- Email: [email protected]
NEOCORTICAL DEATH AFTER CARDIAC ARREST
1099 be rather higher. We are in the course of a comparative study of the Panex scaler and the Pitman monitor, both instruments being used by individual technicians without knowledge of the other’s results. To date, 15 patients with
to
thrombosis and 10 without have been included. In every case the Pitman monitor confirmed the diagnosis of the presence or absence of thrombosis given by the Panex scaler, but where the Panex scaler gave a rise in count rate of 15%, the Pitman rise was 20% or slightly greater. This confirms the observations of Kakkar et al.2 Other workers have taken a rise in count-rate of 30% as indicative of deep-vein thrombosis using the Pitman monitor.3 We recognise that our evaluation is a crude one and more precise work needs to be done in evaluating the exact count-rate which indicates early deep-vein thrombosis. Until such a study is completed, however, we suggest that such arbitrary figures as 15% and 30% be viewed with caution, and that a figure of 20% rise in countrate which persists and increases in the subsequent 24 hours be taken as indicative of deep-vein thrombosis when the Pitman 235 isotope-localisation monitor is used.
scopical fields from these slides were displayed with appropriately labelled colour-polaroid photomicrographs. The pathology department was consulted concerning problem diagnosis. During the final three weeks, a few common disease processes were demonstrated, using all tissue sections from a representative body. Finally, each " attending physician " received his patient’s full student-based report and all histopathology, and " his students received personally signed copies. All students receive a summary of "
the final results. Student response
was excellent. 100% showed interest, judged by completed reports, tissue sections, or both. 85% completed excellent reports. 8-5% (three reports) were not completed, but listed carefully chosen histopathology. One report was terminated by body replace-
as
ment, since thorax and abdomen were " solid with cancer ". The remaining group started enthusiastically but terminated " because of the stench, and mould" of their experimentally preserved cadaver. We cannot prove that any student learnt any basic
pathology (although some
St. Helier Hospital,
B. Y. PAI.
Carshalton, Surrey. St. Thomas’s Hospital,
D. NEGUS.
London S.E.I.
EARLY INTRODUCTION TO PATHOLOGY
SIR,-Despite increasingly early introduction of clinical medicineinto or during basic science courses, for motivationand to demonstrate clinical relevance,6 comparable early introduction to basic pathology seems to have been largely ignored. for early " clinicalisation ",’ of have hitherto almost totally disgross anatomy here, regarded the obvious potential of elementary gross pathology. Therefore, in our 1970 medical gross anatomy and embryology course, we ran the following pilot experiment. As with all our gross anatomy motivation, it was voluntary and untested. However, the class were told we believed it would prove an interesting and useful link between anatomy and pathology, and would use their records for " attending physician " reports, for which requests continue to increase. 146 students (3 graduate and 143 medical) formed 1 graduate and 36 medical groups. The excellently preserved body, routinely dissected by each group, formed the pathological material source. Standard pathology records, modified to include certain details on extremities, and synchronised with dissection, were used. Hospital records, " attendant physicians’ notes, and subiect-supplied" histories were provided for clinical background. Cadaver tissue sections were excellent, so unlimited labelled specimen jars and histopathological forms were supplied. The pathology record frequently reminded students to take supervised abnormal tissue specimens. 4 medically qualified anatomists, with some experience in patient care and gross pathology, taught in every gross laboratory session, so identification and discussion were readily available. Students used their own descriptions wherever appropriate, though circling the most appropriate record response was generally employed. Each student received histopathological sections from all his cadaver specimens. Micro-
Although responsible
we suspect some accept the concept that the
did), but we believe complete necropsy
clinches, refutes, changes, amends, or adds to the antemortem diagnosis, since they discovered, as have others
previously,* its relative inaccuracy: 9% of their subjects (3 bodies) showed absence of the certified " lethal disease ", while 22%(11 bodies), despite coexistence of the presumed " fatal disease ", died from unsuspected pathology. Therefore, since we feel genuine student interest exists, we are repeating the undertaking during the current semester.
Department of Anatomy, University of Iowa College of Medicine, Iowa City, Iowa 52240, U.S.A.
N. F. METCALF W. K. METCALF D. J. MOFFATT.
we
2. 3.
4. 5. 6. 7.
Kakkar, V. V., Nicolaides, A. N., Renney, J. T. G., Friend, J. R., Clarke, M. B. Lancet, 1970, i, 540. Murray, T. S., Lorrimer, A. R., Cox, F. C., Lorrie, T. D. V. ibid. 1970, ii, 792. Ohio St. Univ. J. Autumn, 1970. Metcalf, W. K., Moffatt, D. J., Griffiths, D. A., Jacobs, A. Anat. Rec. 1969, 163, 341. Jason, H. J. Am. med. Ass. 1970, 212, 2092. Metcalf, W. K., Moffatt, D. J., Richardson, G., Versackas, M. Anat. Rec. (in the press).
NEOCORTICAL DEATH AFTER CARDIAC ARREST SiR,—The premise of Dr. Brierley and his colleagues (Sept. 11, p. 560) is that there is now general acceptance that a patient with severe brain damage whose electroencephalogram is isoelectric, who is totally areflexic, and whose respiratory and therefore cardiac function depends This is upon mechanical ventilation, is already dead. incorrect. Reports from West Germany,9,10 and the Netherlands 11 have stated firmly that human life does not end until there is total and irreversible absence of brain function. Severe brain damage, irreversible coma, or cortical death are not equivalent to total absence of the brain’s functional capacity. Acceptance of non-total loss of brain function, even if irreversible, as a reason for declaring a patient dead, as is now advocated in order to improve the chances of success in organ transplantation,12 means that there will be a special death criterion for a special group of patients-those regarded as suitable organ-donors. This could well lead to the formulation of other special death criteria for other groups, and for other reasons. That different people should be pronounced dead on different criteria ill clearly illogical, unethical, and unjust. Obviously our view is contrary to that of the Harvard Medical School committee,13 which 8. Prutting, J. N.Y. St. J. Med. 1967, 67, 2081. 9. Penin, H., Käufer, C. Der Hirntod. Stuttgart, 1969. 10. Penin, H., Käufer, C. Medsche Mitt., Melsungen, 1970, 44, 139. 11. Netherlands Red Cross Committee on Organ Transplantation, 1971. (English summary obtainable from Netherlands Red Cross, 27 Prinsessegracht, The Hague, Netherlands.) 12. Dempster, W. J. in Matters of Life and Death; p. 51. London, 1970. 13. Ad Hoc Committee on Brain Death, Harvard Medical School. J. Am. med. Ass. 1968, 205, 337. See also Beecher, H. K. New Engl. J. Med. 1969, 281, 1070.
1100 The coma as identical with death. of the Harvard as first in its .arguments report, presented 15 lines, imply that irreversible coma is not a criterion chosen for purely biological reasons, but for emotional, " practical, socio-economic, and " transplantational reasons. It is therefore an emotional criterion with a biological
regards irreversible
"
coating" only. We believe that irreversible
and cortical death are grounds tor stopping treatment and letting the patient die: this is legally and ethically permissible even if the comatose patient is still breathing spontaneously.14 But first, as coma
The Lancet says,15 there must be general agreement that cortical death can be diagnosed clinically-or permanent coma, we would add. Even cortical death and irreversible coma are no grounds for declaring the patient dead and then treating him as if he were a corpse, though warm, breathing, and-if cut open-bleeding. A living body -turns into a corpse by biological reasons only-not by declarations, or the signing of certificates. Ad Hoc Committee
on
Organ Transplantation, Netherlands Red Cross Society, The Hague, Netherlands.
ANNE ROT. Medical Secretary.
H. A. H. VAN TILL, Legal Secretary.
BLUE SCLEROTICS IN IRON DEFICIENCY SIR,-Dr. Hall (Oct. 23, p. 935) reports the interesting observation of blue sclerotics in association with iron deficiency. His first case was that of a woman with rheumatoid arthritis. We find this not uncommon in rheumatoid patients and usually not associated with iron deficiency. The slate-blue coloration is caused not by scleral pigmentation but by thinning of the sclera, which renders the uveal pigment visible. There are two main causes of such thinning in rheumatoid patients-namely, recurrent episodes of scleritis and long-term steroid therapy. It would be interesting to know whether either of these possible causes was present in the original patient, and the underlying diagnoses in the other cases of iron deficiency. Department of Medicine, Royal Postgraduate Medical School, London W.12.
ROBERT M. BENNETT.
VIRUSES AND WHOOPING-COUGH
SIR,-Miss Sturdy and her colleagues (Oct. 30, p. 979) refer to the bacteriological results of the Scottish study,ls but not to the associated virological investigations of which, regrettably, only a preliminary account has been reported." It should be noted that the bacteriological criteria and method of analysis of the Scottish data were chosen to facilitate comparison of different diagnostic techniques, not to evaluate their absolute sensitivity. Thus the 49 % (102 of 210) children with suspected whooping-cough who were classified as showing laboratory evidence of infection with Bordetella pertussis comprised only those from whom the organism was isolated and/or who showed 4-fold or greater rising titres. In many other cases high antibody titres were found without significant rise, probably because of the later stage of infection when the first blood was collected. The performance of the bacteriological tests was further reduced by the fact that 47% of the patients were under one year old, with demonstrably weaker antibody responses than older children; also, lower isolation-rates were found in the previously vaccinated group. The true Till, H. A. H. Medico-legal Aspects of the End of Human Life. Deventer, 1970 (Dutch text, English summary). 15. Lancet, Sept. 11, 1971, p. 590. 16. Combined Scottish Study. Br. med. J. 1970, iv, 637. 17. Calder, M. A., et al. Lancet, 1970, ii, 1079. 14.
proportion of children infected with B. pertussis is therefore far higher than the incontrovertible 49%. The virological investigations showed that the common respiratory viruses of early childhood-adenoviruses and respiratory syncytial virus-predominated but were present in both negative and positive bacteriological groups. Virus infections were not distributed in such a way as to suggest the existence of an important group of bacteriologically
negative, virologically positive, whooping-cough illnesses. More detailed analysis of the Scottish data supports this conclusion. The notoriously imprecise correlation between named respiratory-illness syndromes and specific infections leaves open the possibility that a few illnesses resembling whooping-cough may be caused by agents other than B. pertussis. Nevertheless, it seems unfortunate to distract attention from the dominating importance of B. pertussis in the causation of this important and difficult disease of early childhood, for the control of which our best available weapon is specific vaccine against this organism. In present circumstances we doubt the value of a further large-scale bacteriological and virological search for a viral whooping-
cough. University Department of Infectious Diseases and Regional Virus Laboratory, Ruchill Hospital, Glasgow G20 9NB.
N. R. GRIST C. A. C. Ross.
MEDICAL ONCOLOGY editorial SIR,-Your (Aug. 21, p. 419) and the letter of Dr. Southam (Sept. 25, p. 709) grossly underestimate the present and future role of the radiotherapist in this area of medicine. Dr. Southam’s criteria for an ideal oncologist are fulfilled at present by many radiotherapists in the more emancipated and enlightened centres. The term " radiotherapist " is unfortunately often interpreted as implying a more technical and less clinical approach. Sir, we are not technicians to be guided by a " super G.P. oncologist", and I doubt also that " cancer surgeons " would care to be regarded in the same light. Unfortunately the term " medical oncologist" is wrongly assumed to be synonymous with " chemotherapist" (a role adopted full or part time by hxmatologists or internists). Oncologist is a term that may appropriately be applied only to a specialist devoting all his time to the diagnosis and/or treatment of cancer. This could equally well be a radiotherapist, surgeon, pathologist, or chemotherapist. Until recent years the radiotherapist was the only specialist to whom the term clinical oncologist could be applied. What we urgently require is more teamwork between these specialists and a common basic training in oncology before specialising in one of these modalities. Princess Margaret Hospital, R. M. CLARK. Toronto 5, Canada. BROMISM
SIR,-Dr. James (Oct. 2, p. 762) is
to be congratulated reminding us of the existence of chloral-hydratewithdrawal psychosis. He surely errs, however, in apparently discounting the possibility of bromide withdrawal psychosis. The occurrence of delirium after the drug has been stopped and serum concentrations have fallen markedly is well attested. 1,2 Only one of my three bromism on
patients who showed a withdrawal delirium was known to have been taking a mixture containing chloral hydrate. Thus I believe there are good grounds for accepting bromide-withdrawal psvchosis
as
clinical fact.
Victoria
Hospital, Blackpool.
M. W. P. CARNEY.
van
1.
Mayer-Gross, W., Slater, E., Roth, M. Clinical Psychiatry. London,
2.
Pozuelo-Utanda, J., Crawford, D. C., Anderson, J. S., Int. J. Neuropsychiat. 1966, 2, 90.
1960.
to
thrombosis and 10 without have been included. In every case the Pitman monitor confirmed the diagnosis of the presence or absence of thrombosis given by the Panex scaler, but where the Panex scaler gave a rise in count rate of 15%, the Pitman rise was 20% or slightly greater. This confirms the observations of Kakkar et al.2 Other workers have taken a rise in count-rate of 30% as indicative of deep-vein thrombosis using the Pitman monitor.3 We recognise that our evaluation is a crude one and more precise work needs to be done in evaluating the exact count-rate which indicates early deep-vein thrombosis. Until such a study is completed, however, we suggest that such arbitrary figures as 15% and 30% be viewed with caution, and that a figure of 20% rise in countrate which persists and increases in the subsequent 24 hours be taken as indicative of deep-vein thrombosis when the Pitman 235 isotope-localisation monitor is used.
scopical fields from these slides were displayed with appropriately labelled colour-polaroid photomicrographs. The pathology department was consulted concerning problem diagnosis. During the final three weeks, a few common disease processes were demonstrated, using all tissue sections from a representative body. Finally, each " attending physician " received his patient’s full student-based report and all histopathology, and " his students received personally signed copies. All students receive a summary of "
the final results. Student response
was excellent. 100% showed interest, judged by completed reports, tissue sections, or both. 85% completed excellent reports. 8-5% (three reports) were not completed, but listed carefully chosen histopathology. One report was terminated by body replace-
as
ment, since thorax and abdomen were " solid with cancer ". The remaining group started enthusiastically but terminated " because of the stench, and mould" of their experimentally preserved cadaver. We cannot prove that any student learnt any basic
pathology (although some
St. Helier Hospital,
B. Y. PAI.
Carshalton, Surrey. St. Thomas’s Hospital,
D. NEGUS.
London S.E.I.
EARLY INTRODUCTION TO PATHOLOGY
SIR,-Despite increasingly early introduction of clinical medicineinto or during basic science courses, for motivationand to demonstrate clinical relevance,6 comparable early introduction to basic pathology seems to have been largely ignored. for early " clinicalisation ",’ of have hitherto almost totally disgross anatomy here, regarded the obvious potential of elementary gross pathology. Therefore, in our 1970 medical gross anatomy and embryology course, we ran the following pilot experiment. As with all our gross anatomy motivation, it was voluntary and untested. However, the class were told we believed it would prove an interesting and useful link between anatomy and pathology, and would use their records for " attending physician " reports, for which requests continue to increase. 146 students (3 graduate and 143 medical) formed 1 graduate and 36 medical groups. The excellently preserved body, routinely dissected by each group, formed the pathological material source. Standard pathology records, modified to include certain details on extremities, and synchronised with dissection, were used. Hospital records, " attendant physicians’ notes, and subiect-supplied" histories were provided for clinical background. Cadaver tissue sections were excellent, so unlimited labelled specimen jars and histopathological forms were supplied. The pathology record frequently reminded students to take supervised abnormal tissue specimens. 4 medically qualified anatomists, with some experience in patient care and gross pathology, taught in every gross laboratory session, so identification and discussion were readily available. Students used their own descriptions wherever appropriate, though circling the most appropriate record response was generally employed. Each student received histopathological sections from all his cadaver specimens. Micro-
Although responsible
we suspect some accept the concept that the
did), but we believe complete necropsy
clinches, refutes, changes, amends, or adds to the antemortem diagnosis, since they discovered, as have others
previously,* its relative inaccuracy: 9% of their subjects (3 bodies) showed absence of the certified " lethal disease ", while 22%(11 bodies), despite coexistence of the presumed " fatal disease ", died from unsuspected pathology. Therefore, since we feel genuine student interest exists, we are repeating the undertaking during the current semester.
Department of Anatomy, University of Iowa College of Medicine, Iowa City, Iowa 52240, U.S.A.
N. F. METCALF W. K. METCALF D. J. MOFFATT.
we
2. 3.
4. 5. 6. 7.
Kakkar, V. V., Nicolaides, A. N., Renney, J. T. G., Friend, J. R., Clarke, M. B. Lancet, 1970, i, 540. Murray, T. S., Lorrimer, A. R., Cox, F. C., Lorrie, T. D. V. ibid. 1970, ii, 792. Ohio St. Univ. J. Autumn, 1970. Metcalf, W. K., Moffatt, D. J., Griffiths, D. A., Jacobs, A. Anat. Rec. 1969, 163, 341. Jason, H. J. Am. med. Ass. 1970, 212, 2092. Metcalf, W. K., Moffatt, D. J., Richardson, G., Versackas, M. Anat. Rec. (in the press).
NEOCORTICAL DEATH AFTER CARDIAC ARREST SiR,—The premise of Dr. Brierley and his colleagues (Sept. 11, p. 560) is that there is now general acceptance that a patient with severe brain damage whose electroencephalogram is isoelectric, who is totally areflexic, and whose respiratory and therefore cardiac function depends This is upon mechanical ventilation, is already dead. incorrect. Reports from West Germany,9,10 and the Netherlands 11 have stated firmly that human life does not end until there is total and irreversible absence of brain function. Severe brain damage, irreversible coma, or cortical death are not equivalent to total absence of the brain’s functional capacity. Acceptance of non-total loss of brain function, even if irreversible, as a reason for declaring a patient dead, as is now advocated in order to improve the chances of success in organ transplantation,12 means that there will be a special death criterion for a special group of patients-those regarded as suitable organ-donors. This could well lead to the formulation of other special death criteria for other groups, and for other reasons. That different people should be pronounced dead on different criteria ill clearly illogical, unethical, and unjust. Obviously our view is contrary to that of the Harvard Medical School committee,13 which 8. Prutting, J. N.Y. St. J. Med. 1967, 67, 2081. 9. Penin, H., Käufer, C. Der Hirntod. Stuttgart, 1969. 10. Penin, H., Käufer, C. Medsche Mitt., Melsungen, 1970, 44, 139. 11. Netherlands Red Cross Committee on Organ Transplantation, 1971. (English summary obtainable from Netherlands Red Cross, 27 Prinsessegracht, The Hague, Netherlands.) 12. Dempster, W. J. in Matters of Life and Death; p. 51. London, 1970. 13. Ad Hoc Committee on Brain Death, Harvard Medical School. J. Am. med. Ass. 1968, 205, 337. See also Beecher, H. K. New Engl. J. Med. 1969, 281, 1070.
1100 The coma as identical with death. of the Harvard as first in its .arguments report, presented 15 lines, imply that irreversible coma is not a criterion chosen for purely biological reasons, but for emotional, " practical, socio-economic, and " transplantational reasons. It is therefore an emotional criterion with a biological
regards irreversible
"
coating" only. We believe that irreversible
and cortical death are grounds tor stopping treatment and letting the patient die: this is legally and ethically permissible even if the comatose patient is still breathing spontaneously.14 But first, as coma
The Lancet says,15 there must be general agreement that cortical death can be diagnosed clinically-or permanent coma, we would add. Even cortical death and irreversible coma are no grounds for declaring the patient dead and then treating him as if he were a corpse, though warm, breathing, and-if cut open-bleeding. A living body -turns into a corpse by biological reasons only-not by declarations, or the signing of certificates. Ad Hoc Committee
on
Organ Transplantation, Netherlands Red Cross Society, The Hague, Netherlands.
ANNE ROT. Medical Secretary.
H. A. H. VAN TILL, Legal Secretary.
BLUE SCLEROTICS IN IRON DEFICIENCY SIR,-Dr. Hall (Oct. 23, p. 935) reports the interesting observation of blue sclerotics in association with iron deficiency. His first case was that of a woman with rheumatoid arthritis. We find this not uncommon in rheumatoid patients and usually not associated with iron deficiency. The slate-blue coloration is caused not by scleral pigmentation but by thinning of the sclera, which renders the uveal pigment visible. There are two main causes of such thinning in rheumatoid patients-namely, recurrent episodes of scleritis and long-term steroid therapy. It would be interesting to know whether either of these possible causes was present in the original patient, and the underlying diagnoses in the other cases of iron deficiency. Department of Medicine, Royal Postgraduate Medical School, London W.12.
ROBERT M. BENNETT.
VIRUSES AND WHOOPING-COUGH
SIR,-Miss Sturdy and her colleagues (Oct. 30, p. 979) refer to the bacteriological results of the Scottish study,ls but not to the associated virological investigations of which, regrettably, only a preliminary account has been reported." It should be noted that the bacteriological criteria and method of analysis of the Scottish data were chosen to facilitate comparison of different diagnostic techniques, not to evaluate their absolute sensitivity. Thus the 49 % (102 of 210) children with suspected whooping-cough who were classified as showing laboratory evidence of infection with Bordetella pertussis comprised only those from whom the organism was isolated and/or who showed 4-fold or greater rising titres. In many other cases high antibody titres were found without significant rise, probably because of the later stage of infection when the first blood was collected. The performance of the bacteriological tests was further reduced by the fact that 47% of the patients were under one year old, with demonstrably weaker antibody responses than older children; also, lower isolation-rates were found in the previously vaccinated group. The true Till, H. A. H. Medico-legal Aspects of the End of Human Life. Deventer, 1970 (Dutch text, English summary). 15. Lancet, Sept. 11, 1971, p. 590. 16. Combined Scottish Study. Br. med. J. 1970, iv, 637. 17. Calder, M. A., et al. Lancet, 1970, ii, 1079. 14.
proportion of children infected with B. pertussis is therefore far higher than the incontrovertible 49%. The virological investigations showed that the common respiratory viruses of early childhood-adenoviruses and respiratory syncytial virus-predominated but were present in both negative and positive bacteriological groups. Virus infections were not distributed in such a way as to suggest the existence of an important group of bacteriologically
negative, virologically positive, whooping-cough illnesses. More detailed analysis of the Scottish data supports this conclusion. The notoriously imprecise correlation between named respiratory-illness syndromes and specific infections leaves open the possibility that a few illnesses resembling whooping-cough may be caused by agents other than B. pertussis. Nevertheless, it seems unfortunate to distract attention from the dominating importance of B. pertussis in the causation of this important and difficult disease of early childhood, for the control of which our best available weapon is specific vaccine against this organism. In present circumstances we doubt the value of a further large-scale bacteriological and virological search for a viral whooping-
cough. University Department of Infectious Diseases and Regional Virus Laboratory, Ruchill Hospital, Glasgow G20 9NB.
N. R. GRIST C. A. C. Ross.
MEDICAL ONCOLOGY editorial SIR,-Your (Aug. 21, p. 419) and the letter of Dr. Southam (Sept. 25, p. 709) grossly underestimate the present and future role of the radiotherapist in this area of medicine. Dr. Southam’s criteria for an ideal oncologist are fulfilled at present by many radiotherapists in the more emancipated and enlightened centres. The term " radiotherapist " is unfortunately often interpreted as implying a more technical and less clinical approach. Sir, we are not technicians to be guided by a " super G.P. oncologist", and I doubt also that " cancer surgeons " would care to be regarded in the same light. Unfortunately the term " medical oncologist" is wrongly assumed to be synonymous with " chemotherapist" (a role adopted full or part time by hxmatologists or internists). Oncologist is a term that may appropriately be applied only to a specialist devoting all his time to the diagnosis and/or treatment of cancer. This could equally well be a radiotherapist, surgeon, pathologist, or chemotherapist. Until recent years the radiotherapist was the only specialist to whom the term clinical oncologist could be applied. What we urgently require is more teamwork between these specialists and a common basic training in oncology before specialising in one of these modalities. Princess Margaret Hospital, R. M. CLARK. Toronto 5, Canada. BROMISM
SIR,-Dr. James (Oct. 2, p. 762) is
to be congratulated reminding us of the existence of chloral-hydratewithdrawal psychosis. He surely errs, however, in apparently discounting the possibility of bromide withdrawal psychosis. The occurrence of delirium after the drug has been stopped and serum concentrations have fallen markedly is well attested. 1,2 Only one of my three bromism on
patients who showed a withdrawal delirium was known to have been taking a mixture containing chloral hydrate. Thus I believe there are good grounds for accepting bromide-withdrawal psvchosis
as
clinical fact.
Victoria
Hospital, Blackpool.
M. W. P. CARNEY.
van
1.
Mayer-Gross, W., Slater, E., Roth, M. Clinical Psychiatry. London,
2.
Pozuelo-Utanda, J., Crawford, D. C., Anderson, J. S., Int. J. Neuropsychiat. 1966, 2, 90.
1960.