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an abscess in the thigh. In this ward he died. Post-mortem examination showed death to be due to strepto-coccal septicaemia, contributed to by an abscess in thepelvis resulting from secondary infection of a bruisedarea in the pelvis. The coroner was naturally concernedto examine the possibility that the deceased becameinfected in a ward which contained patients sufferingfrom haemolytic and non-heemolytic infection. Therewas evidence that, after treating infectious cases, thenurse changed her outer clothing and was disinfected.The house-surgeon said he did not think that the deceasedcontracted air-borne infection from the other two

patients. Infection from the case of erysipelas wasunlikely ; infection from the case of abscess in the thighwas possible, but that case had remained only six hoursin the ward. The coroner, recording a verdict of deathby misadventure, said he could not exclude the possibilityof infection from one of the other two patients, though itwas fair to say that infection might also have come fromelsewhere. It was perhaps more likely that the infectioncame from the ward because there was definite evidenceof infectious cases there and no evidence of an infectioussource elsewhere. In his opinion there had been no neg-ligence or want of care on the part of anyone concerned.

.

Mental Hospital Kitchen not a FactoryIn Wood v. London County Council a kitchenmaid

employed at the Bexley Mental Hospital, whose righthand had been injured by an electrically operated meatmachine, claimed damages from the L.C.C. for the

negligence of their officials and alternatively for thefailure to fence the machine as required by section 14of the Factories Act. Mr. Justice Tucker found that thekitchen was a " factory " within the lengthy definitionin section 151 (1) of the 1937 act ; the mincing machinewas dangerous and was not fenced as the act required ;but, as he also found that the plaintiff had been guiltyof contributory negligence, he decided in favour of theL.C.C. On her appeal the Court of Appeal said thekitchen was not within the act ; if it were, extraordinaryresults would follow ; work could not begin before 7 A.M.or continue after 6 P.M.-an impossible situation for theconduct of a mental hospital. A kitchen, he said. wasnot within the Factories Act even when carried on in alarge way by people running a restaurant for trade orgain. But, even supposing the kitchen to be a factory,the Court of Appeal concurred in the finding of contri-butory negligence which was fatal to the plaintiff’s claim.Hospital managements (which may be surprised by thesuggestion that they carry on a factory) have often beenadvised to cover themselves by insurance against therisks of accidents and claims of this nature. The plain-tiff’s form of action obliged her to prove negligence orbreach of duty ; it was not like a workmen’s compensa-tion case where it is quite unnecessary to show that theemployer was at fault.

THE A.M.A. CONVICTED

AFTER a trial lasting eight weeks the criminal pro-ceedings at Washington against the American MedicalAssociation, the editor of its Journal, and several otherdefendants has ended surprisingly. On the charge ofconspiracy to violate the Sherman Act (the so-called" anti-trust " law aimed against monopolies) theassociation and also the district medical society atWashington have been found guilty while the eighteenindividual defendants have been acquitted. Juries havethe historical mission of mitigating the rigid logic of thelaw. There is patent inconsistency in a verdict which con-demns two impersonal organisations while exempting fromcriminal responsibility the members and officers of thosebodies; it is only by the agency of’individuals that the sug-gested conspiracy could have been designed and conducted.. We summarised last month (Lancet, April 5, p. 457)the indictments and the opening speeches. The defend-ant organisations and practitioners- were tried under astatute of Congress which forbids and punishes everycombination or conspiracy " in restraint of trade " inthe District of Columbia. Medical practice is " trade "for this purpose : so also is the work of hospitals or ofother bodies which provide medical care. A societycalled Group Health Incorporated sought to furnish

medical treatment on a flat-rate prepayment basis bysalaried practitioners. The defendants were accused ofconspiring to restrain Group Health from arrangingmedical and hospital care for its members and theirdependants, to restrain the Group Health doctors andothers in the District of Columbia from pursuing theiravocation, and to restrain the Washington hospitalsfrom doing their work. The defendants, it was said.tried to coerce doctors who might join or be consultedby the Group Health staff by threats of disciplinarvproceedings and by obstructing the grant of hospitalfacilities. The defence replied that there was no criminalconspiracy but merely legitimate persuasion, and thatany disciplinary proceedings were merely reasonableaction taken in good faith under the Association’sconstitution and rules to protect the organisation and itsstandards of medical practice. The judge duly explainedto the jury that the corporate defendants would becriminally responsible if authorised officers, acting for orin the name of the corporation, did acts within theapparent scope of the corporate powers in forming orfurthering the allegea. conspiracy. The reports of hissumming up do not appear to justify any simultaneousfinding of corporate guilt and individual immunity. Itis reasonable to suppose that the jury reached its verdict(as so often) by way of compromise. The convicted _

bodies seem to have adequate material for an appeal.If the conviction stands, the result is that some highlydistinguished medical practitioners have happily escapedbeing branded as criminals, while Group Health is givena chance to show what voluntary cooperative healthinsurance can do for classes of moderately paid citizenswithout interference from professional trade-unionism.The evidence tendered to the jury occupies some 300

pages in nine successive issues of the J .A.M .A.l It is likelythat one of the most impressive witnesses was Dr. HughCabot, C.M.G., who will be known to many in Britainthrough his service with our medical units during thelast war. He described his work at the Mayo Clinic atRochester, Minnesota, where group practice has beencarried on by salaried practitioners of good reputation.He said he was now working as medical director with apartnership of physicians for a body known as HealthServices Incorporated, at Boston : there was remunera-tion by contract between the medical group and thebusiness side of the undertaking : patients had themodern advantages of specialised treatment. Dr. Cabottraced the prepayment system back to the Britishfriendly societies. He said it was not unethical for a

_

doctor to take a salary from a group : there was noground for refusing hospital facilities to a salaried doctor.He instanced also the Ross-Loos Clinic with its salariedstaff, and the Stanacola (Standard Oil Co.) group formedin Louisiana at the instance of employees. He suggesteda classification of "

producer " organisations, set up

primarily by physicians who offered medical care on aprepayment basis, and " consumer " organisationswhere the initiative came from the patients. Some-where between these two he placed the industrial estab-lishment which arranged for the care of workers in aparticular undertaking and possibly also for that of theirfamilies. He cited the Southern Pacific Railroad’shospital arrangements at San Francisco. Group prac-tice, he said, promoted preventive medicine. On theordinary " fee-for-service

" basis a doctor could not stopJones in the street and say "You ought to have yourchildren vaccinated " ; under group-practice conditionshe could do so. The witness saw no great danger to theprinciple of free choice of physician. Called by theprosecution, his evidence may well have had greatinfluence upon the minds of the jury.American comment on the trial indicates preoccupa-

tion with the trade-union aspect. Last February theSupreme Court of the United States held that, for thepurpose of the Sherman Act and " restraint of trade," thelabour unions.are not really in trade or commerce at all.The occasion was a dispute involving a carpenters’union ; irritated by the irresponsible tactics of the bigAmerican unions, critics have been swift to note thatmedical associations are deemed to be in trade whilecarpenters are not, and that a medical society can beschooled by the law courts while labour unions are, in asense, outside the law.

1. J. Amer. med. Ass. Feb. 15 to April 12, 1941, inel.