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What is the next move? Firstly, an epidemiologi-cal survey should be mounted to determine whetheror not there really is a problem-is the failure-rate5% or 20%? This investigation could show,secondly, whether failure-rates are substantiallyhigher from some centres than from others: big dis-crepancies would suggest that technical factors areimportant and that the solution lies in trainingand logistics. What if the investigation did pointthe finger at inexperienced surgeons? There simplyare not enough experienced surgeons to operate onall the hips that require replacement. We face threeoptions: firstly, only the hips that can be operatedon by competent surgeons should be treated (leav-ing the rest, perhaps 50%, disabled); secondly, allare treated, some by inexperienced surgeons (whichmay mean that 20% are disabled); thirdly, wearrange for some hip replacements to be done bynon-medically-qualified technicians. The last possi-bility would represent an entirely novel and indeedheretical approach in British medicine, but it mightwell be the best of the three. Other countries arealready training paramedicals to do set-piece oper-ations : many non-medical people have the manualdexterity to do an operation such as hip replace-ment. Such a technician would, of course, play nopart in preoperative selection nor in postoperativecare and would operate only under the generalsupervision of an orthopaedic surgeon. For routinereplacement of the hip, however, such a personmight be less readily bored than the average ortho-paedic surgeon, as well as being technically moredextrous.

UNNECESSARY MENISCECTOMY

THERE is a dictum that a surgeon seeking a tornmeniscus is committed to a meniscectomy, for withoutdoing the operation he may miss a posterior-horn tear:Watson-Jones1 declared, "the cartilage must be removedwhether the split is seen or not". On this basis, normalmeniscuses are probably removed in their thousands,though the operation notes may record a "transversetear of the mid-portion" (often caused by linear tractionon a curved structure) or a "frayed posterior horn".Does losing a pristine meniscus matter? It was Fair-banks2 who, ahead of his time, drew attention to radio-logical abnormalities after meniscectomy, and controlledstudies3 have since laid the blame squarely on’ the oper-ation. Ten years or so after operation, around 85% ofpatients have degenerative changes.4-6 Pain, instability,sensations of locking, and painful catches on flexion arereported sequelæ;7 but, oddly, radiographic changesseem unrelated to knee symptoms.8 Pope9 found that

1. Watson-Jones, R. Fractures and Joint Injuries; vol. II, p. 769. Edinburgh,1956.

2 Fairbanks, T. J. J. Bone Ft Surg. 1948, 30B, 664.3 Jackson, J. P. Br. med. J. 1968, ii, 525.4 Tapper, E., Hoover, N. W.J. Bone Jt Surg. 1969, 51A, 517.5 Gear, M. W. L. Br. J. Surg. 1967, 54, 270.6 Huckell, J. R. Can. J. Surg. 1965, 8, 254.7. Dandy, D. J., Jackson, R. W.J. Bone Jt Surg. 1975, 57B, 349.8. Smillie, I. S. Injuries of the Knee Joint; Edinburgh, 1970, p. 127.

removal of one cartilage reduced the whole joint’senergy-absorbing capacity by half, and removal of bothreduced it by four-fifths.A number of surgeons imply that they seldom remove

a normal meniscus,10-14 though Steward remarks that"one is astute who can keep his errors in diagnosingtears as low as 10%". In a prospective study reportedlast year, 16 the clinical diagnosis was incorrect in 28%of cases; Smillie, 17 in his unsurpassed series, removed anormal meniscus in only 4% of operations. An error-rateof even this low order would mean roughly a thousandnormal meniscuses being removed each year in the Uni-ted Kingdom-the lowest price to be paid for not neg-lecting a posterior-horn tear. Smillie’s figures18 suggest .

that the large majority of these posterior tears are

horizontal cleavage lesions, and there is little evidencethat leaving a torn meniscus in situ will necessarily beharmful. Noble and Hamblen,19 examining subjects whocame to necropsy (most of them elderly), found thatnearly two-thirds had at least one horizontal cleavagelesion; in their view, not all were likely to have hadsymptoms. Subsequently Noble 20 reported that patientswith horizontal tears were usually improved by menis-cectomy, but fewer than half were completely relieved ofsymptoms. Tapper and Hoover4 found that ten to thirtyyears after meniscectomy 45% of males and 10% offemales had symptom-free knees, and the experience ofJohnson et al,21 was much the same. Clearly, to cut isnot always to cure. We need to know more about thenatural history of meniscus complaints and about theirresponse to non-surgical treatments; Cassells22 and LeQuesne et al.23 claim success with juxta-meniscal1steroid injections in meniscus degeneration.The only two advances in meniscus management since

Annandale’s paper of 188524 have been arthrographyand arthroscopy. Arthroscopy was described over half acentury ago;25 advocates16 26 claim that, by identifyingnormal meniscuses, it saves operation in at least a

quarter of cases. Dandy and Jackson26 thought the arth-roscope had influenced management in half their 800patients. They also reported resolution of symptoms in73 of 92 patients in whom meniscectomy was withheldbecause of arthroscopy. In expert hands arthroscopyclearly eliminates almost all diagnostic error. Whethermany centres will be able to acquire the necessary ex-perience, or even an arthroscope, is another matter.’Therefore, it is some comfort that interest in arthrogra-phy has reawoken. High rates of diagnostic accuracyhave been claimed by some 21 but not all.21 Meniscec-

9. Pope, M. H., Johnson, R., Weinstein, A., Wilder, D. J. Bone Jt Surg. 1975,57A, 570.

10. Murdoch, G. Clin. Orthop. 1960, 18, 123.11. Helfet, A. Disorders of the Knee; Philadelphia, 1974, p. 117.12. Lotem, M., Fried, A. Isr.J. med. Sci. 1971, 7, 733.13. Wynn-Parry, C. B., Nichols, P. J. R., Lewis, N. R., Ann. phys. Med. 1958,

4, 201.14. Appel, H. Acta orthop. scand. 1970, suppl. 133.15. Stewart, M. Campbell’s Operative Orthopædics; p. 909, St. Louis, 1971.16. DeHaven, K. E., Collins, H. R.J. Bone Jt Surg. 1975, 57A, 802.17. Smillie, I. S. Injuries of the Knee Joint; Edinburgh, 1970, p. 96.18. Smillie, I. S. ibid. p. 50.19. Noble, J., Hamblen, D. L.J. Bone Jr Surg. 1975, 57B, 180.20. Noble, J. Br. J. Surg. 1975, 62, 97.21. Johnson, R. J., Kettelkamp, D. B., Clark, W., Leaverton, P. J. Bone Jt Surg.

1974, 56A, 719.22. Cassels, S. W. Clin. Orthop. 1971, 76, 123.23. Le Quesne, M., Bensason, M., Kemmer, C., Anouroux, J. Ann. rheum. Dis.

1970, 29, 689.24. Annandale, T. Br. med. J. 1885, ii, 525.25. Takagi, K. J. Jap. orthop. Ass. 1933, 8, 132.26. Dandy, D. J., Jackson, R. W.J. Bone Jr Surg. 1975, 57B, 346.27. Nicholas, J. A., Freiberger, R. H., Killoran, P. J. ibid. 1970, 52A, 203.

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tomy is a very common and usually easy operation fromwhich most patients benefit. But amazingly little isknown about the function of the removed structure, thebenefits and drawbacks of its removal, or the true sig-nificance of its various tears. Meanwhile, for those with-out arthroscopy or arthrography services, who discoverno obvious disease at arthrotomy, simple closure of thejoint may have much to commend it.

LIVING-OR EXISTING-IN HOSPITAL

THE plight of people living in long-stay hospitals hasslowly improved over the past decade, and one hopesthat the scandalous revelations of that period are nowbehind us for good. Further improvements, however,may prove more difficult to achieve although the need isas great as before. A quarter of a million people in Bri-tain still reside more or less permanently in hospitals,and no-one could say that care is now uniformly excel-lent. The danger of stagnation of effort is again severe,at a time when money is short, political effort is directedelsewhere, and publicity settles on more interesting sub-jects. One organisation which has done a great deal tohelp improve the lot of long-stay patients, largely byspreading knowledge of pioneering ideas, is KingEdward’s Hospital Fund for London. The latest publica-tion from the King’s Fund, Living in Hospital, deservesa particularly wide readership. It is concerned with thealterations to the social environment needed to trans-form an institution into something approaching a home,and with the organisational changes needed to stimulateindependence in apathetic residents.

Inevitably the suggestions sound banal, and hospitaldoctors may well complacently dismiss this booklet asperipheral to their interests. They cannot, however,escape a share of responsibility for the continuing inex-cusable inadequacies in the social environment of long-stay hospitals. Indeed, sins of omission make a majorcontribution to the failure. Doctors who are unwilling todischarge their wider responsibilities to patients, by par-ticipating vigorously in the team effort to encouragegreater independence, must retreat to a narrower medi-cal role--and must do so explicity, lest they be seen asleaders on whom other care-staff should model their be-haviour. If the doctor has no interest in his patients’ clo-thing, further education, or opportunities for sexual acti-vity, or in the residents’ committee, then he should makeit clear that he expects someone else to be given responsi-bility for these important social matters. There is a fun-damental conflict of aims in a progressive long-stay hos-pital, and this conflict ought to be discussed frequently.The patients need treatment because of some chronicdisability, and the organisation is set up to perform thistask; but the efficient running of the organisation mustnever be allowed to subjugate the patients so that con-formity, obedience, and unobtrusive cooperation are

seen as model behaviour. Living in Hospital shouldbecome a primer for all staff in long-stay hospitals-andindeed for the staff of those community homes which aresupposed to replace them eventually. The need for such

1. Living in Hospital: the Social Needs of People in Long-term Care. By JAMESELLIOIT. Obtainable from King’s Fund Centre, 24 Nutford Place, Lon-don W1H 6AN. £2.50.

a document is itself an indictment of the service givento many of the young disabled, the aged, the mentallyill, and the mentally handicapped. Only a persistent, im-aginative, and vigorous effort for another decade in alllong-stay hospitals is likely to make this important book-let obsolete.

BARBARA CASTLE REVISITS THE N.H.S.

MRS CASTLE’S distinctions as Secretary of State forSocial Services are two-fold. In the first place, as a

doughty fighter within the Cabinet, she has achievedmore of the gross national product for the N.H.S. thanever before, and saved it from excessive cuts in the cur-rent review of Government expenditure. Secondly, hertenure in office has been a superb example of the politi-cian at work. This is, of course, linked with the first dis-tinction and it is because of attitudes arising from thelatter than the former is in danger of being overlooked,The text’ of the Nye Bevan Memorial Lecture given onDec. 3, 1975, contains insights into the politician sideat work. This dateline, when Mrs Castle was in theheart of her negotiations with both the consultants andjunior hospital doctors, gives it an added interest. It isnatural that in such a lecture the contribution of NyeBevan, as the Minister responsible for creating theN.H.S. in 1948, should be to the fore but Mrs Castle’srecollections of his past battles with the medical profes-sion seem to have been chosen with our contemporarytroubles in mind. Does she see herself under like attack?Perhaps so: "The language used against Aneurin Bevanas the row went on is an immense consolation to me atthe present time’’; she writes, and later she quotes a tell-ing phrase of Bevan’s in 1948 when he answered a rhe-torical question about his own "unreasonableness" bysaying it was a quality that he appeared to have incommon with every Minister of Health whom theB.M.A. had met. Many Ministers since may have

equally well taken consolation from that phrase. Else-where Mrs Castle says that Bevan "won" in his deter-mination to introduce the service because "he kept hisnerve ... and at the eleventh hour he broke their [doc-tors] remnants of resistance by accepting Lord Moran’ssuggestion"-a situation akin to that in late 1975 when,after her insistence that all pay beds must be phased outand after heavy fire from the doctors, the Goodmancompromise of a phased withdrawal, supervised by anindependent commission, was suddenly produced.

Otherwise the pamphlet goes over old ground: theN.H.S. has been deprived of its "fair share of naturalresources" largely because of the undemocratic natureof the Service’s structure. On budgeting, Mrs Castleexplains that the myth that large extra resources wouldbe available if private money were allowed to play alarger part in financing the N.H.S. is "one reason whythe government has agreed to set up the Royal Commis-sion." Clearly she sees public sympathy as a force to bereckoned with. Unfortunately there is no hint here ofher scheme to offer National Health Service beds—andapparently preferential treatment-to patients freeoverseas. It will be interesting to see how public sym-pathy responds to the latest manceuverings.

1. N.H.S. Revisited. Barbara Castle. Fabian Tract 440 (available fromFabian Society, 11 Dartmouth Street, London SW1H 9BN, price 35p postfree).