- Email: [email protected]
THE POSITION OF NEUROLOGY
1238 that is-we planted ourselves firmly among the silly ones. Setting out for Folkestone from a southern suburb
Letters
at 11 A.M., bowling through Maidstone, and after only brief impaction at Ashford won through to the coast by 12.45. This, we said, is too easy. But wait! Setting course for home at 5 P.M. (" my dear, the children must be in bed by half-past seven ") we joined a halfmile queue at Ashford, and got through in a quarter of an hour. At Maidstone the queue, double-banked, started over three miles from the town, and was moving at rather less than 1 mile an hour. After three-quarters of an hour of this we acted boldly, cut off on to a by-road, and rejoined the crowd proximal to the obstruction. At Swanley the line was only a mile long ; and we reached home-62 miles from the coast-in 41/2 hours. By this time our three little wonders were in jubilant form. Not so my missus and I. " Never again," we sighed. But
to
the Editor
we were soon
we
THE POSITION OF NEUROLOGY
SIR,-It is impossible not to concur, in part at least, with the reasons you proffer for the difficult situation of clinical neurology in this country since 1948. Yet I venture to submit that we must probe a little deeper if we are to gain an effective insight into the situation. You say that " there is a tendency to believe that in the provinces neurology should be undertaken by general physicians ; and that both the practice and the teaching of general medicine would be impoverished by the appointment of neurologists." I do my colleagues the general physicians the justice to say that I do not believe they regard themselves as competent to act as consultant neurologists, and that they would not make any such claim for themselves. Moreover it is not where there are medical schools in the provinces that neurologists are lacking, though they are too few, but in large industrial and in some rural areas where no such schools exist. How, then, can teaching be impoverished where no teaching is, or alternatively how could the teaching of medicine be enriched when neurology is " undertaken - sinister word-by general physicians. Let us be frank about this matter, if we are to discuss it at all. The very numerous young men trained for, and
shall. *
*
*
Derby Day always brings its little store of excitement, but our proximity to the racecourse is a doubtful asset. True, all clinics are cancelled, but not with the idea of letting us go to watch the fun. At all other times competition for outpatient appointments is fierce, but on this one day of the year the local inhabitants have no wish to see a specialist. On the other hand the casualty officer is usually provided with reinforcements, and empty beds are kept ready for Pott’s fractures, perforated peptic ulcers, and cerebral haemorrhages, which are the chief sporting risks of the turf. Attacks of paranoid hysteria (‘’ I’ve been robbed ! ") are not infrequent, and there is said to be a significant increase in the incidence of pediculosis. Complications among inpatients are few, but the house-surgeon always goes round the chronic blocks after the commentary, reducing hernise. Our first admission was a school-teacher from the Midlands who, in the heat of the final furlong, had a rigor. " And what might a Birmingham schoolmaster be doing on Epsom downs on a Wednesday afternoon ? we asked. " Brushing up his arithmetic, of course," came the reply ; then, as a glum afterthought : " Subtraction sums." But on the whole this was a satisfactory year. Few patients, merry or moribund, could resist backing Never Say Die. and even a confused old granny, who has entertained suicidal notions for years, insisted on 2s. each way. "
.
*
*
*
By a fortunate coincidence I was again in London this year at the time of the Chelsea flower show. Superlatives do not do justice to the magnificent blooms modera horticulture produces, but I was best pleased by the scientific section where I learnt that while Londoners must expect to water their gardens in >9 years out of Poor Londoners 10, Maneunians only need do it in <5. I thought, how they must long for that elusive < year in 10 when they are spared the drudgery of watering-can and hose-pipe. Next morning I returned home to Manchester ; persistent rain washed out an afternoon’s tennis. I couldn’t even get into the garden to tackle the weeds made luxuriant by all this confounded rain. *
*
*
Long after everyone else had gone home, a tired ahd hungry surgeon still sat in the library, uninterestedly turning the pages of The Lancet. From time to time he cast impatient glances at the clock on the wall, shook his head, and sighed. At last he rose-‘I think it’s all right for me to go home ; my children should be in bed by now." * * * .
Ne,w,3 from School.—The fountain pen broke. I thing it could be mended with cellotape. There is a big crack in the plastic above the nib. Everyone was trying to throw balls We have been over and on top of the tower. A lot were lost. planning how to rebel against the Masters. We overpower Mr. Smith-Jones in the shooting range at gun point, (He is the shooting master.) then we raid Catterick Camp on visitors day, capture a plane from Leeming Bar aerodrome from which we scatter pamphlets on Northallerton and nearby appealing to boys to join us. Soon we have an army of 500. In the end we will conquer the earth and rule it. Love from David. _
.
"
,
eagerly desiring, consulting appointments as general physicians find the number of vacancies woefully inadequate, and the lists of candidates when any vacancy arises as woefully long. What more natural than that they should view with dismay the lessening of consultant openings for them every time, under the present unmeaning system of limitation of consultants, that a neurologist is made
a
consultant ?
With
no
illusions
as
to their
inadequacy to cope with the thorny problems of neurology they are ready to accept the simple notion that the general physician might take over the neurological estate and administer it as a side line, and are prepared to dub neurology a luxury if this will help. In truth, neurology is nobody’s side line. It happens to be a difficult and precise discipline in which we in this country-and let there be no false modesty about ithave long excelled, so that its study has brought more postgraduates to this country from overseas over the past few generations than any other single branch of medicine. It happens also to be an indispensable discipline, and if it is to be allowed to go by the board to meet the complications created by the National Health Service and the present redundancy of potential consultants in general medicine, we shall not be able to restore it, or the damage to the prestige of British medicine which its loss will entail. The grounds upon which the neurology committee of the Royal College of Physicians submit that there is a deficiency of adequately trained neurologists cannot be gainsaid by anyone who knows the facts, nor their submission that the neurosurgeon is by temperament and " training unfitted to undertake " the whole field of neurology within which the main incidence of illness is medical and not surgical. Yet when, as now, matters of politics and finance, and not the informed and dispassionate view of the needs of the community and of medicine, determine the pattern of development of medicine, situations incompatible with its proper growth and differentiation must arise and will continue to arise. Unhappily, as I most strongly hold, every professional body that represents medicine with the Ministry of Health has become so deeply entangled in financial controversy over questions of the emolument, and material gratifications of doctors that none is left to speak with single mind and complete disinterestedness upon what isessentially an academic problem—namely, the rational growth and differentiation of medicine as an activity upon which so
1239 much of the welfare of the community hangs. This, perhaps, is where an Academy of Medicine, standing aloof from the chafferings of the market-place, might have filled a rôle of the first importance. F. M. M. R. WALSHE. London, W.1. ARTHROPLASTY
v.
ARTHRODESIS
SIR,—Your leading article of May 29 discusses the relative claims of arthrodesis and arthroplasty of the osteo-arthritic hip-joint with such fair judgment that I hesitate to criticise. At the same time I must do my best to dismiss the myth you have raised once again that " the variety of methods of arthrodesis reflects the difficulty of producing certain fusion of the hip-joint." If enough people go on saying this long enough, someone will begin to. believe it. Let it be understood quite clearly that there is no difficulty whatever in securing sound arthrodesis of the hip-joint provided only that the first principles of surgi-
1. The diameter of the prosthesis should be 4 mm. less than the femoral head as measured by callipers at the time of
operation. 2. The femoral head should be trimmed with a cutter and not an osteotome, so that an accurate fit
special can
be
obtained. 3. A preliminary guide-wire introduced into the head and neck of the bone is essential if the length and position of the prosthesis is to be gauged accurately in advance. 4. The shank should be centrally placed in the neck with the prosthesis in mid position, neither in valgus nor in varus. 5. The point of the prosthesis should not penetrate the femoral cortex. 6. The nail and cap should be riveted together at the time of operation, so that the over-all length is correct. In the original model, which was demonstrated by the makers (Down Brothers) at the British Orthopaedic Association’s meeting in Nottingham in 1949, the cap and nail were shown in one piece and the prosthesis is still sometimes supplied in this form. This is a mistake if accuracy is to be achieved, unless a very large stock of prostheses is carried. The two elements can be riveted together by the surgeon at the time of the operation ; it takes less than half a minute. This technique has been used for many years ; it is simple and perfectly reliable. 7. Finally, meticulous technique, unhurried gentleness, and perfect hæmostasis are essential for a good result.
cal technique and after-treatment are observed. If a surgeon wants to arthrodese a hip-joint he can always do so. The articular cartilage must of course be removed completely, and there must be internal fixation with grafts or nails, and with protection in plaster for about four months (which never did any harm to a knee-joint It is too soon to be dogmatic about the ultimate provided only that the surgeon knows how to deal with success of this method. This prosthesis is not a panacea, stiff joints by active and not by passive measures). but the results-when the above points have been Your editorial implies that there is uncertainty about observed-are promising and it is worthy of further arthrodesis of the hip-joint ; but the fact is that the careful trial. certainty of the result of arthrodesis is the very special F. P. FITZGERALD. London, W.I. merit of this operation. The joint will of course be as stiff as it was before ; there may be some slight difficulty REMUNERATION OF HOSPITAL MEDICAL STAFF in reaching the shoe-lace or sitting bolt-upright in a but there can be no doubt at all that the patient SIR,-I received recently bulletin no. 3 of the Central chair ; Consultants and Specialists Committee, which purports will walk ten or twenty miles, jump hedges, vault fences, to explain to the profession the rationale of the recent climb mountains, and engage in every recreation without award to hospital medical staff. ever thinking about himself or his hip-joint. There are of course still older patients, aged 60-90 Paragraph1 states that " Consultants entered the service on the appointed day in 1948 upon interim ’ terms (for years, and also those with bilateral osteo-arthritis, in whom arthroplasty is a far better treatment-but here example, the maximum salary of a part-time consultant was again we must beware recent criticisms ; the results £1600 per annum)." However, it should be appreciated that this maximum was available for as little as eight sessions. can be good if the operation is done well, and most It might reasonably be assumed from this that the rate for a recent failures have arisen not because the operation whole-time consultant would commence at f2200 per annum, was bad but because the operation was done badly. as a basis for negotiation. In fact, although the statement There seems to be no doubt that arthrodesis is best informs us that a whole-time consultant was entitled to opt, for young and vigorous patients up to the age of about if he so wished, to keep his old pre-service terms (stating that 60 years, but that beyond that age, and for patients with few could have so opted since the prospective new terms were bilateral osteo-arthritis, arthroplasty is better-though I so superior) no new terms were offered and whole-time consultants were obliged to continue at a salary which in should add that of all the happy patients who see me month by month, I do not know of any more happy many cases was 25-33% below the recommended minimum of the Spens scale in terms of 1939 money values. This than those whose arthritic hip-joints havee been state of affairs continued, not until July 22, 1949 deplorable arthrodesed. The important point, which should really but until January, 1950, when the 1948 scale came 3), (para. be obvious, is that neither arthrodesis nor arthroplasty into existence. Many by that time were heavily in debt and of the hip-joint can succeed unless the operation and the overdrawn at the bank. Part-time consultants meanwhile after-treatment are done properly. could no doubt offset the increase in the cost of living to some extent by higher fees, and in any case had a sessional fee of REGINALD WATSON-JONES. London, W.I. E200 per annum for their hospital services, plus travelling SIR,—In your leading article you mentioned two allowances and allowances for subscriptions, &c., denied to An adverse differential was their whole-time colleagues. methods of hip arthroplasty-Smith-Petersen’s cup and therefore applied to the whole-time consultant at the outset Judet’s acrylic head. In my opinion neither of these of the scheme. methods is satisfactory. Cup arthroplasty, or any such Paragraph 3 informs us that on July 22, 1949, the Joint procedure which introduces a " loose body " into the hip, Committee advised hospital staffs to enter into permanent has got obvious mechanical defects. An acrylic head, but omits to state that this was done only after a contracts, or other prosthesis which necessitates excision of the head promise had been secured from the Ministry that remuneration of the femur, is a mistake because if anything untoward This factor, together was a subject suitable for arbitration. should happen further treatment is very difficult. with other important items, is given in para. 9 of the bulletin For upwards of seven years I have been using a but is there given out of its correct context, which is misleading. steel prosthesis, by means of which the femoral head Furthermore, some coercion was exercised by the Ministry can be retained. It consists of a hollow cannulated in an attempt to " stampede" the Joint Committee into which fits over the head the and trimmed of advising consultants to accept contracts when Sir Lionel femur, cap a trifin nail which fixes it to head and neck of the bone..1 Whitby received a letter : "... when any deadlock arises in future discussions, both sides can consider which is the In a fairly large series of cases the following points ha:V’e best thing to do, and if arbitration seems best the Minister emerged : will certainly agree to it and to be bound by the result, subject 1. Fitzgerald, F. P. J. Bone Jt Surg. 1952, 30B, 120. only to Parliament ... but you will appreciate the impossi-
Letters
at 11 A.M., bowling through Maidstone, and after only brief impaction at Ashford won through to the coast by 12.45. This, we said, is too easy. But wait! Setting course for home at 5 P.M. (" my dear, the children must be in bed by half-past seven ") we joined a halfmile queue at Ashford, and got through in a quarter of an hour. At Maidstone the queue, double-banked, started over three miles from the town, and was moving at rather less than 1 mile an hour. After three-quarters of an hour of this we acted boldly, cut off on to a by-road, and rejoined the crowd proximal to the obstruction. At Swanley the line was only a mile long ; and we reached home-62 miles from the coast-in 41/2 hours. By this time our three little wonders were in jubilant form. Not so my missus and I. " Never again," we sighed. But
to
the Editor
we were soon
we
THE POSITION OF NEUROLOGY
SIR,-It is impossible not to concur, in part at least, with the reasons you proffer for the difficult situation of clinical neurology in this country since 1948. Yet I venture to submit that we must probe a little deeper if we are to gain an effective insight into the situation. You say that " there is a tendency to believe that in the provinces neurology should be undertaken by general physicians ; and that both the practice and the teaching of general medicine would be impoverished by the appointment of neurologists." I do my colleagues the general physicians the justice to say that I do not believe they regard themselves as competent to act as consultant neurologists, and that they would not make any such claim for themselves. Moreover it is not where there are medical schools in the provinces that neurologists are lacking, though they are too few, but in large industrial and in some rural areas where no such schools exist. How, then, can teaching be impoverished where no teaching is, or alternatively how could the teaching of medicine be enriched when neurology is " undertaken - sinister word-by general physicians. Let us be frank about this matter, if we are to discuss it at all. The very numerous young men trained for, and
shall. *
*
*
Derby Day always brings its little store of excitement, but our proximity to the racecourse is a doubtful asset. True, all clinics are cancelled, but not with the idea of letting us go to watch the fun. At all other times competition for outpatient appointments is fierce, but on this one day of the year the local inhabitants have no wish to see a specialist. On the other hand the casualty officer is usually provided with reinforcements, and empty beds are kept ready for Pott’s fractures, perforated peptic ulcers, and cerebral haemorrhages, which are the chief sporting risks of the turf. Attacks of paranoid hysteria (‘’ I’ve been robbed ! ") are not infrequent, and there is said to be a significant increase in the incidence of pediculosis. Complications among inpatients are few, but the house-surgeon always goes round the chronic blocks after the commentary, reducing hernise. Our first admission was a school-teacher from the Midlands who, in the heat of the final furlong, had a rigor. " And what might a Birmingham schoolmaster be doing on Epsom downs on a Wednesday afternoon ? we asked. " Brushing up his arithmetic, of course," came the reply ; then, as a glum afterthought : " Subtraction sums." But on the whole this was a satisfactory year. Few patients, merry or moribund, could resist backing Never Say Die. and even a confused old granny, who has entertained suicidal notions for years, insisted on 2s. each way. "
.
*
*
*
By a fortunate coincidence I was again in London this year at the time of the Chelsea flower show. Superlatives do not do justice to the magnificent blooms modera horticulture produces, but I was best pleased by the scientific section where I learnt that while Londoners must expect to water their gardens in >9 years out of Poor Londoners 10, Maneunians only need do it in <5. I thought, how they must long for that elusive < year in 10 when they are spared the drudgery of watering-can and hose-pipe. Next morning I returned home to Manchester ; persistent rain washed out an afternoon’s tennis. I couldn’t even get into the garden to tackle the weeds made luxuriant by all this confounded rain. *
*
*
Long after everyone else had gone home, a tired ahd hungry surgeon still sat in the library, uninterestedly turning the pages of The Lancet. From time to time he cast impatient glances at the clock on the wall, shook his head, and sighed. At last he rose-‘I think it’s all right for me to go home ; my children should be in bed by now." * * * .
Ne,w,3 from School.—The fountain pen broke. I thing it could be mended with cellotape. There is a big crack in the plastic above the nib. Everyone was trying to throw balls We have been over and on top of the tower. A lot were lost. planning how to rebel against the Masters. We overpower Mr. Smith-Jones in the shooting range at gun point, (He is the shooting master.) then we raid Catterick Camp on visitors day, capture a plane from Leeming Bar aerodrome from which we scatter pamphlets on Northallerton and nearby appealing to boys to join us. Soon we have an army of 500. In the end we will conquer the earth and rule it. Love from David. _
.
"
,
eagerly desiring, consulting appointments as general physicians find the number of vacancies woefully inadequate, and the lists of candidates when any vacancy arises as woefully long. What more natural than that they should view with dismay the lessening of consultant openings for them every time, under the present unmeaning system of limitation of consultants, that a neurologist is made
a
consultant ?
With
no
illusions
as
to their
inadequacy to cope with the thorny problems of neurology they are ready to accept the simple notion that the general physician might take over the neurological estate and administer it as a side line, and are prepared to dub neurology a luxury if this will help. In truth, neurology is nobody’s side line. It happens to be a difficult and precise discipline in which we in this country-and let there be no false modesty about ithave long excelled, so that its study has brought more postgraduates to this country from overseas over the past few generations than any other single branch of medicine. It happens also to be an indispensable discipline, and if it is to be allowed to go by the board to meet the complications created by the National Health Service and the present redundancy of potential consultants in general medicine, we shall not be able to restore it, or the damage to the prestige of British medicine which its loss will entail. The grounds upon which the neurology committee of the Royal College of Physicians submit that there is a deficiency of adequately trained neurologists cannot be gainsaid by anyone who knows the facts, nor their submission that the neurosurgeon is by temperament and " training unfitted to undertake " the whole field of neurology within which the main incidence of illness is medical and not surgical. Yet when, as now, matters of politics and finance, and not the informed and dispassionate view of the needs of the community and of medicine, determine the pattern of development of medicine, situations incompatible with its proper growth and differentiation must arise and will continue to arise. Unhappily, as I most strongly hold, every professional body that represents medicine with the Ministry of Health has become so deeply entangled in financial controversy over questions of the emolument, and material gratifications of doctors that none is left to speak with single mind and complete disinterestedness upon what isessentially an academic problem—namely, the rational growth and differentiation of medicine as an activity upon which so
1239 much of the welfare of the community hangs. This, perhaps, is where an Academy of Medicine, standing aloof from the chafferings of the market-place, might have filled a rôle of the first importance. F. M. M. R. WALSHE. London, W.1. ARTHROPLASTY
v.
ARTHRODESIS
SIR,—Your leading article of May 29 discusses the relative claims of arthrodesis and arthroplasty of the osteo-arthritic hip-joint with such fair judgment that I hesitate to criticise. At the same time I must do my best to dismiss the myth you have raised once again that " the variety of methods of arthrodesis reflects the difficulty of producing certain fusion of the hip-joint." If enough people go on saying this long enough, someone will begin to. believe it. Let it be understood quite clearly that there is no difficulty whatever in securing sound arthrodesis of the hip-joint provided only that the first principles of surgi-
1. The diameter of the prosthesis should be 4 mm. less than the femoral head as measured by callipers at the time of
operation. 2. The femoral head should be trimmed with a cutter and not an osteotome, so that an accurate fit
special can
be
obtained. 3. A preliminary guide-wire introduced into the head and neck of the bone is essential if the length and position of the prosthesis is to be gauged accurately in advance. 4. The shank should be centrally placed in the neck with the prosthesis in mid position, neither in valgus nor in varus. 5. The point of the prosthesis should not penetrate the femoral cortex. 6. The nail and cap should be riveted together at the time of operation, so that the over-all length is correct. In the original model, which was demonstrated by the makers (Down Brothers) at the British Orthopaedic Association’s meeting in Nottingham in 1949, the cap and nail were shown in one piece and the prosthesis is still sometimes supplied in this form. This is a mistake if accuracy is to be achieved, unless a very large stock of prostheses is carried. The two elements can be riveted together by the surgeon at the time of the operation ; it takes less than half a minute. This technique has been used for many years ; it is simple and perfectly reliable. 7. Finally, meticulous technique, unhurried gentleness, and perfect hæmostasis are essential for a good result.
cal technique and after-treatment are observed. If a surgeon wants to arthrodese a hip-joint he can always do so. The articular cartilage must of course be removed completely, and there must be internal fixation with grafts or nails, and with protection in plaster for about four months (which never did any harm to a knee-joint It is too soon to be dogmatic about the ultimate provided only that the surgeon knows how to deal with success of this method. This prosthesis is not a panacea, stiff joints by active and not by passive measures). but the results-when the above points have been Your editorial implies that there is uncertainty about observed-are promising and it is worthy of further arthrodesis of the hip-joint ; but the fact is that the careful trial. certainty of the result of arthrodesis is the very special F. P. FITZGERALD. London, W.I. merit of this operation. The joint will of course be as stiff as it was before ; there may be some slight difficulty REMUNERATION OF HOSPITAL MEDICAL STAFF in reaching the shoe-lace or sitting bolt-upright in a but there can be no doubt at all that the patient SIR,-I received recently bulletin no. 3 of the Central chair ; Consultants and Specialists Committee, which purports will walk ten or twenty miles, jump hedges, vault fences, to explain to the profession the rationale of the recent climb mountains, and engage in every recreation without award to hospital medical staff. ever thinking about himself or his hip-joint. There are of course still older patients, aged 60-90 Paragraph1 states that " Consultants entered the service on the appointed day in 1948 upon interim ’ terms (for years, and also those with bilateral osteo-arthritis, in whom arthroplasty is a far better treatment-but here example, the maximum salary of a part-time consultant was again we must beware recent criticisms ; the results £1600 per annum)." However, it should be appreciated that this maximum was available for as little as eight sessions. can be good if the operation is done well, and most It might reasonably be assumed from this that the rate for a recent failures have arisen not because the operation whole-time consultant would commence at f2200 per annum, was bad but because the operation was done badly. as a basis for negotiation. In fact, although the statement There seems to be no doubt that arthrodesis is best informs us that a whole-time consultant was entitled to opt, for young and vigorous patients up to the age of about if he so wished, to keep his old pre-service terms (stating that 60 years, but that beyond that age, and for patients with few could have so opted since the prospective new terms were bilateral osteo-arthritis, arthroplasty is better-though I so superior) no new terms were offered and whole-time consultants were obliged to continue at a salary which in should add that of all the happy patients who see me month by month, I do not know of any more happy many cases was 25-33% below the recommended minimum of the Spens scale in terms of 1939 money values. This than those whose arthritic hip-joints havee been state of affairs continued, not until July 22, 1949 deplorable arthrodesed. The important point, which should really but until January, 1950, when the 1948 scale came 3), (para. be obvious, is that neither arthrodesis nor arthroplasty into existence. Many by that time were heavily in debt and of the hip-joint can succeed unless the operation and the overdrawn at the bank. Part-time consultants meanwhile after-treatment are done properly. could no doubt offset the increase in the cost of living to some extent by higher fees, and in any case had a sessional fee of REGINALD WATSON-JONES. London, W.I. E200 per annum for their hospital services, plus travelling SIR,—In your leading article you mentioned two allowances and allowances for subscriptions, &c., denied to An adverse differential was their whole-time colleagues. methods of hip arthroplasty-Smith-Petersen’s cup and therefore applied to the whole-time consultant at the outset Judet’s acrylic head. In my opinion neither of these of the scheme. methods is satisfactory. Cup arthroplasty, or any such Paragraph 3 informs us that on July 22, 1949, the Joint procedure which introduces a " loose body " into the hip, Committee advised hospital staffs to enter into permanent has got obvious mechanical defects. An acrylic head, but omits to state that this was done only after a contracts, or other prosthesis which necessitates excision of the head promise had been secured from the Ministry that remuneration of the femur, is a mistake because if anything untoward This factor, together was a subject suitable for arbitration. should happen further treatment is very difficult. with other important items, is given in para. 9 of the bulletin For upwards of seven years I have been using a but is there given out of its correct context, which is misleading. steel prosthesis, by means of which the femoral head Furthermore, some coercion was exercised by the Ministry can be retained. It consists of a hollow cannulated in an attempt to " stampede" the Joint Committee into which fits over the head the and trimmed of advising consultants to accept contracts when Sir Lionel femur, cap a trifin nail which fixes it to head and neck of the bone..1 Whitby received a letter : "... when any deadlock arises in future discussions, both sides can consider which is the In a fairly large series of cases the following points ha:V’e best thing to do, and if arbitration seems best the Minister emerged : will certainly agree to it and to be bound by the result, subject 1. Fitzgerald, F. P. J. Bone Jt Surg. 1952, 30B, 120. only to Parliament ... but you will appreciate the impossi-