Germany

Germany. Area of Germany-468,746 sq. km. Population-on June 16, 1925-63,178,619 persons (30,583,823 males and 32,594,796 females), compared to 64,925,993 persons in 1910. Population density-134.24 per 1 sq. km in 1925 (compared to 124.19 in 1910 and 127.16 in 1919). I. Demography. Natural movement of population is expressed in the following table per 1,000 population (average annual coefficient): Table 1. Mortality Increase 20.7 + 15.0 18.2 + 14.9 16.2 + 13.6 17.3 + 11.3 15.6 + 12.7 15.0 + 12.5 19.0 + 7.8 21.4 - 1.0 19.2 - 4.0 20.5 - 6.6 24.7 -10.4 15.6 + 4.4 15.1 + 10.8 13.9 + 11.4 14.4 + 8.5 13.9 + 7.1 12.2 + 8.3 11.9 + 8.8 11.7 + 7.8 12.0 + 6.3 Years Birth rate 33.1 29.8 28.6 28.3 27.5 26.8 20.4 15.2 13.9 14.3 20.0 25.9 25.3 22.9 21.0 20.5 20.7 19.5 18.3 Table 2. Age and sex composition of population according to census of 1925. Age group Total Men Women From 0 to 5 years 5,871,517 3,986,512 6,213,829 5 to 10 years 6,543,101 6,150,535 5,307,280 10 to 15 years 4,579,622 4,283,469 3,907,510 15 to 20 years 3,846,561 3,233,339 2,727,775 20 to 25 years 2,165,956 1,616,046 1,057,717 25 to 30 years 584,217 335,633 73,611 During the war population growth fell, even taking negative values due to increased mortality and decreased birth rate. Character of birth rate: in 1926 per 100 newborns there were 3.3 stillborn, in 1927-3.2. In 1926 of 632,570 born-23,308 were stillborn. Infant mortality is decreasing: per 100 children born alive, died before reaching one year: in 1922-13.0, in 1923-13.2, in 1924-10.9, in 1925-10.5, in 1926-10.2, in 1927-9.7. Mortality statistics in Germany in 1926 by type of disease per 10,000 population (general coefficient for men 121.6, for women-112.3) gives: Table 3. Causes of mortality Congenital weakness........ Senile debility....... Postpartum diseases..... Scarlet fever............. Measles................. Diphtheria.............. Typhoid fever............ Erysipelas............... Tuberculosis of lungs..... of other organs ..... miliary ........... Pneumonia............. Influenza................. Other contagious diseases... Diseases of respiratory organs... circulatory organs... nervous system... digestive organs... genitourinary organs... Suicides............ Accidents and violent death... Other diseases........... Unknown diseases........ Women Men 5.9 8.1 11.0 14.7 24.6 - 0.1 0.2 0.6 0.7 0.3 0.4 0.2 0.2 0.2 0.3 8.2 8.2 1.4 1.4 0.2 8.0 9.7 2.6 2.5 0.4 0.6 5.1 17.8 17.8 11.2 10.7 9.8 8.4 2.5 3.4 1.4 3.9 1.6 6.0 5.9 7.1 0.5 0.7 II. Organization of healthcare. Healthcare affairs are decentralized, divided among state, municipal, public-legal, and private-charitable organizations. Functions of state healthcare are divided between all-German institutions and institutions of individual states (constitution of 1919). The all-German department performs legislative and regulatory functions, while the practical implementation of healthcare measures, supervision and control over municipal, public, and private-charitable healthcare belong to the institutions of the federal states. In general, there is no strict demarcation of functions: in individual cases, federal states are granted the right to directly enact healthcare laws. There is no separate Ministry of Health in Germany; there is no central department or bureau for healthcare matters. These functions are divided between the Ministry of the Interior, the All-German Ministry of Labor, and the Ministry of National Economy, with special departments where a limited number of specialist advisors are registered. As a technical advisory body to the Ministry of the Interior, the Reichsgesundheitsamt (All-German Health Department), founded in 1876 to monitor the implementation of legally prescribed measures, is subordinate. It is currently the most powerful and productive healthcare body, participates in the preparation and development of all healthcare issues, studies in subordinate institutes or proposes for study in other institutes current medical-sanitary problems, keeps records of the sanitary condition of the country, registers outstanding phenomena in the field of sanitation and hygiene in Germany and abroad, informs the Ministry of the Interior about them, and conducts extensive expert activities. The most important discoveries and researches-Koch's, Haffkine's, Löffler's, Schaudinn's and others-came from the scientific institutes subordinate to the department. The staff of the department consists of two hundred employees. Scientific work is concentrated in 4 divisions. I. Chemical-hygienic with laboratories for studying questions of oncology, hygiene of food products, water supply and sanitation, housing hygiene. II. Medical division deals with questions of combating general dangerous diseases, medical statistics (jointly with Statistical Administration), tropical hygiene, estate medical questions, school medicine, protection of infancy and children, antituberculosis dispensarization, sanatorium affairs, care of the mentally ill, questions of the living conditions of orderlies, midwives and medical personnel, questions of racial hygiene, hospital affairs, etc. A special subsection in cooperation with the Ministry of Labor deals with questions of industrial and occupational hygiene. III. Veterinary. IV. Bacteriological. In direct connection with the All-German Health Department is the All-German Council for Public Health (established in 1902), which enjoys considerable independence and the right to enter into direct relations with individual state institutions, to conduct investigations. Members of the All-German Council are chosen from among scientists and the most prominent figures in healthcare. The President of the All-German Council is the President of the All-German Health Department. The main activity of the All-German Council is the fight against epidemic diseases. - The healthcare activities of the Ministry of Labor (6 divisions) are mainly devoted to questions of social insurance and industrial hygiene. In the subsections, questions of protection of pregnancy, as well as protection of labor of adolescents and women, supervision of work in health-hazardous productions; social care for the disabled, widows and orphans, housing of the population and questions of resettlement affairs are developed.-Healthcare activities of other ministries are limited to narrow departmental frameworks and are mainly of an informational and consultative nature. Demographic statistics are in the hands of the Ministry of National Economy. Special statistics of causes of mortality are concentrated in the Ministry of the Interior.-Autonomous organizations, regulated and partly subsidized by the All-German government: a) Emperor Wilhelm Society for the Promotion of Sciences (founded in 1911) with a number of special institutes for research on the most important scientific medical and biological problems in their relation to state and social moments; b) All-German Committee for Sanitary Education (since 1920); c) All-German Committee for Physical Education; d) Association of private-charitable healthcare organizations. The budget of these organizations is composed, mainly, of voluntary membership dues and donations. Healthcare of federal states. Departmental state healthcare organization in individual states is generally similar to the all-German organization. In Prussia alone there is a separate Ministry of National Welfare (Wohlfahrtspflege), which deals with healthcare issues withdrawn from the competence of the Ministry of the Interior. Only in the small state of Oldenburg is there a Ministry of Social Care, whose sphere of tasks includes healthcare. Municipal healthcare. The organization of healthcare in cities is extremely diverse. In a number of large cities there is a special healthcare department in the city administration-in Hamburg, Bremen, Berlin, Cologne, Essen, etc. Such departments also exist in some small communities. In some cities healthcare is headed by a special commission, consisting mostly of members of the city administration and headed by a physician-member of the city administration. Such commissions exist in Berlin, Cologne and other cities. Commissions often split into a number of subcommissions, for example, in Berlin: for hospital affairs, psychiatric hospitals, for sanatoriums, for emergency medical care, for social hygiene. The executive body of these commissions is usually the healthcare department, headed by a special head-city physician or city medical advisor, who is responsible to the said healthcare commission. To serve municipal needs in the healthcare sector, special municipal physicians are hired: school physicians, for combating tuberculosis, with infant mortality, etc.

These physicians must present certain evidence of their suitability for the specified area of healthcare. It is interesting to note that by a special decree of the Prussian Ministry of Public Welfare of December 14, 1921, it was deemed desirable that only physicians who had completed special 4-month courses in social hygiene at one of the academies of social hygiene in Berlin, Breslau, or Düsseldorf be admitted to communal healthcare work. In rural districts and counties there are district and county communal physicians, who, however, are never members of the district or county self-government bodies. In some districts and even in large cities, communal healthcare is supervised not by a communal physician but by a state district physician, and conversely, in some places the functions of district physicians, who perform state supervision in the field of healthcare, are assigned to city physicians. The functions of provincial self-government bodies in the field of healthcare mostly derive from certain legally established obligations, whereas the corresponding functions of districts and cities are to a large extent carried out on a voluntary basis in performing certain healthcare works. Obligatory by law for provinces are the following measures: establishment and maintenance of institutions for the mentally ill, idiots, blind, epileptics, and deaf-mutes; care for the disabled; organization of obstetric assistance; as for districts, they are assigned in the order of obligation: organization and maintenance of therapeutic and sanitary institutions for contagious patients; organization of vaccination; implementation of certain measures listed in the law for combating tuberculosis; organization of out-of-hospital care for the disabled; establishment of district obstetric aid stations; and implementation of measures in accordance with the law on venereal diseases of November 17, 1927. As for non-obligatory healthcare functions, provincial self-government bodies may engage in the establishment and maintenance of neurological clinics, patronage for the mentally ill, institutions for the chronically ill, etc. District self-government bodies, in the order of non-obligatory functions, manage the organization of epidemic control, training of medical personnel, issues of professional and housing hygiene, organization of chemical-sanitary institutions, as well as issues of protection of motherhood and infancy and childhood, school sanitary supervision, care for the mentally ill, alcoholics, sanatorium affairs, sanitary education, organization of various therapeutic institutions beyond those prescribed by law, organization of emergency medical aid, promotion of physical culture, etc. Sanitary affairs of railways, the fleet, the postal and telegraph departments are under the jurisdiction of the respective ministries and states.

III. Medical care for the population. Medical care in Germany is provided to the population predominantly for payment in various therapeutic and preventive institutions. For insured persons, payment is made by insurance funds; for the poor, by charitable organizations and corresponding communities, in which case proof of poverty is required; the rest of the population is obliged to pay for the assistance provided to them themselves. In many hospitals there are two classes, in which patients are accommodated differently, depending on the payment. At the head of most hospitals are persons not of medical rank. In many cities, especially small ones, and in rural areas, hospitals do not have a permanent staff of physicians and often even do not have a permanent chief physician; patients are admitted to such hospitals by private practicing physicians who continue the treatment during the patients' stay in the hospital. As for outpatient treatment, insured persons receive outpatient care from physicians employed by insurance funds. These physicians conduct home visits, receiving for their labor compensation based on the number of visits made to them by patients or most often based on the number of insured members assigned to them for treatment. In the latter case, by agreement of the physicians' union with the insurance funds, a certain annual fee is established for the treatment of each insured person. The relations between physicians serving insurance funds and the insurance funds have been unusually strained for many years; physicians have repeatedly struck, demanding increased compensation; in some cities, for example, Berlin, in connection with physicians' strikes, insurance funds organized outpatient clinics and polyclinics, which, after the end of the strike, were granted only the right to serve the families of insured persons, but not the insured persons themselves. Dispensers organized by insurance funds in many cities for tuberculosis and venereal diseases are forced to limit their activities only to giving advice to patients, without the right to treat them. This is caused by the opposition of the physicians' union, which fears a decrease in the earnings of private practicing physicians and insurance physicians who serve insured persons in their offices. Only some communal outpatient clinics, located at hospitals, provide therapeutic assistance free of charge to the poorest population; however, there are very few such clinics. As for specialized therapeutic institutions, they, with the exception of some physical therapy institutions of insurance funds in the largest cities, are very little accessible to the broad strata of the working population. As for pharmaceutical assistance, it is also provided free of charge only to insured persons, on prescriptions from insurance physicians, and even then with the insured person usually covering 10% of the cost of the prescription themselves. The funds may increase this share to 20% of the cost of the prescription. Regarding the choice of physicians, the social insurance law imposes on insurance funds the obligation to provide their members, provided this does not place an especially heavy burden on the insurance funds, with at least a choice between 2 physicians. In practice, two systems of medical care for insured persons are distinguished: the system of invitation by insurance funds of firmly paid fund physicians, the so-called system of limited freedom of choice of physician (between a certain number of specified physicians), and the system of free choice of physician. Depending on local conditions, one or another system is applied. Legislation in this area imposes no obligations on insurance funds. Home medical care as a special type of assistance is not organized, and the population has to resort to the services of private practicing physicians; only in individual cases are the corresponding bills paid by insurance funds. Emergency medical care is organized either by self-government bodies, mostly also on the basis of self-sufficiency (with only the poor exempt from payment), or by fire departments—for the corresponding divisions of the fire department—or by philanthropic societies. First aid stations at enterprises exist only in the very largest ones and are maintained at the expense of the owners. The entire peasant population does not receive any free medical care. The overwhelming majority of therapeutic institutions are maintained by communities, city self-government bodies; a small part—on the funds of private benefactors, various philanthropic societies, unions, etc. The degree of provision of the German population with physicians, compared to the pre-war period, is evident from the following figures: Per 10,000 inhabitants there were physicians: 1911 1921 Berlin .............. 10.9 4.9 5.99 In 1913 there were 34,136 physicians in Germany, in 1921—36,186 physicians, although the territory of the state had significantly decreased. In 1927 there were 43,717 physicians (including 1,757 women) in Germany, i.e., 6.9 per 10,000 population. The distribution of physicians among cities, towns, and villages is extremely uneven, with a maximum coefficient in large cities and fashionable resorts, and a minimum in villages.

The total number of licensed dentists in Germany is 8,578 (1.4 per 10,000 population). The education of dentists (technicians) is not regulated by laws. As for the number of beds in therapeutic institutions, it has significantly increased, as is evident from the following table: Number of beds in therapeutic institutions: in public in private total 1914........ 183,292 106,593 289,885 1917........ 245,865

44.751 320.015 In Prussia, the number of beds per 10,000 population was 41.06 in 1913; in 1925 it was already 58.00. The number of hospitalized patients also increased sharply: in Prussia per 10,000 population there were: in 1913.......349.67 in 1925 ..... . 512.9. The average length of stay for a patient in German hospitals is 25-30 days; in 1924 it was 32 days in the Rudolf Virchow Hospital in Berlin, 30.7 in Friedrichshain, 26.4 in Urban, and 37.2 in Moabit. This is explained, on the one hand, by the fact that workers, who face the danger not only of reduced wages but also of dismissal from their jobs during illness, are admitted to the hospital even for the most serious illnesses and often in a serious condition, and on the other hand, by the fact that hospitals also have a significant number of chronic patients. For example, in the Schwabing Hospital (Munich) in October 1925, the number of chronic patients was 30.6%, in March 1926 it was 28.9%. The costs of maintaining patients are covered in 60% by sickness insurance funds, 12-15% by contributions from private individuals, and the rest by municipalities, charitable organizations, etc. Medical-sanitary institutions in Germany are not connected with the population they serve, since the latter does not participate in the life of these institutions. Only in the last 2-3 years have medical institutions attempted to organize so-called social-hospital care (Soziale Krankenhausfürsorge) through the medium of special nurses who were to have care for the needy families of patients and for the patients themselves after their discharge from the hospital. This institution, however, is now only in its initial stage of development. According to German laws, treatment is permitted to every person without exception, regardless of age, sex, citizenship, and education. Persons without a diploma are not permitted to call themselves physicians. Some types of medical care are prohibited to persons without a medical diploma (for example, all types of preventive vaccinations and treatment of venereal diseases). Pharmacists are not required to require a physician's signature on prescriptions, except for prescriptions for potent narcotics. - Midwives: any woman who has completed elementary school and has taken at least a nine-month course in a midwifery school is admitted to examinations. The activities of midwives are regulated by the laws of the individual federal states. In rural districts, midwives are subordinate to the district physician. Midwives undergo a re-examination every two years. In sparsely populated and less affluent districts, there are district midwives in municipal service. Record-keeping is mandatory. - Personnel for patient care. Passing a special examination is required for employment in patient care in hospitals, clinics, state, municipal, and private medical institutions under state or municipal control (no examination is required for private practice). - To protect professional interests and regulate class relations, there are a number of professional unions and class organizations (among the latter are medical chambers - Arztekammern), which play an important political and social role. Middle and lower medical personnel are united by special professional unions. - Pharmacy. Pharmacies in Germany belong to private individuals on the basis of personal (without the right of transfer or resale) or real privilege. In addition to privately owned ones (in 1928 - about 7,000), there are also hospital pharmacies (about 100). Management of a pharmacy can be entrusted only to a person who has completed higher pharmaceutical education, which is obtained in universities and special higher pharmaceutical schools (there are 3 in Germany). Supervision of pharmacy and regulation of the granting of privileges are concentrated in the highest health authorities of the individual states that make up Germany. In some of them there are special committees dealing with pharmacy - Apothekerkammer - in Baden, Landesausschuss für Apotheken - in Bavaria, etc. IV. Sanitary supervision of food products is carried out by special departments of the sanitary police. Sanitary standards for determining the wholesomeness of food products and the sanitary safety of items of general use were established by the law of May 14, 1879, substantially amended and supplemented in 1927. These laws also establish standards for the construction of warehouses, stores for food products and household items. The role of the sanitary police and its duty is to supervise markets, bazaars, warehouses of food products, stores of such products; the sanitary police has the right to take samples for analysis at any time, to impose police fines, and to initiate legal proceedings. Supervision of the sale of meat and milk is under the jurisdiction of the veterinary police, special attention is paid to tuberculosis, anthrax, trichinosis, and glanders. Control of milk is carried out on the basis of special laws that establish standards for milk quality as well as methods of its transport. V. Sanitary education is conducted exclusively by private and public organizations. There is no state sanitary education authority, either all-German or in individual states. The public health departments - Reichsgesundheitsamt, Landesgesundheitsamt, etc. - only direct and regulate the activities of the largest private societies. All relatively large sanitary education organizations are united in the 'All-German Committee for Sanitary Education', which is divided into state committees in the individual federal states. The state committees branch out into city, district, and rural committees. The activities of the All-German Committee and all subcommittees are centered around the Dresden Hygiene Museum, which is under the direction of the All-German Committee. The hygiene museum in Dresden is a private enterprise. Models, mannequins, collections, traveling exhibitions, films, visual aids, and publications made by the museum are distributed throughout Germany according to the plan of the All-German Health Department. Educational films are produced by the cultural department of UFA; special courses are arranged for the training of lecturers. VI. Fight against dangerous diseases. Table 4 (see art. 655) shows the morbidity (in absolute figures) of the most important infectious diseases in Germany in recent years. The law of June 30, 1900, concerning the fight against dangerous diseases applies to leprosy, cholera, typhus, yellow fever, bubonic plague, and smallpox and prescribes the mandatory registration of all cases of illness and suspicions of these diseases. Compulsory smallpox vaccination is provided for by the law of April 6, 1874, according to which all newborns are subject to compulsory smallpox vaccination in the first year of life. The fight against childhood infectious diseases within the framework of state and public health is limited by laws on closing school classes in which a case of illness appears, on the mandatory reporting of cases of diphtheria, measles, and scarlet fever, and on the mandatory disinfection of an apartment after recovery or death of the patient. Fight against tuberculosis. In 1926, in the 46 largest cities of Germany, there were 16,846 deaths from tuberculosis. The central organization is the German Central Committee for the Fight against Tuberculosis. The Central Committee is a private institution of a semi-official nature, with special commissions: for lupus, for consultation and dispensarization, for the care of tuberculosis patients, etc. The financial resources of the committee consist of special appropriations from the All-German government, allocations from the income of the vodka monopoly, appropriations from hospital insurance funds, and, in its main part, from membership fees (approx. 2,000 members), voluntary donations, income from lotteries. Along the line of sanitary education for the fight against tuberculosis, several museums, permanent and traveling exhibitions have been organized. Every year courses are held for school doctors and others, popular books and brochures are published for the population and special guides for teachers. For the fight against tuberculosis, at the disposal of hospital insurance funds and other social health institutions, there are a number of dispensaries and sanatoriums, partly supported by private charitable organizations. Forest rest homes, night rest homes, forest schools for tuberculosis patients, open-air schools, rural colonies with gardening schools are maintained by city and rural communes independently or with the participation of hospital funds (see table 5). In large cities, special hospitals for tuberculosis patients are maintained, mostly located in the forest (the hospital in Sommerfeld near Berlin, in Hohenkrug near Stettin, etc.).

Dispensaries have become most widespread in recent years. In 1920, there were approximately 3,000 dispensaries in Germany; due to the decentralization of dispensary affairs, an exact count is impossible despite the efforts of the All-German Committee for their unification? Of the 906 tuberculosis dispensaries that voluntarily placed themselves under the guidance of the central committee, 27% were urban, 37% mixed, and 36% rural. Of these, 64.5% are maintained by municipalities, 34% by private organizations, and 1.2% by sick funds, factory enterprises, joint-stock companies, etc. Through the aforementioned 906 dispensaries in 1920, 193,985 patients passed through, which amounts to 56.9 per 10,000 inhabitants of the respective areas. In them, 520,549 medical examinations were performed during the year. Annual courses are arranged to prepare nurses for dispensaries; for preschool children, there are special dispensaries, and kindergartens, shelters, etc., are organized. Table 5. Network of tuberculosis sanatoriums in Germany. Institutions for tuberculosis patients: 1) Sanatoriums for adults with pulmonary tuberculosis..... 2) Sanatoriums for adults with bone tuberculosis..... 3) Sanatoriums for children with pulmonary tuberculosis..... 4) Sanatoriums for children with bone tuberculosis..... Forest rest homes for threatened by tuberculosis scrofulous children..... Forest schools..... Homes for convalescents..... Tuberculosis hospitals, tuberculosis departments in general hospitals, shelters..... 144 | 314 The fight against venereal diseases is regulated by the law of 1927. Treatment of venereal diseases and diseases of the sexual organs is permitted exclusively to physicians; all written advice is prohibited. Violation of the law is punishable by imprisonment for up to a year and a monetary fine. Unscrupulous physicians are subject to punishment. A person suffering from a venereal disease and not ceasing sexual intercourse is subject to punishment by imprisonment for up to three years; prosecution may be initiated at the request of the aggrieved party. A venereal disease patient entering marriage, knowing of their disease without warning the other party, is subject to punishment. Prosecution of the guilty is provided for at the initiative of health organizations. In case of danger of spreading infection, compulsory treatment and even internment are permissible. Mothers who give a healthy wet nurse a child knowingly suffering from a venereal disease; wet nurses who know or suspect they have a venereal disease; any wet nurse without a medical certificate of absence of venereal disease, as well as any person hiring a wet nurse without a medical certificate, are subject to punishment. Pimps, owners of brothels, etc., are subject to punishment; the sale of venereal medicines without permission is prosecuted; advertising of preventive measures is permitted only on the basis of official testing of the remedy. The Society for the Fight against Venereal Diseases in Germany is the central place for the fight against venereal diseases by educating the population and setting up consultation points, publishing popular books, leaflets, memoranda for parents, journals, correspondence with authorities, etc. In addition to the usual specialized outpatient clinics and clinics for the treatment of venereal diseases, almost all first aid stations have 'disinfection departments' for preventive treatment after suspicious cohabitation. Fight against alcoholism. Abuse of alcoholic beverages as such is not punished. Under § 362, a person who abuses alcohol to such an extent that family members dependent on him are forced to resort to public charity is punished by arrest and is subject to police supervision. The law may prohibit visiting drinking establishments for a period of 3 months to 1 year to persons committing excesses in a state of intoxication. Recidivists are placed in treatment institutions for alcoholism treatment. A certain percentage of the income from the wine monopoly is allocated to combat alcoholism and to open sanatoriums for alcoholics. By agreement concluded between the All-German Ministry of the Interior, the Society for the Fight against tuberculosis, the Society for the Fight against Venereal Diseases, all the aforementioned organizations participate in the expenses for the fight against alcoholism. Among the public organizations for the fight against alcoholism should be mentioned: The Blue Cross, the German Anti-Alcohol Union, the All-German Central Union for the Fight against Alcohol. In Germany, a network of anti-alcohol dispensaries has been organized, numbering about 250, mostly under the leadership of the clergy.

VII. Care for the disabled, deaf-mutes, blind, and mentally ill in most of the federal states of Germany is the responsibility of social welfare agencies. Prevention of accidents and emergency medical services are regulated by an order of the Imperial Chancellor of May 11-12, 1912. The organization of this matter is entrusted to individual communes; the organization of emergency and first aid in Berlin is considered exemplary. The expenses are shared by communes and private enterprises. - Protection of deaf-mutes and the blind. There is no state legislation regarding the care of deaf-mutes and the blind. In most federal states of Germany, a law on compulsory schooling for deaf-mutes and the blind is in effect; generally, this area falls more within the sphere of social welfare than of health care. For the prevention of blindness, the laws of Prussia, Bavaria, and Thuringen impose on midwives and obstetricians by threat of punishment the duty to immediately after birth cauterize the eyes of every newborn with a 2-percent solution of silver nitrate according to Credé. Care for the mentally ill, epileptics, and psychopaths is regulated by the laws of individual federal states. In Saxony, Württemberg, Baden, Hesse, Mecklenburg, and Oldenburg, it is provided at the expense of the state. In Prussia, the law places the care of the mentally ill on the provinces; in Bavaria, on the districts. Some large communes have taken this matter upon themselves. The number of hospitals and institutions for the mentally ill is approximately 500 (half of them municipal, the other half private). Admission to institutions for the mentally ill is only permitted with the permission or at the request of a serving physician; discharge from such institutions is only permitted with the permission of a physician serving in state or municipal service or by decision of an expert commission. For the care of epileptics, there are special shelters and sanatoriums maintained by communes or district administrations. For the care of child psychopaths, there are special consultation centers, dispensaries, educational homes, and schools with special teaching staff and under constant medical supervision. All these institutions are partly maintained by communes and partly by social welfare organizations and are subject to the all-German law on the protection of youth (of June 9, 1922). VIII. Protection of motherhood and infancy, school sanitation. Protection of motherhood and infancy is carried out mainly by sick funds and communes. The activities of communes consist in organizing consultation centers for pregnant women and young mothers, dispensaries for infants, children's homes, shelters, nurseries, milk kitchens, etc. The organization of corresponding institutions varies in different states and cities and is left to the discretion of the heads of municipal organizations for the care of public health. The central public organizations for the protection of motherhood and infancy with all-German state and municipal subsidies are the Kaiserin Augusta-Victoria Haus in Berlin and the Deutsche Vereinigung für Säuglings- u. Kleinkinderschutz with branches in all individual German states. - School sanitation. To record the individual health status of children, periodic examinations of schoolchildren are conducted, with the results of the examination entered into a health journal or health sheet, with subdivisions for anamnesis and examination (Personalbogen, Gesundheitsschein). Usually after examination by the school physician, parents are summoned for a consultation. In addition to the general condition, main attention is paid to the nutritional status, musculature, and appearance (especially skin diseases). In the upper grades, the examination is linked to testing for professional fitness, and with the consent of parents, students are sent for special psychotechnical testing. Treatment of children is not within the tasks of school medicine; parents are informed of the results of the examination and the conclusion about necessary measures. School dispensary nurses, if necessary, visit the pupil's apartment to familiarize themselves with sanitary conditions. - School nutrition. In many schools, children receive breakfast, mostly organized by communes. In some communes, school lunches have also been introduced. (In the child's health journal, the nutritional status coefficient is noted to determine the quantity and quality of food.) For particularly weak children, there are forest schools where children spend the whole day and receive breakfast and lunch. - Rest homes for children are established by communes in the mountains, on the coast, or in wooded areas and are under the jurisdiction of the youth health departments (Department of Public Health, Jugendamt, etc.). The internal regulations are under the direction of a physician. A number of former military buildings and camps have been converted into rest homes. Rest homes, colonies, and sanatoriums are maintained by communes and sick funds; partly they are subsidized by private societies and associations. All laws and regulations concerning school medicine apply to schools for adolescents, vocational, and commercial and industrial schools. Special attention is paid to sanitary education (especially on questions of sexual life and venereal diseases). Communes organize for adolescents playgrounds for games, gymnastics, and sports. Participation in physical exercises is not compulsory. IX. State protection of labor. The basis is the code of 1869 with later additions and amendments. By the law of November 23, 1918, an 8-hour working day was introduced de jure. In connection with additional laws issued in December 1923, the 8-hour working day is actually maintained only for 45% of enterprises. Sunday and holiday rest is guaranteed by § 105 of the Code. For industries associated with special dangers to health, a shortened working day is provided (§ 120). Night work is generally prohibited, with the exception of bakeries. The labor of women and adolescents is regulated by special laws of the code (§ 134, 137 and 154). From 8 p.m. women's labor is prohibited (on Saturdays from 5 p.m.). Working women enjoy additional rest of not less than one hour in total. The law provides for pregnant women the right to be exempt from work for six weeks before childbirth (the law speaks of the right to leave, but not of the prohibition of work before childbirth) and six weeks after childbirth with prohibition of work. Leave before and after childbirth does not apply to rural and domestic working women. It is forbidden to hire women for particularly heavy physical work. Children under 13 are forbidden to work in factories; from 13 years, work of not more than 6 hours and not later than 6 p.m. is permitted. Regular breaks are established, of not less than 1/2 hour each and not less than twice a day. The sanitary condition of factories is supervised by the sanitary police and factory inspection. Special laws regulate labor in industries harmful to health. The factory inspection is divided into districts, and in each there is a factory physician. In addition to the factory physician, there are district physicians on municipal service who supervise the condition of factory sanitation within the commune. By the law of February 4, 1920, factory and district physicians must be in contact with workers' councils (Betriebsrate). In fact, the entire institution of labor inspection is detached from the masses. Large industrial enterprises independently organize sanitary supervision and protection of labor. - From scientific research institutes for industrial medicine and hygiene should be named: the Institute for Work Physiology in Berlin, the Institute for the Study of Industrial and Traumatic Diseases in Dortmund (maintained by the Dortmund commune and the professional union of Dortmund and surroundings), the State Institute for the Study of Industrial Medicine in Jena. X. Insurance. The state law on insurance, issued on June 19, 1911 and still in force, consists of five volumes with 1,805 paragraphs and covers insurance: a) for sickness, b) for accidents in industry, trade, agriculture, and forestry, c) for invalid heirs, d) on waterways. The organs of insurance (authorized, self-governing organizations) are for sickness insurance the sick funds, for accidents - professional associations (Berufsgenossenschaften), for invalids and heirs - insurance institutes. Public agencies of state insurance: the insurance administration, main insurance administrations, federal insurance administrations, all-German insurance administration. The budget is covered by the state and communes. At the administrations there are commissions of employers and employees (without salary) for the consideration of cases and disputes. Representatives from workers are compensated for the time spent. Sickness insurance is based on the principle of 'active' compulsion for the employer and 'passive' for the employees. Insurance applies to workers, apprentices, messengers, farm laborers, craft apprentices, to employees, masters, sales clerks, pharmacy assistants and pharmacy apprentices, stage artists, teachers, artisans, and the crew of the fleet.

The insurance contribution ceases, but is not prohibited when the wage established by the Ministry of Labor is exceeded. The main types of sick funds: so-called local sick funds and corporate funds (the latter are organized by corporations of artisans, etc.). Sick funds form unions and associations; at the head of the administration is a presidium and an executive commission of 90 members, elected by workers and employers. Mandatory benefits: medical assistance, assistance and benefits for parturient women, funeral allowance, supply of medicines, glasses, apparatuses, prostheses, etc., monetary benefits in the amount of 1/2 to 3/4 of the wage; if a patient is placed in a hospital, his family is given a benefit in half the amount. In acute diseases, medical assistance is provided without time limitation; in chronic diseases - from 26 to 52 weeks. Tuberculosis patients receive medical assistance and monetary benefits for two years if there are indications based on periodic examinations by the funds. Categories of parturient women served by sick funds: insured female workers, wives or daughters of insured persons, indigent pregnant women in general. Pregnant women receive medical assistance, allowance for childbirth expenses, enhanced nutrition for 4 weeks before and 6 weeks after childbirth, allowance for feeding the child, if the mother feeds it herself, for 12 weeks after childbirth. In 1926, there were 7,517 sick funds in Germany: 2,593 local, 4,142 factory (large factories, plants and enterprises have the right to organize independent insurance funds with the rights of local sick funds - Betriebskrankenkassen), 782 corporate, formed by artisan, handicraft associations, corporations, guilds (Handwerkskrankenkassen). The total number of insured persons in 1926 was 18,402,147 (69.3% in local, 11.1% in provincial, 17.1% in urban and 2.5% in corporate funds). For mining and industrial workers, there are special funds regulated by the laws of individual federal states (Knappschaftskassen). Mining sick funds are departments of the general organizations for insurance of mining workers. Administrative supervision over sick funds and the highest judicial function is performed by the All-German Insurance Administration under the All-German Ministry of Labor. Accident insurance. Its bodies are 1) professional associations, 2) executive bodies of state and municipal enterprises. "The subject of insurance is compensation for any harm caused by bodily injury or death; intentionally caused accidents or accidents during the commission of a crime or any act with a criminal intent are excluded" (Law of April 11, 1921, § 550). Compensation: increased sick monetary benefit from the 5th to the end of the 16th week, medical care - from the 14th week (up to the 14th - at the expense of the sick fund). Annuity for the period of disability: in case of total disability, 2/3 of the annual earnings, and in case of helplessness (absence of relatives for care) - full annuity. In case of partial disability - depending on the coefficient of disability. (War invalids receive benefits for loss of 30% of working capacity.) In case of death - funeral allowance equal to 1/15 of the annual salary; widows until remarriage receive an annual annuity in the amount of 1/5 of the annual earnings. Children receive the same annuity until they come of age. Insurance of invalids and their heirs is concentrated in so-called insurance institutions (Versicherungsanstalten), the rights and obligations of which are regulated by special laws. Insurance sums are covered by the employer and the employee in the form of disability stamps. Insurance of seamen. The carrier is the All-German insurance institution for employees, subordinate to the Ministry of Labor. The bodies of insurance and social security for seafarers are the "Seafarers' Professional Association" and the "Invalids' Insurance Fund" for widows and orphans of seafarers. Health care for railway workers is subject to the generally accepted norms of social insurance. In addition, there are a number of independent railway insurance funds on general principles. A distinctive feature of the entire insurance business of Germany organizationally is dispersion, lack of centralization. The total number of annuity recipients (for illness, old age, disability, widowhood, orphanhood) on January 1, 1928 was 2,972,000; this does not include pension annuities of mining industries and annuities for employees' insurance, covering more than 400,000 persons. The income of insurance funds (including mining) in 1926 amounted to 1,564,852 thousand marks. (In 1927, by estimate - 1,662 million marks.) Expenditures in 1926 - 1,444 million marks. (In 1927 - 1,665 million marks.) The income of the entire social insurance, including sick funds, in 1927 amounted to 3,926 million marks, expenditures - 3,302 million marks; the participation of the all-German budget in social insurance expenditures is calculated at approximately 10%.

XI. Health care budget in Germany cannot be determined exactly. The state budget occupies the most modest place, participating with an amount of 3 million marks. From the Federal States, the budget of Prussia - 14,196 thousand marks (data for 1926). From the municipalities, the health care expenditures of the Berlin district in 1927: for the center - 24.3 million marks, for the periphery - 26.3 million marks. This does not include expenditures on "welfare" (Wohlfahrt), which, among other things, includes a number of health care tasks. Expenditures for social supervision of minors in the Berlin district in 1927 amounted to 18.1 million marks. In total, health care expenditures (excluding insurance organizations) are estimated for 1926 at 1,924 million marks, expenditures for other items of "welfare" (unemployment provision, housing question, public utility institutions) at 2,000 million marks. Ya. Gol'denberg, D. Gorfin.