- Email: [email protected]
CYTOTOXIC EFFECT OF LYMPHOID CELLS FROM PATIENTS WITH RHEUMATOID ARTHRITIS
615 I should like to thank Prof. J. Dausset for supplying the leucocyteR. R. Race for undertaking some of the
agglutinating sera and Dr. red-cell grouping tests.
Blood Group Reference Laboratory, London, S.W.1.
K. L. G. GOLDSMITH.
ENCEPHALOPATHY AND FATTY DEGENERATION OF THE VISCERA SlR,ňThe communication by Dr. Reye and his coworkers1 interested us, because we have been working on the same problem since 1961. We, too, have observed comatose states of hitherto unknown aetiology in children with severe vomiting, agitation, convulsions, loss of consciousness, fever, and enlarged liver; at necropsy severe fatty degeneration of the liver, cerebral oedema, and changes in other organs were regular findings. We have called this unknown disorder " latent hepatopathy ". Our first complete postmortem in such a case was in 1960. In 1961 our attention was drawn to the great increase in activity of glutamic-oxaloacetic acid transaminase (G.o.T.) and glutamic-pyruvic acid transaminase (G.P.T.) in the serum of one of these patients. This increase points to the important part which the impaired liver function plays in the origin of this syndrome.2 The encephalitic symptoms in the terminal phase led clinical workers to believe that the syndrome was an encephalitis. This view must be rejected for the following reasons:
1. inflammatory changes in the brain have never been confirmed on microscopy. 2. The findings in the cerebrospinal fluid are not consistent with encephalitis. 3. The severe cerebral oedema on the one hand and the reversibility of the central nervous system changes on the other prove indirectly that the changes are metabolic in origin. 4. The association of this syndrome with impairment of liver function and an abnormal microscopic appearance in the liver suggests that the liver is implicated from the outset. 5. The increased activity of some of the intracellular enzymes, especially of the transaminases, supports the view that diffuse liver impairment is prominent in this syndrome. This is indirectly confirmed by the restoration to normal of the transaminase levels in the children who recovered, which corresponds chronologically with the return to normal of these enzymes in epidemic hepatitis. We are convinced that the escape of the two transaminases from the liver cells into the extracellular space, and the fatty changes in the liver cells, are manifestations of severe liver damage. The escape of G.O.T. and G.P.T. from the liver cell in this syndrome is caused neither by a negative nitrogen balance nor by changes in bloodpotassium values.3
Although treatment was unsuccessful in 6 of our patients, there is perhaps some hope if the following regimen is instituted promptly: (1) The intravenous infusions of glucose solution and insulin. (2) Maintenance of water metabolism at the lowest possible level. (3) Decreasing and lowering the metabolism. (4) Prevention of further loss of adenosine triphosphate, thus conserving energy in the liver cell ment
of its
at
the
price
of
some
impair-
integrity.
A mixture of
chlorpromazine,’Dolsin’ (a drug containing pethidine), and promethazine was used for the first time to lower the metabolism in our last patient. The average body temperature was 35-36°C (95GF). The main significance of this treatment lies in the " stabiliser activity " of phenothiazine and antihistaminic drugs on Reye, R. D. K., Morgan, G., Baral, J. Lancet, 1963, ii, 749. Stejskal, J., Oslejsková, M., Gregorová, Y. Paper read at the Faculty Children’s Hospital, Brno. 1962. 3. Stejskal, J., Kluska, V., Kania, V., Teyschl, O. Paper read at the biochemical meeting of Czech Academy of Science, Olomouc. 1963.
1 2.
the liver cell.
Shanes4 and othersthese drugs by blocking reactions that require energy, particularly by limiting the breaking off of adenosine triphosphate for the electrolyte pump. This stops further losses of energy, and thus the imminent danger of the metabolic collapse of the liver cell is averted. If this short-term treatment proves successful in other cases it will further support the view that severe livercell damage is at the root of the syndrome. From our clinical observations, we believe that a single cause-a hepatotoxic substance, toxin, or virus-is unlikely, but that a number of noxious agents may have the same effect. The most important factor, in our opinion, is preceding liver impairment. The summation of various hepatotoxic influences within a short time is not unlikely. A detailed report on this subject will be published within the next act on
According
to
the liver cell
few months in Czechoslovak Pediatrics. Infectious Diseases Department, Faculty Children’s Hospital,
Cěrnopolni 9, Brno, Czechoslovakia.
JAROSLAV STEJSKAL VLADIMIR KLUSKA.
CYTOTOXIC EFFECT OF LYMPHOID CELLS FROM PATIENTS WITH RHEUMATOID ARTHRITIS
SIR,-Dr. P. R. J. Burch 6 has recently suggested that inflammatory polyarthritis is an autoimmune disease caused by the appearance of one or more " forbidden " clones. The findings of Braunsteiner et al. are in conformity with this suggestion: when they added lymphnode cells from cases of rheumatoid arthritis (R.A.) to cultures of human amnion cells, they found a cytolytic effect. In other so-called autoimmune diseases a cytolytic effect of lymphoid cells has been demonstrated, for example by Koprowski and Fernandes,8 and by Berg and Källén.9 In our study mononuclear cells separated from synovial fluid in cases of systemic lupus erythematosus (S.L.E.) and in
of R.A. were found to exert a cytotoxic effect foetal fibroblasts (from subcutaneous tissue) in primary tissue cultures: Foetal human skin was cultured on glass, with a medium some cases
on
consisting of 5% chick embryonic extract, 20% human serum, and 75% Parker 199. When growth was vigorous, the medium was removed, the cultures were washed with tyrode solution, and mononuclears from the synovial fluid were added. The mononuclears were separated on cotton-wool,10 washed repeatedly with Parker 199, and resuspended in Parker 199 to final concentration of 1-3 million per ml. No serum was added. The cultures were studied under phase-contrast for forty-eight hours, and changes in cultural appearance were recorded by photography. The age of the cultures, which varied from about a week to five weeks, did not seem to be a
now
critical. The cytotoxic effect resulted in an almost complete cell death within about fifteen hours. This effect was preceded by a " contactual agglutination " 8 of the mononuclears on the surface of the fibroblasts. In 3 out of 3 cases of S.L.E. (without subcutaneous nodules) the synovial mononuclears exerted a cytotoxic effect. Two of these cases showed a positive sensitised sheep-cell (s.s.c.) test. In s.s.c.-positive cases of R.A., the frequency of a cytotoxic effect was 3/4 in cases with subcutaneous nodules, and 1/5 in cases without such nodules. In 2 cases of persistently s.s.c.negative R.A., and in 9 non-rheumatoid control cases with a negative s.s.c. test, no cytotoxic effect could be demonstrated. The controls comprised 4 cases of ankylosing spondylitis, 1 case Shanes, A. M. Pharmacol. Rev. 1958, 10, 165. Judah, J. D., Ahmed, K., McLean, A. E. Ann. N.Y. Acad. Sci. 1963, 104, 926. 6. Lancet, 1963, i, 1253. 7. Braunsteiner, H., Dienstl, F., Eibl, M. Klin. Wschr. 1963, 41, 889. 8. Koprowski, H., Fernandes, M. V. J. exp. Med. 1962, 116, 467. 9. Berg, O., Kallén, B. Acta path. microbiol. scand 1963, 58, 72. 10. Walker, R. I., Palmer, J. G. Blood, 1962, 20, 109. 4. 5.
616 of Reiter’s syndrome, cases of osteoarthritis.
cases
of
atypical polyarthritis, and
2
tests were
test.
Studies are in progress in order to elucidate the question of whether complement accelerates or facilitates the cytotoxic effect of rheumatoid synovial mononuclears. Preliminary results indicate that a cytotoxic effect may also be demonstrated in psoriatic arthropathy. A full report will be presented elsewhere. HELGE HEDBERG University of Lund,
BENGT KÄLLÉN.
Sweden.
DIURETICS IN DIABETES INSIPIDUS
SIR,-Crawford and Kennedy 12 reported favourable results with chlorothiazide and hydrochlorothiazide in diabetes insipidus-both in patients and in animals in which the condition was experimentally induced. We investigated the effect of several diuretics on two patients
(see table). DIURESIS
(MEAN
thiazide
were
effective; while the best result was obtained with
vasopressin When polythiazide and vasopressin tannate were given together, the anti-diuresis induced by the vasopressin was unaffected by the polythiazide. This was surprising, because in healthy persons polythiazide acts as a diuretic. But after our two patients had had their vasopressin tannate, polythiazide tannate.
made in 4 different cases. There was difference in the result between the first and the second
Repeated no
2
AND STANDARD
DEVIATION)
IN TWO PATIENTS WITH
DIABETES INSIPIDUS
Between receiving one drug and another the patients received no other medication. The difference between means of the 24-hourly output of urine was held to be significant The accompanying figure summarises the when p<0’01. results. Amisometradine did not substantially reduce the urinary output; chlorthalidone and, to a greater degree, poly1. Crawford, J. D., Kennedy, G. C. Nature, Lond. 1959, 183, 891. 2. Kennedy, G. C., Crawford, J. D. Lancet, 1959, i, 866.
did
not
increase their secretion of urine.
In both patients the ratio of the intake of fluids to urinary excretion was always around 1; but, when vasopressin tannate was given alone or with polytliiazide, the ratio fell progressively to 0.20. Neitlier of the catients had anv sisnincant change in
weight.
H. ABITBOL E. R. ORTIZ QUEVARA J. N. CUCCHI C. M. COLQUE.
Department of Physiology,
Pharmacology, and Medicine, Cuyo National University School of Medicine, Mendoza, Argentine.
THE WHOLE TRUTH Atkin SIR,-Dr. (March 7) points out that the pressing need for research in mental illness was not given prominence at the annual conference of this Association. Our difficulty was that " the whole truth " is a big subject to be covered in a two-day conference. We had, in fact, tape-recorded comments on research for discussion, but reluctantly omitted this item from our programme. These comments will, however, be included in the repeat play-back of our recordings to be given at 5 P.M. on April 22 at this address. Any of your readers wishing to hear these anonymous contributions from mental patients’ relatives and from representatives of the mental-health services will be welcome. We agree with Dr. Atkin that tape-recorded comments from patients themselves would be instructive, but we have not easily found patients who were not only willing to cooperate with us but also able to give factual, reliable, and reasonably concise accounts of their experiences. If any psychiatrist or general practitioner could put us in touch with patients who could help us in this matter we would consider tape-recording them for future use.
MARY ADAMS National Association for Mental Health, 39, Queen Anne Street, W.1.
Chairman, Public Information Committee.
G-GROUP CHROMOSOMES AND CELLULAR GROWTH
SiR,-Some clearly defined clinical syndromes have been shown abnormalities.
to
be
associated
with
chromosomal
Lejeune et al.1 described trisomy in one of the G-group chromosomes in mongolism, and the deletion of a chromosome of the same group has been reported in chronic myeloid leukxmia .2-5 The aberrant chromosome was named the Philadelphia or PhI-chromosome. Morphological deviations of the G-group chromosomes can be detected in some cases of chronic lymphatic leukxmia (the so-called Chl-chromosome),6in tumours, and in some cases of somatic and mental underdevelopment unrelated to mongolism.lo-3 Burch"11 1. 2. 3. 4. 5.
Action of diuretics
on
urinary output in diabetes insipidus.
6. 7. 8. 9. 10. 11. 12. 13. 14.
Lejeune, J. M., et al. C.R. Acad. Sci., Paris, 1959, 248, 172. Nowell, P. C., Hungerford, D. A. Science, 1960, 132, 1497. Nowell, P. C., Hungerford, D. A. Nat. Cancer Inst. 1961, 27, 1013. Baikie, A. G., Court Brown, W. M., Buckton, K. E., Harnden, D. G., Jacobs, P. A., Tough, I. M. Nature, Lond. 1960, 188, 1165. Tough, I. M., Baikie, A. G., Harnden, D. G., King, M. J., Court Brown, W. M., Buckton, K. E., Jacobs, P. A., McBride, J. A. Lancet, 1961, i, 411. Fitzgerald, P. H. et al. Human Chromosome Newsletter, 1962, 7, 13. Gunz, F. W., Fitzgerald, P. H. Brit. med. J. 1962, ii, 1097. Ishihara, T. et al. J. Nat. Cancer Inst. 1961, 27, 893. Bottura, C., Ferrari, I. Human Chromosome Newsletter, 1962, 7, 12. Fitzgerald, P. H. Lancet, 1962, ii, 456. Schmid, W., Biesele, J. J., Lawlis, M. G. ibid. p. 409. Ellis, J. R. et al. Heredity, 1962, 17, 144. Delhanty, J. D. A., Shapiro, A. J. ment. Defic. Res. 1962, 6, 38. Burch, P. R. J. Nature, Lond. 1963, 197, 1042.
agglutinating sera and Dr. red-cell grouping tests.
Blood Group Reference Laboratory, London, S.W.1.
K. L. G. GOLDSMITH.
ENCEPHALOPATHY AND FATTY DEGENERATION OF THE VISCERA SlR,ňThe communication by Dr. Reye and his coworkers1 interested us, because we have been working on the same problem since 1961. We, too, have observed comatose states of hitherto unknown aetiology in children with severe vomiting, agitation, convulsions, loss of consciousness, fever, and enlarged liver; at necropsy severe fatty degeneration of the liver, cerebral oedema, and changes in other organs were regular findings. We have called this unknown disorder " latent hepatopathy ". Our first complete postmortem in such a case was in 1960. In 1961 our attention was drawn to the great increase in activity of glutamic-oxaloacetic acid transaminase (G.o.T.) and glutamic-pyruvic acid transaminase (G.P.T.) in the serum of one of these patients. This increase points to the important part which the impaired liver function plays in the origin of this syndrome.2 The encephalitic symptoms in the terminal phase led clinical workers to believe that the syndrome was an encephalitis. This view must be rejected for the following reasons:
1. inflammatory changes in the brain have never been confirmed on microscopy. 2. The findings in the cerebrospinal fluid are not consistent with encephalitis. 3. The severe cerebral oedema on the one hand and the reversibility of the central nervous system changes on the other prove indirectly that the changes are metabolic in origin. 4. The association of this syndrome with impairment of liver function and an abnormal microscopic appearance in the liver suggests that the liver is implicated from the outset. 5. The increased activity of some of the intracellular enzymes, especially of the transaminases, supports the view that diffuse liver impairment is prominent in this syndrome. This is indirectly confirmed by the restoration to normal of the transaminase levels in the children who recovered, which corresponds chronologically with the return to normal of these enzymes in epidemic hepatitis. We are convinced that the escape of the two transaminases from the liver cells into the extracellular space, and the fatty changes in the liver cells, are manifestations of severe liver damage. The escape of G.O.T. and G.P.T. from the liver cell in this syndrome is caused neither by a negative nitrogen balance nor by changes in bloodpotassium values.3
Although treatment was unsuccessful in 6 of our patients, there is perhaps some hope if the following regimen is instituted promptly: (1) The intravenous infusions of glucose solution and insulin. (2) Maintenance of water metabolism at the lowest possible level. (3) Decreasing and lowering the metabolism. (4) Prevention of further loss of adenosine triphosphate, thus conserving energy in the liver cell ment
of its
at
the
price
of
some
impair-
integrity.
A mixture of
chlorpromazine,’Dolsin’ (a drug containing pethidine), and promethazine was used for the first time to lower the metabolism in our last patient. The average body temperature was 35-36°C (95GF). The main significance of this treatment lies in the " stabiliser activity " of phenothiazine and antihistaminic drugs on Reye, R. D. K., Morgan, G., Baral, J. Lancet, 1963, ii, 749. Stejskal, J., Oslejsková, M., Gregorová, Y. Paper read at the Faculty Children’s Hospital, Brno. 1962. 3. Stejskal, J., Kluska, V., Kania, V., Teyschl, O. Paper read at the biochemical meeting of Czech Academy of Science, Olomouc. 1963.
1 2.
the liver cell.
Shanes4 and othersthese drugs by blocking reactions that require energy, particularly by limiting the breaking off of adenosine triphosphate for the electrolyte pump. This stops further losses of energy, and thus the imminent danger of the metabolic collapse of the liver cell is averted. If this short-term treatment proves successful in other cases it will further support the view that severe livercell damage is at the root of the syndrome. From our clinical observations, we believe that a single cause-a hepatotoxic substance, toxin, or virus-is unlikely, but that a number of noxious agents may have the same effect. The most important factor, in our opinion, is preceding liver impairment. The summation of various hepatotoxic influences within a short time is not unlikely. A detailed report on this subject will be published within the next act on
According
to
the liver cell
few months in Czechoslovak Pediatrics. Infectious Diseases Department, Faculty Children’s Hospital,
Cěrnopolni 9, Brno, Czechoslovakia.
JAROSLAV STEJSKAL VLADIMIR KLUSKA.
CYTOTOXIC EFFECT OF LYMPHOID CELLS FROM PATIENTS WITH RHEUMATOID ARTHRITIS
SIR,-Dr. P. R. J. Burch 6 has recently suggested that inflammatory polyarthritis is an autoimmune disease caused by the appearance of one or more " forbidden " clones. The findings of Braunsteiner et al. are in conformity with this suggestion: when they added lymphnode cells from cases of rheumatoid arthritis (R.A.) to cultures of human amnion cells, they found a cytolytic effect. In other so-called autoimmune diseases a cytolytic effect of lymphoid cells has been demonstrated, for example by Koprowski and Fernandes,8 and by Berg and Källén.9 In our study mononuclear cells separated from synovial fluid in cases of systemic lupus erythematosus (S.L.E.) and in
of R.A. were found to exert a cytotoxic effect foetal fibroblasts (from subcutaneous tissue) in primary tissue cultures: Foetal human skin was cultured on glass, with a medium some cases
on
consisting of 5% chick embryonic extract, 20% human serum, and 75% Parker 199. When growth was vigorous, the medium was removed, the cultures were washed with tyrode solution, and mononuclears from the synovial fluid were added. The mononuclears were separated on cotton-wool,10 washed repeatedly with Parker 199, and resuspended in Parker 199 to final concentration of 1-3 million per ml. No serum was added. The cultures were studied under phase-contrast for forty-eight hours, and changes in cultural appearance were recorded by photography. The age of the cultures, which varied from about a week to five weeks, did not seem to be a
now
critical. The cytotoxic effect resulted in an almost complete cell death within about fifteen hours. This effect was preceded by a " contactual agglutination " 8 of the mononuclears on the surface of the fibroblasts. In 3 out of 3 cases of S.L.E. (without subcutaneous nodules) the synovial mononuclears exerted a cytotoxic effect. Two of these cases showed a positive sensitised sheep-cell (s.s.c.) test. In s.s.c.-positive cases of R.A., the frequency of a cytotoxic effect was 3/4 in cases with subcutaneous nodules, and 1/5 in cases without such nodules. In 2 cases of persistently s.s.c.negative R.A., and in 9 non-rheumatoid control cases with a negative s.s.c. test, no cytotoxic effect could be demonstrated. The controls comprised 4 cases of ankylosing spondylitis, 1 case Shanes, A. M. Pharmacol. Rev. 1958, 10, 165. Judah, J. D., Ahmed, K., McLean, A. E. Ann. N.Y. Acad. Sci. 1963, 104, 926. 6. Lancet, 1963, i, 1253. 7. Braunsteiner, H., Dienstl, F., Eibl, M. Klin. Wschr. 1963, 41, 889. 8. Koprowski, H., Fernandes, M. V. J. exp. Med. 1962, 116, 467. 9. Berg, O., Kallén, B. Acta path. microbiol. scand 1963, 58, 72. 10. Walker, R. I., Palmer, J. G. Blood, 1962, 20, 109. 4. 5.
616 of Reiter’s syndrome, cases of osteoarthritis.
cases
of
atypical polyarthritis, and
2
tests were
test.
Studies are in progress in order to elucidate the question of whether complement accelerates or facilitates the cytotoxic effect of rheumatoid synovial mononuclears. Preliminary results indicate that a cytotoxic effect may also be demonstrated in psoriatic arthropathy. A full report will be presented elsewhere. HELGE HEDBERG University of Lund,
BENGT KÄLLÉN.
Sweden.
DIURETICS IN DIABETES INSIPIDUS
SIR,-Crawford and Kennedy 12 reported favourable results with chlorothiazide and hydrochlorothiazide in diabetes insipidus-both in patients and in animals in which the condition was experimentally induced. We investigated the effect of several diuretics on two patients
(see table). DIURESIS
(MEAN
thiazide
were
effective; while the best result was obtained with
vasopressin When polythiazide and vasopressin tannate were given together, the anti-diuresis induced by the vasopressin was unaffected by the polythiazide. This was surprising, because in healthy persons polythiazide acts as a diuretic. But after our two patients had had their vasopressin tannate, polythiazide tannate.
made in 4 different cases. There was difference in the result between the first and the second
Repeated no
2
AND STANDARD
DEVIATION)
IN TWO PATIENTS WITH
DIABETES INSIPIDUS
Between receiving one drug and another the patients received no other medication. The difference between means of the 24-hourly output of urine was held to be significant The accompanying figure summarises the when p<0’01. results. Amisometradine did not substantially reduce the urinary output; chlorthalidone and, to a greater degree, poly1. Crawford, J. D., Kennedy, G. C. Nature, Lond. 1959, 183, 891. 2. Kennedy, G. C., Crawford, J. D. Lancet, 1959, i, 866.
did
not
increase their secretion of urine.
In both patients the ratio of the intake of fluids to urinary excretion was always around 1; but, when vasopressin tannate was given alone or with polytliiazide, the ratio fell progressively to 0.20. Neitlier of the catients had anv sisnincant change in
weight.
H. ABITBOL E. R. ORTIZ QUEVARA J. N. CUCCHI C. M. COLQUE.
Department of Physiology,
Pharmacology, and Medicine, Cuyo National University School of Medicine, Mendoza, Argentine.
THE WHOLE TRUTH Atkin SIR,-Dr. (March 7) points out that the pressing need for research in mental illness was not given prominence at the annual conference of this Association. Our difficulty was that " the whole truth " is a big subject to be covered in a two-day conference. We had, in fact, tape-recorded comments on research for discussion, but reluctantly omitted this item from our programme. These comments will, however, be included in the repeat play-back of our recordings to be given at 5 P.M. on April 22 at this address. Any of your readers wishing to hear these anonymous contributions from mental patients’ relatives and from representatives of the mental-health services will be welcome. We agree with Dr. Atkin that tape-recorded comments from patients themselves would be instructive, but we have not easily found patients who were not only willing to cooperate with us but also able to give factual, reliable, and reasonably concise accounts of their experiences. If any psychiatrist or general practitioner could put us in touch with patients who could help us in this matter we would consider tape-recording them for future use.
MARY ADAMS National Association for Mental Health, 39, Queen Anne Street, W.1.
Chairman, Public Information Committee.
G-GROUP CHROMOSOMES AND CELLULAR GROWTH
SiR,-Some clearly defined clinical syndromes have been shown abnormalities.
to
be
associated
with
chromosomal
Lejeune et al.1 described trisomy in one of the G-group chromosomes in mongolism, and the deletion of a chromosome of the same group has been reported in chronic myeloid leukxmia .2-5 The aberrant chromosome was named the Philadelphia or PhI-chromosome. Morphological deviations of the G-group chromosomes can be detected in some cases of chronic lymphatic leukxmia (the so-called Chl-chromosome),6in tumours, and in some cases of somatic and mental underdevelopment unrelated to mongolism.lo-3 Burch"11 1. 2. 3. 4. 5.
Action of diuretics
on
urinary output in diabetes insipidus.
6. 7. 8. 9. 10. 11. 12. 13. 14.
Lejeune, J. M., et al. C.R. Acad. Sci., Paris, 1959, 248, 172. Nowell, P. C., Hungerford, D. A. Science, 1960, 132, 1497. Nowell, P. C., Hungerford, D. A. Nat. Cancer Inst. 1961, 27, 1013. Baikie, A. G., Court Brown, W. M., Buckton, K. E., Harnden, D. G., Jacobs, P. A., Tough, I. M. Nature, Lond. 1960, 188, 1165. Tough, I. M., Baikie, A. G., Harnden, D. G., King, M. J., Court Brown, W. M., Buckton, K. E., Jacobs, P. A., McBride, J. A. Lancet, 1961, i, 411. Fitzgerald, P. H. et al. Human Chromosome Newsletter, 1962, 7, 13. Gunz, F. W., Fitzgerald, P. H. Brit. med. J. 1962, ii, 1097. Ishihara, T. et al. J. Nat. Cancer Inst. 1961, 27, 893. Bottura, C., Ferrari, I. Human Chromosome Newsletter, 1962, 7, 12. Fitzgerald, P. H. Lancet, 1962, ii, 456. Schmid, W., Biesele, J. J., Lawlis, M. G. ibid. p. 409. Ellis, J. R. et al. Heredity, 1962, 17, 144. Delhanty, J. D. A., Shapiro, A. J. ment. Defic. Res. 1962, 6, 38. Burch, P. R. J. Nature, Lond. 1963, 197, 1042.