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money available for the medical treatment of thepersons insured with the State, which is calculatedmonthly by multiplying the number of those personsat the end of each month by one-twelfth of 7.4267yen. For this remuneration, which is to be increasedwhen epidemic disease is exceptionally prevalent,the association assumes responsibility for the pro-vision of medical treatment, and for the maintenance,by intra-professional discipline, of an efficient medicalservice. Most of the health insurance societies havemade similar arrangements with the association,which thus takes a position in the Japanese healthinsurance scheme which is without parallel in anyother country.

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THE JAPANESE MEDICAL ASSOCIATION

In Japan, as in most other countries, the effectiveorganisation of the medical profession is a recent

development. The first association of medical practi-tioners was formed in 1874 as a private voluntarybody. It was followed by other organisations,notably the Meiji Medical Association, consisting ofgraduates of the Imperial University, and sharpdifferences arose between them on various questions ofmedical politics. The nucleus of the present associa-tion was formed in 1903, chiefly owing to the effortsof the late Baron Kitasato, who, like the late SirVictor Horsley, devoted much time and energy tothe organisation of the medical profession of hiscountry.

In 1923 the association became a statutory bodyand membership was made compulsory upon allmedical practitioners. The first president was BaronKitasato, who on his death in June, 1931, was

succeeded by Dr. Taichi Kitashima, the presentpresident.The organisation of the association is similar to

that of the American Medical Association. The localpractitioners join the local county or municipalmedical societies, of which there are 694, and theseare grouped in 47 prefectural societies, which uniteto form the Japanese Medical Association. Allpractising doctors are required by law to join thelocal medical society.

All doctors engaged in clinical practice must beavailable for the treatment of insured persons, andcannot relinquish insurance practice without theconsent of the association. The insurance doctorsreceive their remuneration from the association,which has chosen to adopt the payment perattendance system, and has drawn up a list ofservices, containing 287 items, each of which carriesa number of points varying from 1 point for a

urethral irrigation to 400 points for a cholecystectomyor similar operation. The money available is distri-buted monthly among the insurance doctors in propor-tion to the number of points allocated to each doctorby the prefectural medical society, after scrutiny ofthe doctor’s monthly statements of services rendered.The duties of the insurance doctors are set out inthe agreement between the Government and theassociation, and for the most part are expressed ingeneral terms. It is considered unnecessary to laydown detailed regulations for the conduct of insurancepractice. The association is given in large measurea free hand to see to it that the insurance doctorsshall " in consideration of the spirit of health insurance,engage in the examination and treatment with fairand warm attitude, and without any discriminationwhatever between insured persons and generalpatients."

So far as I, a foreign observer, was able to forman opinion the association has been remarkably

successful in carrying out the important duties withwhich it has been entrusted. Insurance practicemaintains a high standard of efficiency, and the

arrangements for medical treatment give generalsatisfaction. Japan has had no practical experienceof the friction and disputes that have impeded theprogress of health insurance in some Europeancountries. The doctors give good service and thevalue of the doctor’s services is recognised. Thisresult must largely be attributed to the work of theassociation, which as a statutory body takes an

important place in the community and exercises animmense influence on the individual practitioners.

DENTAL TREATMENT

The arrangements made for the provision of dentaltreatment under the insurance scheme resemble thosemade for medical treatment. The Japanese DentalAssociation, which is organised on the same lines asthe J.M.A., assumes full responsibility for the dentaltreatment of the persons insured with the State,and of many of those who are members of the healthinsurance societies. The insured persons have freechoice of dentist, and in many respects the conditionsapplying to the provision of medical treatment applyalso to dental treatment.

MEDICINE AND THE LAW

Standing Mute of MaliceLAST week at the Middlesex sessions Francis

Martin, aged 30, declined to speak when chargedwith housebreaking. A jury therefore had to decidewhether, in the old legal phrase, he stood " mute ofmalice " or

" mute by the visitation of God." Theevidence was that his speech and hearing were normal;Dr. H. A. Grierson, the Brixton prison medical officer,said Martin had conversed with him that very day.The jury found him " mute of malice," whereupona plea of " not guilty " was automatically entered.He was tried next day on the housebreaking charge.The householder described how he returned homeand on the stairs found Martin, whose explanationwas that he was a police constable in pursuit of athief. At the trial Martin again refused to speak;he was found " guilty " and, this not being his firstoffence, was sentenced to 20 months’ imprisonment.The chairman directed that the sentence should bewritten down for the prisoner to read. A policeinspector stated that, soon after he had been arrested,Martin said " if he (the householder) had been a fewminutes later, I should have got all he had and beenaway." The chairman seems to have concludedthat the muteness was assumed in order to annoythe court.The law was not always so reasonable towards

persons standing mute. By an arbitrary rule of thecommon law to stand mute in treason or misdemeanourwas reckoned a confession of guilt, but to stand mutein felony was not. In the dawn of our criminal pro-cedure, when our forefathers had not long abandonedtrial by ordeal (a system whereby the result of the trialwas deemed left to divine intervention), there wasan idea that a man accused of felony must not betried by the mere human agency of a jury unless heconsented. Edward I. directed that evil-doers whowould not "put themselves upon inquests," i.e., sub-mit to be tried by jury, must be put in prison forte etdure for refusing to stand to the common law. Soonafterwards, legal history assures us, anyone whowould not consent to be tried was remitted to prison,

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put into a low dark room, stripped and laid on hisback with nothing beneath him, his hands and feetdrawn by cords to the four corners of the room. Itwas ordered " that as many weights be laid uponhim as he can bear, and that he shall have no mannerof sustenance but the worst bread and the worst

water, and that he shall not eat the same day in whichhe drinks nor drink the same day in which he eats,and that he shall so continue until he die " or untilhe answers. Under this species of judicial homicide,men seem sometimes to have lingered for 40 days.Subsequently what was known as the peine forte etdure was evolved ; to extort the man’s consent tobe tried, he was crushed under a mass of iron till heyielded or died. Some prisoners, it is said, preferred todie rather than plead ; by dying unconvicted theypreserved their property for the benefit of theirfamilies unforfeited. This grotesque and barbaroustorture was not formally ended till 1772, when itwas enacted that anyone standing mute on arraign-ment for felony or piracy might be convicted as ifhis guilt had been established by confession or verdict.In 1827 another Act (which also abolished benefit ofclergy) provided that, on refusal to plead, the courtcould order a plea of " not guilty" to be entered.It was under this provision that Martin’s case wasdealt with.

Deafness as a Disability for Drivers

At a Sutton inquest on Jan. 4th on the death ofan old lady who had been injured by a motor-car,the motorist who gave evidence was found to sufferfrom deafness. Equipment was placed on the tableof the court to enable him to hear the coroner’squestions. There seems to have been no reason to

suppose that the injuries had any connexion withthe driver’s deafness ; the jury returned a verdictof "accidental death" and added no rider. Thecoroner suggested that the motorist should mentionhis disability when applying for a licence. A solicitorappearing for the motorist pointed out that deafnessis not specified as one of the disabilities to be dis-closed either in the section of the Road Traffic Actwhich deals with applications or in the statutory formto be filled in by the applicant. The form mentions

epilepsy, sudden attacks of disabling giddiness or

fainting, eyesight, loss of hand or foot, and defectof movement, control, or muscular power of eitherarm or leg, but says nothing about deafness. Thecoroner seems to have referred to the additionalwords both in the Act and on the form which requiredisclosure of any other disease or disability whichwould be likely to cause the applicant’s driving tobe a source of danger to the public. The solicitorreplied that his client’s deafness could not be deemeda disability of this kind inasmuch as he had driven150,000 miles without hitting anything.

It is possible that if an applicant were refused alicence on account of deafness the reviewing authoritymight decline to interfere. But there are many deafpersons who prove themselves careful drivers. Itwould seem hard that a careful driver with a cleanrecord should now be disqualified by an accidentfor which he was in no way to blame.

MILFORD COTTAGE HOSPITAL.-The Mayor ofLymington, Councillor W. E. Kirkman, recently openeda new wing of this hospital, containing two wards oftwo beds each and a smaller one for emergencies. Itis hoped thus to provide for patients who do not wishto go into the general wards and cannot afford privaterooms.

THE POOR IN NEWCASTLE

FOOD AND RENT

THE Newcastle Dispensary has issued the report ofan investigation by Miss Doris G. Rogers, who isstudying conditions of life in families connected withthe Dispensary. The following is a summary of herobservations.A preliminary inquiry into the income of 230

families revealed that after deduction of the cost ofrent, heat, light, insurance, and clothing, the majorityappeared to be left with inadequate resources for thepurchase of their food. It was therefore thoughtdesirable to make a more detailed examination of theactual diet obtained under these conditions. Anumber of households were requested to keep actualdaily accounts of every item of expenditure for oneweek. Of these, 36 budgets were accepted and theybrought the diet of 211 persons under inspection.The selection was made by taking the average samplesof families who had at some time attended the

dispensary. Outstandingly bad cases and families

handicapped by illness were deliberately avoided :the object was to investigate only cases representativeof the average type of unemployed in both " slum "and " new housing " areas. The term " slum " is hereused in its ordinary rather than in its legal sense,being applied to old tenement properties. In

Newcastle-upon-Tyne in 1932 there were 3092 one-roomed tenements and 5781 two-roomed tenements.

In the first place the arrangements for food storagein the 25 slum homes that were visited were found tobe very unsatisfactory. Where these conditionsprevailed, the budget books showed that the house-wives bought supplies in halfpenny and penny-worths,thus losing the economic advantage of getting theirstores in weekly quantities. In the new housing areas,on the other hand, there was ample provision for foodstorage and the bulk of the food was bought weekly.The families examined were divided into the

following groups : (a) unemployed in slum areas, 22 ; ;(b) unemployed in new housing area, 11 ; and (c)families in regular employment living in slum areas, 3.The mean family income in the 33 unemployed familieswas 32s. -1d. ; the families in slum property showeda mean income of 32s. 10 2 1 d. and those in new propertyan income of 30s. 42d. Most of them were in debt bythe end of the week.The families living under slum housing conditions

showed a mean rental of 5s. 102d. per family,amounting to about 18 per cent. of income. This

average is affected by the exceptionally high rentwhich was paid in two cases, amounting to 25 per cent.of income. In the new housing area the rent mean is9s. 2., or 30 per cent. of income. After deductingall " essential " expenditure, which includes heat,light, insurance, clothing, cleaning materials, medicineand medical payments, the " available " food incomein the slum areas amounted to 15s. 82d. per family perweek. In the new housing area there was an " avail-able" food income of 12s. 6. per family. Thesebalances must also provide for such items as cigarettes,newspapers, church colleotion, coppers for thechildren, and pocket-money to the husbands. Ofthese non-essentials the expenditure amounted to

1 . per person in the new housing areas and to ratherless than 2d. in the slum area.The three families in employment lived under

typical slum conditions and were in no wise selectedfor their housekeeping abilities. Table 1 summarisesthe mean expenditure of the three groups of people.