722

viz., Prof. R. J. Johnstone (Belfast) and Dr.Eardley Holland (London). Proceeding to theelection of officers, Prof. Blair Bell was chosen pre-sident, Prof. Munro Kerr vice-president, Mr. ComynsBerkeley (London) treasurer, Prof. W. Fletcher Shaw(Manchester) and Dr. H. Russell Andrews (London)secretaries. Sir Francis Champneys was appointedvice-patron of the College in recognition of his serviceto obstetrics and gynæcology, and especially to theCollege during the process of its formation. Finally,the following were elected members of the ExecutiveCommittee-viz., Prof. Blair Bell, Mr. ComynsBerkeley, Prof. Munro Kerr, Mr. Rivett, and Prof.Fletcher Shaw.

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Annotations.

MEDICAL DEFENCE.

"Ne quid nimis."

THE tendency of recent years to add more and morescientific tests and standards to the practice ofmedicine has had at least one real disadvantage tothe medical profession. It has made it increasingly,difficult to get patients to appreciate the fact thatmedicine can never be an exact science. They are- every year more apt to judge the results of treatmentby an arbitrary and sometimes grotesque standard,usually infused by natural but undue optimism. Ifthe standard is not reached they promptly blame thedoctor, and woe betide him if he has omitted to callin the aid of any modern scientific measure applicableto the case. The absolute necessity of a precautionaryX ray in any case of injury which might conceivablyinvolve fracture has been urged again and again,yet Sir Herbert Waterhouse, in his presidential addressat the annual general meeting of the Medical DefenceUnion on Thursday of last week, had to report oncemore that most of the cases causing his Union anxiety-had been those involving failure to advise radio-graphy. " Unless we are in a position to prove," heobserves, " that such advice has been given, the.defence of our member becomes a matter of great- difficulty or even impossible." There are, however, ,,

other risks attendant upon the practice of medicine.As the solicitors, Messrs. Hempson, point out in theirreport, there is the unscrupulous type of person whothinks that he may escape payment if he only voiceshis dissatisfaction loudly enough and threatens tocharge a professional man with negligence. Againstsuch there is no immunity, either in consulting workor in the public health service. There is also the-possibility in public health or other whole-timeemployment of disputes with employers or complaintsby ratepayers or other members of the public. Therisk is certainly in the minds of a growing proportionof the profession, and we are glad to learn that theamembership of the Medical Defence Union now standsat 15,945 and that its financial position has never beenbetter. Its work covers a very wide range of serviceto medical men and women ; defence against actionplays a relatively small part. The counsel of experi-enced advisers can often avert proceedings, and prompt.attack may be the best form of defence. The Unionmay be said to handle every variety of difficulty,connected with the practice of medicine. Perhaps themost outstanding case of the year was that, reportedin our columns at the time, in which a medical manwas held liable for the hire of a car ordered by himfor the transport of a patient. This was one of thetwo cases in which the Union suffered defeat; and atany rate should do service to the profession by callingattention to the importance of disclaiming personalliability when giving an order on behalf of a patient.In the other case the failure was due to the injudiciousconduct of the member after action had been

1 THE LANCET, 1928, ii., 1145, and 1929, i., 1258.

threatened ; this illustrates again the importance ofconsulting the Union early and of abiding faithfully byits advice throughout. Another feature of the year’swork was the action taken to maintain the professionalstandard by referring to the General Medical Councilthe conduct of certain registered practitioners. Inevery case the Council found the charge proved, andin one case ordered the removal of the name fromthe Register. More cases than usual have been settledout of court because the Union had no hope ofsuccessful action. There were nine of these cases:two involved the loss or partial loss of the sight of oneeye, one owing to instillation of the wrong drops andthe other to leakage of anaesthetic ; three were casesin which a swab or instrument had been left in thebody at operation ; one patient had been burnedduring treatment by diathermy ; in two cases therewere obviously mistaken diagnoses under circum-stances in which it might have been difficult to provethat reasonable skill and care had been exercised, andin the ninth case the practitioner had been carriedaway by sympathy for relatives and had signed anurgency certificate without actually examining thepatient. The policy of the Union, however, is stronglyopposed to the settlement of claims out of court, andevery possible avenue of defence is thoroughly exploredbefore compromise is admitted. In the last 15 years1641 cases have been handed over to the solicitors bythe Council of the Union and the total cost of subse-quent litigation was £14,676. In the 63 heaviest casesthe average cost per member was about £381. It seemsalmost incredible that there are still thousands ofpractitioners who are unwilling to pay £1 a year or alife sum of £25 to insure against this risk. In thewords of the solicitors : " It is no exaggeration to saythat no medical man is free from this risk, and thatevery case he attends is a source of possible danger ...however small the risk the results may be disastrousand peace of mind is cheap at £1 a year." Membershipof one of the defence societies is the only way ofsecuring it.

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FLUKE INFECTIONS OF MAN’S BILIARY

PASSAGES.

DURING the past year some significant observationshave been made in Russia on infection by flukes of thebile-ducts and gall-bladder of man. P. Sdrudowski,of Baku, on the Caspian Sea, and his assistant,F. Taguboff, have reported that, in fæcal examinationof 900 persons, ova of liver.-dwelling fiukes were foundfour times-those of Fasciola hepatica and those ofDicrocoelium lanceatum each being noted twice.All four patients had such hepatic symptoms asjaundice and a large and tender liver. K. Plavtov, ofNakhi-Chevan, at the head of the Sea of Azov, reportson a herdsman who passed eggs of F. hepatica withoutsymptoms, and on eight other persons passing thoseof D. lanceatum, of whom one at least was ill withan intense anaemia, but without anything to pointto the liver as a seat ’of infection. Again, N. Karibow,of Tiflis, saw two boys of about 11, from differentGeorgian provinces, of whom one was wi thout symptomsand the other suffered from biliary colic, while in boththe eggs of F. hepatica could always be found not onlyin the faeces but by duodenal catheter. Since in mostof these cases where fiuke’s eggs were discoveredsymptoms of hepatic disturbance were present, thereis little doubt that true parasitism existed. That thisneed not be so is evident from observations byS. M. Koulaguine,11 who was struck by finding that of40 persons in whose faeces he found eggs of theseparasites, 38 seemed perfectly healthy. He suspected,therefore, that the trematode eggs which he had seenhad been swallowed with food, and he was indeed ableto observe instances -in which a meal of boiled liverinfected by these two fiukes resulted in the evacuationof their eggs in the faeces over the next three or fourdays. He confirmed this observation on his own person;having first satisfied himself that he- was free from

1 Russian Jour. Trop. Med., 1929. vii., 131.