- Email: [email protected]
BLOOD GASES AND LUNG FUNCTION
59
spend a considerable proportion of their time in the community following up this type of patient. The readmission figures are given in the paper. The patient mentioned by Dr. Shepherd was diagnosed as suffering from subnormality at the Maudsley. He was admitted and discharged from St. Mary Abbots in 1967 (this was the year I reported in the paper). He was readmitted in 1968 and during his stay was seen by a consultant from Leavesden Hospital who agreed the diagnosis of
subnormality and accepted him for Leavesden. Dr. Barker and Dr. Bewley raise another important point. My colleagues and I admit to St. Mary Abbots all the functional psychiatric conditions in old age and those psychogeriatric patients where there is clearly a need for care under a psychiatrist and psychiatric nurse, as opposed to geriatric care. From the point of view of future planning, it is important that one part of the medical service should not be used to subsidise another part. We should plan for a comprehensive psychiatric service and equally geriatricians will wish to plan for a comprehensive geriatric service. I think that there will be a small number of long-stay patients coming from psychiatric units in district general hospitals. These patients, however, are likely to have multiple handicaps, both physical and mental, and are patients who will need the resources of the district general hospital, though perhaps their needs will be better served in that part devoted to the younger chronic sick. I have no doubt that a unit such as St. Mary Abbots can provide a better service for psychiatric patients, whether they be acute or long-term, than can the old type of mental hospital. I agree, however, with the correspondents who point out the need to assess the results in detail, and hope that resources will be made available to make this possible. St. Mary Abbots Hospital, A. A. BAKER. London W.8.
SHOULD DIABETICS MARRY ? SIR,-We would like to associate ourselves wholeheartedly with Professor Edwards1 who has consistently pointed out that familial aggregations do not necessarily indicate a genetic defect, especially since no chromosomal abberrations have as yet been noted in diabetes mellitus. There is abundant published evidence that the mode of inheritance of diabetes is not clearly established. VallanceOwen2 regards it as an autosomal dominant, Penrose and Watson3 as sex-linked, Pincus and White 4 as recessive, and Simpson 5 as multifactorial. In a recent study of 350 diabetic children under the age of 16 we found that 95% of the parents were not diabetic. 50% of the families had a relative with diabetes and these ranged from great-aunts and great-uncles to second cousins, many of whom were over 40 years old and a considerable number of whom were treated by diet alone. We were also impressed by the fact that 12 children had a preceding history of chickenpox three weeks before the onset of full-blown diabetes mellitus. John 6 has long suggested that diabetes may be caused by infection. Mumps has been accepted as producing diabetes. Recently, Craighead et al. showed that encephalomyelitic strains of virus produced diabetes in mice treated with the virus. Clearly, there are some cases of diabetes that are not inherited. Therefore to condemn diabetics to a life of purgatory because of the fear of the consequences of having 1. Edwards J. H. Lancet, 1969, i, 1045. 2. Vallance-Owen, J. Diabetes, 1964, 13, 241. 3. Penrose, L. S., Watson, E. M. Proc. Am. Diabetes Ass. 1946, 5, 165. 4. Pincus, G., White, P. Am. J. med. Sci. 1933, 186, 1. 5. Simpson, N. E. Ann. hum. Genet. 1962, 26, 1. 6. John, H. J. J. Pediatrics, 1949, 35, 723. 7. Craighead, J. E., McLane, M. F., Steinke, J. Metabolism, 1968, 17, 1154.
diabetic offspring, in the absence of any accurate probability table, is unrealistic and turns the scientific doctor into a mystic. With the increased sensitivity of tests for carbohydrate intolerance, the number of elderly diabetics will increase and every family will have at least one diabetic relative if the relatives live long enough. It might be as well for the World Health Organisation to put the question: Should anybody marry ? "
"
of Environmental Health and Pathology, U.C. Medical Center, Cincinnati, Ohio.
Departments
NAOMI BAUMSLAG RALPH E. YODAIKEN.
CARPAL-TUNNEL SYNDROME SIR,-We should like to answer some of the points made in the correspondence which arose from our article on the carpal-tunnel syndrome (May 3, p. 918). Dr. Backhouse and Dr. Kay (June 7, p. 1150) question the lack of prominence given to rheumatoid arthritis in our report. We would not deny the frequency of median-nerve compression in a rheumatoid population, which has been demonstrated by various workers, but our series was drawn from patients with distal sensory symptoms in the upper limbs referred to general orthopxdic clinics. Of our 113 patienrs only 1 had clinical evidence of rheumatoid arthritis. Our impression, from the Oxford medical-record-linkage study, is that the
large majority of patients undergoing operative carpaltunnel decompression in our region do not have rheumatoid arthritis. As Dr. de Swiet pointed out (June 7, p. 1151) we did indeed omit to mention that myxoedema is an indication for conservative treatment. Dr. Matricali and his colleagues (June 14, p. 1217) reinforce our advocacy of preoperative electrodiagnostic confirmation of median-nerve compression; but this facility is not as widely available as one would wish. We still believe that clinical suspicion is a reasonable indication for operation, though prognosis should be more guarded than it was in the past. Nuffield Orthopædic Centre C. SEMPLE Headington,
Oxford OX3 7LD.
J.
A. O. CARGILL.
BLOOD GASES AND LUNG FUNCTION SIR,-Dr. Fairley1 suggests that the regression equations we gave for patients with chronic obstructive bronchitis for predicting probable values for arterial oxygen tension (Pao2) and carbon-dioxide tension (Paco2) from a knowledge of the F.E.V.1 (May 31, p. 1073) may, in spite of highly significant correlation coefficients, give misleading information because the standard errors are large. This is a common problem when regression equations are derived from clinical data. We acknowledge the statistical validity of his comments but think that in a clinical situation the equations can nevertheless in the majority of instances give guidance to the probable blood-gas tensions, and we do not claim more than this. We agree that changes in arterial oxygen tension are not related in a linear fashion to oxygen content, and it may be, as he suggests, that the relationship between lung function and arterial oxygen content might be more meaningful clinically. We have no information on this point at the moment.
A correlation between Pao2 and single-breath carbonmonoxide transfer factor (D.L.CO) was not given because, although Pao2 fell with increasing airway obstruction, D.L.CO remained at a low but constant level irrespective 1.
Fairley, H. B. Lancet, 1969, i,
1313.
60 of the degree of airway obstruction. Pa02 cannot therefore be used to predict D.L.CO. Moreover, because the alveolar oxygen tension is mainly dependent in these subjects on the alveolar carbon-dioxide tension (which is equivalent to PaC02), and Paco2 also did not correlate with D.L.CO, it is clear that the alveolar-arterial oxygen gradient cannot be used to oredict D.L.CO. K. N. V. PALMER University Department of Medicine, M. L. DIAMENT. Aberdeen AB9 2 ZD. Foresterhill,
failure-rate1 of mechanical means its efficacy is considerable -in addition to the special groups of patients which I have already detailed (June 21, p. 1262). Long-term information which will appear in due course will further confirm the suggestion that the risk of thromboembolism attached to oestrogen-containing preparations may well have been removed with this progestin-only oral contraceptive. Syntex Pharmaceuticals Ltd., G. A. CHRISTIE. Maidenhead.
XYY KARYOTYPE IN MONOZYGOTIC TWINS SIR,-The current interest in the nature of the behaviour disturbances associated with the extra Y chromosome prompts us to report the first case, to our knowledge, of a pair of monozygotic twins concordant for XYY karyotype. These boys of mixed Negro-White ancestry have been followed by us since infancy, both having had febrile convulsions between the ages of 3 and 6 years. One of the twins also had petit-mal seizures; the other had surgical correction of an undescended testicle at the age of 10. During childhood the twins preferred to be with each other rather than their peers and were generally passive, although on occasion they demonstrated physical violence toward other children. At age 14, first one twin and then the other manifested sudden aggressive outbursts, which, in at least one of the twins, were preceded on each occasion by a premonitory abdominal sensation, and followed by relaxation and somnolence. Because of these episodes it was decided to examine their chromosomes. Both twins are now, at the age of 15 years, 73 in. (185 cm.) tall, and in a special class of slow learners. A detailed investigation of the patients and their family is in progress. Department of Medical Genetics, JOHN D. RAINER New York State Psychiatric Institute and LISSY F. JARVIK College of Physicians and Surgeons, SYED ABDULLAH Columbia University, TAKASHI KATO. New York 10032.
ED.L.
*** Dr. Butler and Dr. Hill send the following reply.-
CHLORMADINONE ACETATE AS ORAL CONTRACEPTIVE SIR,-Dr. Butler and Dr. Hill (June 21, 1962) have not answered the crucial question whether they specifically checked by tablet-counting that their patients had indeed taken all their tablets; and they include the statement that method-failure pregnancies became more common with increasing months of use. I have analysed our method and total failure rates, month by month, for up to two years, and find that the method-failure rate does not vary significantly over the entire period, whereas the total-failure rate does increase slightly-suggesting that, as patients become more familiar with the preparation, so their tablet-taking becomes less dependable. Dr. Butler and Dr. Hill inquire whether the women in our worldwide series were of the same ethnic group, stature, and weight as the patients used by the F.P.A., without indicating these details for their own patients. The fact that the trials were carried out in the U.K. does not preclude the possibility of inclusion of patients of other races-thus comparison cannot be given. Certainly in our trials, which include considerable experience in European women, none of these factors influenced the pregnancy-rate. Dr. Butler and Dr. Hill raise the question of women being of proven fertility. In a series of patients, identical to those used in the Mexican contraceptive trials, contraceptive placebos (lactose tablets) were used to establish the incidence of placebo side-effects. The Pearl index (method failure) was 260, proving that these women were truly fertile. The place of chlormadinone acetate in contraception should be as an elegant, more dependable, and safer alternative to mechanical means-and compared with the high
SIR,-Dr. Christie’s questions can be answered briefly. Counting pills-no; daily record of pill-taking and other
consecutively complete-yes; ethnic groups-overwhelmingly Caucasian ; 70% weighed over 120 lb. We hoped Dr. Christie would welcome the suggestion that better results might be obtained by prescribing a larger dose to bigger-built British women. facts
The hard fact is that in our series 13 out of 208 became pregnant in the space of less than 2 years. Council for the Investigation of Fertility Control, London W.1.
women
CHRISTINE BUTLER HILARY HILL.
DO PREGNANT WOMEN TAKE THEIR IRON? SIR,-Dr. Bonnar and his colleagues2 demonstrated by repeated tests that 32% of 60 pregnant women did not take their iron, and further emphasised the value of testing the stools for therapeutic iron before diagnosing any anxmia of pregnancy as refractory. Our own experience in 1966 was similar. We also used a simple filter-paper technique, but employed the prussian-blue reaction. We found, in random sampling of 483 antenatal patients in hospital and domiciliary practice, that 28% were not taking their iron.3 Kilpatrick labelled the tablets with a marker, and found that only 60-70% of Cardiff schoolgirls took their iron tablets regularly.4 It is unfortunate that Dr. Bonnar and his colleagues ixnplied that this lack of cooperation in women in taking iron had merely been " suspected ", when they quoted previous workers including Kilpatrick and ourselves. The similarity of the results obtained by three groups working in different parts of the British Isles is remarkable. It suggests that any of these simple tests may be helpful in the hxmatological management of iron deficiency. Lambeth and St. Thomas’s London.
Hospitals,
London Hospital, E.1.
R. G. HUNTSMAN. G. C. JENKINS.
NATIONAL SOCIETY FOR TRANSPLANT SURGERY Mr. R. E. WESTERMAN (Chairman of the Board of Trustees, The National Society for Transplant Surgery, 11 Alma Road, Cardiff CF2 5BD) writes: " This society was registered as a charity in March, 1968, the principal objectives being the enrolment of voluntary donors to bequeath organs for cadaveric transplantation surgery, the raising of funds for research and facilities in transplant surgery, and the education of potential donors to an awareTo ness of the interdependence of mankind in this sphere. ensure legal clarity and to avoid unnecessary distress each bequest is countersigned by the next of kin. We believe our expanding register of donors to be the largest in the world and wish to make details available to interested transplantationsurgery units. We seek guidance on how best to place our services at the disposal of the medical profession."
Peel, J., Potts, M. Textbook of Contraceptive Practice; p. 47. London, 1969. 2. Bonnar, J., Goldberg, A., Smith, J. A. Lancet, 1969, i, 457. 3. Afifi, A. M., Banwell, G. S., Bennison, R. J., Boothby, K., Griffiths, P. D., Huntsman, R. G., Jenkins, G. C., Lewin Smith, R. G., McIntosh, J., Qayum, A., Ross Russell, I., Whittaker, J. N. Br. med. J. 1966, i, 1021. 4. Kilpatrick, G. S. Proc. R. Soc. Med. 1966, 59, 1220. 1.
spend a considerable proportion of their time in the community following up this type of patient. The readmission figures are given in the paper. The patient mentioned by Dr. Shepherd was diagnosed as suffering from subnormality at the Maudsley. He was admitted and discharged from St. Mary Abbots in 1967 (this was the year I reported in the paper). He was readmitted in 1968 and during his stay was seen by a consultant from Leavesden Hospital who agreed the diagnosis of
subnormality and accepted him for Leavesden. Dr. Barker and Dr. Bewley raise another important point. My colleagues and I admit to St. Mary Abbots all the functional psychiatric conditions in old age and those psychogeriatric patients where there is clearly a need for care under a psychiatrist and psychiatric nurse, as opposed to geriatric care. From the point of view of future planning, it is important that one part of the medical service should not be used to subsidise another part. We should plan for a comprehensive psychiatric service and equally geriatricians will wish to plan for a comprehensive geriatric service. I think that there will be a small number of long-stay patients coming from psychiatric units in district general hospitals. These patients, however, are likely to have multiple handicaps, both physical and mental, and are patients who will need the resources of the district general hospital, though perhaps their needs will be better served in that part devoted to the younger chronic sick. I have no doubt that a unit such as St. Mary Abbots can provide a better service for psychiatric patients, whether they be acute or long-term, than can the old type of mental hospital. I agree, however, with the correspondents who point out the need to assess the results in detail, and hope that resources will be made available to make this possible. St. Mary Abbots Hospital, A. A. BAKER. London W.8.
SHOULD DIABETICS MARRY ? SIR,-We would like to associate ourselves wholeheartedly with Professor Edwards1 who has consistently pointed out that familial aggregations do not necessarily indicate a genetic defect, especially since no chromosomal abberrations have as yet been noted in diabetes mellitus. There is abundant published evidence that the mode of inheritance of diabetes is not clearly established. VallanceOwen2 regards it as an autosomal dominant, Penrose and Watson3 as sex-linked, Pincus and White 4 as recessive, and Simpson 5 as multifactorial. In a recent study of 350 diabetic children under the age of 16 we found that 95% of the parents were not diabetic. 50% of the families had a relative with diabetes and these ranged from great-aunts and great-uncles to second cousins, many of whom were over 40 years old and a considerable number of whom were treated by diet alone. We were also impressed by the fact that 12 children had a preceding history of chickenpox three weeks before the onset of full-blown diabetes mellitus. John 6 has long suggested that diabetes may be caused by infection. Mumps has been accepted as producing diabetes. Recently, Craighead et al. showed that encephalomyelitic strains of virus produced diabetes in mice treated with the virus. Clearly, there are some cases of diabetes that are not inherited. Therefore to condemn diabetics to a life of purgatory because of the fear of the consequences of having 1. Edwards J. H. Lancet, 1969, i, 1045. 2. Vallance-Owen, J. Diabetes, 1964, 13, 241. 3. Penrose, L. S., Watson, E. M. Proc. Am. Diabetes Ass. 1946, 5, 165. 4. Pincus, G., White, P. Am. J. med. Sci. 1933, 186, 1. 5. Simpson, N. E. Ann. hum. Genet. 1962, 26, 1. 6. John, H. J. J. Pediatrics, 1949, 35, 723. 7. Craighead, J. E., McLane, M. F., Steinke, J. Metabolism, 1968, 17, 1154.
diabetic offspring, in the absence of any accurate probability table, is unrealistic and turns the scientific doctor into a mystic. With the increased sensitivity of tests for carbohydrate intolerance, the number of elderly diabetics will increase and every family will have at least one diabetic relative if the relatives live long enough. It might be as well for the World Health Organisation to put the question: Should anybody marry ? "
"
of Environmental Health and Pathology, U.C. Medical Center, Cincinnati, Ohio.
Departments
NAOMI BAUMSLAG RALPH E. YODAIKEN.
CARPAL-TUNNEL SYNDROME SIR,-We should like to answer some of the points made in the correspondence which arose from our article on the carpal-tunnel syndrome (May 3, p. 918). Dr. Backhouse and Dr. Kay (June 7, p. 1150) question the lack of prominence given to rheumatoid arthritis in our report. We would not deny the frequency of median-nerve compression in a rheumatoid population, which has been demonstrated by various workers, but our series was drawn from patients with distal sensory symptoms in the upper limbs referred to general orthopxdic clinics. Of our 113 patienrs only 1 had clinical evidence of rheumatoid arthritis. Our impression, from the Oxford medical-record-linkage study, is that the
large majority of patients undergoing operative carpaltunnel decompression in our region do not have rheumatoid arthritis. As Dr. de Swiet pointed out (June 7, p. 1151) we did indeed omit to mention that myxoedema is an indication for conservative treatment. Dr. Matricali and his colleagues (June 14, p. 1217) reinforce our advocacy of preoperative electrodiagnostic confirmation of median-nerve compression; but this facility is not as widely available as one would wish. We still believe that clinical suspicion is a reasonable indication for operation, though prognosis should be more guarded than it was in the past. Nuffield Orthopædic Centre C. SEMPLE Headington,
Oxford OX3 7LD.
J.
A. O. CARGILL.
BLOOD GASES AND LUNG FUNCTION SIR,-Dr. Fairley1 suggests that the regression equations we gave for patients with chronic obstructive bronchitis for predicting probable values for arterial oxygen tension (Pao2) and carbon-dioxide tension (Paco2) from a knowledge of the F.E.V.1 (May 31, p. 1073) may, in spite of highly significant correlation coefficients, give misleading information because the standard errors are large. This is a common problem when regression equations are derived from clinical data. We acknowledge the statistical validity of his comments but think that in a clinical situation the equations can nevertheless in the majority of instances give guidance to the probable blood-gas tensions, and we do not claim more than this. We agree that changes in arterial oxygen tension are not related in a linear fashion to oxygen content, and it may be, as he suggests, that the relationship between lung function and arterial oxygen content might be more meaningful clinically. We have no information on this point at the moment.
A correlation between Pao2 and single-breath carbonmonoxide transfer factor (D.L.CO) was not given because, although Pao2 fell with increasing airway obstruction, D.L.CO remained at a low but constant level irrespective 1.
Fairley, H. B. Lancet, 1969, i,
1313.
60 of the degree of airway obstruction. Pa02 cannot therefore be used to predict D.L.CO. Moreover, because the alveolar oxygen tension is mainly dependent in these subjects on the alveolar carbon-dioxide tension (which is equivalent to PaC02), and Paco2 also did not correlate with D.L.CO, it is clear that the alveolar-arterial oxygen gradient cannot be used to oredict D.L.CO. K. N. V. PALMER University Department of Medicine, M. L. DIAMENT. Aberdeen AB9 2 ZD. Foresterhill,
failure-rate1 of mechanical means its efficacy is considerable -in addition to the special groups of patients which I have already detailed (June 21, p. 1262). Long-term information which will appear in due course will further confirm the suggestion that the risk of thromboembolism attached to oestrogen-containing preparations may well have been removed with this progestin-only oral contraceptive. Syntex Pharmaceuticals Ltd., G. A. CHRISTIE. Maidenhead.
XYY KARYOTYPE IN MONOZYGOTIC TWINS SIR,-The current interest in the nature of the behaviour disturbances associated with the extra Y chromosome prompts us to report the first case, to our knowledge, of a pair of monozygotic twins concordant for XYY karyotype. These boys of mixed Negro-White ancestry have been followed by us since infancy, both having had febrile convulsions between the ages of 3 and 6 years. One of the twins also had petit-mal seizures; the other had surgical correction of an undescended testicle at the age of 10. During childhood the twins preferred to be with each other rather than their peers and were generally passive, although on occasion they demonstrated physical violence toward other children. At age 14, first one twin and then the other manifested sudden aggressive outbursts, which, in at least one of the twins, were preceded on each occasion by a premonitory abdominal sensation, and followed by relaxation and somnolence. Because of these episodes it was decided to examine their chromosomes. Both twins are now, at the age of 15 years, 73 in. (185 cm.) tall, and in a special class of slow learners. A detailed investigation of the patients and their family is in progress. Department of Medical Genetics, JOHN D. RAINER New York State Psychiatric Institute and LISSY F. JARVIK College of Physicians and Surgeons, SYED ABDULLAH Columbia University, TAKASHI KATO. New York 10032.
ED.L.
*** Dr. Butler and Dr. Hill send the following reply.-
CHLORMADINONE ACETATE AS ORAL CONTRACEPTIVE SIR,-Dr. Butler and Dr. Hill (June 21, 1962) have not answered the crucial question whether they specifically checked by tablet-counting that their patients had indeed taken all their tablets; and they include the statement that method-failure pregnancies became more common with increasing months of use. I have analysed our method and total failure rates, month by month, for up to two years, and find that the method-failure rate does not vary significantly over the entire period, whereas the total-failure rate does increase slightly-suggesting that, as patients become more familiar with the preparation, so their tablet-taking becomes less dependable. Dr. Butler and Dr. Hill inquire whether the women in our worldwide series were of the same ethnic group, stature, and weight as the patients used by the F.P.A., without indicating these details for their own patients. The fact that the trials were carried out in the U.K. does not preclude the possibility of inclusion of patients of other races-thus comparison cannot be given. Certainly in our trials, which include considerable experience in European women, none of these factors influenced the pregnancy-rate. Dr. Butler and Dr. Hill raise the question of women being of proven fertility. In a series of patients, identical to those used in the Mexican contraceptive trials, contraceptive placebos (lactose tablets) were used to establish the incidence of placebo side-effects. The Pearl index (method failure) was 260, proving that these women were truly fertile. The place of chlormadinone acetate in contraception should be as an elegant, more dependable, and safer alternative to mechanical means-and compared with the high
SIR,-Dr. Christie’s questions can be answered briefly. Counting pills-no; daily record of pill-taking and other
consecutively complete-yes; ethnic groups-overwhelmingly Caucasian ; 70% weighed over 120 lb. We hoped Dr. Christie would welcome the suggestion that better results might be obtained by prescribing a larger dose to bigger-built British women. facts
The hard fact is that in our series 13 out of 208 became pregnant in the space of less than 2 years. Council for the Investigation of Fertility Control, London W.1.
women
CHRISTINE BUTLER HILARY HILL.
DO PREGNANT WOMEN TAKE THEIR IRON? SIR,-Dr. Bonnar and his colleagues2 demonstrated by repeated tests that 32% of 60 pregnant women did not take their iron, and further emphasised the value of testing the stools for therapeutic iron before diagnosing any anxmia of pregnancy as refractory. Our own experience in 1966 was similar. We also used a simple filter-paper technique, but employed the prussian-blue reaction. We found, in random sampling of 483 antenatal patients in hospital and domiciliary practice, that 28% were not taking their iron.3 Kilpatrick labelled the tablets with a marker, and found that only 60-70% of Cardiff schoolgirls took their iron tablets regularly.4 It is unfortunate that Dr. Bonnar and his colleagues ixnplied that this lack of cooperation in women in taking iron had merely been " suspected ", when they quoted previous workers including Kilpatrick and ourselves. The similarity of the results obtained by three groups working in different parts of the British Isles is remarkable. It suggests that any of these simple tests may be helpful in the hxmatological management of iron deficiency. Lambeth and St. Thomas’s London.
Hospitals,
London Hospital, E.1.
R. G. HUNTSMAN. G. C. JENKINS.
NATIONAL SOCIETY FOR TRANSPLANT SURGERY Mr. R. E. WESTERMAN (Chairman of the Board of Trustees, The National Society for Transplant Surgery, 11 Alma Road, Cardiff CF2 5BD) writes: " This society was registered as a charity in March, 1968, the principal objectives being the enrolment of voluntary donors to bequeath organs for cadaveric transplantation surgery, the raising of funds for research and facilities in transplant surgery, and the education of potential donors to an awareTo ness of the interdependence of mankind in this sphere. ensure legal clarity and to avoid unnecessary distress each bequest is countersigned by the next of kin. We believe our expanding register of donors to be the largest in the world and wish to make details available to interested transplantationsurgery units. We seek guidance on how best to place our services at the disposal of the medical profession."
Peel, J., Potts, M. Textbook of Contraceptive Practice; p. 47. London, 1969. 2. Bonnar, J., Goldberg, A., Smith, J. A. Lancet, 1969, i, 457. 3. Afifi, A. M., Banwell, G. S., Bennison, R. J., Boothby, K., Griffiths, P. D., Huntsman, R. G., Jenkins, G. C., Lewin Smith, R. G., McIntosh, J., Qayum, A., Ross Russell, I., Whittaker, J. N. Br. med. J. 1966, i, 1021. 4. Kilpatrick, G. S. Proc. R. Soc. Med. 1966, 59, 1220. 1.