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was said that visits to the clinic averaged from 350to 400 weekly. On Dec. 31st U.S. district attorneyLeslie C. Garnett and corporation counsel ElwoodSeal ruled that G.H.A. was operating illegally. Not

only was it illegally practising medicine but also itwas illegally in the insurance business. At the sametime it was announced that Dr. Allen E. Lee and Dr.M. Scandiffio were on trial before the District MedicalSociety for violation of the society’s laws in con-nexion with their activities in the G.H.A. clinic. OnJan. 4th, 1938, it was announced that 260 newmembers had been admitted to G.H.A. from twofresh government agencies. On Jan. 7th the Senate’s

legislative council advised that " it is not clear thatthe expenditure was one which the corporation didnot have authority to make." " The diversion bythe HOLC," Senator McCarran rejoined, " mayhave been legally right but it was morally wrong."By this time interest in the district was thoroughly

aroused and public discussion of G.H.A. becamecommon. In a debate with Dr. T. Swann Harding,Dr. A. B. Bennett of the District Medical Societydescribed the English system as a horrible example :" In England, where they have State medicine," hesaid, "the government spends$25,000,000 a year foradministration of it. The doctors are supposed totreat 28 patients in two hours, which means fourminutes to each patient." On Feb. 1st the G.H.A.plan was endorsed by the district branch of theNational Lawyers’ Guild, which held that the asso-ciation was not subject to the insurance laws andwas not engaged in the practice of medicine. OnMarch 2nd a letter was sent by R. T. Berry, secretaryof the association, to officers and trustees of local

hospitals inviting them to a meeting, and com-

plaining that hospitals were discriminating againstthe medical staff of G.H.A. Membership in theassociation entitled the insured to 21 days’ hospitalisa-tion, but it was said that members were being" denied treatment by licensed physicians and sur-geons of their own choice in the hospitals of theDistrict of Columbia." On March 17th Dr. Scandiffiowas expelled from the medical society ; Dr. Lee, itwas announced, had resigned from G.H.A. HerbertL.Willett, jr., director of the Community Chest(an organisation for collecting in one campaign sub-scriptions to all local charities), announced that

pledges were being cancelled " because hospitals arerefusing to admit G.H.A. doctors." A spokesman forthe Loan Corporation told a newspaper writer thatsocial pressure had been exerted on doctors then onthe staff or who had contemplated joining it. Inone case a G.H.A. doctor, it was stated, was forcedto declare that his patient was brought by him inhis private capacity, rather than as a G.H.A. member,before the surgeon would operate for acute appendi-citis. President Roosevelt on the other handexpressed his sympathy with G.H.A. at a pressconference.

In the House of Representatives on March 23rdRepresentative Scott charged the District MedicalSociety with endangering the lives of federal employeesand their families through its controversy withG.H.A. He reported that a government worker hadbeen turned out of a local hospital, though she wassuffering from an acute attack of appendicitis, becauseshe demanded a G.H.A. physician. Two days laterthe appendix ruptured and she had an emergencyoperation in another hospital. This charge was deniedby Dr. F. X. McGovern for the medical society ; atthe operation in the second hospital when the appendixwas removed it was, he said, neither acutely inflamednor ruptured. At the present time events seem to be

moving rapidly towards a crisis. The Group HealthAssociation is appealing to its friends not to boycottthe Community Chest which provides hospitalisationfor the indigent but has no control over hospitalpolicy. Another of the association’s doctors is ontrial by his society in Texas for unethical conduct. -A prominent Washington laryngologist, Dr. V.Dabney, who has been a member of the medical

society for 30 years, has joined the association’s staff.Senator Robert Wagner, offering in the Senate a

resolution providing$50,000 for investigating nationalhealth problems, expressed his belief that healthinsurance should have come before unemploymentinsurance and old-age pensions. Finally the Wash-ington newspapers of April 12th report a letter fromthe president of the District Medical Society to thepresident of Group Health Association which reads asfollows :-

" These statements suggest that the MedicalSociety is opposed to such programs and hasadopted obstructionist tactics, has refused to cooperateand is trying to block such programs. On thecontrary, the Society has long recognized the need forbetter medical care for persons of low income and weare earnestly seeking a sound, safe, satisfactorysolution of the problem.

" The Society is willing to cooperate with any laygroup, including Group Health Association, in settingup and carrying out a program to this end. Theonly conditions are that the programs must belegal, ethical, economically sound and provide servicein conformance with recognized medical standards."We sincerely believe a program can be worked

out under these conditions, which will provideadequate medical care for persons of low income.free choice of physician and a system of regularmonthly payments, in the nature of insurancepremiums."

MEDICINE AND THE LAW

Must the Surgeon Count the Swabs ?Mahon v. Osborne, tried at the Manchester assizes

last week, was one of those cases where a swab hassomehow been left behind in the patient’s bodywhen the wound is closed after an operation. The

surgeon had relied on the counting and checking ofthe swabs by an experienced theatre staff. Wherewould the jury place the blame 1 Would they say-as in Byrne v. Thorn in 1904-that, if the nursemade a mistake, the operating surgeon was liablebecause the counting was a vital part of the operationundertaken by the surgeon ? Or would they-as inthe South African decision in 1924 (Van Wyk f.

Lewis)-hold the theatre sister to be independent ofthe surgeon so that any negligence on her part wassomething for which he should not be made toaccount ? In the end they seem to have said-as inJames v. Dunlop in 1931-that the surgeon wasliable upon the particular facts of the case.Thomas Mahon, a labourer, was brought to

Davyhulme Park Hospital near Stretford on

March 4th, 1937. He was suffering from a perforatedduodenal ulcer. Mr. R. P. Osborne operated thesame day. Owing to the subsequent condition of thepatient, the visiting surgeon of the hospital conducteda second operation on June 12th, and a swab 10 in.by 8 in. was found in the body. The patient diednext day. His mother brought an action for damagesfor negligence. Mr. Osborne’s defence was that hewas assisted by a highly trained nursing staff onwhose care and skill he was entitled to rely ; therewas in use a system by which swabs were carefully

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counted and checked ; in the circumstances, he con-tended, it was not the surgeon’s duty, nor was itin the best interest of patients, for him to count theswabs or check the removal ; that was the duty ofthe theatre nursing staff. He had inquired if all’the swabs were accounted for ; on receiving an

answer in the affirmative, he closed the wound. Forthe plaintiff it was claimed that it was the duty ofthe man who put in the swabs to take them out.Here there is perhaps a suggestion that the surgeon,in interfering with a patient’s body, commits somekind of trespass or assault ; but the patient hasimpliedly invited the surgeon to do what is necessary.On the surgeon’s side it was pointed out that swabsare extremely difficult to detect by sight or touch ;they may be indistinguishable in colour from thesurrounding tissues ; the same swab may be usedseveral times in the course of an operation ; the

surgeon cannot possibly keep a mental note of thenumber used. This particular swab had no forcepsattached. Perhaps the forceps had fallen off ;perhaps two swabs were folded together. It wasstated that over 3000 abdominal operations hadtaken place at the hospital and this was the firstmisadventure of this kind. In accordance withsound standards of hospital practice a tally was kepton a blackboard of the number of swabs used. Theywere grouped in bundles of five and were checked bythe theatre staff before use. Mr. Justice Atkinson

pressed Mr. Osborne to give his own theory of themistake. The witness said he thought there mighthave been a miscount ; possibly two swabs weregiven him at one time, the one with forceps attached,the other without. Miss Ashburner, the theatresister responsible for the checking, described themethod adopted. By the time the swabs reached thetable they had been counted three times. She wasnot conscious herself of having done anything amiss.Her evidence caused the court to inquire how shecame to have omitted to enter a defence in the

proceedings. She had originally been made a

defendant like Mr. Osborne, but she had put in noappearance ; judgment had therefore been signedagainst her in defatilt and the court had beeninformed that, so far as she was concerned, the soleduty of the jury was to assess the amount of damagesshe would have to pay. She gave her own explana-tion. She had written to Mr. Osborne about theclaim made against her, and she had been interviewedby Mr. O. A. Hempson, a partner in the firm ofsolicitors acting (through the Medical Defence Union)for Mr. Osborne. There had evidently been a mis-understanding. Neither Mr. Hempson nor Mr.Osborne had undertaken her defence. Mr. Hempsonindeed made it clear in the witness-box that hewould never have advised that the surgeon and thetheatre sister should have their case conducted by thesame legal advisers. The judge was satisfied that

everybody had acted in good faith and that MissAshburner, who ought to have taken legal advice,never intended to admit liability. The judgmentsigned against her was, by consent of all parties,cancelled. But, with the case thus reopened againstMiss Ashburner, no specific allegations of negligencewere formulated so far as she was concerned nor didthe plaintiff’s counsel seem prepared to imputeblame to her. It was not surprising that the juryeventually found no negligence on her part. Mean-while expert witnesses had testified to the care andskill of Mr. Osborne. Mr. John Morley, professor ofsurgery at Manchester University, reminded thecourt that the surgeon has to balance in his judgmentthe harm he may do by an extensive search as against

the harm he may do by leaving a swab behind. Headded that a swab was difficult to detect whensaturated with fluid and difficult to discover bytouch. The judge told the jury that Mr. Osbornehad given his evidence with conspicuous franknessand was a witness who would command their con-fidence. The jury declared themselves unanimouslyof opinion that Mr. Osborne was working underdifficult conditions during the operation, but theycame to the conclusion that he had not made a

reasonably sufficient search for swabs and that a

search would have disclosed the missing swab. Onthis finding the plaintiff was awarded E616 3s. 6d.and costs against Mr. Osborne, with a stay ofexecution for 14 days pending consideration of appeal.How a jury reaches its unanimous conclusions in

questions of such technical difficulty is one of the

mysteries of our forensic system. Possibly an actualexperience of the surgeon’s task in the operatingtheatre would go far to convince juries that countingswabs at the close of an operation is not so simplea matter as counting the number of persons on a

bench in the law courts and that other considerationsmay make it impracticable to explore the patient’sbody at leisure. In effect the verdict in Mahon v.

Osborne means that a surgeon is not to delegate thetask of checking the swabs to the sister who istrained to undertake it, but that he must somehowkeep count of every swab while his mind is intentupon the all-engrossing complexities of the operation.The verdict does not seem to suggest that the surgeonis responsible for the sister’s possible error, so muchas that he himself must do everything.

RESPONSIBILITY FOR NURSES

A legal journal, in a preliminary comment onMahon v. Osborne, observes that the reports of thecase do not disclose the exact status of the DavyhulmePark Hospital. " We must presume," adds our con-temporary, " that nothing at all, either in law or infact, could be said against its owners." This remark

may serve to link up the case with recent discussionat the Stowmarket District Nursing Association,where it was suggested that the employing bodymight be well advised to declare that it accepted noliability for claims made on the basis of the allegednegligence of a nurse. The public health departmentof the East Suffolk county council had written topoint out the need of adequate insurance againstpossible claims. It was said that a recent actionhad resulted in damages being awarded against a

cottage hospital to the amount of f:3649 on the

ground of the alleged negligence of the staff ; the

hospital had been insured, but the policy providedthat the maximum payable on any one claim shouldbe S1000. Thus a substantial sum had to be foundfrom other sources. To disclaim liability for thenegligent acts or omissions of its servants and agentsmay not be easy for a nursing association. While theparallel may not be exact, the London PassengerTransport Board could hardly protect itself fromclaims made by injured pedestrians by merelyannouncing that it would not in future hold itselfliable to pay damages for traffic injuries caused bythe drivers of the Board’s vehicles. The law of

agency and the principle of respondeat superior aretoo strong for that.

Mistake in Dose of Sleeping DraughtThe risks of consultation by telephone were revealed

at the inquest on Lady Rankeillour on April 28th.A patient had been suffering from shingles ; her

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teeth had been extracted and she was under the careof a nurse who had been attending her since lastNovember. Her medical attendant was paying hera visit once a week. The nurse, to summarise theevidence she gave at the inquest, telephoned to thedoctor that the patient was unable to sleep. Sheasked his advice and mentioned the possible use ofparaldehyde about which he had spoken some timebefore. She understood the doctor to say that sheshould give 6 oz. in 8 oz. of paraffin. She had not

given paraldehyde to a patient for 16 years and shedid not remember the dose. She wrote down whatshe understood to be the doctor’s direction. Sheasked if she could obtain it without a prescriptionand he said " Yes." She then asked a chemist for20 oz. in a bottle. She administered the dose of6 oz. in paraffin by the mouth before giving t gr. ofheroin by hypodermic injection. She found nextmorning that she could not wake the patient. Thedoctor was hurriedly communicated with and he atonce demed that he had ordered a dose of 6 ounces.He was sure that he had said " 6 drachms " over thetelephone, while the nurse evidently had no doubtthat he had said " 6 ounces." Dr. John Taylor,pathologist, who stated that death was due to

syncope, informed the coroner that the official dose

by the mouth was from 2 to 2 drachms. Thecoroner repeatedly pressed the nurse about the dis-appearance of the piece of paper on which she hadwritten down the doctor’s instructions. The witness,who was naturally distressed, could say no morethan that she had torn it up. After all, as she pointedout under pressure, the note was in her own hand-

writing and she could have written another one ifminded to deceive the tribunal. The family of thedeceased generously abstained from accusing any ofthe parties of negligence. The inquest brought outthe fact that paraldehyde is neither a poison on thePoisons List nor a dangerous drug within the 1920Act. There are no restrictions in obtaining it. Thechemist who supplied it was understood to have toldthe nurse that 6 oz. was a large dose and that hethought the maximum was 2 oz. He was aware thatit is a drug which is somewhat flexibly administered.

INTERNATIONAL CONGRESS OFLEPROSY AT CAIRO

THE first three leprosy conferences on an inter-national scale were held in Berlin, Bergen, and

Strasbourg, the last of these being held fifteen yearsago. At these conferences important agreements werearrived at. In 1931, through the generosity of theAmerican Leprosy Foundation, a meeting of a

limited number of experts was held in the Philippines.This latter took the form of a round-table conference,and after three weeks’ deliberations a classificationand terminology of leprosy was arrived at whichhas been generally accepted and which has donemuch to get rid of the confusion which formerlysurrounded this difficult subject.The fourth international congress was held in Cairo

from March 21st to 27th, under the patronage ofKing Farouk, who opened the first session. Subsequentsessions were held at the faculty of medicine of theUniversity of Egypt.The scientific side of the congress was organised

by the International Leprosy Association. Importantworkers in leprosy from nearly all countries whereleprosy is a serious problem accepted the invitation to

attend. Fifty countries in all were represented,most of them by official delegates. After that of

Egypt itself the largest delegation was from Brazil,where much excellent anti-leprosy work has beendone during the last few years.The aim of the congress was to combine as far as

possible the international and round-table modes ofprocedure. Papers were read and discussed at themorning sessions, while four subcommittees made upof exponents known to hold different views met inthe evenings to thrash out important aspects of

leprosy : classification ; treatment; endemiology andcontrol; and in-vitro cultivation of 3[ycobacteriumZeprm. It was proposed (a) as far as possible to reachagreement on matters in dispute, and (b) failingagreement, to formulate common methods of pro-cedure along which all could work, and commonmethods of record which would make it possible tocompare results obtained in different places. In spiteof the short time available, satisfactory progress wasmade, and the lines have been clarified along whichconcerted action should be taken before the next

congress five years hence. Resolutions based uponthe reports of the first three subcommittees wereadopted by the congress and will be published shortlyin a special bulletin.The papers read at the congress were divided into

six sections, one whole session being devoted to each :geographical distribution and epidemiology ; clinical

types and classification ; research, including cultiva-tion and inoculation of the leprosy organism ; treat-

ment ; methods of control; miscellaneous, includingrat and buffalo leprosy.

DISCUSSIONS AND COMMUNICATIONS

Differences between types of leprosy. - Amongmany aspects of interest and importance raisedperhaps the most outstanding was the differencebetween the two main types of leprosy. The term" cutaneous," as applied to one of these types, hasnow been definitely abandoned in favour of the term" lepromatous." There is general agreement that thelepromatous type of lesion differs widely from theneural and especially from the tuberculoid. Thisdifference extends to all aspects of leprosy. Theclinical and histological pictures are distinct ; theprognosis is much more favourable in the tuber-culoid ; the lines of treatment differ in the twotypes, as do also the methods of control. Thetuberculoid type of lesion, at first supposed to beconfined to one or two countries, is now recognisedto have a much wider distribution ; it may, in fact,be the commonest type.

In the discussions on treatment, the primaryimportance of general physical improvement wasagain emphasised. It is recognised that the prin-cipal predisposing causes may vary in differentplaces ; also that the disease may take on a severerform and be less amenable to treatment in someplaces than in others, though whether this is due tophysiological, sociological, or economic differences isnot yet clearly determined. The oils of the variouschaulmoogra or hydnocarpus species still hold firstplace under special treatment. Reports were givenfrom various centres where better results had beenobtained with larger doses of the oil or esters, asmuch as 20 c.cm. or more being given subcutaneouslyper week. These larger doses are now made possibleby the pure quality of the oil prepared from carefullyselected seeds. French workers reported promisingresults with a new preparation, a combination ofchaulmoogra and cholesterol which, in the form of afine emulsion, is given intravenously.Epidemiology.-One of the most important aspects

of leprosy centres round methods of conductingleprosy surveys and recording results. The findings