- Email: [email protected]
THE MENTAL NURSE IN THE COMMUNITY
498 Severalls Hospital which is now run on the " firm " system. Apparently Dr. Rollin believes that the need for beds is related to the present occupation.
Beds, bricks, and buildings never cured a depression, controlled schizophrenia, nor helped manage senility. It is doctors, nurses, and creative administration that matter. If doctors are duds, nurses incompetent, and administration a dead hand, naturally patients will accumulate in hospital, beds will be short, and the burden on the community great. The assumption that this burden is greater if there are fewer hospital beds may well be specious. My evidence suggests that a dynamic psychiatric service reduces both hospital beds and community burden. There is, of course, an optimum number of beds but it appears well below 1-8/100. Statistical studies which ignore the industry and ability of people are only valid when this factor is not involved. Thus the recent criticisms by Rehin and Martinand Jones and Sidebotham2 are concerned with side issues, and have not been allowed to include the most vital influences on, and aspects of, the future scale of provision of psychiatric needs-the calibre and quantity of staff. If this continues to improve, as I think it will, the number of beds will continue to fall. Dr. Rollin is kind to award me the credit of the dramatic decrease of beds at Severalls. He is wrong again. The facts are as follows. In the mid 1950s a new chief male nurse, group secretary, and matron were appointed. On July 22, 1952, a doctor with advanced ideas came on the junior staff and tremendous industry began our decrease in numbers. Further appointments, together with additional medical establishment and cooperation of most of the staff, medical, nursing, and administrative, have been jointly responsible for further decrease of numbers. No matter how industrious and competent, one person can achieve nothing alone. I do not think the " burden on the community " is any greater now than 5 years ago. I will be glad to afford Dr. Atkin or Dr. Rollin every opportunity to prove otherwise. I will be pleased, if invited, to carry out a few days’ investigation and report why it is the number of beds occupied at his hospital is not falling in spite of rising admissions and outpatients. I wager Dr. Rollin El 00 that if my recommendations are adopted the number at his hospital will fall. It is true there are hordes of ex-mental-hospital patients in Metropolitan London. There always have been. Critics can play up and enthusiasts can play down the trouble and un-
happiness they
cause.
I agree with Dr. Atkins’ last points 5 years ago.3
paragraph-I made
the
same
Dr. Joules (Feb. 9) draws attention to a deplorable practice whereby some mental hospitals have reduced numbers by not admitting the elderly. At Severalls all the ground-floor wards in the main hospital block accommodate a geriatric unit for some 400 senile patients. Development of a " month in/month out " policy, where possible, is helping to deal with a situation that was desperate. We are not fussy and have admitted to relatives a rest, to enable the local authority people give clean up their home, and in this last few weeks we have let people come in from the cold. I think most people would agree that every psychiatrically ill patient, his family, accommodation, and other social factors should be scrutinised. A prescription as to whether he stays in the community, is admitted to hospital, or is readmitted to the community from hospital, should be made by an expert who has mastered his subiect (and not been mastered bv it) to
1. Psychiatric Services in 1975. Planning, 1963, 2. Mental Hospitals at Work, London, 1962. 3. Lancet, 1958, ii, 583.
29, no. 468.
positive grounds; as opposed to what happens all too a patient stays at home or in hospital by default or prejudice or predetermined decision. I am glad to agree with Dr. Rollin that Parkinson’s Law applies. It should be stated as follows: whenever the number of beds in psychiatric hospitals increases, the number of patients will expand to fill them. If the Minister decided to add 100,000 psychiatric beds to the service each year, and psychiatric hospitals continued producing institutional neurosis, we ought to get 10% of on
often,
the oooulation behind bars bV Severalls Hospital, Colchester, Essex.
A.D.
2000
RUSSELL BARTON.
A PSYCHIATRIC UNIT IN A LARGE GENERAL HOSPITAL
SIR,-Dr. Little (Feb. 16) raises several issues. I to comment on one point.
should like
He gives details of the diagnosis in 1200 patients admitted his unit in 1961 and uses this to substantiate his claim that no selection of cases takes place. In the report of the chief mental welfare officer of the City of Leeds for 1961 the fol. lowing paragraph appears: " For years it was the practice in Leeds to admit the majority of patients suffering from mental illness for a period of observation to St. James’s Hospital but now owing to lack of accommodation and change of policy there, more patients are admitted direct to mental hospitals; the figures show that the numbers of compulsory admissions to mental hospitals from Leeds have more than doubled." The increased activity of the psychiatric unit shown by the increase of admissions from 1000 to 1200 patients per year has had the somewhat unusual result of doubling the compulsory admissions to mental hospitals from the City of Leeds. There is, of course, selection of patients taking place; it is selection by exclusion. Because of the relatively small number of beds at the unit (there are, I understand, only 6 female observation beds, for instance), it is quite unable to cater for many serious acute cases of mental illness which occur in the area, and which the psychiatric hospitals serving the city are
to
now
admitting directly.
I agree with Dr. Little that " the time has arrived for an independent survey and comparison to clarify the defects and advantages of the treatment of mental illness in mental hospitals and general hospitals ", but unless and until the psychiatric unit in the general hospital is given a definite catchment area and made to accept complete and continuing responsibility for all the cases of psychiatric illness in this area (as is the case with most psychiatric hospitals), any such comparison will be grossly inaccurate. High Royds Hospital, Menston, Ilkley, Yorkshire.
R. MCDONALD.
THE MENTAL NURSE IN THE COMMUNITY SIR,-While agreeing with the first part of Dr. Edelston’s letter of Feb. 9 about the difference in role between psychiatric social worker and mental nurse, we
should like to comment on his statement: " I fail to see what precisely is the special function of the mental nurse in the community other than the social services that could be carried out by the local authority health visitor." In recent years there has been considerable change in the training and role of mental nurses, emphasis being placed upon increasing their understanding of ways in which to help both individual patients and groups. For five years in our mental-health service, we have had selected nurses working in the community from the hospitalas part of the team with doctors and psychiatric social workers. Incidentally, we also work closely with health visitors whom we meet
regularly.
499 Both health visitors and mental nurses have a part to play in a mental-health service, but the special contribution of the mental nurse is knowledge and experience of working with patients who have had a severe mental illness, who may have residual symptoms, or who, at any time, may have a recurrence of their previous illness. PETER HUNTER FRANCIS PILKINGTON Moorhaven Hospital, Ivybridge.
KENNETH WEEKS.
THE LUNGS IN KYPHOSCOLIOSIS
SIR,-Greater emphasis should be placed on the orthopxdic aspects of respiratory disease. In my view more bronchitic or asthmatic youths have spinal or thoracic-cage deformities than have not. The deformities are
that
often remarkable for their obviousness and the fact they have been completely overlooked. The most
important (1) A scoliotic type of deformity in which one hemithorax is unduly protuberant or the other is flattened, similar to the appearance in severe pleural fibrosis (see Laonnec plates VI are:
and VH). A loss of the normal curvature in the thoracic spine in the lateral chest X-ray, the vertebral bodies lying above each other like a tower of child’s blocks, associated maybe with a flattening of the thorax, the distance between spine and anterior chest wall being reduced; and the obverse kyphosis and barrel chest. (3) Pigeon chest and its obverse depressed sternum. These are commonly associated with asthma, bronchitis, bronchiectasis, and a susceptibility to pneumonia, and perhaps with dextrocardia and even dissecting aneurysm. Which comes first-the bronchitis, &c., or the deformity-is hard to but it is that the British say, possible susceptibility to bronchitis is partly congenital.
(2)
normal. The=erialpO2 was 67 mm. Hg, the pCO,, 24 mm. Hg, the pH 7-46 and the hxmoglobin saturation 94%. The carbondioxide content of a different sample of venous blood was 15-7 mEq. per litre. Microscopic examination of renal tissue obtained by percutaneous biopsy revealed abnormalities in all glomeruli consisting of extensive cellular proliferation, crescent and fibroustissue formation, neutrophil infiltration, patchy areas of necrosis, and adhesions of the glomerular tufts to Bowman’s capsule. All glomeruli appeared to be in approximately the same " subacute." stage of evolution, probably best classified as The tubules appeared normal except for proteinacious and haematin casts, and there was minimal interstitial inflammation. Several small arterioles appeared normal. The patient was given 60 mg. of prednisone daily, and, except for a transient period of subjective wellbeing, had a downhill course over ten days, with a rise of blood-urea nitrogen to 250 mg. per 100 ml., hyperkalaemia to 6-7 mEq. per litre, and, terminally, gross haemoptysis and severe dyspnoea. Permission for necropsy was not obtained.
The association of diffuse pulmonary haemorrhage with nephritis has an ominous prognosis. Although the cause of this disorder remains unclear, adrenal steroids in most instances have failed to alter the clinical course.
seen
D. HAMILTON. NEPHRITIS WITH LUNG HÆMORRHAGE
SIR,-Glomerulonephritis with associated pulmonary hemorrhage, commonly referred to as Goodpasture’s syndrome,! is uncommon and usually rapidly fatal. 2-6 In 4 of the 5 patients who were treated with adrenal steroids, there was no apparent change in the clinical course.3-6 We wish to describe an additional re-emphasise the ineffectiveness of steroids.
case
and
to
A 35-year-old white male had malaise, feverish feelings, and two weeks before admission to hospital, followed by spasms of coughing productive of bright-red blood several
chills
times daily. These symptoms, accompanied by dyspnoea, weakness, and cloudy urine, continued until admission. He had a normal temperature and blood-pressure, a pulse-rate of 112 per minute, and a few scattered rales over both posterior lung fields. X-ray of the chest showed extensive infiltrations extending outward from both hilar areas. The haemoglobin was 6 g. per 100 ml., the white-cell count was 12,400 with a normal differential, the blood-urea nitrogen 44 mg. per 100 mi., the serum-sodium, potassium, and chloride were normal, and the antistreptolysin titre was not increased. Urinalysis revealed a pH of 5-0, a specific gravity of 1-012, -I--I--Iproteinuria, and many white cells, red cells, hyaline, and redcell casts on microscopy. The patient was given several transfusions of whole blood and felt somewhat improved. Vital capacity, total lung capacity, and residual volume were reduced to approximately 70% of predicted values, there was no obstruction to air flow, and the diffusing capacity was just below the lower limits of 1. 2.
Goodpasture, E. W. Amer. J. med. Sci. 1919, 158, 863. Parkin, T. W., Rusted, I. E., Burchall, H. B., Edwards, J. E. Amer. J. Med. 1955, 18, 220. 3. Rusby, N. L., Wilson, C. Quart. J. Med. 1962, 116, 501.
4. 5. 6.
Leff, I. L., Fazekas, G. Ann. intern. Med. 1962, 56, 296. Saltzman, R. W., West, M., Chomet, B. ibid. p. 409. Soergel, K. H., Sommers, S. C. Amer. J. Med. 1962, 32, 499.
Boston Veterans Administration
Hospital, Boston, Massachusetts.
RUSSELL E. RANDALL, Jr. JON S. GLAZIER MARVIN LIGGETT.
GLUTEN, CŒLIAC DISEASE, AND COLLAGEN SYNDROMES
SIR,-In their important article, Digestive System Manifestations of the Collagen Diseases,l Patterson and Wierzbinski show how commonly alimentary lesions are found in these syndromes. But both their title and their text imply that involvement of the small intestine is only incidental to the systemic process. In my opinion it is primary and crucial. Hitherto the significance of this small-gut involvement has been consistently underratedpartly because of the tradition whereby pathologists are influenced by what is seen clinically first, and partly because the sterile autoimmune theory of the pathogenesis of collagen syndromes at present prevails.2 According to the new concept which I briefly outline here, collagen syndromes arise from a primary lesion in the small intestine. And they can, I believe, be explained by hereditary maladaptation to a new type of food. In the biological history of human beings, the use of grains is a comparatively recent innovation; and for prepalaeolithic man, predominantly carnivorous, it must have been biologically disturbing and abrupt. The domestication of cereals (particularly wheat and rye) led from nomadism to agriculture and eventually to civilisation.3 But the epochal changes when man changed from a food gatherer, predator, and cannibal to a food producer may well have been paralleled by the failure of a significant minority to cope with the new foodstuff-through enzyme inadequacy. This failure of adaptation, in prehistoric times, could have taken the form of widespread and severe coeliac disease-an inherited disorder in which the small intestine cannot function properly in the presence of gluten. To coeliacs, cereal food-or more precisely the gluten complex it contains-would be lethal before they could reach reproductive maturity; and a trait which was partially dominant could in this way have become rare (as 1. Patterson, J. F., Wierzbinski, S. J. Med. Clin. N. Amer. 1962, 46, 1387. 2. Richardson, J. Brit. med. J. 1961, i, 1187. 3. Braidwood, R. J., Howe, B. Prehistoric Investigation in Iraqi Kurdistan; p. 163. Chicago, 1960.
Beds, bricks, and buildings never cured a depression, controlled schizophrenia, nor helped manage senility. It is doctors, nurses, and creative administration that matter. If doctors are duds, nurses incompetent, and administration a dead hand, naturally patients will accumulate in hospital, beds will be short, and the burden on the community great. The assumption that this burden is greater if there are fewer hospital beds may well be specious. My evidence suggests that a dynamic psychiatric service reduces both hospital beds and community burden. There is, of course, an optimum number of beds but it appears well below 1-8/100. Statistical studies which ignore the industry and ability of people are only valid when this factor is not involved. Thus the recent criticisms by Rehin and Martinand Jones and Sidebotham2 are concerned with side issues, and have not been allowed to include the most vital influences on, and aspects of, the future scale of provision of psychiatric needs-the calibre and quantity of staff. If this continues to improve, as I think it will, the number of beds will continue to fall. Dr. Rollin is kind to award me the credit of the dramatic decrease of beds at Severalls. He is wrong again. The facts are as follows. In the mid 1950s a new chief male nurse, group secretary, and matron were appointed. On July 22, 1952, a doctor with advanced ideas came on the junior staff and tremendous industry began our decrease in numbers. Further appointments, together with additional medical establishment and cooperation of most of the staff, medical, nursing, and administrative, have been jointly responsible for further decrease of numbers. No matter how industrious and competent, one person can achieve nothing alone. I do not think the " burden on the community " is any greater now than 5 years ago. I will be glad to afford Dr. Atkin or Dr. Rollin every opportunity to prove otherwise. I will be pleased, if invited, to carry out a few days’ investigation and report why it is the number of beds occupied at his hospital is not falling in spite of rising admissions and outpatients. I wager Dr. Rollin El 00 that if my recommendations are adopted the number at his hospital will fall. It is true there are hordes of ex-mental-hospital patients in Metropolitan London. There always have been. Critics can play up and enthusiasts can play down the trouble and un-
happiness they
cause.
I agree with Dr. Atkins’ last points 5 years ago.3
paragraph-I made
the
same
Dr. Joules (Feb. 9) draws attention to a deplorable practice whereby some mental hospitals have reduced numbers by not admitting the elderly. At Severalls all the ground-floor wards in the main hospital block accommodate a geriatric unit for some 400 senile patients. Development of a " month in/month out " policy, where possible, is helping to deal with a situation that was desperate. We are not fussy and have admitted to relatives a rest, to enable the local authority people give clean up their home, and in this last few weeks we have let people come in from the cold. I think most people would agree that every psychiatrically ill patient, his family, accommodation, and other social factors should be scrutinised. A prescription as to whether he stays in the community, is admitted to hospital, or is readmitted to the community from hospital, should be made by an expert who has mastered his subiect (and not been mastered bv it) to
1. Psychiatric Services in 1975. Planning, 1963, 2. Mental Hospitals at Work, London, 1962. 3. Lancet, 1958, ii, 583.
29, no. 468.
positive grounds; as opposed to what happens all too a patient stays at home or in hospital by default or prejudice or predetermined decision. I am glad to agree with Dr. Rollin that Parkinson’s Law applies. It should be stated as follows: whenever the number of beds in psychiatric hospitals increases, the number of patients will expand to fill them. If the Minister decided to add 100,000 psychiatric beds to the service each year, and psychiatric hospitals continued producing institutional neurosis, we ought to get 10% of on
often,
the oooulation behind bars bV Severalls Hospital, Colchester, Essex.
A.D.
2000
RUSSELL BARTON.
A PSYCHIATRIC UNIT IN A LARGE GENERAL HOSPITAL
SIR,-Dr. Little (Feb. 16) raises several issues. I to comment on one point.
should like
He gives details of the diagnosis in 1200 patients admitted his unit in 1961 and uses this to substantiate his claim that no selection of cases takes place. In the report of the chief mental welfare officer of the City of Leeds for 1961 the fol. lowing paragraph appears: " For years it was the practice in Leeds to admit the majority of patients suffering from mental illness for a period of observation to St. James’s Hospital but now owing to lack of accommodation and change of policy there, more patients are admitted direct to mental hospitals; the figures show that the numbers of compulsory admissions to mental hospitals from Leeds have more than doubled." The increased activity of the psychiatric unit shown by the increase of admissions from 1000 to 1200 patients per year has had the somewhat unusual result of doubling the compulsory admissions to mental hospitals from the City of Leeds. There is, of course, selection of patients taking place; it is selection by exclusion. Because of the relatively small number of beds at the unit (there are, I understand, only 6 female observation beds, for instance), it is quite unable to cater for many serious acute cases of mental illness which occur in the area, and which the psychiatric hospitals serving the city are
to
now
admitting directly.
I agree with Dr. Little that " the time has arrived for an independent survey and comparison to clarify the defects and advantages of the treatment of mental illness in mental hospitals and general hospitals ", but unless and until the psychiatric unit in the general hospital is given a definite catchment area and made to accept complete and continuing responsibility for all the cases of psychiatric illness in this area (as is the case with most psychiatric hospitals), any such comparison will be grossly inaccurate. High Royds Hospital, Menston, Ilkley, Yorkshire.
R. MCDONALD.
THE MENTAL NURSE IN THE COMMUNITY SIR,-While agreeing with the first part of Dr. Edelston’s letter of Feb. 9 about the difference in role between psychiatric social worker and mental nurse, we
should like to comment on his statement: " I fail to see what precisely is the special function of the mental nurse in the community other than the social services that could be carried out by the local authority health visitor." In recent years there has been considerable change in the training and role of mental nurses, emphasis being placed upon increasing their understanding of ways in which to help both individual patients and groups. For five years in our mental-health service, we have had selected nurses working in the community from the hospitalas part of the team with doctors and psychiatric social workers. Incidentally, we also work closely with health visitors whom we meet
regularly.
499 Both health visitors and mental nurses have a part to play in a mental-health service, but the special contribution of the mental nurse is knowledge and experience of working with patients who have had a severe mental illness, who may have residual symptoms, or who, at any time, may have a recurrence of their previous illness. PETER HUNTER FRANCIS PILKINGTON Moorhaven Hospital, Ivybridge.
KENNETH WEEKS.
THE LUNGS IN KYPHOSCOLIOSIS
SIR,-Greater emphasis should be placed on the orthopxdic aspects of respiratory disease. In my view more bronchitic or asthmatic youths have spinal or thoracic-cage deformities than have not. The deformities are
that
often remarkable for their obviousness and the fact they have been completely overlooked. The most
important (1) A scoliotic type of deformity in which one hemithorax is unduly protuberant or the other is flattened, similar to the appearance in severe pleural fibrosis (see Laonnec plates VI are:
and VH). A loss of the normal curvature in the thoracic spine in the lateral chest X-ray, the vertebral bodies lying above each other like a tower of child’s blocks, associated maybe with a flattening of the thorax, the distance between spine and anterior chest wall being reduced; and the obverse kyphosis and barrel chest. (3) Pigeon chest and its obverse depressed sternum. These are commonly associated with asthma, bronchitis, bronchiectasis, and a susceptibility to pneumonia, and perhaps with dextrocardia and even dissecting aneurysm. Which comes first-the bronchitis, &c., or the deformity-is hard to but it is that the British say, possible susceptibility to bronchitis is partly congenital.
(2)
normal. The=erialpO2 was 67 mm. Hg, the pCO,, 24 mm. Hg, the pH 7-46 and the hxmoglobin saturation 94%. The carbondioxide content of a different sample of venous blood was 15-7 mEq. per litre. Microscopic examination of renal tissue obtained by percutaneous biopsy revealed abnormalities in all glomeruli consisting of extensive cellular proliferation, crescent and fibroustissue formation, neutrophil infiltration, patchy areas of necrosis, and adhesions of the glomerular tufts to Bowman’s capsule. All glomeruli appeared to be in approximately the same " subacute." stage of evolution, probably best classified as The tubules appeared normal except for proteinacious and haematin casts, and there was minimal interstitial inflammation. Several small arterioles appeared normal. The patient was given 60 mg. of prednisone daily, and, except for a transient period of subjective wellbeing, had a downhill course over ten days, with a rise of blood-urea nitrogen to 250 mg. per 100 ml., hyperkalaemia to 6-7 mEq. per litre, and, terminally, gross haemoptysis and severe dyspnoea. Permission for necropsy was not obtained.
The association of diffuse pulmonary haemorrhage with nephritis has an ominous prognosis. Although the cause of this disorder remains unclear, adrenal steroids in most instances have failed to alter the clinical course.
seen
D. HAMILTON. NEPHRITIS WITH LUNG HÆMORRHAGE
SIR,-Glomerulonephritis with associated pulmonary hemorrhage, commonly referred to as Goodpasture’s syndrome,! is uncommon and usually rapidly fatal. 2-6 In 4 of the 5 patients who were treated with adrenal steroids, there was no apparent change in the clinical course.3-6 We wish to describe an additional re-emphasise the ineffectiveness of steroids.
case
and
to
A 35-year-old white male had malaise, feverish feelings, and two weeks before admission to hospital, followed by spasms of coughing productive of bright-red blood several
chills
times daily. These symptoms, accompanied by dyspnoea, weakness, and cloudy urine, continued until admission. He had a normal temperature and blood-pressure, a pulse-rate of 112 per minute, and a few scattered rales over both posterior lung fields. X-ray of the chest showed extensive infiltrations extending outward from both hilar areas. The haemoglobin was 6 g. per 100 ml., the white-cell count was 12,400 with a normal differential, the blood-urea nitrogen 44 mg. per 100 mi., the serum-sodium, potassium, and chloride were normal, and the antistreptolysin titre was not increased. Urinalysis revealed a pH of 5-0, a specific gravity of 1-012, -I--I--Iproteinuria, and many white cells, red cells, hyaline, and redcell casts on microscopy. The patient was given several transfusions of whole blood and felt somewhat improved. Vital capacity, total lung capacity, and residual volume were reduced to approximately 70% of predicted values, there was no obstruction to air flow, and the diffusing capacity was just below the lower limits of 1. 2.
Goodpasture, E. W. Amer. J. med. Sci. 1919, 158, 863. Parkin, T. W., Rusted, I. E., Burchall, H. B., Edwards, J. E. Amer. J. Med. 1955, 18, 220. 3. Rusby, N. L., Wilson, C. Quart. J. Med. 1962, 116, 501.
4. 5. 6.
Leff, I. L., Fazekas, G. Ann. intern. Med. 1962, 56, 296. Saltzman, R. W., West, M., Chomet, B. ibid. p. 409. Soergel, K. H., Sommers, S. C. Amer. J. Med. 1962, 32, 499.
Boston Veterans Administration
Hospital, Boston, Massachusetts.
RUSSELL E. RANDALL, Jr. JON S. GLAZIER MARVIN LIGGETT.
GLUTEN, CŒLIAC DISEASE, AND COLLAGEN SYNDROMES
SIR,-In their important article, Digestive System Manifestations of the Collagen Diseases,l Patterson and Wierzbinski show how commonly alimentary lesions are found in these syndromes. But both their title and their text imply that involvement of the small intestine is only incidental to the systemic process. In my opinion it is primary and crucial. Hitherto the significance of this small-gut involvement has been consistently underratedpartly because of the tradition whereby pathologists are influenced by what is seen clinically first, and partly because the sterile autoimmune theory of the pathogenesis of collagen syndromes at present prevails.2 According to the new concept which I briefly outline here, collagen syndromes arise from a primary lesion in the small intestine. And they can, I believe, be explained by hereditary maladaptation to a new type of food. In the biological history of human beings, the use of grains is a comparatively recent innovation; and for prepalaeolithic man, predominantly carnivorous, it must have been biologically disturbing and abrupt. The domestication of cereals (particularly wheat and rye) led from nomadism to agriculture and eventually to civilisation.3 But the epochal changes when man changed from a food gatherer, predator, and cannibal to a food producer may well have been paralleled by the failure of a significant minority to cope with the new foodstuff-through enzyme inadequacy. This failure of adaptation, in prehistoric times, could have taken the form of widespread and severe coeliac disease-an inherited disorder in which the small intestine cannot function properly in the presence of gluten. To coeliacs, cereal food-or more precisely the gluten complex it contains-would be lethal before they could reach reproductive maturity; and a trait which was partially dominant could in this way have become rare (as 1. Patterson, J. F., Wierzbinski, S. J. Med. Clin. N. Amer. 1962, 46, 1387. 2. Richardson, J. Brit. med. J. 1961, i, 1187. 3. Braidwood, R. J., Howe, B. Prehistoric Investigation in Iraqi Kurdistan; p. 163. Chicago, 1960.