40 year Tuskegee syphilis experiment and the Non-consensual experiments in Guatemala
Originally Posted by LJS - This whole idea that researchers are intentionally hiding information on CFS is completely ridiculous. ...
I think this thread should be locked, I do not want new comers visiting the forum thinking a majority of CFS believe in these ridicules conspiracy and government cover up theories.
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OK. When I was first reading about conspiracy theories and CFIDS years ago I too thought it was all just crazy stuff. But, when the information was put together, all the weird pieces from the US and the UK, I could conclude nothing else but that there was indeed conspiracy at work with regards to CFS research, origin, etc. Americans don't want to believe that our country is capable of being evil like this. I didn't want to believe it either. I supported the Federal government as a contractor, but...when you look at the actions of the CDC and other Fed health orgs during the last three decades and then look over at all that has/is going on in the UK, you can really only conclude one thing: somebody(ies) have/are up to no good with ME/CFS. Have you read Hillary Johnson's Osler's Web? You can read the major points on her website at
www.oslersweb.com -
I believe that Dr. Collins (NIH) did publicly state that there was "40 deliberate infections" that are being investigated, reaching up to the White House. That's not theory - not when the head of the NIH states publicly that there are 40 other "deliberate infections".
Let us review what the US Public Health organizations have done to their own population in the South during a 40 year period starting before WWII and running on until 1972. Then let's look at what the US Public Health orgs did AFTER WWII and the horrors of Nazi Germany human experimentation (1946 to 1948) in Guatemala:
So, conpiracy theories must remain on this site. They are part of the picture even though none of us wants to believe our country's are capable of evil. Actually, it really is just a few evil people within our governments, like Reeves et al at the CDC and the Weasel, et al in the UK.
In the WIKI below it really was only a small group of people doing the evil. However, in the Tuskegee experiment it took 40 years before someone came forward and tried to get people to listen. I believe it took two years before he got someone to listen and look into this situation. The same man that ran the Guatemala experiment was also running the Tuskegee experiement as well. And until the day he died, he saw nothing wrong in his actions.
So, it takes one or just a few people to do major damage and destruction and not a whole government. And we see that with tiny groups or individuals in terrorism and we are seeing it again and again in basic research, medicine, etc. Anywhere humans and their egos and money are involved.
This is not a whack job conspiracy thing - sadly it is all probably very true. So, no, I don't believe this topic of conspiracy theories will be closed. It is part of the politics and history of CFS/ME, retrovirus research, and anything that has to do with human beings.
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Tuskegee syphilis experimentFrom Wikipedia, the free encyclopedia See also: Human experimentation in the United States
A doctor draws blood from one of the Tuskegee test subjects
The Tuskegee syphilis experiment[1] (
also known as the Tuskegee syphilis study or Public Health Service syphilis study) was a clinical study conducted between 1932 and 1972 in Tuskegee, Alabama, by the U.S. Public Health Service. Investigators recruited 399 impoverished African-American sharecroppers, who were already infected with syphilis, for research related to the natural progression of the untreated disease.[1]
The Public Health Service, working with the Tuskegee Institute, began the study in 1932. Nearly 400 poor black men with syphilis from Macon County, Ala., were enrolled in the study. For participating in the study, the men were given free medical exams, free meals and free burial insurance. They were never told they had syphilis, nor were they ever treated for it. According to the Centers for Disease Control, the men were told they were being treated for "bad blood," a local term used to describe several illnesses, including syphilis, anemia and fatigue.
The 40-year study was controversial for reasons related to ethical standards, primarily because researchers failed to treat patients appropriately after the 1940s validation of penicillin as an effective cure for the disease. Revelation of study failures led to major changes in U.S. law and regulation on the protection of participants in clinical studies. Now studies require informed consent (with exceptions possible for U.S. Federal agencies which can be kept secret by Executive Order[2]), communication of diagnosis, and accurate reporting of test results.[3]
By 1947 penicillin had become the standard treatment for syphilis. Choices might have included treating all syphilitic subjects and closing the study, or splitting off a control group for testing with penicillin. Instead, the Tuskegee scientists continued the study, withholding penicillin and information about it from the patients. In addition, scientists prevented participants from accessing syphilis treatment programs available to others in the area. The study continued, under numerous supervisors, until 1972, when a leak to the press resulted in its termination. Victims included numerous men who died of syphilis, wives who contracted the disease, and children born with congenital syphilis.[4]
The Tuskegee Syphilis Study, cited as "arguably the most infamous biomedical research study in U.S. history,"[5] led to the 1979 Belmont Report and the establishment of the Office for Human Research Protections (OHRP).[6] It also led to federal regulation requiring Institutional Review Boards for protection of human subjects in studies involving human subjects. The Office for Human Research Protections (OHRP) manages this responsibility within the US Department of Health and Human Services (HHS).[7]
Contents [hide]
1 History
1.1 Study clinicians
1.2 Study details
2 Non-consensual experiments in Guatemala
3 Study termination
4 Aftermath
5 Ethical implications
6 In popular culture
7 See also
8 References
9 Further reading
9.1 Primary sources
9.2 Secondary Sources
10 External links
[edit] History
[edit] Study clinicians
“ For the most part, doctors and civil servants simply did their jobs. Some merely followed orders, others worked for the glory of science. ”
— Dr John Heller, Director of the Public Health Service's Division of Venereal Diseases[8]
Some of the Tuskegee Study Group clinicians. Dr. Reginald D. James (third to right), a black physician involved with public health work in Macon County, was not directly involved in the study. Nurse Rivers is on the left.
Dr. Taliaferro Clark
Dr. Oliver WengerThe venereal disease section of the U.S. Public Health Service (PHS) formed a study group at its national headquarters. Dr. Taliaferro Clark was credited with its origin. His initial goal was to follow untreated syphilis in a group of black men for 6 to 9 months, and then follow up with a treatment phase. When he understood the intention of other study members to use deceptive practices, Dr. Clark disagreed with the plan to conduct an extended study.[clarification needed] He retired the year after the study began.
Representing the PHS, Clark had solicited the participation of the Tuskegee Institute (a historically black college (HBCU) that was well-known in Alabama) and of the Arkansas regional PHS office. Dr. Eugene Dibble, an African American doctor, was head of the John Andrew Hospital at the Tuskegee Institute. Dr. Oliver C. Wenger, a caucasian, was director of the regional PHS Venereal Disease Clinic in Hot Springs, Arkansas. He and his staff took a lead in developing study procedures.
Wenger and his staff played a critical role in developing early study protocols. Wenger continued to advise and assist the Tuskegee Study when it turned into a long-term, no-treatment observational study.[9]
Dr. Raymond H. Vonderlehr was appointed on-site director of the research program and developed the policies that shaped the long-term follow-up section of the project. For example, he decided to gain the "consent" of the subjects for spinal taps (to look for signs of neurosyphilis) by depicting the diagnostic test as a "special free treatment". Vonderlehr retired as head of the venereal disease section in 1943, shortly after penicillin had first been shown to be a cure for syphilis.
Nurse Eunice Rivers, an African-American trained at Tuskegee Institute who worked at its affiliated John Andrew Hospital, was recruited at the start of the study. Dr. Vonderlehr was a strong advocate for her participation, as she was the direct link to the community. During the Great Depression of the 1930s, the Tuskegee Study began by offering lower class African Americans, who often could not afford health care, the chance to join "Miss Rivers' Lodge". Patients were to receive free physical examinations at Tuskegee University, free rides to and from the clinic, hot meals on examination days, and free treatment for minor ailments.
As the study became long term, Nurse Rivers became the chief person with continuity. Unlike the changing state of national, regional and on-site PHS administrators, doctors, and researchers, Rivers stayed at Tuskegee University. She was the only study staff person to work with participants for the full 40 years. By the 1950s, Nurse Rivers had become pivotal to the study—her personal knowledge of the subjects enabled maintenance of long-term follow up. In the study's later years, Dr. John R. Heller led the national division.
By the late 1940s, doctors, hospitals and public health centers throughout the country routinely treated diagnosed syphilis with penicillin. In the period following World War II, the revelation of the Holocaust and related Nazi medical abuses brought about changes in international law. Western allies formulated the Nuremberg Code to protect the rights of research subjects. No one appeared to have reevaluated the protocols of the Tuskegee Study according to the new standards.
In 1972 the Tuskegee Study was brought to public and national attention by a whistleblower, who gave information to the Washington Star and the New York Times. Heller of PHS still defended the ethics of the study, stating: "The men's status did not warrant ethical debate. They were subjects, not patients; clinical material, not sick people."[10]Dr. Raymond Vonderlehr
Dr. John Heller
Dr. Eugene Dibble
Eunice Rivers, nurse and study co-ordinator
[edit] Study details
Subject blood draw, circa 1953A Norwegian in 1928 had reported on the pathologic manifestations of untreated syphilis in several hundred White males. This study is known as a retrospective study since investigators pieced together information from the histories of patients who had already contracted syphilis but remained untreated for some time.
Subjects talking with study coordinator, Nurse Eunice RiversThe Tuskegee study group decided to build on the Oslo work and perform a prospective study to complement it. In the earlier phases of the study this was not inherently unethical since there was nothing the investigators could do therapeutically at the time. Researchers could study the natural progression of the disease as long as they did not harm their subjects. They reasoned that the knowledge gained would benefit humankind, however, it was determined afterward that the doctors did harm their subjects, by depriving them of appropriate treatment that could have been administered once it had been discovered. The study was characterized as "the longest non-therapeutic experiment on human beings in medical history."[11]
The US health service Tuskegee study began as a clinical trial of the incidence of syphilis in the Macon County population. Initially, subjects were studied for six to eight months and then treated with contemporary methods including Salvarsan, mercurial ointments, and bismuth. These methods were, at best, mildly effective. The disadvantage that these treatments were all highly toxic was balanced by the fact that no other methods were known. The Tuskegee Institute participated in the study, as its representatives understood the intent was to benefit public health in the local poor population.[12] The Tuskegee University-affiliated hospital effectively loaned the PHS its medical facilities and other predominantly black institutions and local black doctors participated as well. The Rosenwald Fund, a major Chicago-based philanthropy devoted to black education and community development in the South, provided financial support to pay for the eventual treatment of the patients. Study researchers initially recruited 399 syphilitic Black men, and 201 healthy Black men as controls.
Continuing effects of the Stock Market Crash of 1929 and the beginning of the Great Depression led the Rosenwald Fund to withdraw its offer of funding. Study directors issued a final report as they thought this might mean the end of the study once funding to buy medication for the treatment phase of the study was withdrawn.
Medical ethics considerations were limited from the start and rapidly deteriorated. To ensure that the men would show up for the possibly dangerous, painful, diagnostic, and non-therapeutic spinal taps, the doctors sent the 400 patients a misleading letter titled "Last Chance for Special Free Treatment" (see insert). The study also required all participants to undergo an autopsy after death in order to receive funeral benefits. After penicillin was discovered as a cure, researchers continued to deny such treatment to many study participants. Many patients were lied to and given placebo treatments so researchers could observe the full, long term progression of the fatal disease.[12]
Drawing blood from subject for testing.The Tuskegee Study published its first clinical data in 1934 and issued their first major report in 1936. This was prior to the discovery of penicillin as a safe and effective treatment for syphilis. The study was not secret since reports and data sets were published to the medical community throughout its duration.
During World War II, 250 of the subject men registered for the draft. These men were consequently diagnosed as having syphilis at military induction centers and ordered to obtain treatment for syphilis before they could be taken into the armed services.[13]
PHS researchers prevented them from getting treatment, thus depriving them of chances for a cure, service to the nation, and gaining the benefit of the G.I. Bill for education, passed after the war. At the time, the PHS representative was quoted as saying: "So far, we are keeping the known positive patients from getting treatment."[13]
By 1947 penicillin had become standard therapy for syphilis. The US government sponsored several public health programs to form "rapid treatment centers" to eradicate the disease. When campaigns to eradicate venereal disease came to Macon County, study researchers prevented their patients from participating.[13]
By the end of the study in 1972, only 74 of the test subjects were alive. Of the original 399 men, 28 had died of syphilis, 100 were dead of related complications, 40 of their wives had been infected and 19 of their children were born with congenital syphilis.
[edit]
Non-consensual experiments in Guatemala
Main article: Syphilis experiments in GuatemalaIn October 2010 it was revealed that in Guatemala, the project went even further.
It was reported that from 1946 to 1948, American doctors deliberately infected prisoners, soldiers, and patients in a mental hospital with syphilis and, in some cases, gonorrhea, with the cooperation of some Guatemalan health ministries and officials. A total of 696 men and women were exposed to syphilis without the informed consent of the subjects. When the subjects contracted the disease they were given antibiotics though it is unclear if all infected parties were cured.[14] Wellesley College's historian Susan Reverby made the discovery while examining archived records of John Charles Cutler, a government researcher involved in the now infamous Tuskegee study.[15]
In October 2010, the U.S. formally apologized to Guatemala for conducting these experiments.
[edit] Study termination
Peter Buxtun, a PHS venereal disease investigator, the "whistle-blower".
Group of Tuskegee Experiment test subjects
Charlie Pollard, survivor
Herman Shaw, survivorIn 1966 Peter Buxtun, a PHS venereal-disease investigator in San Francisco, sent a letter to the national director of the Division of Venereal Diseases to express his concerns about the ethics and morality of the extended Tuskegee Study. The Center for Disease Control (CDC), which by then controlled the study, reaffirmed the need to continue the study until completion; i.e., until all subjects had died and been autopsied. To bolster its position, the CDC sought, and gained support for the continuation of the study, from local chapters of the National Medical Association (representing African-American physicians) and the American Medical Association (AMA).
In 1968 William Carter Jenkins, an African-American statistician in the PHS, part of the Department of Health, Education, and Welfare (HEW), founded and edited The Drum, a newsletter devoted to ending racial discrimination in HEW. The cabinet-level department included the CDC. In The Drum, Jenkins called for an end to the Tuskegee Study. He did not succeed; it is not clear who read his work.[16]
Buxtun finally went to the press in the early 1970s. The story broke first in the Washington Star on July 25, 1972. It became front-page news in the New York Times the following day. Senator Edward Kennedy called Congressional hearings, at which Buxtun and HEW officials testified. As a result of public outcry the CDC and PHS appointed an ad hoc advisory panel to review the study. It determined the study was medically unjustified and ordered its termination. As part of the settlement of a class action lawsuit subsequently filed by the NAACP, the U.S. government paid $9 million (unadjusted for inflation) and agreed to provide free medical treatment to surviving participants and to surviving family members infected as a consequence of the study.
[edit] Aftermath
In 1974 Congress passed the National Research Act and created a commission to study and write regulations governing studies involving human participants. On May 16, 1997, President Bill Clinton formally apologized and held a ceremony for the Tuskegee study participants: "What was done cannot be undone. But we can end the silence. We can stop turning our heads away. We can look at you in the eye and finally say on behalf of the American people, what the United States government did was shameful, and I am sorry ... To our African American citizens, I am sorry that your federal government orchestrated a study so clearly racist."[17] Five of the eight remaining study survivors attended the White House ceremony.
The Tuskegee Syphilis Study significantly damaged the trust of the black community toward public health efforts in the United States.[18] As a result, many distrust the medical community and are reluctant to participate in programs such as organ donation. The study may also have contributed to the reluctance of many poor black people to seek routine preventive care.[19] Two groups of researchers at Johns Hopkins debated the effects that the Tuskegee Study has had on black Americans and their willingness to participate in medical trials.[20] Distrust of the government because of the study contributed to persistent rumors in the black community that the government was responsible for the HIV/AIDS crisis by introducing the virus to the black community."
In 1990, the Southern Christian Leadership Conference conducted a survey among 1056 African American Church members in five cities. They found that 34% of the respondents believed that AIDS was an artificial virus, 35% believed that AIDS is a form of genocide, and 44% believed that the government is not telling the truth about AIDS."[10]
[edit] Ethical implications
This section requires expansion.
Depression-era U.S. poster advocating early syphilis treatment. Although treatments were available, participants in the study did not receive them.After penicillin was found to be an effective treatment for syphilis, the study continued for another 25 years without treating those suffering from the disease. After the study and its consequences became front-page news, it was ended in a day.[21] The aftershocks of this study, and other human experiments in the United States, led to the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research and the National Research Act. The latter requires the establishment of institutional review boards (IRBs) at institutions receiving federal support (such as grants, cooperative agreements, or contracts).
[edit] In popular culture
Dr. David Feldshuh wrote a stage play in 1992 based on the history of the Tuskegee study, titled Miss Evers' Boys. It was a runner-up for the 1992 Pulitzer Prize in drama.[22] In 1997 it was adapted for an HBO made-for-TV movie. The HBO adaptation was nominated for eleven Emmy Awards,[23] and won in four categories.[24]
Don Byron's debut album, Tuskegee Experiments, is named after the study.[25]
Marvel Comics' limited series Truth: Red, White & Black reinterpreted the Tuskegee Experiment as part of the Weapon Plus program.[26]
Carlo Boccadoro's composition Bad Blood, takes inspiration from the tragic facts and discrimination related to the study.[27]
[edit] See also
Human experimentation in the United States
Human subject research
World Medical Association
International Conference on Harmonisation for Registration of Pharmaceuticals
Declaration of Geneva
Declaration of Helsinki
Operation Whitecoat
[edit] References
1.^ a b "Tuskegee Study - Timeline". NCHHSTP. CDC. 2008-06-25.
http://www.cdc.gov/tuskegee/timeline.htm. Retrieved 2008-12-04.
2.^ "Code of Federal Regulations Title 45 Part 46 Protections of Human Subjects 46.1.1(i)" (PDF). U.S. Department of Health and Humand Services. 2009-01-15.
http://www.hhs.gov/ohrp/documents/OHRPRegulations.pdf. Retrieved 2010-02-22.
3.^ "Final Report of the Tuskegee Syphilis Study Legacy Committee". Tuskegee Syphilis Study Legacy Committee. 1996-05-20.
http://www.hsl.virginia.edu/historical/medical_history/bad_blood/report.cfm. Retrieved 2008-12-04.
4.^ Heller J (1972-07-26). "Syphilis Victims in U.S. Study Went Untreated for 40 Years; Syphilis Victims Got No Therapy". New York Times (Associated Press).
http://select.nytimes.com/gst/abstract.html?res=F40616F6345A137B93C4AB178CD85F468785F9. Retrieved 2008-12-04.
5.^ Katz RV, Kegeles SS, Kressin NR, et al. (November 2006). "The Tuskegee Legacy Project: willingness of minorities to participate in biomedical research". J Health Care Poor Underserved 17 (4): 698–715. doi:10.1353/hpu.2006.0126. PMID 17242525. PMC 1780164.
http://muse.jhu.edu/cgi-bin/resolve...-2089&volume=17&issue=4&spage=698&aulast=Katz.
6.^ Office for Human Research Protections (OHRP) (2005-06-23). "Protection of Human Subjects". Title 45, Code of Federal Regulations, Part 46. US Department of Health and Human Services.
http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm. Retrieved 2008-12-04.
7.^ "Office for Human Research Protections". Department of Health and Human Services. 2008-09-28.
http://www.hhs.gov/ohrp/. Retrieved 2008-12-04.
8.^ Cockburn, Alexander; Jeffrey St. Clair (1998). Whiteout: The CIA, Drugs and the Press. London: Verso. pp. 67. ISBN 1859841392.
http://books.google.com/books?id=s5...&hl=en&sa=X&oi=book_result&resnum=2&ct=result.
9.^ DiClemente RJ, Blumenthal DS (2003). Community-based health research: issues and methods. New York: Springer Pub. pp. 50. ISBN 0-8261-2025-3.
http://www.google.co.in/books?id=KN_-9lwSI5oC.
10.^ a b "Research Ethics: The Tuskegee Syphilis Study". Tuskegee University.
http://www.tuskegee.edu/Global/Story.asp?s=1207598. Retrieved 2008-12-04.
11.^ Jones J (1981). Bad Blood: The Tuskegee Syphilis Experiment. New York: Free Press. ISBN 0029166764.
12.^ a b Parker, Laura (1997-04-28). "'Bad Blood' Still Flows In Tuskegee Study". USA Today.
http://www.tuskegee.edu/global/Story.asp?s=1209852. Retrieved 2008-12-04.
13.^ a b c "Doctor of Public Health Student Handbook" (PDF). University of Kentucky College of Public Health. 2004. pp. 17.
http://www.ukcph.org/Portals/0/DoctorofPublicHealth/Dr.P.HStudentHandbook.pdf.
14.^ Chris McGreal (2010-10-01). "US says sorry for 'outrageous and abhorrent' Guatemalan syphilis tests Experiments in 1940s saw hundreds of Guatemalan prisoners and soldiers deliberately infected to test effects of penicillin". Guardian UK (Guardian News and Media Limited).
http://www.guardian.co.uk/world/2010/oct/01/us-apology-guatemala-syphilis-tests. Retrieved 2010-10-01.
15.^ Laura Neegaard (2010-10-02). "US apologizes for '40s syphilis study in Guatemala". Associated Press (Forbes magazine).
http://www.guardian.co.uk/world/2010/oct/01/us-apology-guatemala-syphilis-tests. Retrieved 2010-10-02.
16.^ Bill Jenkins left the PHS in the mid-1970s for doctoral studies. In 1980, he joined the CDC Division of Sexually Transmitted Diseases, where he managed the Participants Health Benefits Program that ensured health services for survivors of the Tuskegee Study.
17.^ "Remarks by the President in apology for study done in Tuskegee". Office of the Press Secretary, The White House. 1997-05-16.
http://clinton4.nara.gov/textonly/New/Remarks/Fri/19970516-898.html. Retrieved 2009-09-06.
18.^ Thomas SB, Quinn SC (November 1991). "The Tuskegee Syphilis Study, 1932 to 1972: implications for HIV education and AIDS risk education programs in the black community". Am J Public Health 81 (11): 1498–505. doi:10.2105/AJPH.81.11.1498. PMID 1951814. PMC 1405662.
http://www.ajph.org/cgi/pmidlookup?view=long&pmid=1951814.
19.^ Cohen E (2007-02-26). "Tuskegee's ghosts: Fear hinders black marrow donation". CNN.
http://www.cnn.com/2007/HEALTH/02/07/bone.marrow/index.html. Retrieved 2008-12-04.
20.^ "Did Tuskegee damage trust on clinical trials?". CNN. 2008-03-17. Archived from the original on 2008-06-13.
http://web.archive.org/web/20080613...08/HEALTH/03/17/clinical.trials.ap/index.html. Retrieved 2008-12-04.
21.^ Chadwick A (2002-07-25). "Remembering the Tuskegee Experiment". NPR.
http://www.npr.org/programs/morning/features/2002/jul/tuskegee/. Retrieved 2008-12-04.
22.^ "The Pulitzer Prizes : Drama". The Pulitzer Prizes -- Columbia University.
http://www.pulitzer.org/bycat/Drama.
23.^ Geddes, Darryl (1997-09-11). "HBO's adaptation of Feldshuh's play Miss Evers' Boys is up for 12 Emmys". Cornell Chronicle.
http://www.news.cornell.edu/Chronicle/97/9.11.97/Emmys.html.
24.^ "Awards for Miss Evers' Boys". IMDb.
http://www.imdb.com/title/tt0119679/awards.
25.^
http://www.nonesuch.com/albums/tuskegee-experiments
26.^ Black in Action, Entertainment Weekly.
27.^
http://http://www.sentieriselvaggi.org/multimedia/audio
[edit] Further reading
[edit] Primary sources
Caldwell, J. G; E. V. Price, et al. (1973). "Aortic regurgitation in the Tuskegee study of untreated syphilis". J Chronic Dis 26 (3): 187–94. doi:10.1016/0021-9681(73)90089-1. PMID 4695031.
Hiltner, S. (1973). "The Tuskegee Syphilis Study under review". Christ Century 90 (43): 1174–6. PMID 11662609.
Kampmeier, R. H. (1972). "The Tuskegee study of untreated syphilis". South Med J 65 (10): 1247–51. PMID 5074095.
Kampmeier, R. H. (1974). "Final report on the "Tuskegee syphilis study". South Med J 67 (11): 1349–53. PMID 4610772.
Olansky, S.; L. Simpson, et al. (1954). "Environmental factors in the Tuskegee study of untreated syphilis". Public Health Rep 69 (7): 691–8. PMID 13177831.
Rockwell, D. H.; A. R. Yobs, et al. (1964). "The Tuskegee Study of Untreated Syphilis; the 30th Year of Observation". Arch Intern Med 114: 792–8. PMID 14211593.
Schuman, S. H.; S. Olansky, et al. (1955). "Untreated syphilis in the male negro; background and current status of patients in the Tuskegee study.". J Chronic Dis 2 (5): 543–58. doi:10.1016/0021-9681(55)90153-3. PMID 13263393.
