Early nursing reform in nineteenth-century London: A doctor-driven phenomenon

Medical History

Volumn 46, Issue 3, 2002, Pages 325-350

  Helmstadter, Carol ^a  

^a Ontario Nurses' Association   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CLINICAL MEDICINE; FEMALE; HEALTH CARE POLICY; HISTORY; HISTORY OF MEDICINE; HUMAN; UNITED KINGDOM;

CLINICAL MEDICINE; FEMALE; HEALTH CARE REFORM; HISTORY OF NURSING; HISTORY, 19TH CENTURY; HUMANS; LONDON;

EID: 0036636568     PISSN: 00257273     EISSN: None     Source Type: Journal    
DOI: 10.1017/s0025727300069386     Document Type: Article

References (159)

1. Baly has written two articles specifically to debunk this traditional view, 'The Nightingale nurses: the myth and the reality', in Christopher Maggs (ed.), Nursing history: the state of the art, London, Croom Helm, 1983, pp. 33-59, and 'Florence Nightingale and the establishment of the first School at St. Thomas's: myth v. reality', in Vern Bullough, Bonnie Bullough and Marietta P Stanton (eds), Florence Nightingale and her era: a collection of new scholarship, New York, Garland, 1990, pp. 3-22.
2. Baly has written two articles specifically to debunk this traditional view, 'The Nightingale nurses: the myth and the reality', in Christopher Maggs (ed.), Nursing history: the state of the art, London, Croom Helm, 1983, pp. 33-59, and 'Florence Nightingale and the establishment of the first School at St. Thomas's: myth v. reality', in Vern Bullough, Bonnie Bullough and Marietta P Stanton (eds), Florence Nightingale and her era: a collection of new scholarship, New York, Garland, 1990, pp. 3-22.
3. Brian Abel-Smith, The hospitals 1800-1948: a study in social administration in England and Wales, London, Heinemann, 1964, pp. 16-31, 43-4, 66.
4. Parliamentary Papers (hereafter PP), Sixth Report of the Medical Officer of the Privy Council 1863, 1864, vol. 28, pp. 463-743, on pp. 484-5.
5. Charing Cross Hospital Archive (hereafter CCH), Minutes of Board of Governors 1834-45, pp. 78-9; St Thomas's Hospital Archive, London Metropolitan Archives/H1/ST (henceforth STH), 'Hints for nurses', pp. 1-4, SJ/A39/7.
6. Charing Cross Hospital Archive (hereafter CCH), Minutes of Board of Governors 1834-45, pp. 78-9; St Thomas's Hospital Archive, London Metropolitan Archives/H1/ST (henceforth STH), 'Hints for nurses', pp. 1-4, SJ/A39/7.
7. See, for example, John Flint South, Facts relating to hospital nurses, London, Richardson Bros, 1857, pp. 10-12; Robert Bentley Todd, Clinical lectures on certain acute diseases, Philadelphia, Churchill, 1860, p. 133.
8. See, for example, John Flint South, Facts relating to hospital nurses, London, Richardson Bros, 1857, pp. 10-12; Robert Bentley Todd, Clinical lectures on certain acute diseases, Philadelphia, Churchill, 1860, p. 133.
9. While doctors were very active in the founding of the London Hospital, due to a squabble between the physicians and surgeons in the eighteenth century, officers on staff were disbarred from serving on the Board. (A E Clark-Kennedy, The London: a study in the voluntary hospital system, 2 vols, London, Pitman Medical Publishing Co., 1963, vol. 1, pp. 85-7.)
10. Westminster Hospital Archive (hereafter WH), London Metropolitan Archives/H2AVH, Minutes of Board of Governors (hereafter MBG), 26 June 1816, Al/25.
11. Baly, 'The Nightingale nurses', op. cit., note 1 above, pp. 39-40. "What we call the Nightingale system was a hotch potch of what the Fund could wring out of St. Thomas's - which was not much", Baly writes. "What the nurse was taught and who taught her and who examined her are questions which were left unanswered" ('The First School at St. Thomas's', op. cit., note 1 above, pp. 12, 20). Although it was founded in 1860, Nightingale felt her school did not provide the moral and practical instruction which she wanted until 1872 when Miss Torrance, followed by Miss Machin, became the Home Sisters. They were not allowed to give clinical instruction in the wards. Baly indicates that Nightingale chose St Thomas's for her school because she hoped to see it rebuilt as a model hospital. Bonham-Carter thought Wardroper incapable of making a sound judgement and Nightingale thought she governed like a virago. (Monica E Baly, Florence Nightingale and the nursing legacy, 2nd ed., London, Whurr, 1997, pp. 31-6, 140, 148-54.)
12. Baly, 'The Nightingale nurses', op. cit., note 1 above, pp. 39-40. "What we call the Nightingale system was a hotch potch of what the Fund could wring out of St. Thomas's - which was not much", Baly writes. "What the nurse was taught and who taught her and who examined her are questions which were left unanswered" ('The First School at St. Thomas's', op. cit., note 1 above, pp. 12, 20). Although it was founded in 1860, Nightingale felt her school did not provide the moral and practical instruction which she wanted until 1872 when Miss Torrance, followed by Miss Machin, became the Home Sisters. They were not allowed to give clinical instruction in the wards. Baly indicates that Nightingale chose St Thomas's for her school because she hoped to see it rebuilt as a model hospital. Bonham-Carter thought Wardroper incapable of making a sound judgement and Nightingale thought she governed like a virago. (Monica E Baly, Florence Nightingale and the nursing legacy, 2nd ed., London, Whurr, 1997, pp. 31-6, 140, 148-54.)
13. Baly, 'The Nightingale nurses', op. cit., note 1 above, pp. 39-40. "What we call the Nightingale system was a hotch potch of what the Fund could wring out of St. Thomas's - which was not much", Baly writes. "What the nurse was taught and who taught her and who examined her are questions which were left unanswered" ('The First School at St. Thomas's', op. cit., note 1 above, pp. 12, 20). Although it was founded in 1860, Nightingale felt her school did not provide the moral and practical instruction which she wanted until 1872 when Miss Torrance, followed by Miss Machin, became the Home Sisters. They were not allowed to give clinical instruction in the wards. Baly indicates that Nightingale chose St Thomas's for her school because she hoped to see it rebuilt as a model hospital. Bonham-Carter thought Wardroper incapable of making a sound judgement and Nightingale thought she governed like a virago. (Monica E Baly, Florence Nightingale and the nursing legacy, 2nd ed., London, Whurr, 1997, pp. 31-6, 140, 148-54.)
14. Benjamin Golding, Historical account of the origin and progress of St. Thomas's Hospital, Southwark, London, Longman, Hurst, Rees, Orme and Brown, 1819, pp. 189-215; Abel-Smith, op. cit., note 2 above, pp. 7-8.
15. Benjamin Golding, Historical account of the origin and progress of St. Thomas's Hospital, Southwark, London, Longman, Hurst, Rees, Orme and Brown, 1819, pp. 189-215; Abel-Smith, op. cit., note 2 above, pp. 7-8.
16. WH, Laws and Regulations for the Government of the Westminster Hospital 1835, pp. 9-10, 31-2, A34/1/1.
17. WH, MBG, 10 Sept. 1850, A1/36; 12 Apr. 1850, A1/38; 1 July 1862, A1/40.
18. WH, MBG, 22 Apr., 13 and 27 May 1818, A1/25.
19. WH, MBG, 28 Oct. 1818, 6 Jan. 1819, 19 Jan. and 27 Oct. 1819, H2/WH/A1/25; 8 Aug. 1821, 16 July 1822, A1/26.
20. WH, MBG, 13 and 20 Dec. 1826, A1/27.
21. London Hospital Archive (hereafter LH), Minutes of House Committee, 19 Dec. 1818, A5/6.
22. St George's Hospital Archive (hereafter SGH), MBG 1838-42, 31 July 1839.
23. Ibid., 7 Aug. 1839
24. Ibid., 16 and 23 Dec. 1840.
25. WH, Laws and Regulations of the Westminster Hospital 1835, pp. 9-10, 26-8, 31-2, A34/1/1.
26. WH, MBG, 9 and 16 Aug. 1836, A1/31.
27. WH, MBG, 23 Aug. and 25 Oct. 1836, A1/ 31.
28. WH, MBG, 27 Feb. 1838, A1/31.
29. WH, MBG, 3 Apr. 1838, A1/31.
30. Guy's Hospital Archive (hereafter GY), London Metropolitan Archives/H9/GY, Report of the Charity Commissioners, June 30 1837, pp. 54-60, A71/1.
31. WH, MBG, 3 Apr. and 29 May 1838, A1/ 31.
32. WH, MBG, 11 Dec. 1838, A1/32.
33. WH, MBG, 2 Feb. 1841, A1/32.
34. WH, MBG, 9 and 16 Mar. 1841, A1/33.
35. WH, MBG, 30 Aug. 1842, A1/33.
36. WH, MBG, 19 Oct. 1847, HA1/35.
37. WH, MBG, 23 Jan. 1849, A1/35.
38. SGH, MBG (1842-46), 28 Dec. 1842.
39. University College Hospital Archive (hereafter UCH), Minutes of General Committee, 12 Mar. and 8 Oct. 1845, A1/2/1.
40. WH, MBG, 10 May 1826, A1/27.
41. David Thomson, England in the nineteenth century, 1815-1914, London, Penguin, 1991, pp. 63-7.
42. WH, MBG, 27 Dec. 1864, A1/41.
43. Richard Price, Labour in British society, Dover, Croom Helm, 1986, pp. 34-9, 42-3, 109-10.
44. Martin J Wiener, Reconstructing the criminal: English culture, law and policy 1830-1914, Cambridge University Press, 1990, pp. 16-18, 26-7, 32-8, 45.
45. WH, MBG, 30 Oct. 1849, A1/35.
46. WH, MBG, 4 Sept. 1849, A1/35; 29 Nov. 1853, A1/37; 29 June 1858, A1/38.
47. WH, MBG, 21 Dec. 1841, 4 July 1843, A1/ 33; 27 Jan. 1846, A1/34.
48. Middlesex Hospital Archive (hereafter MH), MBG (1845-47), 17 Mar., 28 Apr. and 24 Aug. 1847.
49. King's College Hospital Archive (hereafter KH), Committee of Management, 9 May 1843, CM/M2.
50. Lionel S Beale, Hospitals, patients, doctors and nurses; a lecture, London, J A Churchill, 1874, p. 19; KH, Minutes of Committee of Management, 23 May 1851, CM/M4.
51. UCH, Minutes of General Committee 1844-57, 9 Apr. and 21 May 1851.
52. Ibid., 7 July 1852, 3 Aug. and 16 Nov. 1853.
53. WH, MBG, 4 Jan. and 1 Feb. 1853, A1/36.
54. KH, Minutes of Committee of Management, 16 Feb. and 9 Mar. 1855, CM/M4.
55. R B Todd, 'Education of medical students', British Magazine, 1837, 11: 335-8, 460-3, 12: 95-100, 337-41.
56. R B Todd, 'Education of medical students', British Magazine, 1837, 11: 335-8, 460-3, 12: 95-100, 337-41.
57. Ibid., 12: 95-100, on p. 96.
58. STH, 'Training institution for nurses for hospitals, families and the sick poor', c.1848, SJ/ A17/1.
59. Anne Summers, 'The costs and benefits of caring: nursing charities c. 1830-C.1860', J Barry and C Jones (eds), Medicine and charity before the welfare state, London, Routledge, 1991 and 1995, pp. 133-48, on p. 134.
60. Archives of the Community of the Sisters of St John the Divine, Birmingham, Minutes of Public Meeting held at Hanover Square, 13 July 1848, pp. 13-14.
61. Ibid., pp. 1-6, 13-14, 18-19.
62. Katherine Williams, 'From Sarah Gamp to Florence Nightingale: a critical study of hospital nursing systems from 1840 to 1892', in Celia Davies (ed.), Rewriting nursing history, Totowa, NJ, Croom Helm, 1980, pp. 41-75, on pp. 57-8. Williams bases her argument on two articles written in 1897. In the 1890s a small group of lady nurses, one of whom wrote one of these two articles, had seized control of the nursing leadership and were indeed trying to dissociate themselves from the old working-class nurses. These second generation lady nurses were anything but philanthropists. They were pushing for state registration for nursing in part as a strategy to run the working-class nurses out of business.
63. (See Carol Helmstadter, 'Doctors and nurses in the London teaching hospitals: class, gender, religion and professional expertise 1850-1890', Nursing Hist. Rev., 1997, 5: 161-97, on pp. 181-2.) Florence Nightingale opposed state registration on precisely these grounds-that many of the older, clinically experienced working-class nurses would not be able to meet the requirements laid down for state registration. (See, for example, British Library (hereafter BL) Miss Pringle to Mrs Fenwick, 6 Mar. 1888, Add. MSS 47735, fol. 81; Nightingale's notes, [1889], Add. MSS 47736, fol. 5.)
64. Mary Jones to Florence Nightingale, 16 June 1863, BL Add. MSS 47743, fols 202-206.
65. Sir Edward Cook, The life of Florence Nightingale, 2 vols, London, Macmillan, 1913, vol. 1, pp. 159, 462-4, 502; BL Add. MSS 47743, Jones to Nightingale, 28 Mar. 1860, fols 3-6; ibid., 10 May 1860, fols 11-13; ibid., 11 May 1860, fol. 14; ibid., 27 Aug. 1860, fols 26-27; ibid., 16 Oct. 1860, fols 35-36.
66. KH, Minutes of Committee of Management, 25 July 1856, CM/M5; CCH, MBG, 14 Mar. 1865. This was not true of the All Saints Sisters who dismissed all the old nursing staff at University College Hospital when they took over in 1862. (UCH, Minutes of General Committee 1857-66, 23 Apr. 1862, A1/2/2.)
67. Carol Helmstadter, 'Robert Bentley Todd, St. John's House, and the origins of the modern trained nurse', Bull. Hist. Med., 1993, 67: 282-319, on pp. 299-300, 304-5.
68. STH, R Few, A history of St. John's House, London, 1884, pp. 5-7, SJ/A39/30.
69. WH, MBG, 12 Apr., 3 and 10 May 1853, A1/36.
70. STH, Lady Superintendent's Diary, 17 Aug. through 14 Sept. 1854, SJ/A20/3; WH, MBG, 22 Aug. 1854, A1/37.
71. STH, Lady Superintendent's Diary, 15 Dec. 1855, SJ/A20/3.
72. Ibid., 29 Mar. 1855, 31 Mar. 1856, SJ/A20/3.
73. Baly, Nightingale and the nursing legacy, op. cit., note 8 above, pp. 8-9.
74. Lancet, 1864, ii: 298-9.
75. H C Cameron, Mr. Guy's Hospital 1726-1948, London, Longmans, Green, 1954, p. 346; GY, Officers' Reports 1853-57, 5 Aug. 1857, A67/1.
76. Lucy Ridgely Seymer, Florence Nightingale's nurses: the Nightingale Training School, 1860-1960, London, Pitman Medical Publishing Co., 1960, pp. 25-6.
77. UCH, Minutes of General Committee, 24 Oct. 1860, A1/2/2.
78. Ibid., 15 Jan., 13 Feb., 24 Apr., 17 and 31 July 1861, A1/2/2.
79. Ibid., 29 Jan., 26 Mar., 9 and 23 Apr. 1862, A1/2/2.
80. Royal Free Hospital Archive (hereafter RFH), Minutes of Weekly Board, 2, 16 and 30 July 1868.
81. BL, A J Lawrence to Florence Nightingale, 9 June 1868, Add. MSS 45801, fols 63-67.
82. RFH, Minutes of Weekly Board, 26 Mar. 1868, 8 July 1869.
83. Ibid., 3 Feb. and 10 Mar. 1870.
84. WH, MBG, 14 May and 12 Nov. 1861, A1/ 39.
85. WH, MBG, 28 Jan. 1862, A1/40.
86. WH, MBG, 25 Feb. and 4 Mar. 1862, A1/ 40.
87. SGH, MBG 1856-59, 1 Dec. 1858.
88. LH, Reports of House Committee (1857-65), 5 Mar. 1862, A4/12.
89. WH, MBG, 30 June 1863, A1/40.
90. PP, op. cit., note 3 above, p. 595.
91. MH, MBG (1847-49), 18 and 25 Jan, 3 Feb. 1848.
92. CCH, MBG (1856-65), Report of House Committee, 7 Jan. 1863.
93. CCH, Minutes of the Medical Committee, 12 Feb. and 29 Dec. 1863, 26 Jan., 29 Mar., 20 Dec. 1864, 10 Jan., 21 Mar. 1865.
94. Ibid., MBG (1865-68), 5 Apr. 1865, 5 Jan. 1866.
95. SGH, MBG 1864-66, 24 Jan., 21 Feb. and 20 Apr. 1866; Br. med. J., 1866, ii: 445. Hawkins was responsible for many of the improvements to the living and working conditions for the nurses. (See, for example, SGH, MBG, 9 and 30 May 1866.)
96. BL, 'Middlesex Hospital report on the subject of nursing', Dec. 1865, and 'Report of Weekly Board appointed 6 February 1866', Add. MSS 45752, fols 125-28.
97. MH, Minutes of Medical Committee, 22 June 1867; MBG, 3 Sept. 1867.
98. WH, MBG, 5 May 1863, A1/40.
99. WH, MBG, 30 June and 14 July 1863, A1/ 40.
100. WH, MBG, 1 July 1862, A1/40.
101. WH, MBG, 24 Feb., 16 and 23 June, 8 and 15 Dec. 1863; 12 and 26 Jan., 9 Feb., 26 Apr. 1864, A1/40; 31 Jan., 30 May 1865, A1/41.
102. WH, MBG, 25 Aug., 10 Nov. 1863, A1/40; 14 June 1864, A1/41.
103. WH, MBG, 19 July and 4 Oct. 1864, A1/41.
104. F M L Thompson, The rise of respectable society: a social history of Victorian Britain 1830-1900, London, Fontana, 1988, pp. 156-7.
105. 'Report on the metropolitan hospitals: II. The Westminster Hospital', Br. med. J., 1868, ii: 228-9.
106. The St John's House sisters, their assistant or ordinary nurses and the probationers all wore uniforms which were the prototype of the traditional nursing uniform. The All Saints sisters, who nursed at University College Hospital, wore nuns' habits but their nurses and probationers wore standard nursing uniforms.
107. 'The Westminster Hospital', Br. med. J., 1868, ii: 228-9.
108. WH, Register of Servants of the Westminster Hospital, no pagination, A40/3; MBG 13 Aug. 1867, A1/42.
109. WH, MBG, 17 Oct. 1827, A1/28.
110. STH, 'Nurses sent to military hospitals in the east', p. 11, NC8/1.
111. STH, 'List of nurses and sisters who left', p. 2, NC8/4.
112. WH, MBG, 1 Jan 1856, A1/37.
113. WH, MBG, 4 Sept. 1855, A1/37.
114. Joseph Bell, 'Nursing in the Edinburgh Infirmary', Nineteenth Century, April, 1876, pp. 929-33, on p. 930.
115. Geoffrey Rivett, The development of the London Hospital system 1823-1982, London, King Edward's Hospital Fund for London, 1986, pp. 36-8.
116. Fanny Taylor, Eastern hospitals and English nurses: the narrative of twelve months experience in the hospitals of Koulali and Scutari, London, Hurst & Blackett, 1856, vol. 1, pp. 9-10.
117. WH, MBG, 24 Oct. and 5 Dec. 1854, A1/ 37.
118. WH, MBG, 23 Aug. 1864, A1/41.
119. See, for example, WH, MBG, 26 Apr. 1859, A1/39; MBG, 13 Feb. 1872, A1/44.
120. WH, MBG, 4 Feb. 1868, A1/42.
121. WH, MBG, 21 Jan. 1868, A1/42.
122. WH, MBG, 1 Sept., 15 Dec. 1868, A1/42.
123. WH, MBG, 19 and 26 Oct. 1869, 14 Feb. 1870, A1/43; 31 May and 21 June 1870, A1/43.
124. WH, MBG, 18 July, 5 and 27 Dec. 1871, A1/44.
125. WH, MBG, 27 Dec. 1871, 30 Jan. 1872, A1/44.
126. STH, Mrs Wardroper to Bonham-Carter, 27 and 29 Nov. 1866, NC18/7/30 and 32; Baly, Nightingale and the nursing legacy, op. cit., note 8 above, p. 241.
127. WH, MBG, 9 Apr. and 7 May 1872, A1/44.
128. WH, MBG, 13 Feb. and 9 Apr. 1872, A144.
129. WH, MBG, 5 Nov. 1872, A1/44; Register of Servants, no pagination, A40/3.
130. WH, MBG, 12 Nov. 1872; Report of Sub-Committee on Nursing, 21 Jan. 1873, A1/44.
131. Alcock had been a student and a House Surgeon at the Westminster and later an army surgeon. In 1844 he went into the diplomatic service from which he retired in 1871. John Langdon-Davies, Westminster Hospital: two centuries of voluntary service 1719-1948, London, John Murray, 1948, p. 11; Dictionary of National Biography, Supplement, vol. 22, Oxford University Press, 1917, pp. 29-30.
132. Alcock had been a student and a House Surgeon at the Westminster and later an army surgeon. In 1844 he went into the diplomatic service from which he retired in 1871. John Langdon-Davies, Westminster Hospital: two centuries of voluntary service 1719-1948, London, John Murray, 1948, p. 11; Dictionary of National Biography, Supplement, vol. 22, Oxford University Press, 1917, pp. 29-30.
133. WH, MBG, Report of Sub-Committee on Nursing, 21 Jan. 1873, A1/44.
134. WH, MBG, 9 Jan. 1872, A1/44.
135. WH, MBG, Report of Sub-committee on Nursing, 11 Feb. 1873, 18 Mar. 1873, A1/44.
136. WH, MBG, 1 Apr. 1873, A1/44.
137. Baly, The first school at St. Thomas's', op. cit., note 1 above, pp. 18-19.
138. Eric O Jewesbury, The Royal Northern Hospital: the story of a hundred years' work in north London, London, H K Lewis, 1956, p. 41.
139. WH, MBG, 20 May 1873, A1/44.
140. WH, MBG, Report of Nursing Sub-Committee, 9 June 1874, A1/45.
141. LH, Reports of House Committee, 5 Dec. 1874, A4/14.
142. Ibid., 3 Mar. 1875, A4/14.
143. GY, General Court, 11 Mar. 1880, pp. 176-8, A225/2.
144. WH, MBG, 24 Mar. 1874, A1/45.
145. Although the hospital was founded as late as 1849, St Mary's faced the same problem in doing this as the Westminster, a lack of accommodation for the probationers. By 1880, the hospital was already housing some of its nursing staff outside the hospital building. (St Mary's Archive, 23 July 1880, SM/AD1/15.)
146. WH, MBG, Report of Nursing Sub-Committee, 9 June 1874, A1/45.
147. J G Humble and Peter Hansell, Westminster Hospital 1716-1966, London, Pitman Medical Publishing Co., 1966, p. 83; WH, MBG, Report of Nursing Sub-Committee, 9 June 1874, A1/45.
148. Humble and Hansell, op. cit., note 138 above, pp. 62, 83.
149. Baly, Nightingale and the Nursing legacy, op. cit., note 8 above, p. 46.
150. STH, 'Nursing in a large town', pp. 22, 38, NC7/2.
151. WH, MBG, 11 May and 5 Oct. 1880, A1/ 47.
152. STH, H Bonham-Carter, unsigned rough draft of letter of recommendation, 2 Aug. 1880, NC18/26/45.
153. BL, Mary Jane Pyne to Florence Nightingale, 23 Oct. 1880, Add. MSS 47745.
154. WH, MBG, 23 and 30 Dec. 1879, A1/46.
155. STH, Mrs Wardroper's Reports 1878 and 1879, NTS/A3/3 and A3/4; Baly, Nightingale and the nursing legacy, op. cit., note 8 above, pp. 164-5.
156. See St Bartholomew's Hospital Archive, Minutes of Medical Committee 1843-78, 1 Apr. and 24 June 1876, MC1/1; GY, Mr Lushington's Statement, 12 July 1880, A224/3; GY, Printed Reports of General Court, 3, 10-11 Mar. 1880, A 225/1-2.
157. WH, MBG, Report of Nursing Sub-Committee, 9 June 1874, A1/45.
158. Hospitals increased the nurses' wages steadily from the beginning of the century until the training schools were established. The Westminster paid £8 a year in 1809; in 1873 assistant nurses made up to £16 6s. and the Head Nurses up to £26 5s. (WH, MBG, 28 June 1809, A1/24; Report of Sub-Committee on Nursing, 11 Feb. 1873, A1/44.) The nineteenth century was not an inflationary period; rather the value of money remained fairly stable.
159. For example, see South, op. cit., note 5 above, pp. 15-16.