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be able to return to useful active work. The cost oftreatment also in an acute hospital is high because of thestandard of service rendered, being somewhere between£ 10 and f20 a week and in a few cases even more. Achronic-sick patient in his home or in a hospital for lessacute cases will cost much less. It is easy to understandtherefore how anxious those in charge of acute hospitalsmust be to prevent their beds becoming " silted up

"

as they express it.With the very welcome assistance of the King Edward’s

Hospital Fund for London, some hospitals have beenable to open " annexes " for less acute cases especiallyamong the aged, in which treatment initiated in the

parent hospital can be continued. It is of great import-ance in my opinion to prevent these annexes becominghomes for the dying, by the admission of a reasonablenumber of cases that will be able to return home. Butthe same danger of

" silting up " exists in these institu-

tions as in other hospitals. One way of preventing thisis to make preliminary arrangements with the relativesof a patient for his return home, at the time of hisadmission to hospital. But of even greater importance,both in limiting admissions and accelerating discharge,is to bring the hospital to the patient. It is desirable tohave a geriatric specialist, whole or part-time, on thestaff of every general hospital of any size. This con-sultant can usefully see many aged patients in theirhomes in consultation with the general practitionerbefore admission, except of course in really urgent cases.If complete liaison can be established between thisofficer, the medical staff of the local authority, and thepractitioners of the district, much can be done to limitadmissions and to make possible a return home as soonas the acute stage is passed, particularly if there is a

fully equipped geriatric outpatient department withinreasonable distance of the patients’ homes.

There are many and varied facilities provided in someareas for the assistance of invalids in their homes. Meals-on-wheels schemes provide them with a hot meal daily ;but why this should be limited to two hours in themiddle of the day, and the usefulness of the service

thereby curtailed, I have never been able to understand.Then there are home, nurses, home helps, and homephysiotherapists. I realise that there is considerabledanger in agreeing to pay the relative of a chronic invalidfor acting as a home help to him, but one cannot forgetthe high cost to the nation if the same patient is admittedto, or retained, in an acute hospital. Dr. F. R. O’Shiel,medical officer of health for Stepney, has an ingeniousscheme for bathing old people in their homes. A bath,a boiler, and’ Calor’ gas are taken to them. The washingof soiled linen is a major problem in the nursing care ofthe chronic sick in their homes because so many of thesepeople are singly or doubly incontinent. Where hospitalauthorities araable and willing to undertake this service,charging the local authorities the out-of-pocket expenses,a solution can be found ; but even so, difficulties arelikely to arise as the bed linen and other clothing isoften much worn and scanty and needs replacement.A useful suggestion that has been tried out in a few

places is that hospital and local authorities or voluntaryassociations should share the expense of running " half-way houses " to accommodate aged patients for whomno active treatment is required but who, it is anticipated,may never be fully restored to health. These " frailambulants," as they have been called, must be keptunder medical supervision and returned to the hospitalgeriatric unit when necessary. They can be kept activeand take their share in the work of the home more easilythan in hospital.

THE INFIRM AND THE SICK

There are many old- people who have no availablerelative and are incapable of looking after themselves

completely, who become the responsibility of the weliaicdepartment of the local authority. An increasing numberof these are being accommodated in relatively smallhostels and are comfortable and happy in them. Ail

goes well in fact until they are taken ill, when they cea’eto be the responsibility of the welfare authority, that i,only permitted to make provision for the treatment oiminor ailments or illnesses ordinarily nursed at home.If operation or specialised treatment is required, thepatient must of course be taken to hospital, but if neitheris necessary it is much better not to remove such patient;,who all too often die when moved. Some method shouldtherefore be devised for the hospital authority, which isalone permitted to deal with such cases, to be responsiblefor them without their removal. But how can this beequitably arranged between the hospital authority(hospital management committee) and the local authority(welfare committee) ? The following definitions havebeen laid down by the Ministry of Health :

" Sicx—and therefore properly the responsibility of theregional hospital board-patients requiring continued medicaltreatment also supervision and nursing care. This wouldinclude very old people who, though not suffering from anyparticular disease, are confined to bed on account of extremeweakness.

" INFIRM-and therefore properly the responsibility of thelocal authority-persons who are normally able to get up andwho could attend meals either in the dining room or in anearby day-room. This class would include those who needa certain amount of help from the staff in dressing, toilet, ormoving from room to room, and those who from time to time-for example in bad weather-may need to spend a fewdays in bed."The hospital authority might be willing to pav a

proportion of the cost of running the hostel, determinedby the number of days spent in bed ; but this would behardly right as both aged and infirm patients seem tobenefit by an occasional day in bed. To divide the cost

equally between the two authorities would be even lessjustifiable. It might be more equitable if the hospitalauthority provided all specialist, medical, and nursingrequirements, while the local authority was responsiblefor premises, food, and general attention ; but thiswould seem to be a little hard on the local authority.Surely it is time that the Ministry of Health called aconference and after considering the various views

expressed issued a circular recommending joint actionand defining financial responsibility.

THREE YEARS OF THE TRIBUNAL

THE chairman, Sir REGINALD SHARPE, K.C., has

presented a report of the National Health ServiceTribunal for England and Wales, on its first three years’work.! As the ultimate step in disciplinary action,proceedings before the tribunal are instituted whenrepresentation is made that the continued inclusion of apractitioner in any list of medical practitioners, dentists.chemists, or opticians would be prejudicial to the effici-ency of the service. The tribunal also considers applica-tions for reinstatement from practitioners who have beenexcluded from a list.

Sir Reginald was appointed by the Lord Chancelloron July 8, 1948, and other members were thereafter

appointed by the Minister of Health. At each hearingthree members are present-the chairman (or his deputy.an executive council member, and a practitioner memberbelonging to the same profession as the practitioner whosecase is being considered. Up to July 5 last, 32 caseshad been brought to the notice of the tribunal, all ofthem by executive councils, and it had had 1 applicationfor reinstatement on an executive council’s list.

Of these 33 cases, 30 had been disposed of. In 15,the tribunal directed the removal of the practitioner’s1. From the office of the clerk of the tribunal, 2, John Adam

Street, London, W.C.2.

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name from the list, and in all but 1 an order was madefor payment of costs by the practitioner. The practi-tioners concerned were 1 doctor,2 9 dentists, 2 chemists,and 3 opticians. In 8 cases, the representation wasdismissed, and in 2 of these an order was made for thepayment of part of the practitioner’s costs by the execu-tive council. These cases involved 1 medical practitioner,4 dentists, and 2 opticians. Two separate representationswere made against 1 dentist. In 4 cases, representationwere withdrawn by leave of the tribunal, and in 3 ofthese an undertaking either not to practise or to limithis practice was given by the practitioner. The remaining2 cases did not come before the tribunal. In the case of adentist, two separate representations were made againsthim, and, the first being successful, the second lapsed. Inthe second case, a dentist died before the hearing.The one application for reinstatement was that of a

dentist who had given an undertaking not to practisewithout the leave of the tribunal. This application wasrefused. 6 cases were heard in London and 26 in the

provinces. The majority of hearings were competed inone day, but one case took five days. An appeal wasmade to the Minister of Health in 7 of the 15 cases inwhich removal of a name had been directed. In only 1case, that of a chemist, -was the appeal upheld, and theMinister did not make an order for the payment of theappellant’s costs.

Medicine and the Law

Medical Partnership and Restraint of TradeA COVENANT to bar a man from practising a profession

is liable to be held void as being ’contrary to publicpolicy because it is in " restraint of trade." An agreementfor a professional partnership usually contains a stipula-tion that a retiring partner shall not, for a specified time,practise in competition with the remaining partnerswithin a specified distance. In the recent case of Whitehilland others v. Bradford Mr. Justice Danckwerts has

upheld a restriction of this kind.3Four doctors signed in 1945 a partnership agreement

for carrying on general medical practice at A. It allowed -a partner to retire on giving six months’ notice ; - thecontinuing partners could buy his share. A further

provision prohibited a retiring partner for 21 years" from directly or indirectly carrying on or beinginterested or concerned in carrying on the business orprofession of medical surgery... anywhere withina radius of ten miles of the parish church of A." Thedefendant doctor gave his partners notice of his retire-ment but told them that he was advised that the restric-tive condition was void as being contrary to publicpolicy ; he announced his intention of practising withinthe 10-mile radius as soon as his retirement took effect.They asked the court for an injunction to restrainhim from breaking the condition to which he hadaoTppr)

The learned judge granted the injunction. He observedthat the bulk of the practice was within 5 miles of A,though there were many patients residing between 5and 10 miles from that town. The defendant doctorhad contended that a 5-mile radius would have givenadequate protection to the partnership. If so, said thejudge, the defendant could have set up his surgery5 miles away and could have drawn his patients frominside the 5-mile area. " It seems to me verv difficultto set a limit narrower than 10 miles within which patientswould not be likelv to resort to their old doctor." Hecame to the conclusion that the 10-mile limit was " notunnecessary to protect the practice."There was a further question of the effect of the

National Health Service Act which forbade the sale of

2. This case was reported at length in The Lancet, 1951, i, 1122.3. Times, Oct. 30, 1951, p. 7.

practices. When enacting this prohibition, Parliamentmight have been expected to prohibit also this type eof restrictive covenant. Parliament had not done so ;on the contrary, the purport of section 1 of the AmendingAct of 1949 (dealing with existing partnership agreementsand making limited modifications thereof) seemed notto disturb the effect of the covenant. The court sawno reason why the remaining partners should not enforcethe restriction.

Amputation following Ligation of Varicose Veins

Damages of 12,000 were awarded on Oct. 26 at anAssize Court hearing at Chester.4 A claim was broughtby a woman laboratory assistant alleging negligencein the surgical treatment of varicose veins. One monthafter the ligation of varicose veins she had had to undergoa below-knee amputation of the left leg. She alsoclaimed that a paravertebral sympathetic block, per-formed by an anaesthetist 5 days after the operation,had been responsible for loss of sensation and controlof functions. The defendants were a house-surgeon,the anaesthetist, and the hospital management com-mittee. All denied negligence.The patient, aged 24, had been in normal health until

the operation on Aug. 19, 1949. At this operation thehouse-surgeon ligated varices in the right leg to hissatisfaction but was unable to control bleeding whicharose when a ligature tore through the left saphenousvein. After three successive ligatures had torn away, hesummoned the surgical superintendent, who was able tostop the bleeding by ligating the femoral vein and someof its tributaries. After the operation the circulationto the leg was poor ; but no fears were entertaineduntil Aug. 23, when, in the evening, the house-surgeonwas shocked to find that signs of grave circulatoryobstruction had developed since noon. The limb wasseen by the consultant surgeon, who had been on holiday,and he asked the anaesthetist to perform a sympatheticblock in an attempt to improve the circulation. Thiswas done immediately but with little benefit. Thecondition of the leg failed to improve and finallyamputation was undertaken on Sept. 20, 1949.The points at issue were several. The house-surgeon

thought that interference with the femoral artery hadoccurred at some point in the operation but was unableto account for it. Cross-examined, he said that he hadsuccessfully performed some forty varicose ligations.On this occasion he had found it necessary to use

gall-bladder forceps at one stage.Two surgeons,- called for the plaintiff, criticised the

use of so large an instrument in this operation. Inanswer to a question by defending counsel, one of thesewitnesses agreed that, when the surgical superintendentwas called, the primary consideration was to save thegall-patient’s life, in jeopardy from blood-loss.One of the surgeons attributed the sensory and motor

loss to sacral nerve damage following a wrongly placedinjection. Counsel defending the ansesthetist arguedthat the consequences of the injection were of littleimportance in determining the fate of the limb, whichwas already decided at the time of the injection. In

support, surgical evidence was called seeking to showthe cause to be a massive venous thrombosis. The

patient described a period of severe pain after the

operation and during the injection. She did not recalldenying a sensation of pins and needles, nor did sheremember making a definite complaint of pain while theinjection was being made. She heard the surgicalspecialist say, " This should never have happened,"when he first saw her on Aug. 24.A settlement was reached after an adjournment and

was approved by the judge.4. Manchester Guardian, Oct. 23, 24, and 27. 1951 ; Liverpool

Daily Post, Oct. 15 and 24, 1951.