- Email: [email protected]
THE MINISTER ON THE N.H.S.
1074
Letters to the Editor SENIOR NURSING-STAFF STRUCTURE SIR,-There is at present being circulated among hospitals a report of a committee widely known by the chairman’s name as the Salmon report.! It is a long, ingenious, and rather verbose document, but most consultants need only study with care two parts of it. The first is that on the status of ward sisters, henceforward apparently to be denigrated with the title, significantly redolent of prison and Poor Law, of charge nurses. The second is on nurse teaching. Status of Ward Sisters The report as a whole is very sensibly designed to tidy up the present chaos in which any head of a nursing team in a hospital, whether it has 20 beds or 2000, is known as a matron, and anyone beneath her who is not a nurse or a sister as an assistant matron. But in doing so the committee has erected a formidable hierarchy. Since the nursing members of the committee were all administrators it is not surprising that the status of administrators is enhanced. Since ward sisters were not members of the committee it is not perhaps surprising that theirs is depressed. If in fact this report is implemented one wonders whether any nurse with ability and self-respect will ever consent to remain a ward sister for more than a short term. She will hold the lowliest job but one in this hierarchy, and she will have above her a nursing officer who is fully equipped to act with the maximum power of detailed interference but who, because she has five wards to control ", will neither take the doctor’s instructions directly nor have the patients’ intimate confidence. Sir James Spence said, in a celebrated passage: " the essential unit of medical practice is the occasion when in the intimacy of the consulting room or sick room a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it." Because the community believes that this is the essential unit, it regards most highly those persons most skilled in consultation and personal treatment, and it rewards them accordingly. To the persons who facilitate this art, the medical administrators, the community is grateful as it should be, but not more so. The senior administrative medical officer of a regional hospital board may " control " 200 hospitals but he is not graded higher or paid more than a senior consultant in any one of them. Because he has administrative gifts he ascends a ladder which is parallel to but is not derived from or above that of the clinician. What is the corollary of this in the nursing world ? Can we paraphrase Spence for that world ? I think we can. I suggest the following: " the essential unit of hospital nursing is the circumstance in which a person ill in a ward looks to the sister to carry out the instructions given her by doctors promptly and accurately, and in addition both to anticipate and to relieve those many needs and discomforts, physical and mental, which attend his illness. This is the art of nursing and all else in the nursing world derives from it." The public knows this, our "
profession knows it, and secretly the administering nursing profession knows it too. The " centurion " of nurses (grade 7 in the Salmon report) may pretend to have control " of 150 beds and may have deployment of 100 nurses, and she is fulfilling a useful community service, but she is not nursing, and no amount of verbiage can disguise this. Does the community really want her held in higher esteem and paid more because she has " administrative gifts " ? I doubt it. The report of course does not apportion salaries to these posts, but one would "
not to believe that the is the higher the grade the greater the pay. It would not be the least bit difficult to arrange that ward sisters receive status and pay commensurate with their skill and their seniority through a lifetime of personal service to patients if they wish. If after a period they want a change they could be transferred to other employment in the nursing world, in 1. Report of the Committee on Senior Nursing Staff Structure. H.M. Stationery Office. 1966. See Lancet, 1966, i, 1085.
have
to
be very
principle expected
ingenuous indeed
administration or elsewhere, without loss of pay or self-respect, but if they do so elect for a change let us not be deluded into pretending that they are about to perform a higher form of nursing. There may be good reason why a matron should be paid more than the most highly skilled and senior of her staff, but there is no reason at all why her administrative assistants should be. Nurse Teaching The second part of the report to be looked at is that on teaching. Because teaching is the subject of a separate report -the Platt report-it has not received much attention in this one. But strangely no attempt has been made to integrate teaching into the structure of the nursing profession as a whole. The subject matter of the teaching is changing constantly, the changes being nearly always instigated by doctors and almost never by nurses. But the nurses who teach form a closed caste, prepared for their work by a two-year course, just like those who choose to spend a lifetime teaching Latin or elementary mathematics. On this basis they then teach solidly for some 44 weeks a year, and never nurse another patient in their lives -they might want to in their early years, but they are too exalted, and after a while the desire goes and is replaced by fear. Is it surprising that relations between ward sisters and nursing tutors are so bad,and that among the latter recruitment is low and wastage high. The Salmon report does nothing about this, except to strengthen the gilded rails of the platform which keeps nursing teachers above and apart. Fortunately, some hospitals already send all ward sisters on first appointment to the nurses training school to learn something of the art of teaching. It is high time that all new sister tutors were made to spend several weeks of each year doing holiday duty in different wards and departments of their hospital, without loss of pay, and that they were then expected to keep up this habit for the rest of their tutoring career. Whether they should all be paid more than ward sisters is, I think, arguable. It is not difficult for a young and intelligent nurse to study and take examinations, for which she certainly deserves some recompense. If she comes back to ward work again she should be stepped up several rungs of what should be a long ladder of ward sisters’ pay on account of this extra skill, but she is not, by the very fact of having had this teaching-training, a better nurse. In any case it is high time the question was asked whether the nursing tutor’s course needs to be two years. Does she need two years to learn all that she ought to know, or does she need two years only in order to justify her extra pay ? These are questions which consultants should be asking themselves before they find all their patients in the hands of charge-nurses who are just collecting experience on their way to higher things or have not the brains to get on, or, if they are very lucky indeed, in the hands of rare selfless persons who have decided to forgo material rewards in order to retain the privilege of doing the one thing which they wished to do when they took up the nursing profession-namely, to nurse sick
oeoole. Newcastle upon Tyne 3.
H. A. DEWAR.
THE MINISTER ON THE N.H.S. to the last two questions put to him in his interview with The Lancet (Oct. 29, p. 957), Mr. Kenneth Robinson makes statements about responsibility which illustrate the depth of the gulf between politician and profession, which betray a complete misunderstanding of professional relations, and which, if used as a basis for action, will destroy the National Health Service. The statements are as
SiR,ņIn his replies
follows: " ... one of the healthiest things about the National Health Service is that anything that any of us do is subject to the scrutiny of Parliament.... It is accountable to the people through their elected representatives inevitably if one set up anything on the lines of the B.B.C. or the U.G.C. the accountability to the public would be would be overminimal, and, whatever gains there might be whelmingly counterbalanced by the disappearance of this principle of accountability. ...
...
1075 "... in a service which deals with people, and people at their most vulnerable when they are ill, I think that it is absolutely vital that any member of Parliament on behalf of any of his constituents can get up in the House of Commons and ask me why that constituent was not properly treated at such-and-such a hospital ".
These statements and sentiments are fundamentally wrong. The healthiest thing about a profession is its direct accountability to the public, and the healthiest thing about a professional training is that it teaches a man this sort of accountability. We carry this responsibility to patients fully on our own shoulders and the appearance or disappearance of the Health Service has nothing to do with it. Personal responsibility of this" sort is worth a hundred of the sorts of accountabilities transmitted via members of Parliament, Ministers of Health, and Government departments, and must not be taken over by them. If the Minister wants to answer specific complaints about the specific treatment of a specific patient at a specific hospital, then he is envisaging a take-over which can be nothing less than disastrous for patients and doctors alike, and which must not happen. Complaints should be directed to and dealt with by the doctor concerned; and if the outcome is unsatisfactory the patient should be directed to the hospital medical staff committee, who should I hope care enough about medicine to put the patient’s welfare before any fear of correcting a colleague. If we do not care in this way, then we are not mature enough to be doctors, let alone to be on medical committees, and it is right and proper that we should be treated as schoolchildren, sneaked on by patients, and given a wigging by teacher. My main fear, from the letters and conversations by which one learns the view of one’s colleagues, is that we have already shirked our responsibilities and allowed this sort of parliamentary accountability to take over. If it goes on the next generation of doctors will be unfit to take these responsibilities upon themselves, and the profession will have lost control of its conscience and will find itself (as has already been suggested) attempting to recreate a favourable public image by the pathetic varnishings of a public-relations officer. The Hospital for Sick Children, Great Ormond Street, NIGEL LEGG. London W.C.1. "
SIR,-It is disappointing to learn from the report of the interview that The Lancet had with the Minister of Health that he has rejected the idea of raising money by a national sweepstake. He does not say why, except that " it isn’t only a question of money that bedevils the N.H.S. This "
seems
poor grounds for not solving what is a huge problem, even
if it is
not
the only one I would submit that it is the main probcan hardly be a hospital in the country that is not crying out for funds-for rebuilding, for equipment, and for better staff accommodation. Adequate funds could solve the staff shortage as well, for they would permit reasonable salaries to be paid to medical staff, and stem the vast emigration; they would enable the nursing staff to be properly remunerated, and reduce the loss of trained nurses into industry and private work; and they would allow much more use to be made of ancillary workers such as ward clerks and technicians, leaving medical and nursing staff free for looking after patients, rather than for form-filling and other non-professional tasks. It is money alone which limits the number and quality of recruits to the last category. Imposing a small charge for treatment which, in these days, most people could meet, is a measure which much of the profession-especially G.P.S.-would welcome.
lem. There
Romsey,
Hampshire.
JAMES M. B. BURN.
PROLONGED COMA AFTER HEAD INJURY SIR,-In their article (Oct. 29, p. 938) Dr. Crompton and his colleagues state that the nine people whose brains they examined had had no evidence of intracranial hasmatoma or of posttraumatic oedema and yet they say that there had been no lucid interval of consciousness after injury. I submit that the persis-
loss of consciousness is sufficient evidence of itself to suppose that the brain may have been excessively swollen as the result of the head injury. The lesions above and below the tentorium could still be accounted for by the secondary effect of the cerebral swelling following trauma and/or asphyxia soon after injury. Neurosurgical Unit, Hurstwood Park Hospital, Haywards Heath, W. J. ATKINSON. Sussex. tent
GASTRIC ULCER AND GASTRITIS SIR,-The letter from Dr. Anderson and Mr. Soman (Oct. 22, p. 908) interested me for several reasons, on which I should like to comment. The " earlier beliefs " on the influence of hyperacidity in the genesis of gastric and duodenal ulcer were born of the chance discovery that acid was the one factor in gastric which could easily be measured. Since then physiology " acidity " has dominated the thinking of pathologists on the subject, and in the realm of therapeutics, medical or surgical, everything which appeared to reduce gastric acidity has been considered " physiological " treatment. In the light of modern methods the " earlier beliefs " are seen to have been founded on very inadequate analytical procedures-and the more refined analyses of today produce much conflicting evidencebut acidity " has lost none of its mystique. Dr. Anderson and Mr. Soman refer to the fact that a persisting gastritis will, in adverse circumstances, lead to chronic gastric ulcer. I am in hearty agreement, but I object to the inference that no stage exists between gastritis and chronic ulcer, with implied slur on the acute ulcer, which is infinitely more common than the chronic ulcer and is a far more potent cause of all the manifestations of the disease, including dyspepsia, haemorrhage, and perforation. Obsession with the chronic ulcer ranks with the fetish of acidity as a cause of wrong thinking on peptic disease. Dr. Anderson and Mr. Soman cite Mackay and Hislop as finding that " ulceration could heal in the presence of continuing widespread gastritis ". They could as well cite the experience of every surgeon who has ever done a partial gastrectomy for peptic disease and has troubled to look at his specimen with his naked eye and microscopically. In many patients with proved ulcer this has healed by the time the operation is performed, yet in all such cases microscopic examination shows persisting gastritis. It is indeed because of the readiness with which ulcers will heal in the presence of chronic gastritis that so-called medical " treatment is so frequently successful in healing the ulcer " -but medical treatment cannot prevent the almost invariable recurrence of ulcers and symptoms. Hitherto this has been achieved only by surgical operation-partial gastrectomy achieves it by removing the more severe and irreversible gastritis in the pyloric half of the stomach. Other successful surgical methods doubtless cure or modify the chronic gastritis in some other way. Edgware General Hospital, FRANK FORTY. Middlesex. "
EFFECTS OF VAGOTOMY reference to my letter on this subject,! I should SIR,-With like to modify the position, as stated at that time, and to amplify it. My statement, that no case of persistent or episodic diarrhoea had been seen following selective vagotomy, was based on reports of my follow-up observers, who were referring to the incidence of serious and disabling diarrhoea. After careful personal scrutiny of the notes on these patients, who had had vagotomy and pyloroplasty performed, it seems best to classify diarrhoeas into the following two types: 1. Severe diarrhcea. 1.
This is often extremely urgent, is possibly
Hendry, W. G. Lancet, 1966, i,
1425.
Letters to the Editor SENIOR NURSING-STAFF STRUCTURE SIR,-There is at present being circulated among hospitals a report of a committee widely known by the chairman’s name as the Salmon report.! It is a long, ingenious, and rather verbose document, but most consultants need only study with care two parts of it. The first is that on the status of ward sisters, henceforward apparently to be denigrated with the title, significantly redolent of prison and Poor Law, of charge nurses. The second is on nurse teaching. Status of Ward Sisters The report as a whole is very sensibly designed to tidy up the present chaos in which any head of a nursing team in a hospital, whether it has 20 beds or 2000, is known as a matron, and anyone beneath her who is not a nurse or a sister as an assistant matron. But in doing so the committee has erected a formidable hierarchy. Since the nursing members of the committee were all administrators it is not surprising that the status of administrators is enhanced. Since ward sisters were not members of the committee it is not perhaps surprising that theirs is depressed. If in fact this report is implemented one wonders whether any nurse with ability and self-respect will ever consent to remain a ward sister for more than a short term. She will hold the lowliest job but one in this hierarchy, and she will have above her a nursing officer who is fully equipped to act with the maximum power of detailed interference but who, because she has five wards to control ", will neither take the doctor’s instructions directly nor have the patients’ intimate confidence. Sir James Spence said, in a celebrated passage: " the essential unit of medical practice is the occasion when in the intimacy of the consulting room or sick room a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice of medicine derives from it." Because the community believes that this is the essential unit, it regards most highly those persons most skilled in consultation and personal treatment, and it rewards them accordingly. To the persons who facilitate this art, the medical administrators, the community is grateful as it should be, but not more so. The senior administrative medical officer of a regional hospital board may " control " 200 hospitals but he is not graded higher or paid more than a senior consultant in any one of them. Because he has administrative gifts he ascends a ladder which is parallel to but is not derived from or above that of the clinician. What is the corollary of this in the nursing world ? Can we paraphrase Spence for that world ? I think we can. I suggest the following: " the essential unit of hospital nursing is the circumstance in which a person ill in a ward looks to the sister to carry out the instructions given her by doctors promptly and accurately, and in addition both to anticipate and to relieve those many needs and discomforts, physical and mental, which attend his illness. This is the art of nursing and all else in the nursing world derives from it." The public knows this, our "
profession knows it, and secretly the administering nursing profession knows it too. The " centurion " of nurses (grade 7 in the Salmon report) may pretend to have control " of 150 beds and may have deployment of 100 nurses, and she is fulfilling a useful community service, but she is not nursing, and no amount of verbiage can disguise this. Does the community really want her held in higher esteem and paid more because she has " administrative gifts " ? I doubt it. The report of course does not apportion salaries to these posts, but one would "
not to believe that the is the higher the grade the greater the pay. It would not be the least bit difficult to arrange that ward sisters receive status and pay commensurate with their skill and their seniority through a lifetime of personal service to patients if they wish. If after a period they want a change they could be transferred to other employment in the nursing world, in 1. Report of the Committee on Senior Nursing Staff Structure. H.M. Stationery Office. 1966. See Lancet, 1966, i, 1085.
have
to
be very
principle expected
ingenuous indeed
administration or elsewhere, without loss of pay or self-respect, but if they do so elect for a change let us not be deluded into pretending that they are about to perform a higher form of nursing. There may be good reason why a matron should be paid more than the most highly skilled and senior of her staff, but there is no reason at all why her administrative assistants should be. Nurse Teaching The second part of the report to be looked at is that on teaching. Because teaching is the subject of a separate report -the Platt report-it has not received much attention in this one. But strangely no attempt has been made to integrate teaching into the structure of the nursing profession as a whole. The subject matter of the teaching is changing constantly, the changes being nearly always instigated by doctors and almost never by nurses. But the nurses who teach form a closed caste, prepared for their work by a two-year course, just like those who choose to spend a lifetime teaching Latin or elementary mathematics. On this basis they then teach solidly for some 44 weeks a year, and never nurse another patient in their lives -they might want to in their early years, but they are too exalted, and after a while the desire goes and is replaced by fear. Is it surprising that relations between ward sisters and nursing tutors are so bad,and that among the latter recruitment is low and wastage high. The Salmon report does nothing about this, except to strengthen the gilded rails of the platform which keeps nursing teachers above and apart. Fortunately, some hospitals already send all ward sisters on first appointment to the nurses training school to learn something of the art of teaching. It is high time that all new sister tutors were made to spend several weeks of each year doing holiday duty in different wards and departments of their hospital, without loss of pay, and that they were then expected to keep up this habit for the rest of their tutoring career. Whether they should all be paid more than ward sisters is, I think, arguable. It is not difficult for a young and intelligent nurse to study and take examinations, for which she certainly deserves some recompense. If she comes back to ward work again she should be stepped up several rungs of what should be a long ladder of ward sisters’ pay on account of this extra skill, but she is not, by the very fact of having had this teaching-training, a better nurse. In any case it is high time the question was asked whether the nursing tutor’s course needs to be two years. Does she need two years to learn all that she ought to know, or does she need two years only in order to justify her extra pay ? These are questions which consultants should be asking themselves before they find all their patients in the hands of charge-nurses who are just collecting experience on their way to higher things or have not the brains to get on, or, if they are very lucky indeed, in the hands of rare selfless persons who have decided to forgo material rewards in order to retain the privilege of doing the one thing which they wished to do when they took up the nursing profession-namely, to nurse sick
oeoole. Newcastle upon Tyne 3.
H. A. DEWAR.
THE MINISTER ON THE N.H.S. to the last two questions put to him in his interview with The Lancet (Oct. 29, p. 957), Mr. Kenneth Robinson makes statements about responsibility which illustrate the depth of the gulf between politician and profession, which betray a complete misunderstanding of professional relations, and which, if used as a basis for action, will destroy the National Health Service. The statements are as
SiR,ņIn his replies
follows: " ... one of the healthiest things about the National Health Service is that anything that any of us do is subject to the scrutiny of Parliament.... It is accountable to the people through their elected representatives inevitably if one set up anything on the lines of the B.B.C. or the U.G.C. the accountability to the public would be would be overminimal, and, whatever gains there might be whelmingly counterbalanced by the disappearance of this principle of accountability. ...
...
1075 "... in a service which deals with people, and people at their most vulnerable when they are ill, I think that it is absolutely vital that any member of Parliament on behalf of any of his constituents can get up in the House of Commons and ask me why that constituent was not properly treated at such-and-such a hospital ".
These statements and sentiments are fundamentally wrong. The healthiest thing about a profession is its direct accountability to the public, and the healthiest thing about a professional training is that it teaches a man this sort of accountability. We carry this responsibility to patients fully on our own shoulders and the appearance or disappearance of the Health Service has nothing to do with it. Personal responsibility of this" sort is worth a hundred of the sorts of accountabilities transmitted via members of Parliament, Ministers of Health, and Government departments, and must not be taken over by them. If the Minister wants to answer specific complaints about the specific treatment of a specific patient at a specific hospital, then he is envisaging a take-over which can be nothing less than disastrous for patients and doctors alike, and which must not happen. Complaints should be directed to and dealt with by the doctor concerned; and if the outcome is unsatisfactory the patient should be directed to the hospital medical staff committee, who should I hope care enough about medicine to put the patient’s welfare before any fear of correcting a colleague. If we do not care in this way, then we are not mature enough to be doctors, let alone to be on medical committees, and it is right and proper that we should be treated as schoolchildren, sneaked on by patients, and given a wigging by teacher. My main fear, from the letters and conversations by which one learns the view of one’s colleagues, is that we have already shirked our responsibilities and allowed this sort of parliamentary accountability to take over. If it goes on the next generation of doctors will be unfit to take these responsibilities upon themselves, and the profession will have lost control of its conscience and will find itself (as has already been suggested) attempting to recreate a favourable public image by the pathetic varnishings of a public-relations officer. The Hospital for Sick Children, Great Ormond Street, NIGEL LEGG. London W.C.1. "
SIR,-It is disappointing to learn from the report of the interview that The Lancet had with the Minister of Health that he has rejected the idea of raising money by a national sweepstake. He does not say why, except that " it isn’t only a question of money that bedevils the N.H.S. This "
seems
poor grounds for not solving what is a huge problem, even
if it is
not
the only one I would submit that it is the main probcan hardly be a hospital in the country that is not crying out for funds-for rebuilding, for equipment, and for better staff accommodation. Adequate funds could solve the staff shortage as well, for they would permit reasonable salaries to be paid to medical staff, and stem the vast emigration; they would enable the nursing staff to be properly remunerated, and reduce the loss of trained nurses into industry and private work; and they would allow much more use to be made of ancillary workers such as ward clerks and technicians, leaving medical and nursing staff free for looking after patients, rather than for form-filling and other non-professional tasks. It is money alone which limits the number and quality of recruits to the last category. Imposing a small charge for treatment which, in these days, most people could meet, is a measure which much of the profession-especially G.P.S.-would welcome.
lem. There
Romsey,
Hampshire.
JAMES M. B. BURN.
PROLONGED COMA AFTER HEAD INJURY SIR,-In their article (Oct. 29, p. 938) Dr. Crompton and his colleagues state that the nine people whose brains they examined had had no evidence of intracranial hasmatoma or of posttraumatic oedema and yet they say that there had been no lucid interval of consciousness after injury. I submit that the persis-
loss of consciousness is sufficient evidence of itself to suppose that the brain may have been excessively swollen as the result of the head injury. The lesions above and below the tentorium could still be accounted for by the secondary effect of the cerebral swelling following trauma and/or asphyxia soon after injury. Neurosurgical Unit, Hurstwood Park Hospital, Haywards Heath, W. J. ATKINSON. Sussex. tent
GASTRIC ULCER AND GASTRITIS SIR,-The letter from Dr. Anderson and Mr. Soman (Oct. 22, p. 908) interested me for several reasons, on which I should like to comment. The " earlier beliefs " on the influence of hyperacidity in the genesis of gastric and duodenal ulcer were born of the chance discovery that acid was the one factor in gastric which could easily be measured. Since then physiology " acidity " has dominated the thinking of pathologists on the subject, and in the realm of therapeutics, medical or surgical, everything which appeared to reduce gastric acidity has been considered " physiological " treatment. In the light of modern methods the " earlier beliefs " are seen to have been founded on very inadequate analytical procedures-and the more refined analyses of today produce much conflicting evidencebut acidity " has lost none of its mystique. Dr. Anderson and Mr. Soman refer to the fact that a persisting gastritis will, in adverse circumstances, lead to chronic gastric ulcer. I am in hearty agreement, but I object to the inference that no stage exists between gastritis and chronic ulcer, with implied slur on the acute ulcer, which is infinitely more common than the chronic ulcer and is a far more potent cause of all the manifestations of the disease, including dyspepsia, haemorrhage, and perforation. Obsession with the chronic ulcer ranks with the fetish of acidity as a cause of wrong thinking on peptic disease. Dr. Anderson and Mr. Soman cite Mackay and Hislop as finding that " ulceration could heal in the presence of continuing widespread gastritis ". They could as well cite the experience of every surgeon who has ever done a partial gastrectomy for peptic disease and has troubled to look at his specimen with his naked eye and microscopically. In many patients with proved ulcer this has healed by the time the operation is performed, yet in all such cases microscopic examination shows persisting gastritis. It is indeed because of the readiness with which ulcers will heal in the presence of chronic gastritis that so-called medical " treatment is so frequently successful in healing the ulcer " -but medical treatment cannot prevent the almost invariable recurrence of ulcers and symptoms. Hitherto this has been achieved only by surgical operation-partial gastrectomy achieves it by removing the more severe and irreversible gastritis in the pyloric half of the stomach. Other successful surgical methods doubtless cure or modify the chronic gastritis in some other way. Edgware General Hospital, FRANK FORTY. Middlesex. "
EFFECTS OF VAGOTOMY reference to my letter on this subject,! I should SIR,-With like to modify the position, as stated at that time, and to amplify it. My statement, that no case of persistent or episodic diarrhoea had been seen following selective vagotomy, was based on reports of my follow-up observers, who were referring to the incidence of serious and disabling diarrhoea. After careful personal scrutiny of the notes on these patients, who had had vagotomy and pyloroplasty performed, it seems best to classify diarrhoeas into the following two types: 1. Severe diarrhcea. 1.
This is often extremely urgent, is possibly
Hendry, W. G. Lancet, 1966, i,
1425.