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scarce resources is therefore inevitable. If society has to makea choice between kidney machines and slum clearance, orteaching-aids for deaf children, or higher pensions to give alittle more comfort to people near the end ’of their lives, evendoctors must sometimes see that the choice cannot always bein favour of kidney machines. That is why it is urgent thatmore resources be found for medical care than can be found

by politicians from taxation. That is why we must examinethe possibilities of private medical services in addition to Stateservices. That is why we must think of drawing purchasingpower not only from the E2200 million of expenditure onarmaments, but even more from the perhaps E4000 millionof abortive social expenditure on people who do not need it,and from the E20,000 million of expenditure on everyday orhousehold consumption.

Professor Hamilton is basically in error because, probablyunconsciously, he is overgeneralising to all medical care thecircumstances of emergency care. If a man is knocked downby a bus society will move heaven and earth to save his life.It does not necessarily follow that the same inferences andattitudes are called into play in the mass of medical care forhernias, varicose veins, tonsillectomy, or peptic ulcer. Medicalcare is not wholly a service in crisis.

ARTHUR SELDON.Institute of Economic Affairs,

66a Eaton Square, London S.W.1.

ACCURACY OF DEATH CERTIFICATES

ROBERT M. ALBRECHT.

SIR,-Dr. Benians (April 8, p. 780) rightly rejects the beliefthat the postmortem examination gives the pathologist the lastword on the cause of death. A common error in studies of causesof death, based on death certificates, is to "prove" that thecertificates are accurate because the listed cause of death wasfound on postmortem examination. But cause-of-deathstatistics are based on the leading cause of death. It is not

enough to show that the certified cause was found postmortem. One must show further that the post mortemsupports the opinion that the certified cause was, in fact, theleading cause. Otherwise one could " prove " that a fatal

poisoning, attributed to ischaemic heart-disease on the deathcertificate, was correctly certified because the victim had a fewhealed infarcts in his myocardium.New York 12538. ROBERT M. ALBRECHT.

SHOULD RADIOGRAPHERS TRAIN EARLIER ?

SIR,-May I comment on Miss Chesney’s letter (March 11,p. 566) ?The sample of 155 radiographers which I gave (March 4,

p. 506) amounts to more than 20% of the yearly output of allthe radiographic schools in Great Britain. There is such awide variation between schools that it is only in the sameschool that one can make a valid comparison between differenttypes of students. Although the figures quoted were recent,my experience of training radiographers goes back 30 years.

Miss Chesney says my " figures are too small to be of statis-tical significance ", but gives none herself. If the Society ofRadiographers’ records show anything, why are no figuresgiven ?Those who recruit them know that early school-leavers need

three years to cover the syllabus. It will not be possible tohave the same number of passes if examinations are taken a

year earlier as proposed.The new proposals would benefit the training of a pre-

cocious minority of students. If these proposals were prin-cipally to improve recruitment and training, the Society ofRadiographers would not persist in withholding permission forthese students to be so trained at present.The more intelligent pupils do not leave school at 16. Most

colleges and universities are raising their standards and pupilsare staying at school longer. The new proposals would delaythe radiographic qualification of such recruits.The number of diagnostic radiographers qualifying fell last

year by 10%. To maintain recruitment more schools may

have to accept candidates requiring three years to train.Meanwhile we should not discourage by regulations the bettercandidates who can be trained in two years.

Edinburgh. DAVID W. LINDSAY.DAVID W. LINDSAY.

WHO PAYS FOR TEXTBOOK ILLUSTRATIONS?

D. P. HAMMERSLEYVice Chairman,

Medical Artists’ Association ofGreat Britain.

Department of Medical Illustration,University of Aberdeen, Scotland.

SIR,-I have read with interest the remarks of Dr. Hollman(March 18, p. 616). Those of us who work in the specialtyof medical illustration, whether on the staff of a university orwithin the hospital service, have long been aware that prepara-tion costs of many medical textbooks are being indirectlysubsidised in some measure by the institutions for whom wework, and not infrequently by the illustrators themselves.Only occasionally do artists and photographers receive a

proper financial reward for illustrations they make outsideworking hours, and I have yet to hear of a publisher reimbursinga hospital or university for working-time lost to that institutionwhen one of its servants is engaged in textbook illustrationduring the working-day.The preparation of pictures for a textbook, particularly if it

is a major work making wide use of illustrations, represents aformidable addition to the illustrator’s normal work-load. Hecan seldom expect to do much of the task during normalworking-hours; indeed he may not be permitted to do so by thehead of his department. He must devote to the work manyhours of his own time, often over long periods, and sometimeswith no more reward than the satisfaction of a job well done.He is often placed in the difficult position of feeling duty-bound to undertake the work because the author is one of his

colleagues or because his departmental chief has asked him to" help out ". Or perhaps he will do it because, like many otherswho work in medicine, he is a dedicated person.What we illustrators find particularly unsatisfactory is the

lack of a consistent code of practice between one publisher andanother. In my experience, publisher A will offer an accept-able fee for illustrations, publisher B may be induced to make atoken payment as a result of persistent prodding by the authoror the illustrator, and publisher C will adamantly refuse to makeany payment for illustrations, claiming that the publicationcannot support such an overhead.

Sometimes, the author will pay his illustrator from his ownpocket, but this is often no more than a nominal recognition,since few medical writers can afford to pay realistic fees com-mensurate with the time and skill involved in making thepictures.

Publishers may put forward the argument that, with a limitedmarket, the economics of producing medical textbooks are

finely balanced, and that there is often a large element of risk inintroducing a highly-specialised book, perhaps by an untriedauthor. This may be so. Our contention is that no bookshould be considered for publication if its economic viabilityis to rest on the goodwill of unpaid workers or on an indirectsubsidy from a hospital or university.

Like Dr. Hollman, we should like to see all medical pub-lishers, on commissioning a book, agreeing in advance to paythe full costs of preparation, and making appropriate disburse-ments to those concerned.

BILIRUBIN METABOLISM IN NEWBORNS

SIR,-Investigation of bilirubin metabolism in newbornswith 14C-bilirubin is difficult because of the sampling necessaryfor its estimation, and daily changes of bilirubin-pool size.Schmidt et aLl have reported that exogenous bilirubin loadingis not suitable for estimating the half-life of bilirubin innewborns.We have investigated the disappearance-rate of endogenous

1. Schmidt, D., Grauel, E. L., Syllm-Rapoport, I. Z. Kinderheilk 1966,96, 19.