1
722 viz., Prof. R. J. Johnstone (Belfast) and Dr. Eardley Holland (London). Proceeding to the election of officers, Prof. Blair Bell was chosen pre- sident, Prof. Munro Kerr vice-president, Mr. Comyns Berkeley (London) treasurer, Prof. W. Fletcher Shaw (Manchester) and Dr. H. Russell Andrews (London) secretaries. Sir Francis Champneys was appointed vice-patron of the College in recognition of his service to obstetrics and gynæcology, and especially to the College during the process of its formation. Finally, the following were elected members of the Executive Committee-viz., Prof. Blair Bell, Mr. Comyns Berkeley, Prof. Munro Kerr, Mr. Rivett, and Prof. Fletcher Shaw. ______________ Annotations. MEDICAL DEFENCE. "Ne quid nimis." THE tendency of recent years to add more and more scientific tests and standards to the practice of medicine has had at least one real disadvantage to the medical profession. It has made it increasingly ,difficult to get patients to appreciate the fact that medicine can never be an exact science. They are - every year more apt to judge the results of treatment by an arbitrary and sometimes grotesque standard, usually infused by natural but undue optimism. If the standard is not reached they promptly blame the doctor, and woe betide him if he has omitted to call in the aid of any modern scientific measure applicable to the case. The absolute necessity of a precautionary X ray in any case of injury which might conceivably involve fracture has been urged again and again, yet Sir Herbert Waterhouse, in his presidential address at the annual general meeting of the Medical Defence Union on Thursday of last week, had to report once more 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," he observes, " 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 their report, there is the unscrupulous type of person who thinks that he may escape payment if he only voices his dissatisfaction loudly enough and threatens to charge a professional man with negligence. Against such there is no immunity, either in consulting work or in the public health service. There is also the -possibility in public health or other whole-time employment of disputes with employers or complaints by ratepayers or other members of the public. The risk is certainly in the minds of a growing proportion of the profession, and we are glad to learn that the amembership of the Medical Defence Union now stands at 15,945 and that its financial position has never been better. Its work covers a very wide range of service to medical men and women ; defence against action plays 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 Union may be said to handle every variety of difficulty ,connected with the practice of medicine. Perhaps the most outstanding case of the year was that, reported in our columns at the time, in which a medical man was held liable for the hire of a car ordered by him for the transport of a patient. This was one of the two cases in which the Union suffered defeat; and at any rate should do service to the profession by calling attention to the importance of disclaiming personal liability when giving an order on behalf of a patient. In the other case the failure was due to the injudicious conduct of the member after action had been 1 THE LANCET, 1928, ii., 1145, and 1929, i., 1258. threatened ; this illustrates again the importance of consulting the Union early and of abiding faithfully by its advice throughout. Another feature of the year’s work was the action taken to maintain the professional standard by referring to the General Medical Council the conduct of certain registered practitioners. In every case the Council found the charge proved, and in one case ordered the removal of the name from the Register. More cases than usual have been settled out of court because the Union had no hope of successful action. There were nine of these cases: two involved the loss or partial loss of the sight of one eye, one owing to instillation of the wrong drops and the other to leakage of anaesthetic ; three were cases in which a swab or instrument had been left in the body at operation ; one patient had been burned during treatment by diathermy ; in two cases there were obviously mistaken diagnoses under circum- stances in which it might have been difficult to prove that reasonable skill and care had been exercised, and in the ninth case the practitioner had been carried away by sympathy for relatives and had signed an urgency certificate without actually examining the patient. The policy of the Union, however, is strongly opposed to the settlement of claims out of court, and every possible avenue of defence is thoroughly explored before compromise is admitted. In the last 15 years 1641 cases have been handed over to the solicitors by the Council of the Union and the total cost of subse- quent litigation was £14,676. In the 63 heaviest cases the average cost per member was about £381. It seems almost incredible that there are still thousands of practitioners who are unwilling to pay £1 a year or a life sum of £25 to insure against this risk. In the words of the solicitors : " It is no exaggeration to say that no medical man is free from this risk, and that every case he attends is a source of possible danger ... however small the risk the results may be disastrous and peace of mind is cheap at £1 a year." Membership of one of the defence societies is the only way of securing it. FLUKE INFECTIONS OF MAN’S BILIARY PASSAGES. DURING the past year some significant observations have been made in Russia on infection by flukes of the bile-ducts and gall-bladder of man. P. Sdrudowski, of Baku, on the Caspian Sea, and his assistant, F. Taguboff, have reported that, in fæcal examination of 900 persons, ova of liver.-dwelling fiukes were found four times-those of Fasciola hepatica and those of Dicrocoelium lanceatum each being noted twice. All four patients had such hepatic symptoms as jaundice and a large and tender liver. K. Plavtov, of Nakhi-Chevan, at the head of the Sea of Azov, reports on a herdsman who passed eggs of F. hepatica without symptoms, and on eight other persons passing those of D. lanceatum, of whom one at least was ill with an intense anaemia, but without anything to point to the liver as a seat ’of infection. Again, N. Karibow, of Tiflis, saw two boys of about 11, from different Georgian provinces, of whom one was wi thout symptoms and the other suffered from biliary colic, while in both the eggs of F. hepatica could always be found not only in the faeces but by duodenal catheter. Since in most of these cases where fiuke’s eggs were discovered symptoms of hepatic disturbance were present, there is little doubt that true parasitism existed. That this need not be so is evident from observations by S. M. Koulaguine,11 who was struck by finding that of 40 persons in whose faeces he found eggs of these parasites, 38 seemed perfectly healthy. He suspected, therefore, that the trematode eggs which he had seen had been swallowed with food, and he was indeed able to observe instances -in which a meal of boiled liver infected by these two fiukes resulted in the evacuation of their eggs in the faeces over the next three or four days. 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.

MEDICAL DEFENCE

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Page 1: MEDICAL DEFENCE

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.

______________

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.

____

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.