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MEDICINE AND THE LAW.

Hospitals and Cases of Attempted Suicide.DIFFICULTY has arisen recently in the admission

to voluntary hospitals of patients suffering from theresults of attempted suicide from the necessity forkeeping them under observation more close thanwould be required for their treatment and nursing.The question involved is who is to be pecuniarilyresponsible for watching the patient when the policebring him in and supply the watcher ? The desireon the part of hospitals and police alike at present isto avoid any expenditure which is not in the natureof an obligation. At the Ashton-under-Lyne Infirmary,a voluntary hospital, recent cases of attempted suicidehave been refused admission, and the committee haveinformed the police that as the practice of sending anofficer to remain on duty in the ward has been dis-continued., such cases cannot be taken in owing tothe extra cost which they involve. Two cases atleast of cutthroat, since followed by death, have thusfound their way to the Poor-law infirmary, and theguardians have communicated with the Home Secre-tary in order to ascertain his attitude as to theirposition in the matter. A reply appears to havebeen received of an inconclusive character, but con-taining a phrase to the effect that no regulation ofthe Home Office calls upon the police to provide anofficer to watch over cases " where the patient isnot under restraint."The intended application of the last phrase is

not clear, and the question is of- interest to allvoluntary hospitals. Suicide patients naturally dividethemselves into two classes, those brought in by thepolice, and those brought in by other people, such asrelatives or friends. Presumably, however, a hospitalwould not call in the police in the case of the latterunless obliged, and if the police were so summonedthe patient would in effect become their prisoner, asit would be their duty ultimately to make the usualcriminal charge against him. In the more usual casewhere the police bring to the hospital a patient whohas tried to kill himself in some public place or inprivate premises, he is brought as a prisoner to beultimately charged as such, but in need of immediatecare and treatment. If he had no such need hewould be simply a prisoner, and in either case hemay be tried for an offence against the law ; thereare therefore obviously two reasons for having himwatched, first, that he may not repeat hisattempt; and, secondly, that he may not escape.The hospital is bound to prevent so far as possiblethe suicide of any ordinary patient likely to attempthis own life, but it cannot be fairly argued that itshould be saddled with such prevention on behalf ofpersons known to be dangerous to themselves,amenable to the law, and brought to its wards bythe law’s officers. In no case has it any duty orindeed right to keep in custody persons fit anddesirous to go out. Nevertheless, so far as Londonis concerned, we are informed that the Commissioner-of Police for the metropolis last year- issued an orderthat his men are not to wait in the wards with casesof attempted suicide. What, then, is the hospital todo e’ If a man is brought in, the saving of whose lifeis a question of minutes, he can hardly be refusedadmission ; nor can it be right that the police shouldleave him there undertaking no responsibility, butsaying in effect, " He can be nursed and guarded bythe hospital, and when he is well enough to leave itwe will arrest and charge him."

In the City of London we believe the police willsupply a watcher if requested, but the city policewill have nothing to do with a patient emanating fromoutside the city’s boundary. He therefore has to bewatched at the expense of the hospital at a costwhich may be considerable. It is obvious that thepolice can hardly be expected to take care of patientsin whom they are not interested as prisoners. Rela-tives may possibly be utilised for that purpose insome of those cases which they have themselves

brought in, but generally the hospital will either haveto reject those who have attempted suicide altogether.turning them over to the Poor-law authorities, orthey must undertake the expense attaching to theirsupervision.What appears to be required is a definite instruc-

tion imposed by the central authority, the HomeOffice, upon the police generally, to look after itsprisoners, as long as any voluntary hospital is willingto accept them. There should also be a decision ofthe same authority as to whether such prisonersshould be taken to a Poor-law institution in the firstinstance or to a voluntary hospital where both areequally available.

The .Regulation oj Lead Poisoning.The historian of industrial medicine must always

pay considerable attention to the subject of leadpoisoning, not merely on account of the damage ithas caused in the past-although that has been byno means inconsiderable-as for the reason that thisessentially occupational disease has led to pioneerlegislative measures aimed at its control and preven-tion. Lessons so learned have been extended to

protection against other industrial risks and to themaintenance of general health. A useful volume hasjust been issued which sets forth the text of the lawsand regulations relating to lead poisoning prevailingto-day in different countries. The subject-matter isgrouped according to the various industries in whichlead and its compounds are manipulated, whetherthe mining or smelting of lead, the manufacture ofwhite lead, or the use of lead compounds in otherindustries such as the making of pottery and tinningof metal articles. No effort is made to state thesequence ot events which led up to the present stateof the law ; but some indication is given, at least forGreat Britain, of the satisfactory results obtained.Thus, in the white-lead industry, the annual averageof cases in 1900-04 was 183, in 1915-19 it was 17 ;while in the pottery trade it was 445 in 1896-98,119 in 1900-04, 67 in 1910-14, and only 19 in 1915-19.These reductions have been obtained during a periodof great industrial expansion, with an increase innumbers employed, and so of those exposed to risk,and notwithstanding the coming into force of theWorkmen’s Compensation Act in 1907, which gavecompensation, among others, to those afflicted withindustrial lead poisoning. The question of compensa-tion is dealt with in a special chapter wherein theeffect, through the tendency to notify milder casesthan before, is exhibited ; thus the proportion ofsevere cases which from 1900-04 was 33-2 per cent.of all cases notified, had fallen by 1910-14 to 18-4 percent. ; while moderate cases which formed 20-8 percent. of the cases in 1900-04 had risen to 32-2 percent. in 1910-14.We note that our own code of regulations is more

complete than that of any other country, and thatour overseas dominions have adopted our lead byestablishing regulations on similar lines. Continentalcountries such as France, Belgium, Austria, Germany,Switzerland, and the Netherlands have followed suit,while Greece and even Russia, previous to the debacle,have adopted useful precautions. America up to thepresent appears curiously behind, since only leadsmelting, and that only in New Jersey, seems to becontrolled by regulations. Italy and Spain do notappear in the list. Anyone perusing this documentmust be struck by the manifold uses to which lead isput and the great variety of industries in which it isused, and so will appreciate the difficulties whichsurround the legal control of even so definite andpreventable a disease as lead poisoning.

" Mtirder by Throttling."Leave to appeal against his conviction was refused

by the Court of-Criminal Appeal in the case of JamesAtkins, sentenced to death by Mr. Justice Horridgeat erby assizes. The prisoner, it will be remem-

1 Laws and Regulations Relating to Lead Poisoning. GilbertStone. Pp. 247. H.M. Stationery Office, Imperial House,Kingsway, London, W.C. 2. 1922. Price 5s.

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bered, was indicted for the murder of his wife, whosebody was found buried in his allotment. The mostprominent ground of appeal put forward was that inthe special circumstances the judge should havewarned the jury to accept the medical evidence withthe greatest caution, or, as the court expressed it," scepticism." To this the Lord Chief Justice, whodelivered the judgment of the court, declined toaccede, holding that the evidence of death by asphyxiawas ample. There was little other evidence in thecase, except that proving general circumstances suchas infidelity on the part of the prisoner, and anadmitted quarrel with his wife out-of-doors, followingwhich, he said, she ran from him, and was found byhim lying dead on a heap of stones, after which heburied her to avoid awkward questionings. Themedical witness who had made a post-mortemexamination had said that lividity and discolourationof the face and neck, deep congestion of the lungs,considerable effusion of blood in the skull, in con-junction with a normal heart, and the absence of anytraces of disease or of any seizure, had led him tothe conclusion that death was due to asphyxia fromviolence. It might have been produced by theprisoner placing his hands over the woman’s mouthand nose, and so causing suffocation. It is of someinterest to note that precisely the method abovesuggested by the medical witness was the way inwhich all the murders of the infamous Burke andHare were committed in 182S. This was madeclear by Hare when he turned King’s evidence, andwas corroborated by medical evidence in the onecase tried, that of the old woman Docherty.

Public Health Services.THE CONTROL OF MEDICAL BENEFIT.

THE text of the statement read by Sir ArthurRobinson at the conference on March 30th betweenrepresentatives of the Ministry of Health and of theInsurance Acts Committee may be seen in theSupplement to the British M edical.J ournal of April 8th.From this statement it is perfectly clear, as we

surmised last week, that the offer by the approvedsocieties of the extra 2s. 6d. to make up the capitationfee of 9s. 6d. until the end of 1923, was made in

exchange for some privilege or power not hithertopossessed by these societies under the existing lawand regulations. It was not made clear, in thediscussion following the statement, exactly what thisprivilege is to be. Perhaps no equivalent was

actually specified. Two sentences in the statementmay be quoted (the italics are ours) ’-—

"... In return for accepting these new charges theapproved societies have made it clear that they intend toclaim a voice in the negotiations with the medical professionboth in regard to the capitation rates and the conditions ofservice after the expiry of the present agreement at theend of 1923.

" In view of the extent of the societies’ contribution to thecost of medical benefit under the new scheme, it is difficult tocontest their right to be represented in any future negotia-tions with the profession."We read the phrase " a voice in the negotiations "

to mean setting the standard of medical service anddetermining the monetary value to be attached to theservices demanded. Many approved society officialsmake no secret of their low estimate of insurancepractice in general. These officials are bound to actin what they believe to be the interests of their ownsociety, which are not necessarily the interests of itsindividuals, when they are sick and in need ofmedical aid. From the commonwealth point of viewthey are hardly the best judges of the lines uponwhich the medical service should be developed.With the vague pledge given it may be difficult for theMinister and his advisers to resist the demands of thesocieties, however, whether they appear to be in thepublic interest or not. The Minister will find himselfsqueezed between pressure of Parliamentary control

above and resistance of approved society demandsbelow, and in any such compromise the medicalservice will stand to suffer. The new arrangementwill weaken the hands of the Minister and his advisers,and we would urge him to reconsider the consequencesof accepting the offer made to him. As well mightthe medical profession insist on a voice in the negotia-tions between the Ministry and the approved societiesas to the regulations under which they perform theirpart of the insurance scheme. A good deal ofcriticism of society methods heard by doctors in thecourse of their work might be presented for theirconsideration. This is not a time for recriminations,but it follows that if freedom from friendly society con-trol is to be taken from the doctors, the autonomy of theapproved societies cannot reasonably remain intact.The only control which can be tolerated by medical

men who serve in the National Health Insurancescheme is the control of Parliament through theMinistry of Health. The secretary to the Ministrydoes not appear to appreciate the real meaning of thenew move ; he admitted that he could not speak as tothe motives of the societies. Conferences between therepresentatives of the profession and the approvedsocieties are to be desired. Although an individualisticprofession may in some cases resent even the limitedand supervised control of the Ministry of Health, areturn to capricious and soulless control by the friendlysocieties is quite unthinkable. We speak only ofcontrol. Constant interchange of view would lead tobetter mutual understanding. Much remains to bedone to ensure trust and esteem on each side ; butthe restoration of anything like the circumstancesbetween medical practitioners and the approvedsocieties as they existed before the Insurance Actwould belittle the general practitioner service, lowerthe self-respect of insurance practitioners, and alienatethe goodwill of the medical profession as a whole.

The Services.ROYAL NAVAL MEDICAL SERVICE.

Surg. Lieut. (D) A. Macpherson to be Surg. Lieut.Comdr. (D).

Surg. Comdr. C. J. Aveling to the Vernon; Surg Lieut.-L Comdr. G. E. Heath to R.N. Hospital, Plymouth.

ROYAL ARMY MEDICAL CbRPS.The undermentioned temp. Capts. relinquish their

commns. and retain the rank of Capt. : G. S. Livingston,T. E. Amyot, W. Astin, W. Cooper, and H. Slater.

ARMY DENTAL CORPS.

Lt. (temp. Capt.) J. Marron to be Capt.

ROYAL AIR FORCE.V. R. Smith is granted a short service commission as a

Flight Lt.Temp. Capt. C. Fox-Pitt, Dental Surgeon, is granted a

temporary commission as a Flight Lt. while attached forduty with the R.A.F.

Flight Lt. S. E. Duff resigns his short service commission,and is permitted to retain the rank of Capt.

WAR DECORATIONS.The following decorations have been awarded for distin-

guished service rendered during the war, and the King hasgiven unrestricted permission to the recipients to wear thedecorations : Col. C. A. Hodgetts, C.A.M.C. (Officer of theOrdre de Leopold), and Bt. Col. J. Paul Bush, R.A.M.C., T.F.(Officer of the Ordre de la Couronne), both conferred by theKing of the Belgians ; Temp. Capt. C. G. Harmer, R.A.M.C.(Chevalier of the Legion d’Horineur) conferred by thePresident of the French Republic ; and Capt. Myer Coplans,R.A.M.C., T.F. (the Silver Medal " al merito della SanitaPubblica "), conferred by the King of Italy.

MANCHESTER AND SALFORD SKIN HOSPITAL.-Atthe annual meeting of the Manchester and Salford SkinHospital the report showed that during last year the attend-ances reached 69,024-61,285 ordinary out-patients and7739 X ray patients ; the number of in-patients 347. Inall 22228 were contributed by patients. The ordinaryincome was .S8817 and the expenditure ;E9167..