- Email: [email protected]
A HOSPITAL PLAN FOR 1966 ?
484
In
England Now
A
Running Commentary by Peripatetic Correspondents I have become a student of flies: little flies, big flies, brown flies, black flies, biting flies, tickling flies, buzzing flies, whining flies. In the dry Antipodes they breed-like flies-in their own particular paradise; rain rarely washes away the places where the maggots grow. Their members divided the human race into two groups: those who come to terms with the interminable irritation and are reduced to that curious repetitive pawing motion at the air in front of the face which at least prevents most of these inquisitive insects from going up both nostrils or into the mouth; and those who retreat permanently behind fly-screens and, in this land of sunshine are reduced to pale ghosts unable to increase their skin-melanin contact because of the risk of succumbing, as did one of Wellington’s officers in the Peninsula, to manie a la puce. Perhaps the only hope for Australians is to redevelop a more extensive panniculus carnosus so that they can flick flies off as does the horse or cow. # ......
Two years ago I sent my secretary to a surgeon for investigation of her abdominal pain, and she was diagnosed as having chronic cholecystitis and cholelithiasis on the evidence of negative E.c.G., flat film of the abdomen, and barium meal. Last month she was finally admitted for operation, but, as all the previous reports had been lost, operation was postponed and a cholecystogram done-which was also negative. She kindly produced an attack of renal colic a few days later while still in hospital, and this led to an i.v.p. and the diagnosis of renal stones. Altogether she had two weeks in hospital, and on many days nothing was done for her. She has now stopped complaining about inefficiency in general practice and is awaiting her next hospital stay with some interest to get some more first-hand experience of real
inefficiency. ...... *
I lent my trunk to my daughter for her first term away at school. It is solid leather, an ex-Italian medical-supplies mulepannier which I acquired in North Africa. Its disadvantage of weight is more than offset by its capacity and strength, its steel-reinforced leather handles, and iron-bound corners. It accompanied me over many thousands of miles in Britain and the Middle and Far East for nearly 25 years. Stevedores in many ports have failed to inflict more than superficial damage, but one term at a girls’ boarding-school and it comes home with two large gashes, a missing handle, a flapping hinge, and the rivets torn out of their mounting. It’s not an approved school, either. ....... #
Many of us who, perforce, decorate our own homes find it difficult to foresee what a wallpaper, which is so attractive in one of those heavy pattern books, actually looks like when plastered all over the walls. Here the family doctor is at an advantage. On his domiciliary visits he has an opportunity of seeing varied designs already applied to wide expanses. I have noticed that this aspect of general practice has not been lost upon my equally impoverished consultant colleagues. One of our physicians impresses the patient’s relatives by the clear prognosis he gives them after a lengthy period of silent thought while gazing into the middle distance. I am less impressed. I know that his wife wants their lounge redecorated.
Letters
to
the Editor
A HOSPITAL PLAN FOR 1966 ? SIR,-One cannot but agree with the proposition of " Administrator " that the Hospital Plan, published in 1962, has been bogged down in the succeeding years by the " obvious failure to match money with planning ". Administrator’s plea for standardisation of hospital building, with the possibility of using off-the-shelf plans for district hospitals-and indeed maternity units, geriatric units, accident centres, and outpatient blocks where these are the pressing needs-is a logical development of a national need which is long overdue. At present the regional boards match the hospital to the site, and by developing in stages add enormously to the final cost. It is of course far cheaper in these days of earth-moving equipment to match the site to the standard plan. Standardisation, prefabrication, and industrial building are all attractive remedies for a presumed financial difficulty, but experience in local government with the development of "clasp and scola " (Consortium and Second Consortium of Local Authorities) methods has shown that although they increase the output of a building-programme their effect on capital cost is at best marginal. It appears that Administrator’s answer to the problem of finance is to cut the norms for beds per population-an attractive idea were there any indication that this could be done without damage to the hospital service. Since the plan is largely one of replacement of worn-out and inefficient units where the bed numbers are already inadequate to provide the necessary service-in most regions the Ministry norms for acute beds are already exceeded by the present provision ’-it seems that this solution could only lead to a pile-up of waiting lists and a dangerous situation in winter, when the " yellow warning " is now usual. Your editorial solutionof standardisation of design coupled with a " large increase in the capital available and hence an acceleration in the programme " is even more attractive. Unfortunately the extra money has to come from somewhere, and while we are still modernising every other service in the country it is arguable whether there is the building force available for any large increase in the volume of hospital construction. I suggest that any feasible solution lies in a total re-examination of the hospital concept. The Plan has fallen behind because of the increasing cost of each bed, resulting from the increasing complexity of hospital engineering and the rigid attitude towards the function of a hospital bed. The official idea of a hospital bed has hardly changed since the days of the
Knights Hospitaller of Malta. Hospitals are still rigidly divided into wards according to specialty, and each bed is fully equipped to meet all emergencies. Small wonder that the cost is now of the order of E10.000 a bed. And yet we know that the average stay in an acute bed is some two weeks, and that for a great part of that two weeks’ the patient may be ambulant, and able and willing to care for himself largely. We know also that it is possible to provide simple bed-accommodation at a figure below 2000. Thus at E10,000 a bed S60 million provides 6000 beds, while if the average cost can be reduced to E5000 or E4000 we can have 12,000 or 15,000 beds respectively. Job analysis of hospital work shows that it should be possible to design a standard hospital roughly as follows:
...... *
Adjectives derived from nouns have gained an important, but undeserved, place in our language. The wedge was inserted by the Royal Microscopical Society (which ought to have only one member) and driven in farther by the Patho-
logical Society (probably benign) and the legal profession (to be distinguished from the illegal ones). All over the country there fictional libraries, Arctic laboratories, and anaesthetic nurses. In my new hospital they have a gastrointestinal meeting every week. I don’t know yet where they hold it, but I imagine it must be somewhere near the pylorus.
are
Total cost of hospital .... 2,020,000 Convalescent-care beds would be designed to the standard of the new geriatric hospitals which, if they do not exceed three stories, can be provided at this figure. These beds, with simple facilities equal to those currently available in 90% of our acute 1. A Hospital Plan for England and Wales; 1604. H.M. Stationery Office. 1962. 2.
Lancet, Feb. 12, 1966, p. 358.
Appendix B, p. 274.
Cmnd.
485 would be quite adequate for the ambulant patient operation, or for the modern medical tratment/ investigation of patients other than those requiring intensive nursing care. If one compares these figures with the present estimate of E6-7 million for one 600-bed district hospital it will be seen that the difference of E 4-0 million is widely outside any
hospitals, after
an
underestimate that I may have made in the need for for money outpatient, X-ray, and pathology services. Obviously this kind of hospital would be radically different in design and use from the currently planned extravaganzas. It would have a central block of intensive and intermediate care beds, from which convalescent or hotel-type blocks would radiate. The surgical or gynxcological ward, and indeed the concept of a specialty ward, would vanish in favour of geographical siting of patient according to nursing and medical need. The polyengineering approach could be confined to the central block, and in the convalescent-care blocks patients would be actively encouraged to look after themselvesprovision of cafeteria-meals service, television rooms, and day-rooms would allow the bed-spaces themselves to be oases of the peace and quiet that is conspicuously lacking in modern " hospitals. My kind of hospital obviously demands a radical rethink. The advantages, however, are many. Capital-cost economy is obvious-we would get more for the money. The patient would get the necessary nursing care, and by concentrating the available nursing skills among the patients who need it there could be economies in scarce nursing woman-power leading to improved patient care. My solution offers a possibility of meeting the norms of provision within the present budget and the foreseeable future. No doubt it is not by any means perfect. But it is surely better to try to find a solution than simply to try to alter the rules-with, in the present state of the economy, little hope of more capital, and in the present state of the hospitals no sense in reducing the norms.
possible
"
"
parodontal disease (" pyorrhoea ") claims just as many teeth as does dental decay-though at a somewhat later age-and is also due to consumption of pappy, refined carbohydrates, constituted in this country by white flour and refined sugar. Unless dental decay is attacked by removal of the cause-consumption of these refined foods-the child is merely placed on a very rickety bridge over the first trap, to fall headlong a few years later into the second. Furthermore, the sense of security engendered by fluoridation will lessen still further the attention to removing the cause of dental caries, and so the last dental state may well prove to be much worse than the first. But this is not all. In a work published this month by Dr. G. D. Campbell and myself,3 we advance evolutionary and racial evidence from many parts of the world that dental disease is only part of a much wider disease-complex caused by consumption of these same refined carbohydrates. This complex includes diabetes, coronary thrombosis, obesity, and peptic ulcer. To attempt to antidote one half of one of these conditions, instead of removing the cause of all of them, appears to many people to be as futile as it is objectionable. The apathy of school authorities all over the United Kingdom to the recommendation of the General Dental Council, in 1963, to substitute in tuckshops apples, nuts, and raisins for the sweetstuffs at present being sold in such enormous quantities, stands in striking contrast to the energy displayed in the prosecution of the relatively useless procedure of fluoridation. If the costs of fluoridation were channelled into some subsidisation of the council’s recommendation, so that what is at stake was brought home to the children and their parents, the present deplorable situation over the teeth might show an improvement nf wnrthwliilf- nrnnnrtinnq
Fareham, Hampshire.
CLINICAL ENZYME UNITS
IVAN CLOUT.
FLUORIDATION AND THE COUNCILLORS SIR,-For an account of evidence against fluoridation Dr. Nelson (Feb. 5) should read a report of the 65-day action taken
by Mrs. Gladys Ryan and dismissed by Mr. Justice Kenny July 31, 1963, in the High Court, Dublin. The well-known scientific opponents brought from all over the world appeared as witnesses for the plaintiff. on
The evidence in favour of fluoridation, which is now carried in at least 28 countries, is enormous, but satisfactory published scientific evidence against it does not exist, and the is that published by the National Pure usual literature Water Association, and such magazines as Health for All, to which Mrs. Brady (Feb. 5) contributes. To be sure not all opponents are cranks, but if ethical arguments are valid then additions of, for example, calcium as chalk to flour, iodine to salt: and vitamins A and D to margarine should not be made. It may be appropriate to quote from Oliver, in 1927,1 the type of criticism which is frequently applied to fluoridation " today: Since drinking water has been chlorinated, there has been such a notable increase in endemic goitre, cancer, rheumatoid arthritis, neuritis, and other diseases that the predisposition, if not the actual cause, of some of these diseases is due, in my opinion, to changes produced in the drinking water by chlorination." A. HEPBURN. out
"
"
SIR,-With reference to Dr. McCallum’s remarks (Feb. 5; Dr. Ball’s letter (Jan. 29), it must be emphasised that the
on
argument in that letter was based on a much broader foundation than the ethical one involving parts per million of fluoride. As set out in the leader in the British Medical Journal,1 1. Oliver, J. Med. Press, 1927, 175, 10. 2. Br. med. J. 1965, ii, 1197
T. L. CLEAVE.
SiR,-It is earnestly to be hoped that clinical laboratories everywhere will accept the proposals of the Enzyme Commission of the International Union of Biochemistry for simplifying enzyme units. The international unit has been defined as that amount of enzyme activity which will consume one [1. mole of substrate or produce one fL mole of product per minute. Some confusion, however, has arisen as a result of the statement that " the concentration of an enzyme solution will normally be given as units per millilitre ". When serum-enzyme activities are expressed as " units per ml." the figures frequently encountered are inconveniently low, and the recommendation that milli-units may be used has led several pathologists and clinical biochemists on both sides of the Atlantic to use " milli-units per milli-litre ". Not only are such prefixes unnecessary, but users of this expression overlook the fact that the litre is widely used as a standard volume in clinical biochemistry-e.g., for electrolyte measurements. The numerically identical " units per litre " is much to be
preferred. We are informed by the chairman of the Standing Committee on Enzymes, Prof. E. C. Webb, that this particular aspect has not been discussed by his committee. It would be a great pity if the erroneous belief that official recommendations are being followed should lead to the general acceptance of the pleonastic " milli-units per milli-litre ", for experience has shown that in clinical biochemistry it is often extremely difficult to eradicate bad habits (e.g., V.M.A. for 4-hydroxy-3methoxvmandelic acid) once thev become established. D. N. BARON. London, W.C.1. R. J. HENRY. Los Angeles, U.S.A. A. L. LATNER. Newcastle upon Tyne. R. RICHTERICH. Berne, Switzerland. R. J. WIEME. Ghent, Belgium. Philadelphia, U.S.A. J. H. WILKINSON. 3.
Cleave, T. L., Campbell, G. D. Diabetes, Coronary Thrombosis and the Saccharine Disease. Bristol, 1966.
In
England Now
A
Running Commentary by Peripatetic Correspondents I have become a student of flies: little flies, big flies, brown flies, black flies, biting flies, tickling flies, buzzing flies, whining flies. In the dry Antipodes they breed-like flies-in their own particular paradise; rain rarely washes away the places where the maggots grow. Their members divided the human race into two groups: those who come to terms with the interminable irritation and are reduced to that curious repetitive pawing motion at the air in front of the face which at least prevents most of these inquisitive insects from going up both nostrils or into the mouth; and those who retreat permanently behind fly-screens and, in this land of sunshine are reduced to pale ghosts unable to increase their skin-melanin contact because of the risk of succumbing, as did one of Wellington’s officers in the Peninsula, to manie a la puce. Perhaps the only hope for Australians is to redevelop a more extensive panniculus carnosus so that they can flick flies off as does the horse or cow. # ......
Two years ago I sent my secretary to a surgeon for investigation of her abdominal pain, and she was diagnosed as having chronic cholecystitis and cholelithiasis on the evidence of negative E.c.G., flat film of the abdomen, and barium meal. Last month she was finally admitted for operation, but, as all the previous reports had been lost, operation was postponed and a cholecystogram done-which was also negative. She kindly produced an attack of renal colic a few days later while still in hospital, and this led to an i.v.p. and the diagnosis of renal stones. Altogether she had two weeks in hospital, and on many days nothing was done for her. She has now stopped complaining about inefficiency in general practice and is awaiting her next hospital stay with some interest to get some more first-hand experience of real
inefficiency. ...... *
I lent my trunk to my daughter for her first term away at school. It is solid leather, an ex-Italian medical-supplies mulepannier which I acquired in North Africa. Its disadvantage of weight is more than offset by its capacity and strength, its steel-reinforced leather handles, and iron-bound corners. It accompanied me over many thousands of miles in Britain and the Middle and Far East for nearly 25 years. Stevedores in many ports have failed to inflict more than superficial damage, but one term at a girls’ boarding-school and it comes home with two large gashes, a missing handle, a flapping hinge, and the rivets torn out of their mounting. It’s not an approved school, either. ....... #
Many of us who, perforce, decorate our own homes find it difficult to foresee what a wallpaper, which is so attractive in one of those heavy pattern books, actually looks like when plastered all over the walls. Here the family doctor is at an advantage. On his domiciliary visits he has an opportunity of seeing varied designs already applied to wide expanses. I have noticed that this aspect of general practice has not been lost upon my equally impoverished consultant colleagues. One of our physicians impresses the patient’s relatives by the clear prognosis he gives them after a lengthy period of silent thought while gazing into the middle distance. I am less impressed. I know that his wife wants their lounge redecorated.
Letters
to
the Editor
A HOSPITAL PLAN FOR 1966 ? SIR,-One cannot but agree with the proposition of " Administrator " that the Hospital Plan, published in 1962, has been bogged down in the succeeding years by the " obvious failure to match money with planning ". Administrator’s plea for standardisation of hospital building, with the possibility of using off-the-shelf plans for district hospitals-and indeed maternity units, geriatric units, accident centres, and outpatient blocks where these are the pressing needs-is a logical development of a national need which is long overdue. At present the regional boards match the hospital to the site, and by developing in stages add enormously to the final cost. It is of course far cheaper in these days of earth-moving equipment to match the site to the standard plan. Standardisation, prefabrication, and industrial building are all attractive remedies for a presumed financial difficulty, but experience in local government with the development of "clasp and scola " (Consortium and Second Consortium of Local Authorities) methods has shown that although they increase the output of a building-programme their effect on capital cost is at best marginal. It appears that Administrator’s answer to the problem of finance is to cut the norms for beds per population-an attractive idea were there any indication that this could be done without damage to the hospital service. Since the plan is largely one of replacement of worn-out and inefficient units where the bed numbers are already inadequate to provide the necessary service-in most regions the Ministry norms for acute beds are already exceeded by the present provision ’-it seems that this solution could only lead to a pile-up of waiting lists and a dangerous situation in winter, when the " yellow warning " is now usual. Your editorial solutionof standardisation of design coupled with a " large increase in the capital available and hence an acceleration in the programme " is even more attractive. Unfortunately the extra money has to come from somewhere, and while we are still modernising every other service in the country it is arguable whether there is the building force available for any large increase in the volume of hospital construction. I suggest that any feasible solution lies in a total re-examination of the hospital concept. The Plan has fallen behind because of the increasing cost of each bed, resulting from the increasing complexity of hospital engineering and the rigid attitude towards the function of a hospital bed. The official idea of a hospital bed has hardly changed since the days of the
Knights Hospitaller of Malta. Hospitals are still rigidly divided into wards according to specialty, and each bed is fully equipped to meet all emergencies. Small wonder that the cost is now of the order of E10.000 a bed. And yet we know that the average stay in an acute bed is some two weeks, and that for a great part of that two weeks’ the patient may be ambulant, and able and willing to care for himself largely. We know also that it is possible to provide simple bed-accommodation at a figure below 2000. Thus at E10,000 a bed S60 million provides 6000 beds, while if the average cost can be reduced to E5000 or E4000 we can have 12,000 or 15,000 beds respectively. Job analysis of hospital work shows that it should be possible to design a standard hospital roughly as follows:
...... *
Adjectives derived from nouns have gained an important, but undeserved, place in our language. The wedge was inserted by the Royal Microscopical Society (which ought to have only one member) and driven in farther by the Patho-
logical Society (probably benign) and the legal profession (to be distinguished from the illegal ones). All over the country there fictional libraries, Arctic laboratories, and anaesthetic nurses. In my new hospital they have a gastrointestinal meeting every week. I don’t know yet where they hold it, but I imagine it must be somewhere near the pylorus.
are
Total cost of hospital .... 2,020,000 Convalescent-care beds would be designed to the standard of the new geriatric hospitals which, if they do not exceed three stories, can be provided at this figure. These beds, with simple facilities equal to those currently available in 90% of our acute 1. A Hospital Plan for England and Wales; 1604. H.M. Stationery Office. 1962. 2.
Lancet, Feb. 12, 1966, p. 358.
Appendix B, p. 274.
Cmnd.
485 would be quite adequate for the ambulant patient operation, or for the modern medical tratment/ investigation of patients other than those requiring intensive nursing care. If one compares these figures with the present estimate of E6-7 million for one 600-bed district hospital it will be seen that the difference of E 4-0 million is widely outside any
hospitals, after
an
underestimate that I may have made in the need for for money outpatient, X-ray, and pathology services. Obviously this kind of hospital would be radically different in design and use from the currently planned extravaganzas. It would have a central block of intensive and intermediate care beds, from which convalescent or hotel-type blocks would radiate. The surgical or gynxcological ward, and indeed the concept of a specialty ward, would vanish in favour of geographical siting of patient according to nursing and medical need. The polyengineering approach could be confined to the central block, and in the convalescent-care blocks patients would be actively encouraged to look after themselvesprovision of cafeteria-meals service, television rooms, and day-rooms would allow the bed-spaces themselves to be oases of the peace and quiet that is conspicuously lacking in modern " hospitals. My kind of hospital obviously demands a radical rethink. The advantages, however, are many. Capital-cost economy is obvious-we would get more for the money. The patient would get the necessary nursing care, and by concentrating the available nursing skills among the patients who need it there could be economies in scarce nursing woman-power leading to improved patient care. My solution offers a possibility of meeting the norms of provision within the present budget and the foreseeable future. No doubt it is not by any means perfect. But it is surely better to try to find a solution than simply to try to alter the rules-with, in the present state of the economy, little hope of more capital, and in the present state of the hospitals no sense in reducing the norms.
possible
"
"
parodontal disease (" pyorrhoea ") claims just as many teeth as does dental decay-though at a somewhat later age-and is also due to consumption of pappy, refined carbohydrates, constituted in this country by white flour and refined sugar. Unless dental decay is attacked by removal of the cause-consumption of these refined foods-the child is merely placed on a very rickety bridge over the first trap, to fall headlong a few years later into the second. Furthermore, the sense of security engendered by fluoridation will lessen still further the attention to removing the cause of dental caries, and so the last dental state may well prove to be much worse than the first. But this is not all. In a work published this month by Dr. G. D. Campbell and myself,3 we advance evolutionary and racial evidence from many parts of the world that dental disease is only part of a much wider disease-complex caused by consumption of these same refined carbohydrates. This complex includes diabetes, coronary thrombosis, obesity, and peptic ulcer. To attempt to antidote one half of one of these conditions, instead of removing the cause of all of them, appears to many people to be as futile as it is objectionable. The apathy of school authorities all over the United Kingdom to the recommendation of the General Dental Council, in 1963, to substitute in tuckshops apples, nuts, and raisins for the sweetstuffs at present being sold in such enormous quantities, stands in striking contrast to the energy displayed in the prosecution of the relatively useless procedure of fluoridation. If the costs of fluoridation were channelled into some subsidisation of the council’s recommendation, so that what is at stake was brought home to the children and their parents, the present deplorable situation over the teeth might show an improvement nf wnrthwliilf- nrnnnrtinnq
Fareham, Hampshire.
CLINICAL ENZYME UNITS
IVAN CLOUT.
FLUORIDATION AND THE COUNCILLORS SIR,-For an account of evidence against fluoridation Dr. Nelson (Feb. 5) should read a report of the 65-day action taken
by Mrs. Gladys Ryan and dismissed by Mr. Justice Kenny July 31, 1963, in the High Court, Dublin. The well-known scientific opponents brought from all over the world appeared as witnesses for the plaintiff. on
The evidence in favour of fluoridation, which is now carried in at least 28 countries, is enormous, but satisfactory published scientific evidence against it does not exist, and the is that published by the National Pure usual literature Water Association, and such magazines as Health for All, to which Mrs. Brady (Feb. 5) contributes. To be sure not all opponents are cranks, but if ethical arguments are valid then additions of, for example, calcium as chalk to flour, iodine to salt: and vitamins A and D to margarine should not be made. It may be appropriate to quote from Oliver, in 1927,1 the type of criticism which is frequently applied to fluoridation " today: Since drinking water has been chlorinated, there has been such a notable increase in endemic goitre, cancer, rheumatoid arthritis, neuritis, and other diseases that the predisposition, if not the actual cause, of some of these diseases is due, in my opinion, to changes produced in the drinking water by chlorination." A. HEPBURN. out
"
"
SIR,-With reference to Dr. McCallum’s remarks (Feb. 5; Dr. Ball’s letter (Jan. 29), it must be emphasised that the
on
argument in that letter was based on a much broader foundation than the ethical one involving parts per million of fluoride. As set out in the leader in the British Medical Journal,1 1. Oliver, J. Med. Press, 1927, 175, 10. 2. Br. med. J. 1965, ii, 1197
T. L. CLEAVE.
SiR,-It is earnestly to be hoped that clinical laboratories everywhere will accept the proposals of the Enzyme Commission of the International Union of Biochemistry for simplifying enzyme units. The international unit has been defined as that amount of enzyme activity which will consume one [1. mole of substrate or produce one fL mole of product per minute. Some confusion, however, has arisen as a result of the statement that " the concentration of an enzyme solution will normally be given as units per millilitre ". When serum-enzyme activities are expressed as " units per ml." the figures frequently encountered are inconveniently low, and the recommendation that milli-units may be used has led several pathologists and clinical biochemists on both sides of the Atlantic to use " milli-units per milli-litre ". Not only are such prefixes unnecessary, but users of this expression overlook the fact that the litre is widely used as a standard volume in clinical biochemistry-e.g., for electrolyte measurements. The numerically identical " units per litre " is much to be
preferred. We are informed by the chairman of the Standing Committee on Enzymes, Prof. E. C. Webb, that this particular aspect has not been discussed by his committee. It would be a great pity if the erroneous belief that official recommendations are being followed should lead to the general acceptance of the pleonastic " milli-units per milli-litre ", for experience has shown that in clinical biochemistry it is often extremely difficult to eradicate bad habits (e.g., V.M.A. for 4-hydroxy-3methoxvmandelic acid) once thev become established. D. N. BARON. London, W.C.1. R. J. HENRY. Los Angeles, U.S.A. A. L. LATNER. Newcastle upon Tyne. R. RICHTERICH. Berne, Switzerland. R. J. WIEME. Ghent, Belgium. Philadelphia, U.S.A. J. H. WILKINSON. 3.
Cleave, T. L., Campbell, G. D. Diabetes, Coronary Thrombosis and the Saccharine Disease. Bristol, 1966.