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Geneva and at the branch health office of the Leaguein the Far East, which has been established at

Singapore. The International Health Year-book,comprising notes of the principal happenings indifferent countries, has taken a new form and itslast issue has been so enlarged that it makes quite aformidable volume of reference. New handbookshave been prepared regarding vital statistics and thepublic health administration of different countries.In the more important field of international expert

study some notable contributions have lately beenmade to the science and practice of preventivemedicine, particularly the reports of the InternationalConference on sleeping sickness 1 and on the radio-logical treatment of cancer of the uterus.2 To theseshould be added a comprehensive survey which hasjust appeared of the measures taken in differentcountries for the welfare of the blind. The rapporteurlaid special stress on the progress of combined investi-gations into particular aspects of syphilis, malaria,and the causes of infantile mortality. The successiveconferences on the first subject have focused nationalstudies of the technique of serum reactions, and haveundoubtedly led to greater accuracy and compara-bility of all the diagnostic tests employed for syphilis.A similar comparison of the efficacy of modern

preparations in the treatment of this disease is nowproceeding on a large international scale. Theinquiries which have been pursued by the MalariaCommission, extended in the present year to India,have resulted in a series of authoritative reports whichare doing much to determine the wise selection andeconomic application of different antimalarial measuresaccording to the circumstances and resources of thecountries affected. In the case of infantile mortalitya standard pattern of inquiry has been set up whicheach country can adopt, and those countries whichhave already adopted it have found that it affordsan invaluable guide and stimulus to national effort.Claims such as these made on behalf of the League’swork are substantiated by the facts, and their

recognition should be gratifying to the medicalofficers of our own Ministry of Health and otherBritish technical representatives who have not onlytaken their share in the conferences and committees,but themselves have provided a very essential partof the material and research which has made theseseveral investigations fruitful. In the debate in theSecond Committee some delegates advocated the stillgreater increase of investigations of this kind-forexample, the institution of an intensive world studyof influenza-while others hinted at the danger ofthe Health Organisation trying to do too much withouta more systematic programme. Both contentionshave force, but provided the inquiries are well thoughtout by the responsible body, the Health Committee,before they are put in hand, and the principle isfollowed that there should be only one quality ofwork-the best-their increase should be universallywelcomed.At the Assembly the public health work of the

League has now come to make an exceptional appealon the ground of the universality of its application.While disarmament, tariffs, and opium control affectsome nations vitally but leave others indifferent, thereis no country in the League which cannot benefit byconsultation on one or other of its health problems.In some instances it is evident that these are political

1 League of Nations Health Organisation Report, C.H. 743.Report of the Second International Conference on Sleeping-Sickness, Paris, November, 1928.

2 Ibid., C.H. 788. Reports submitted by the RadiologicalSub-Commission, Geneva, June, 1929.

and administrative rather than purely technical.The recent application of Greece to the League for aCommission to advise on the reorganisation of its

sanitary services is an instance in point. This Com-mission, of which Sir GEORGE BUCHANAN was theBritish member, laid down a scheme which the PrimeMinister of Greece informed the Assembly that hisGovernment has already adopted. In pursuance ofit the services of one of the principal medical officersof the League, Dr. NORMAN WHITE, have now beenlent to the Greek Government, while Mr. VENIZELOShimself, in order to further the scheme, has added theportfolio of a Minister of Health to his other offices.The League has just received a similar request fromBolivia for advice on the organisation of its healthadministration ; while much attention was attractedat the Assembly to communications received fromthe Government of Nankin, as a result of which themedical director, Dr. L. RAJCHMAN, with othermembers of the secretariat, will almost immediatelyvisit China and the Chinese ports. The Assemblyindicated its satisfaction with the principle of theserequests by voting a special credit for the purpose,additional to the normal public health budget and tothe income furnished by the Rockefeller Foundation.From the point of view of hygiene, as well as of its-effect in extending the influence of the League of

Nations, the results of these new and highly responsibleundertakings will be followed with attention and

interest.

BRITISH COLLEGE OF OBSTETRICIANSAND GYNÆCOLOGISTS.

THE Board of Trade has approved the schemesubmitted for its approval last March, and on.

Sept. 13th the incorporation of the British College ofObstetricians and Gynaecologists was completed andwith it the inauguration of a movement for theadvance of the twin sciences of obstetrics and gynæ-cology which should turn to great good. Chief amongits objects is the design to increase the prestige of thisbranch of medicine, to provide a better training anda severer test for medical students in these subjects,along with fuller opportunities for learning them.In giving our support to the movement in the springwe pointed out then what compelling force was givento it by the continuance of the high rate of mortalityin childbirth. We recognised in passing the validityof the practitioner’s plea that it is economicallyimpossible for him to follow out the rules which histeachers impress upon him for the conduct of labour.These are evils whose roots go deep into social problems,but the work of the new College should be helpfulin their solution. Following on the incorporation ofthe College the first meeting of the Council was heldin London on Sept. 25th, when Prof. W. BLAIR BELL(Liverpool) presided and the following were electedmembers of the first general Council. For London :Dame Louise McIlroy, Dr. T. Watts Eden, Dr. J. S.Fairbairn, and Mr. L. C. Rivett. For the Provinces :Prof. A. Donald (Manchester), Sir Ewen Maclean(Cardiff), Prof. Carlton Oldfield (Leeds), Prof. M. H.Phillips (Sheffield), Prof. Beckwith Whitehouse(Birmingham), Dr. Farquhar Murray (Newcastle),and Mr. Leyland Robinson (Liverpool). For Scotland :Prof. R. W. Johnstone (Edinburgh), Prof. Munro Kerr(Glasgow), Dr. W. F. T. Haultain (Edinburgh), andDr. R. A. Lennie (Glasgow). For Ireland: Prof.C. G. Lowry (Belfast), Dr. Bethel Solomons (Dublin),and Dr. T. M. Healy (Dublin). Under Article 40of the Constitution the following were cooptedon the Council for the purpose of organisation-

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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.