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CENTRAL STERILE SUPPLY
663 then to mess about phasing ten extended-design hospitals of similar size over ten years if they are to be maintenance liabilities. If this means spending more on interim developments it should be faced cheerfully because it is cheaper in the end; but the distress and back-pedalling of politicians and vested interest will be horrible to behold-which underlines my belief that the N.H.S. should be run as a National to run,
Corporation.
J. W. PAULLEY. SIR,-I write in support of the point of view of
"
Consultant". Much of what he has written is corroborated by my own experience at this hospital. Baguley Hospital, now a thoracic unit, was originally an infectious-diseases unit. Two of the ward blocks (B4 and B5; are built, on the old " fevers hospital " pattern, on two floors with an external staircase. Each of these blocks, containing roughly 30 beds, is run as a ward on two floors. In order tc increase the bed-occupancy of the upper floors, bed-lifts were requested. In 1963 the regional hospital board (R.H.B.) agreed that lifts should be installed, and offered chair-lifts or stretcherlifts. These were refused by the medical staff, and in 1964 several letters were written to the group secretary of the hospital management committee (H.M.C.) advising that bed-lifts were
necessary.
In May, 1965, the hospital medical staff committee (m.s.c..’ learned from a casual source that a decision had been reached to install stretcher-lifts during the current financial year. Immediate representations were made, urging that bed-lifts were necessary: early in July assurances were sought and obtained from the hospital secretary and from the house committee that any lifts installed would be capable of accommodating a bed. On July 30, 1965, however, at a meeting of the South Manchester H.M.c., on which no member of the medical stafl of this hospital sits, it was decided to accept the R.H.B.’S offer to install stretcher-lifts, since the board had made it clear that considerations of cost precluded the provision of bed-lifts. Minutes of H.M.C. meetings are sent to the secretaries of hospital M.s.c.s, but the minutes of this particular meeting were not sent until Oct. 8, 1965, and by the time their content was appreciated the contract for the lifts had already been given, and the contractors were ready to start. After representations by the M.s.c., the South Manchester H.M.C. agreed that stretcher-lifts would be unsatisfactory, and made representations to the regional board, requesting that plans for the lifts should be modified so that the lifts could accommodate a bed. The R.H.B. rejected these proposals, and indicated that the alternatives lay between having stretcherlifts and having no lifts at all. Faced with these alternatives the H.M.c., despite the appeals of the M.s.c., agreed to accept stretcher-lifts. The M.s.c., however, was unanimous in its opinion that the installation of stretcher-lifts or trolley-lifts would not increase materially the usage of the upstairs wards for medical and surgical emergencies, and for seriously ill patients. In its opinion the only way to obtain maximum bed-occupancy was to provide a lift or lifts capable of taking a bed and an attendant. It appreciated the help that it had received from the R.H.B. and the H.M.c., and was grateful that they should be willing to install lifts which were so badly needed in these wards. But the M.s.c. was unanimous that rather than have installed unsatisfactory lifts, which would preclude the future installation of bed-lifts, it would prefer to do without until such time as an adequate lift or lifts could be provided. Its reasons for this decision were as follows: reaching 1. The transfer of patients from stretchers or beds to trolleys in order to transport them upstairs, where they would again be transferred to a bed, would place a heavy burden on the nursing staff, and would cause discomfort and perhaps danger to patients. 2. Transfer of patients in this way between floors would greatly increase the amount of bed-making and use of bed-linen. 3. In an emergency it is vital to be able to move a patient rapidly between floors-e.g., in the event of sudden acute illness in a patient
upstairs.
4. Wards B4 and B5 each comprise a ward unit on two floors. In busy ward unit it is essential to maintain maximum flexibility of movement of patients. This could not be provided by trolley-lifts. 5. With the development of the cardiopulmonary unit in the new Wythenshawe Hospital, there will be a shortage of cardiothoracic beds, and since wards B4 and B5 are closest to the new unit they will be the most suitable to deal with acutely ill patients from that unit. a
deeply resentful of the fact that at no time hospital medical or nursing staffs consulted while these lifts were under consideration. They appealed against the decision to install stretcher-lifts to the H.M.C., to the R.H.B., and finally to the Minister of Health. The appeals failed. This was hardly surprising, but what rankles is that in rejecting the appeals each of the referees expressed satisfaction that the normal machinery for consultation had been available to all parties in the dispute, that the H.M.C. and R.H.B. had used this machinery, but that the M.s.c. had failed to avail itself of the proper consultative procedures. It is difficult to reconcile this opinion with the known facts of The
was
M.s.c. was
any member of the
the case, but there is no doubt that the records will show that consultation took place. Before this dispute is relegated to the dusty files of oblivion, one should perhaps ponder on the meaning of the word consultation ". To consult is to seek advice. In the present context consultation means discussion of a situation with interchange of ideas in order to resolve any difficulties on differences of opinion which may exist. It does not mean, as in this instance, that a decision is taken to provide an amenity without discussion with the users, whose opinions and advice are ignored. I believe that in the National Health Service, as in every walk of life, consultation is essential. But consultation must be made an active process and not remain just an empty word. "
Baguley Hospital, Wythenshawe, Manchester, 23.
T. M. WILSON.
CENTRAL STERILE SUPPLY SiR,ŅWhile any serious attempt to produce a paper specifically designed as an efficient bacterial barrier to meet the needs of both central sterile supply department (c.s.s.D.) and industry is to be applauded, too great stress on the inclusion of antibacterial agents as suggested by Mr. Fellows (Jan. 29) might well be misleading. The paper industry has for many years included antibacterial and antifungal agents during the actual manufacture of paper and board likely to be used or stored under conditions which would render them susceptible to spoilage. Substances such as o-phenylphenol (in glassine-type papers) and its water-soluble sodium salt, and particularly quaternary ammonium compounds, have been used. On the question of the maintenance of sterility, what good one wonders is a paper with an antifungal or antibacterial agent incorporated in it, if pinholes allow organisms to pass through unimpeded, and if organisms that come in contact with the paper are not moist ? On the latter point, we see no reason to doubt the validity of the work carried out at the Cross-Infection Reference Laboratory, Colindale,l on tests of self-disinfecting surfaces, which indicated that only surfaces which evolved formaldehyde showed any activity against dust-borne bacteria. The letter2 which prompted Mr. Fellows to write deserves some favourable comment, for it puts simply and concisely the various aspects of packaging for sterilised goods which are of prime importance to the hospital c.s.s.D. Particularly interesting were its comments on the use of paper. In practice pinhole-free paper, of even consistency, which does not allow the passage of bacteria in the dry or wet state, is ideal, and to this end a considerable amount of work has been carried out in this laboratory since the Nuffield report3 was published in 1958. In 1961 Hunter et al.4 demonstrated that papers of a certain 1. Kingston, D., Noble, W. C. J. Hyg., Camb. 1964, 62, 519. 2. Allen, S. M., et al. Lancet, 1965, ii, 1343. 3. Sterilisation Practice in Six Hospitals. Nuffield Provincial Hospitals Trust, London, 1958. 4. Hunter, C. L. F., Harbord, P. E., Riddett, D. J. in Symposium on Sterilisation of Surgical Materials. London, 1961.
664 were most suitable as bacterial barriers. But criticisms have been made that when wet such papers may not maintain sterility, and further work has shown that the ability of paper to resist the passage of organisms in the wet state is certainly not an impossible criterion to obtain.In fact, such a paper has been in use for a year. Finally, I agree almost entirely with the statements made by Allen et al .,2 and feel that a greater measure of cooperation between c.s.s.D.s and manufacturers of prepacked dressings is
air-porosity
urgently reauired. Microbiological Division, Johnson & Johnson (Gt. Britain) Ltd., Cosham, Hants.
P. E. HARBORD.
CARE OF THE SUBNORMAL
SIR,-ln your leading article (March 5) describing the papers at the annual conference of the National Association for
given
that I " envisaged the new district general hospitals as centres for outpatient diagnosis, treatment, and day-care ". I did not make any reference in my paper to day-care, which I do not think could be the responsibility of the district general hospital or the regional centre. The regional centre is the hospital to which the more difficult cases would be referred for assessment, investigation, and, frequently, treatment. The responsibility for the day-care patient must rest with the day centres and hostels contemplated by Dr. Pilkington in his talk. It is generally agreed that we must aim to establish a diagnosis and institute appropriate treatment in the first few months of life, and I believe this to be the responsibility of the pxdiatric teams who are based on the district general hospitals and regional centres-in my paper I stated that these units should be closely linked with the public-health authorities and the mental subnormality hospitals, respectively. I think that the mental subnormality hospitals should diminish in number and size over the next few years, and that those which remain should concentrate their efforts towards the establishment of first-class nursing facilities and training (educational) techniques for children requiring long-term hospital stay. GEORGE KOMROWER. Mental Health you
state
CLINICAL PHARMACOLOGY SiR,-Dr. Dollery’s article (Feb. 12) draws attention to a very real problem-namely, the need for the assessment of the usefulness in the many fields of medicine of the new substances produced by the now widely expanded chemical industry, and perhaps also for the reassessment of the usefulness of older remedies. The Committee on Safety of Drugs, under the chairmanship of Sir Derrick Dunlop, has been set up to do much of this work. What is all too easily forgotten, however, is that no committee, however wise its members, can reach useful conclusions without evidence, and that the evidence the Dunlop Committee requires is that provided by properly organised clinical trials. To organise such trials we need clinical pharmacologists not only among consultant physicians, but also in the various specialist branches of medicine, in which new drugs are being developed, if these drugs are to be adequately tested. In anaesthesia the need has been recognised for many years-there was indeed an era when the bulk of those practising clinical pharmacology were in fact anaesthetists, and in the United States the title of clinical pharmacologist was once considered quite seriously as an alternative to that of anxsthesiologist. In other specialties, too, the need is recognised, though not perhaps so widely. Thus there is a place for the clinical pharmacologist who must basically be an ophthalmologist in dealing with drugs affecting the eye, while to study drugs affecting mental disease the clinical pharmacologist must also be a
psychiatrist. 5. 6.
Parker, M. J. Conference on Prevention of Hospital Infection. London, 1963. Harbord, P. E., Stallard, J. A. Unpublished.
obviously therefore a need for training in clinical pharmacology all who have the necessary skill not only in There is
general medicine but also in anxsthesia and other specialties. University Department of Anaesthetics, Royal Infirmary, Manchester.
A. R. HUNTER.
ABORTION BILL AND CLINICAL FREEDOM SiR,—The Abortion Bill, as amended by the House of Lords, appears to violate the principle that the doctor practising privately is legally on the same footing as his colleague employed in the National Health Service; if this Bill were enacted in its present form, abortions could be carried out only by N.H.S. specialists in a State hospital. The committee reporting on drug addictionhas recommended that only doctors working in special centres should be allowed to prescribe drugs for addicts. I believe that the profession should keep a watchful eye on these proposed restrictions of clinical freedom. ALAN S. CLARK.
MEDICAL ENTRY INTO UNITED STATES
SIR,-Professor Hamilton (Jan. 15) fails to appreciate that getting vaccinated and obtaining a visa are procedures before the 7-hour jet-plane flight to the United States, as is the examination of the Educational Council for Foreign Medical Graduates, which may be taken in the United Kingdom. He states that these preparations occupy 6-12 months. But the Pilgrim Fathers had several years of preparation for their epic voyage of about 3 months ". "
Student Health Service, University of New Mexico, Albuquerque, U.S.A.
A. KENNETH YOUNG.
FLUORIDATION AND THE COUNCILLORS
SiR,—The usual practice of food and drug authorities, when they permit the addition of a cumulative poison to a foodstuff, is to limit the permitted amount to one-hundredth of the cumulative toxic dose. Fluoridated water is already in the toxic range, as is further evidenced by the report,2 believed to be the first from the U.S.A., of a death from drinking water containing less than 4 p.p.m. of fluoride. Sauerbrunn et awl. state : " Prolonged polydipsia may be areas where the levels of those drinking usually associated with it not fluorosis." Was Roholm who told us that significant polydipsia is a symptom of fluoride poisoning ? Are councillors now to dictate to those whose water-supplies they insist on treating with added fluorides how much water
hazardous fluoride in
to
may be taken
persons who live in water are not
daily ? WINIFRED M. SYKES Hon. secretary, National Pure Water Association.
ZOLLINGER-ELLISON SYNDROME SIR,-For over four hundred years, by both dictionary definition and universal usage, the word " syndrome" has meant to clinicians a significant grouping of clinical findings. The basis of all clinical diagnosis is the recognition by the human mind of such groupings, which point the way to a line of investigation and management leading in some cirless complete understanding of the disorder. Some of these syndromes have names and others have not. A syndrome that has a name sometimes differs from that described by the original worker, after whom it is called-for example, Raynaud’s syndrome. cumstances to a more or
1. 2.
Interdepartmental Committee on Drug Addiction: Second Report. H.M. Stationery Office, 1965. See Lancet, 1965, ii, 1113. Sauerbrunn, B. J. L., Ryan, C. M., Shaw, J. F. Ann. intern. Med. 1965, 63, 1074.
Corporation.
J. W. PAULLEY. SIR,-I write in support of the point of view of
"
Consultant". Much of what he has written is corroborated by my own experience at this hospital. Baguley Hospital, now a thoracic unit, was originally an infectious-diseases unit. Two of the ward blocks (B4 and B5; are built, on the old " fevers hospital " pattern, on two floors with an external staircase. Each of these blocks, containing roughly 30 beds, is run as a ward on two floors. In order tc increase the bed-occupancy of the upper floors, bed-lifts were requested. In 1963 the regional hospital board (R.H.B.) agreed that lifts should be installed, and offered chair-lifts or stretcherlifts. These were refused by the medical staff, and in 1964 several letters were written to the group secretary of the hospital management committee (H.M.C.) advising that bed-lifts were
necessary.
In May, 1965, the hospital medical staff committee (m.s.c..’ learned from a casual source that a decision had been reached to install stretcher-lifts during the current financial year. Immediate representations were made, urging that bed-lifts were necessary: early in July assurances were sought and obtained from the hospital secretary and from the house committee that any lifts installed would be capable of accommodating a bed. On July 30, 1965, however, at a meeting of the South Manchester H.M.c., on which no member of the medical stafl of this hospital sits, it was decided to accept the R.H.B.’S offer to install stretcher-lifts, since the board had made it clear that considerations of cost precluded the provision of bed-lifts. Minutes of H.M.C. meetings are sent to the secretaries of hospital M.s.c.s, but the minutes of this particular meeting were not sent until Oct. 8, 1965, and by the time their content was appreciated the contract for the lifts had already been given, and the contractors were ready to start. After representations by the M.s.c., the South Manchester H.M.C. agreed that stretcher-lifts would be unsatisfactory, and made representations to the regional board, requesting that plans for the lifts should be modified so that the lifts could accommodate a bed. The R.H.B. rejected these proposals, and indicated that the alternatives lay between having stretcherlifts and having no lifts at all. Faced with these alternatives the H.M.c., despite the appeals of the M.s.c., agreed to accept stretcher-lifts. The M.s.c., however, was unanimous in its opinion that the installation of stretcher-lifts or trolley-lifts would not increase materially the usage of the upstairs wards for medical and surgical emergencies, and for seriously ill patients. In its opinion the only way to obtain maximum bed-occupancy was to provide a lift or lifts capable of taking a bed and an attendant. It appreciated the help that it had received from the R.H.B. and the H.M.c., and was grateful that they should be willing to install lifts which were so badly needed in these wards. But the M.s.c. was unanimous that rather than have installed unsatisfactory lifts, which would preclude the future installation of bed-lifts, it would prefer to do without until such time as an adequate lift or lifts could be provided. Its reasons for this decision were as follows: reaching 1. The transfer of patients from stretchers or beds to trolleys in order to transport them upstairs, where they would again be transferred to a bed, would place a heavy burden on the nursing staff, and would cause discomfort and perhaps danger to patients. 2. Transfer of patients in this way between floors would greatly increase the amount of bed-making and use of bed-linen. 3. In an emergency it is vital to be able to move a patient rapidly between floors-e.g., in the event of sudden acute illness in a patient
upstairs.
4. Wards B4 and B5 each comprise a ward unit on two floors. In busy ward unit it is essential to maintain maximum flexibility of movement of patients. This could not be provided by trolley-lifts. 5. With the development of the cardiopulmonary unit in the new Wythenshawe Hospital, there will be a shortage of cardiothoracic beds, and since wards B4 and B5 are closest to the new unit they will be the most suitable to deal with acutely ill patients from that unit. a
deeply resentful of the fact that at no time hospital medical or nursing staffs consulted while these lifts were under consideration. They appealed against the decision to install stretcher-lifts to the H.M.C., to the R.H.B., and finally to the Minister of Health. The appeals failed. This was hardly surprising, but what rankles is that in rejecting the appeals each of the referees expressed satisfaction that the normal machinery for consultation had been available to all parties in the dispute, that the H.M.C. and R.H.B. had used this machinery, but that the M.s.c. had failed to avail itself of the proper consultative procedures. It is difficult to reconcile this opinion with the known facts of The
was
M.s.c. was
any member of the
the case, but there is no doubt that the records will show that consultation took place. Before this dispute is relegated to the dusty files of oblivion, one should perhaps ponder on the meaning of the word consultation ". To consult is to seek advice. In the present context consultation means discussion of a situation with interchange of ideas in order to resolve any difficulties on differences of opinion which may exist. It does not mean, as in this instance, that a decision is taken to provide an amenity without discussion with the users, whose opinions and advice are ignored. I believe that in the National Health Service, as in every walk of life, consultation is essential. But consultation must be made an active process and not remain just an empty word. "
Baguley Hospital, Wythenshawe, Manchester, 23.
T. M. WILSON.
CENTRAL STERILE SUPPLY SiR,ŅWhile any serious attempt to produce a paper specifically designed as an efficient bacterial barrier to meet the needs of both central sterile supply department (c.s.s.D.) and industry is to be applauded, too great stress on the inclusion of antibacterial agents as suggested by Mr. Fellows (Jan. 29) might well be misleading. The paper industry has for many years included antibacterial and antifungal agents during the actual manufacture of paper and board likely to be used or stored under conditions which would render them susceptible to spoilage. Substances such as o-phenylphenol (in glassine-type papers) and its water-soluble sodium salt, and particularly quaternary ammonium compounds, have been used. On the question of the maintenance of sterility, what good one wonders is a paper with an antifungal or antibacterial agent incorporated in it, if pinholes allow organisms to pass through unimpeded, and if organisms that come in contact with the paper are not moist ? On the latter point, we see no reason to doubt the validity of the work carried out at the Cross-Infection Reference Laboratory, Colindale,l on tests of self-disinfecting surfaces, which indicated that only surfaces which evolved formaldehyde showed any activity against dust-borne bacteria. The letter2 which prompted Mr. Fellows to write deserves some favourable comment, for it puts simply and concisely the various aspects of packaging for sterilised goods which are of prime importance to the hospital c.s.s.D. Particularly interesting were its comments on the use of paper. In practice pinhole-free paper, of even consistency, which does not allow the passage of bacteria in the dry or wet state, is ideal, and to this end a considerable amount of work has been carried out in this laboratory since the Nuffield report3 was published in 1958. In 1961 Hunter et al.4 demonstrated that papers of a certain 1. Kingston, D., Noble, W. C. J. Hyg., Camb. 1964, 62, 519. 2. Allen, S. M., et al. Lancet, 1965, ii, 1343. 3. Sterilisation Practice in Six Hospitals. Nuffield Provincial Hospitals Trust, London, 1958. 4. Hunter, C. L. F., Harbord, P. E., Riddett, D. J. in Symposium on Sterilisation of Surgical Materials. London, 1961.
664 were most suitable as bacterial barriers. But criticisms have been made that when wet such papers may not maintain sterility, and further work has shown that the ability of paper to resist the passage of organisms in the wet state is certainly not an impossible criterion to obtain.In fact, such a paper has been in use for a year. Finally, I agree almost entirely with the statements made by Allen et al .,2 and feel that a greater measure of cooperation between c.s.s.D.s and manufacturers of prepacked dressings is
air-porosity
urgently reauired. Microbiological Division, Johnson & Johnson (Gt. Britain) Ltd., Cosham, Hants.
P. E. HARBORD.
CARE OF THE SUBNORMAL
SIR,-ln your leading article (March 5) describing the papers at the annual conference of the National Association for
given
that I " envisaged the new district general hospitals as centres for outpatient diagnosis, treatment, and day-care ". I did not make any reference in my paper to day-care, which I do not think could be the responsibility of the district general hospital or the regional centre. The regional centre is the hospital to which the more difficult cases would be referred for assessment, investigation, and, frequently, treatment. The responsibility for the day-care patient must rest with the day centres and hostels contemplated by Dr. Pilkington in his talk. It is generally agreed that we must aim to establish a diagnosis and institute appropriate treatment in the first few months of life, and I believe this to be the responsibility of the pxdiatric teams who are based on the district general hospitals and regional centres-in my paper I stated that these units should be closely linked with the public-health authorities and the mental subnormality hospitals, respectively. I think that the mental subnormality hospitals should diminish in number and size over the next few years, and that those which remain should concentrate their efforts towards the establishment of first-class nursing facilities and training (educational) techniques for children requiring long-term hospital stay. GEORGE KOMROWER. Mental Health you
state
CLINICAL PHARMACOLOGY SiR,-Dr. Dollery’s article (Feb. 12) draws attention to a very real problem-namely, the need for the assessment of the usefulness in the many fields of medicine of the new substances produced by the now widely expanded chemical industry, and perhaps also for the reassessment of the usefulness of older remedies. The Committee on Safety of Drugs, under the chairmanship of Sir Derrick Dunlop, has been set up to do much of this work. What is all too easily forgotten, however, is that no committee, however wise its members, can reach useful conclusions without evidence, and that the evidence the Dunlop Committee requires is that provided by properly organised clinical trials. To organise such trials we need clinical pharmacologists not only among consultant physicians, but also in the various specialist branches of medicine, in which new drugs are being developed, if these drugs are to be adequately tested. In anaesthesia the need has been recognised for many years-there was indeed an era when the bulk of those practising clinical pharmacology were in fact anaesthetists, and in the United States the title of clinical pharmacologist was once considered quite seriously as an alternative to that of anxsthesiologist. In other specialties, too, the need is recognised, though not perhaps so widely. Thus there is a place for the clinical pharmacologist who must basically be an ophthalmologist in dealing with drugs affecting the eye, while to study drugs affecting mental disease the clinical pharmacologist must also be a
psychiatrist. 5. 6.
Parker, M. J. Conference on Prevention of Hospital Infection. London, 1963. Harbord, P. E., Stallard, J. A. Unpublished.
obviously therefore a need for training in clinical pharmacology all who have the necessary skill not only in There is
general medicine but also in anxsthesia and other specialties. University Department of Anaesthetics, Royal Infirmary, Manchester.
A. R. HUNTER.
ABORTION BILL AND CLINICAL FREEDOM SiR,—The Abortion Bill, as amended by the House of Lords, appears to violate the principle that the doctor practising privately is legally on the same footing as his colleague employed in the National Health Service; if this Bill were enacted in its present form, abortions could be carried out only by N.H.S. specialists in a State hospital. The committee reporting on drug addictionhas recommended that only doctors working in special centres should be allowed to prescribe drugs for addicts. I believe that the profession should keep a watchful eye on these proposed restrictions of clinical freedom. ALAN S. CLARK.
MEDICAL ENTRY INTO UNITED STATES
SIR,-Professor Hamilton (Jan. 15) fails to appreciate that getting vaccinated and obtaining a visa are procedures before the 7-hour jet-plane flight to the United States, as is the examination of the Educational Council for Foreign Medical Graduates, which may be taken in the United Kingdom. He states that these preparations occupy 6-12 months. But the Pilgrim Fathers had several years of preparation for their epic voyage of about 3 months ". "
Student Health Service, University of New Mexico, Albuquerque, U.S.A.
A. KENNETH YOUNG.
FLUORIDATION AND THE COUNCILLORS
SiR,—The usual practice of food and drug authorities, when they permit the addition of a cumulative poison to a foodstuff, is to limit the permitted amount to one-hundredth of the cumulative toxic dose. Fluoridated water is already in the toxic range, as is further evidenced by the report,2 believed to be the first from the U.S.A., of a death from drinking water containing less than 4 p.p.m. of fluoride. Sauerbrunn et awl. state : " Prolonged polydipsia may be areas where the levels of those drinking usually associated with it not fluorosis." Was Roholm who told us that significant polydipsia is a symptom of fluoride poisoning ? Are councillors now to dictate to those whose water-supplies they insist on treating with added fluorides how much water
hazardous fluoride in
to
may be taken
persons who live in water are not
daily ? WINIFRED M. SYKES Hon. secretary, National Pure Water Association.
ZOLLINGER-ELLISON SYNDROME SIR,-For over four hundred years, by both dictionary definition and universal usage, the word " syndrome" has meant to clinicians a significant grouping of clinical findings. The basis of all clinical diagnosis is the recognition by the human mind of such groupings, which point the way to a line of investigation and management leading in some cirless complete understanding of the disorder. Some of these syndromes have names and others have not. A syndrome that has a name sometimes differs from that described by the original worker, after whom it is called-for example, Raynaud’s syndrome. cumstances to a more or
1. 2.
Interdepartmental Committee on Drug Addiction: Second Report. H.M. Stationery Office, 1965. See Lancet, 1965, ii, 1113. Sauerbrunn, B. J. L., Ryan, C. M., Shaw, J. F. Ann. intern. Med. 1965, 63, 1074.