906

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 28, 1907.

Medical Practitioners and MedicalReferees under the Workmen’s

Compensation Act, I906:The Legal Position.

, ] I z I -"

THE LANCET,] MEDICAL PRACTITIONERS AND WORKMEN’SCOMPENSATION ACT, 1906.

WE published last week a letter from Mr. A. BENTHALLwho refers with approval to the regulations issued underthe Workmen’s Compensation Act, 1906, on the groundthat they authorise the attendance of a medical practitioneron behalf of those whose cases under the Act are submitted,on dispute arising, to medical referees. The class of cases

referred to is that in which a workman has been suspendedor has claimed from a certifying surgeon a certificate of dis-ablement in order to entitle himself to the benefits of the Act.

The reference to the medical referee is to be ordered by the

registrar of the county court on the application of the

employer or of the workman when one or the other is

aggrieved by the granting or the refusal of such a certificate.

The medical man, therefore, who, according to our corre-spondent, will be able to appear before the medical refereeand, so to speak, to make good his view of the patient’s caseon behalf of the employer or of the patient will be one whohas examined the workman on behalf of the employeror who has treated him as his medical attendant..

Possibly it is intended to be suggested that the certi-

fying surgeon also may be present, as he too presumablywould be interested in seeing his certificate upheld andin defending it. We can quite well understand that a

medical man who has attended a workman or who has

examined him on behalf of an employer should desire to be

present in order that his opinion as to the case and as to thematters which he has observed should be fully considered bythe medical referee, and it is from the point of view of the

practitioner so situated that our correspondent has written.With regard to the certifying surgeon, we are inclined todoubt whether he would often have the time or the inclina-

tion to attend gratuitously even in order to defend his

decision, and to do so would be inconsistent with his

position. He is himself an independent judge whose decisionhas been appealed against.With regard to the medical referee, the matter may to

some extent be left to his discretion, but we are inclinedto think that he will prefer to check personally and

without assistance matters of observation recorded byothers and submitted to him in writing. The questionwhether the presence of other medical men is desirable or

not is no doubt one which may fairly give rise to discussion,but we are disposed to doubt whether the regulationsare as clear in allowing it as is argued by Mr. BENTHALL.The regulations prescribe in detail the formalities to

be observed by the employer’or the workman accordingto their respective circumstances when aggrieved by thedecision of a certifying surgeon. Those material to the

question which we are discussing are as follows :-

9 (a). Any application under the foregoing regulationsshall be made in writing and shall state the grounds onwhich the reference is asked for in accordance with the formprescribed in the schedule to these regulations, or as nearthereto as may be. (b) The application shall be accom-

panied by the certificate, or a copy of the. certificate, obtainedfrom the surgeon by whose action the applicant is aggrieved,and by any available report or reports of any medical practi-tioner by whom the workman has been examined ; and if theapplicant is an employer by the notice of disablement orsuspension served on him by the workman, and by an under-taking to pay any reasonable travelling expenses incurred bythe workman in attending for examination by the medicalreferee. (c) The applicant shall also file with the registrarsuch copies of the application and other documents as afore-said as may be necessary for the use of the medical refereeand of the employer or workman, as the case may be’,hereinafter referred to as the respondent, who, together with,the applicant, is directly interested in the application.

14. The medical referee shall, on receipt of an orderof reference duly signed by the registrar -of a countycourt, together with copies of the documents requiredto be sent therein, fix a time and a place fora personal examination of the workman, and shall sendnotice to the employer and the workman accordingly. Itshall be the duty of. the workman, and, if’the employer isthe applicant, of the employer, or a person duly authorisedby him, to attend at the time and place fixed by the medicalreferee, and in the event of failure on the part of the work-man or employer, or both, to appear as required by thisregulation, the medical referee shall decide on the matter

referred to him forthwith upon such information as shallbe available, and with or without a personal examina-tion : provided that where the absence of the employerer his representative, or of the workman, is shown to thesatisfaction of the medical referee to be unavoidable, orwhere the medical referee considers it necessary to applyfor expert assistance as hereinafter provided, it shall be

open to him to adjourn the inquiry on the reference Andto resume it at such a time and place as he may fix, havinggiven due notice to all persons concerned.

15. Except as otherwise provided by Regulation 14, themedical referee shall, before deciding on the matter referredto him, make a personal examination of the workman, andshall consider any statements made or submitted by eitherparty.In addition to these regulations the notice required to be

given by a medical referee to a workman as to the holding of

an inquiry contains the passage : " Any statement made orsubmitted by you shall be considered," which is also found

in the notice to be given to an employer, together with thefollowing, to be used when the employer is the appellant :" You, or some person duly authorised by you, are herebyrequired to attend at the above time and place."

Referring first to the last-quoted sentence, and to the

passage in the regulations bearing upon it, there seemslittle doubt that under it an employer might choose to

be representêd by a medical man, but it is unlikelythat he would be allowed to gain any advantage therebynot within the reach of the workman. Turning to the

other passages quoted it would appear that their meaningis that written statements of the conditions found to exist in

the workman made either by his or by the employer’smedical man can clearly be laid before the medical refereewho thus will be aware of the questions at issue in the casebefore him. It is, however, no doubt intended that he should

give a decision so far as possible his own after forming anindependent opinion free from bias and from the influence ofothers. If it had been intended that a medical man should

907POISONOUS METALLIC CARBONYLS.

or might be present on behalf of the employer or of the work-man, or of both, the Home Office authorities would havesaid so in plain terms. This they have not done and it

seems a little doubtful whether the language used should beaonstrued so as to bear such a meaning. Perhaps it maygive to the medical referee discretion to have present amedical practitioner or practitioners and to hear what theymay have to say on either side, but it must be remem-

bered that the Act is designed for the benefit of the

working man and is not intended to favour the longest purse.The position of a workman when not a member of an

organisation capable of finding funds to pay his medicaladviser might be prejudiced, or might be thought to be pre-judiced, if a medical man appeared on behalf of the

employer before the medical referee and if at the same timethe workman was not similarly supported.

Poisonous Metallic Carbonyls.A VERY interesting reaction discovered by Dr. LUDWIG

MOND is that which takes place between carbon monoxideand nickel or iron. In either case a volatile compound is

formed termed respectively nickel or iron carbonyl. The ireaction is utilised in the recovery of metallic nickel from its

ore, the carbonyl formed decomposing on heating to 150° C.

into nickel and carbon monoxide. In the commercial pro-duction of nickel in this way some cases of fatal poisoningamongst the workpeople have occurred owing to the escapeof the nickel-carbonyl gas. The symptoms are giddiness,dyspnoea, and vomiting, these passing off as soon as the

sufferers are brought into fresh air. After from 12 to 36

hours, however, dyspnosa returns, cyanosis appears, and thetemperature shows a rise. Cough with more or less blood-

stained sputum eventually appears. The pulse-rate increasesbut not in proportion to that of respiration. Delirium fre-

quently occurs and death in the fatal cases takes placebetween the fourth and eleventh days. The chief changesfound post mortem are haemorrhages in the lungs, oedema ofthe lungs, and haemorrhages in the white matter of the brain.The question as to what constituent of nickel carbonyl is

responsible for the toxic effects has been studied by severalobservers and more recently by Mr. H. W. ARMIT in theLister Institute of Preventive Medicine, an account of hiswork appearing in the July number of the JOtl’l’nal of

Hygiene. It is conceivable that the carbon monoxide of the

nickel compound is wholly or partly responsible for thesymptoms or that nickel carbonyl is absorbed as such and

acts toxically, or that the nickel of the compound producesthe symptoms. As an alternative view may be con-

sidered the possibility of nickel carbonyl being absorbedas such, the nickel being set free later, acting toxicallyin the tissues. Mr. ARMIT shows that carbon monoxide

is not the toxic agent because firstly in fatal poisoningfrom minimal doses the actual quantity employed is insuf-ficient when combined with the haemoglobin to produce morethan 5 per cent. of saturation with carbon monoxide and

this amount is harmless. Dr. JOHN S. HALDANE has shown

that in connexion with mine-gas poisoning with less than0’ 1 per cent. of carbon monoxide in the air the blood doesnot become more than 50 per cent. saturated, so that evena prolonged exposure does not cause a complete helplessnees.

With 0’ 2 per cent. the blood will become about 67 per cent.

saturated and complete helplessness, with loss of conscious-ness, would doubtless occur. This percentage would, of

course, in the prolonged exposure finally cause death. The

second argument which Mr. ARMIT gives against the

theory of pure carbon monoxide poisoning is that the

blood of an animal saturated to the extent of 32

per cent. with carbon monoxide loses carbon mon-,

oxide during subsequent poisoning by nickel carbonyl.Thirdly, iron carbonyl is, he says, less toxic than

nickel carbonyl, although it contains more carbon mon-

oxide. It would thus appear that the toxic effect

of nickel carbonyl is not produced by the carbon

monoxide present; and, further, when the quantity of

nickel carbonyl vapour inhaled is only just sufficient to

kill, the total available amount of carbon monoxide is

insufficient to influence the course of poisoning. The next

point obviously to determine was whether nickel carbonyl incontact with the fluids and tissues of the body gives rise toa toxic product of decomposition, and the investigation ofthis part of the problem led to very interesting results. To

begin with, nickel carbonyl in the presence of air and

moisture decomposes and a deposit forms which is due tothe dissociation of the compound and the formation of a

hydrate or carbonate of nickel. Experiment demonstratedthe fact that nickel carbonyl is more soluble in blood serumthan in water, and its solubility in blood itself appeared tobe the same. At the same time, however, there is dissociationof the nickel carbonyl, the product of dissociation provingalso to be more soluble in serum than in water. Bearing inmind the influence of serum in keeping metallic precipitatesin colloidal solution it is not improbable that the dissociation

product exists in serum in colloidal form. The conclusion is

thus reached that first of all the poisonous properties ofnickel carbonyl do not depend, as was at first supposed, onthe carbon monoxide of the compound but on the nickel,and that most probably this metal is deposited as a slightlysoluble compound in a very fine state of subdivision over

the immense area of the respiratory surface. It would be

interesting to know whether iron carbonyl gives rise in thesame circumstances to a similar dissociation product which,if it be physically similar to the nickel product-that is tosay, in a Sue state of subdivision or in a colloidal con-

dition-might be expected to exhibit some analogy in regardto toxio effects. Iron carbonyl, however, is reported to beless toxic than nickel carbonyl, so that it may be assumed

that the former either does not give rise to a dissociationi product, or that, if it does, this product does not act as a. colloidal or mechanical poison.

Child Labour and Public Health.THERE are many probably of the present generation to

whom "The Song of the Shirt " constitutes a reminiscence ofthe reading of their early days and was even then looked

upon as telling of an evil condition of things belonging to a

past age of society, one which modern prosperity and modern

hygienic development had rendered impossible of repetition.To such perhaps the recent exhibition of sweated industriesmay have been something of a revelation. It seems barelycredible that in these days of sanitary inspectors and health