bv the town children. No cases ofrickets of long bones has been met with in Lewis forthe last three years. Individual children removed toa home or even fed with the addition of oil at theirown homes can easily put on a stone in weight in amonth. The children, too, are clean. In the countrydistricts vermin are few in number, though in thetown this infection presents a serious problem. InLewis altogether a wonderfully high standard of cleanli-ness is maintained. No dirtv heads were noticed.The hair is usuallv washed weekly. All the water hasto be carried from the well, as in country districts;even in the towns a number of houses have no waterand few indeed have baths.The result of an investigation into the social condi-

tions in the black and white houses in Lewis is givenin Dr. Miller’s report. Evidently the feeding of theseislanders is an urgent undertaking which should notbe delayed.

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Correspondence.

THE PROMOTION OF MEDICAL HYDROLOGY.

" Audi alteram partem. "

To the Editor of THE LANCET.

SIR,—We desire your support in bringing beforethe profession the need for systematic teaching ofmedical hydrology, by which term is to be under-stood the science of treatment by waters internallyand by heat, cold, and other agencies in baths andexternal applications. The General Medical Councilhave now definitely recommended that instructionin physical treatment should be included in theteaching of therapeutics, and we believe that thescience of medical hydrology must be the foundationof such instruction. A joint committee of the Inter-national Society of Medical Hydrology and theSection of Balneology of the Royal Society of Medicinehas been formed to promote the teaching of medicalhydrology in England, and has already establisheda course of lectures on the subject under the LondonUniversity Extension Board. It has further drawnup a statement and presented it to the Ministry ofHealth, pointing out how far we in England havefallen behind continental countries in this directionand how this state of things may be remedied.

’ Through the medium of your columns we now seek

to inform the medical profession generally of our aims,which may be thus summarised :—

1. Research. The establishment and endowment of a

central institute and laboratory for encouraging and co-ordinating systematic research into the physical and chemicalproperties and the pharmacological action of the Britishmedicinal waters, and of the action and use of baths.

2. Teaching. Post-graduate ; courses in London and atother universities. Students ; inclusion of systematiclectures in the courses on therapeutics. Practical ; studytours to British spas.

3. A complete survey of British medicinal waters.4. Official authorisation of such waters. (Compare the

official authorisation of drugs in the British Pharmacopoeia.)5. For the purpose of carrying out these objects, the

establishment of a permanent advisory committee analogousto the French " Commission dea Eaux -Alin6rales."

Of the total working time lost by the populationthrough illness, a very large proportion is due tochronic disease of the rheumatic type, which are moreeffectively treated by hydrologieal measures than inany other wav. That this is already recognised insome quarters is shown by the voluntary contribu-tions made to our great mineral water hospitals by