569
optimistic. But the Government probably has a stick to persuade the societies to do what used to be Medibank’s work. The uninsured are to get back 40% of the standard fee, the insured 75%. The uninsured has a limit to his outlay for any one procedure of$20, which is double the limit for the insured. But the insured has to see his G.P. at least 50 times a year (or his family does) to come out in front. Is it worth it? The’whole cost of the new scheme falls on general revenue, which is surprising because Medibank II was introduced to take health costs out of general revenue. But the present Australian Government is dedicated to reducing inflation. Inflation is measured by the consumer price index (c.P.I.). The C.P.I. was boosted by the 1976 Medibank II manceuvre, which, however, saved the Government many millions of dollars. By abolishing compulsory health insurance, albeit replacing it with a lower standard of cover, the Government will reduce the C.P.I. by about 1-5% to 2%, a very useful drop in the (quite arbitrary) inflation rate. Of course the whole thing may backfire. Although Australians are addicts for health insurance, many may do their sums and decide to chance it. If the young and healthy-in the knowledge that without cost to themselves they are entitled to standard-ward hospital accommodation and 40% of their medical fees-decide to remain uninsured, there could be a greatly increased demand for standard hospital care. A reduction in the insurance pool would force up the premiums, which are expected to drop in response to the new Government contribution to all medical costs. If the lower rebates for operations and other medical fees do in fact keep the medically uninsured (uninsured, that is, for doctor’s fees) away from private hospitals, whether they have hospital insurance or not, then the public hospital system, which can only just cope with its workload, will be overburdened and the Commonwealth will be faced with sharing the extra bill. Perhaps the intention is to renounce the hospital cost-sharing agreement with the States —a move which would be quite in keeping with the Liberal Government’s attitude to election promises (which included a promise to maintain Medibank T) and to social welfare. The latest example, before the Budget, was to halve its dollar-fordollar contribution to home-care services, so forcing the States to double their contribution (from a much smaller tax base) in order to maintain the same standards of home care. It is to the credit of the States that they have accepted the extra costs. funds
Round the World From
our
Correspondents
Australia LITTLE LEFT OF MEDIBANK
WHEN the Budget was presented on Tuesday, Aug. 15, all the newspaper predictions of the previous week were confirmed. Along with higher taxes the demise of Medibank Standard was announced. Medibank I was the free universal health insurance scheme introduced by Labour in 1975. It was modified to Medibank IF in 1976 by the Liberal (or, in U.K. terms, Conservative) Government by the introduction of a levy (insurance contributions) set at a level which encouraged people to opt for private insurance, so reducing the cost to the Commonwealth Government. Levy payers were insured with Medibank Standard, the truncated remains of Medibank I. Medibank Standard covered all those who were not privately insured. They either paid premiums to Medibank Standard as a deduction from their wages, taken with P.A.Y.E., or had the levy added to their income tax at the end of the year if they could not produce proof of payment to some other fund. On July 1 last, with the introduction of Medibank III the medicalfees rebate was reduced from 85% of the fee, with a maximum
payment of$5, by the patient, to 75% (or$10).
,
At the same time "bulk-billing" (which enabled doctors to send bills direct to Medibank and saved the patient from any payment) was to be abolished, except for pensioners. The outcry from both the Australian Medical Association and the Doctors Reform Society (a group usually found in opposition to the A.M.A.) persuaded the Government that there were other deprived groups in the community. The A.M.A. also pointed out that the decrease in the refund from 85% to 75% would be hard on the incomes of those doctors whose practices were mainly pensioners. The Government, after considerable pressure, backed down and left pensioner benefits (for bulkbilling) at 85% of the Government fee (which is below the A.M.A. fee). Doctors caring for other poor people are less lucky. Though the Government agreed to continue bulk-billing for the "socially disadvantaged"* the rebate would be at the new 75% rate, amounting to a cut of about 12% in doctors’ incomes. Everyone else in Australia has had about 5% increase in income, through wage indexation, during the past year. The budget killed Medibank Standard. All that remains is Medibank Private, which is just like the Hospital Benefits Association, the Hospitals Contributory Fund, and 93 other health-insurance organisations. The Budget also ended compulsory health insurance for everyone-an odd move for a Government determined on forcing people to help themselves. The new scheme offers much reduced rebates for medical bills and free public (State-run) hospital care to all at no cost. There will no longer be any subsidy for the "hospital-only" type of health insurance, and people requiring private or shared rooms in public hospitals plus the doctor (or surgeon) of their choice will be required, as now, to pay directly for these privileges or seek insurance cover with one of the private health funds (including Medibank Private) in order to protect themselves against vast health-care bills for a serious illness. The new system will require an extra$305 million per annum, to be obtained by increasing present income-tax scales by 11 2 %. Hopes that the scheme will be administered by the health
*Our comment of Aug. 26 (p. 466) on the Australian Budget was wrong in suggesting that bulk-billing for the socially disadvantaged had not been retained.-ED. L.
seem
carrot or a
PEER REVIEW
IN May, 1976, Mr Ralph Hunt, Minister for Health, peakof the rapid increase in health-care costs, maintained that, because the decisions and recommendations of doctors on behalf of their patients had caused these costs, it was the duty of the medical profession as a whole to see to it that procedures were introduced which maintained the quality of health care, exerted control over costs, and eliminated superfluous servicing. He added that if such a workable system were not forthcoming from the profession within a few years it would have to be imposed by the Government. There was, needless to say, considerable reaction. Nevertheless, a month later, at its Federal Assembly the Aystralian Medical Association agreed to inquire into the possibility of introducing such a system on a national basis, to determine whether such action would be acceptable to the medical profession, to send two delegates to study schemes already functioning, overseas, and to discuss the different findings at a later seminar, provided that the Federal Government covered all the costs incurred. A national seminar widely representative of medical personnel was held in February, 1977. Mr Hunt attended one session and oiled the wheels by declaring: "My Government believes first and foremost in self-regulation and self-determination". Clearly it would not be easy to dictate to
ing
570
profession ing. a
whose members
were
accustomed
to
do the dictat-
Letters
At the 1978 Federal Assembly on May 29, the A.M.A. by resolution committed its 15 000 members to the concept of peer review, despite the uneasiness of some and the open opposition of others, including the General Practitioners Society. The passing of this resolution entailed explaining to doctors exactly what was to be meant in the Australian context by peer review. It was made quite clear that it would not mean "a review of the work of doctors by their peers or fellow doctors"; the need for such possible action, it was claimed, was already adequately catered for by ethical committees, committees of inquiry, disciplinary tribunals, and many other systems within and without hospitals. What was meant was that programmes and services in hospitals would be evaluated in terms of predetermined professional standards and operated on that basis. The evaluation would be made initially within a hospital by all the peers involved in a particular procedure, who, having made their "clinical audit," would in effect have to police it and ensure that their colleagues conformed within reason to the prescribed pattern. Well-kept records would of course be mandatory, enabling the "audit" to be reviewed as required. This type of procedure is said to be the only known method of evaluating the quality of hospital services, the appropriateness of admission to hospital, and the length of hospital stay. The A.M.A. was opposed to nationwide bureaucratic administration of peer-review systems, as in the "professional services review organisation" (P.S.R.O.) of the U.S. (the value of which is yet to be proven), and to the idea of Australian State Health Authority involvement, which would inevitably also lead to Government control. It was, however, in sympathy with the Canadian practice which had linked systems of medical-care evaluation to the requirements of hospital accreditation.
’
As long ago as the late ’50s an attempt had been made in New South Wales by Dr T. Y. Nelson and Dr E. F. Thomson to introduce to Australia this North American concept of hospital accreditation. Despite many frustrations, the Australian Council on Hospital Standards finally emerged, representative of all medical professional bodies, and as a voluntary and powerful organisation. Hospitals can now apply to the council for the status of accreditation if they have conformed to the standards demanded in the publication The Accreditation
Guide for Australian Hospitals. Other public-spirited members of the medical profession who are concerned about efficiency and costs have already suc-
cessfully introduced peer-review systems for their own hospital specialties, and in one large teaching hospital all medical trainees are required to learn the costs of the equipment used, and of each test carried out, as well as the reasons and justifi-
to
the Editor
LEGIONNAIRES’ DISEASE: RADIOLOGICAL RESOLUTION AND BRONCHOSCOPY
SIR,-Bronchoscopy is often asked for in a patient with delayed radiological resolution after pneumonia. In a previously fit patient with non-cavitating pneumonia radiological changes persist at 4 weeks in only 13% of cases, at eight weeks in less than 3%.’ In legionnaires’ disease, however, resolution is much slower, irrespective of the clinical severity. In thirteen survivors from legionnaires’ disease (L.D.) admitted to this hospital since 1977, radiological changes were seen at 4 weeks in 100% and at 8 weeks in 85%. In July three patients referred to us for bronchoscopy because of delayed resolution of pneumonia were found to have .D., as was a fourth bronchoscoped in February. All have returned to normal health. Case 1.-A 57-year-old man was admitted in 1977 with leftlower-lobe pneumonia, and discharged after 10 days. 3 months later persisting radiological changes were noted. Bronchoscopy was normal. The diagnosis of L.D. was then considered, and confirmed by an immunofluorescent antibody titre (LF.A.T.) of 1 :512 (previously less than 1 :32). Case 2.-A 60-year-old man was admitted in June with lobar pneumonia, confusion, lymphopenia, hyponatrxmia, and hypoalbuminxmia, a combination which suggested L.D.23 Erythromycin was given intravenously, with rapid clinical improvement. I.F.A.T. was only 1:32, and in view of persisting pyrexia and consolidation, bronchoscopy was requested. This was performed four weeks after admission, and was normal. A serum sample taken the next day now had I.F.A.T. 1:1024. Case 3.-A 57-year-old man was transferred from another hospital for bronchoscopy because of slow clinical and radiological resolution of lobar pneumonia. L.D. was considered, and confirmed by LF.A.T. rising to 1:512. The bronchoscopy cancelled. Case 4.-Bronchoscopy was requested in a 68-year-old woman with persisting left-lower-lobe consolidation. 3 months earlier she had had pneumonia while staying in the same Benidorm (Spain) hotel that has been implicated in other cases of L.D. in 19734 and 1977,5 and was admitted to hospital there for 2 weeks. I.F.A.T. was 1:256, so bronchoscopy was not done. Delayed resolution of acute pneumonia in a previously fit patient is a problem familiar to all physicians. We suggest that in such a case legionnaires’ disease should be considered before bronchoscopy is performed. A. C. MILLER Department of Thoracic Medicine, S. B. PEARSON City Hospital, W. H. RODERICK SMITH Nottingham NG5 1PB was
-
--
cations for the tests. The hospital industry of Australia now costs about$2.5 billion per annum, and it is estimated that if 10% of its public hospital beds were closed (many of which are not used and/or are in the wrong districts) a saving of$260 million would result. The bed ratio is high-6.8per 1000 population in N.S.W. Further, if for each patient the period in hospital was reduced by one day, the savings would run into millions of dollars. It seems reasonable, in view of the relative costs, to suggest that paramedical home care might be substituted for many patients in the later stages of a spell in hospital.
The new Guide to Clinical Review, published jointly by the Australian Council on Hospital Standards, the Australian Hospital Association, and the A.M.A., explains to doctors how criteria auditing is achieved and gives examples. It also quotes John Ruskin: "Quality is never an accident. It is always the result of intelligent effort. There must be a will to produce superior work"-to which might be added, at a reasonable cost.
SICKLE-CELL DISEASE: TWO NEW THERAPEUTIC STRATEGIES
SIR,-At the XVIIth Congress of the International Society of Hasmatology, held in Paris in July, M. Perutz noted that since 1970 more than sixty chemotherapeutic agents for sicklecell disease cued to molecular aspects of sickle haemoglobin have been proposed. At the same congress R. L. Nagel classified such agents as non-covalent, covalent, modifiers of high oxygen affinity (i.e., inducing left-shifted oxygen-dissociation curves, L.S.O.D.C., or membrane modifiers. Beutler has 1.
2. 3. 4. 5.
Israel, H. L., Weiss, W., Eisenberg, G. M., Strandness, D. E., Flippin, H. F.Med. Clins N.Am. 1956, 40, 1291. Miller, A. C., Pearson, S. B. Thorax, (in the press). Jenkins, P. F., Miller, A. C., Osman, J., Pearson, S. B., Rowley, J. M. Br. J. Dis. Chest, (in the press). Lawson, J. H., Grist, N. R., Reid, D., Wilson, T. S. Lancet, 1977, ii, 1083. Kerr, D. N. S., Brewis, R. A. L., Macrae, A. D. Br. med. J. 1978, ii, 538.
optimistic. But the Government probably has a stick to persuade the societies to do what used to be Medibank’s work. The uninsured are to get back 40% of the standard fee, the insured 75%. The uninsured has a limit to his outlay for any one procedure of$20, which is double the limit for the insured. But the insured has to see his G.P. at least 50 times a year (or his family does) to come out in front. Is it worth it? The’whole cost of the new scheme falls on general revenue, which is surprising because Medibank II was introduced to take health costs out of general revenue. But the present Australian Government is dedicated to reducing inflation. Inflation is measured by the consumer price index (c.P.I.). The C.P.I. was boosted by the 1976 Medibank II manceuvre, which, however, saved the Government many millions of dollars. By abolishing compulsory health insurance, albeit replacing it with a lower standard of cover, the Government will reduce the C.P.I. by about 1-5% to 2%, a very useful drop in the (quite arbitrary) inflation rate. Of course the whole thing may backfire. Although Australians are addicts for health insurance, many may do their sums and decide to chance it. If the young and healthy-in the knowledge that without cost to themselves they are entitled to standard-ward hospital accommodation and 40% of their medical fees-decide to remain uninsured, there could be a greatly increased demand for standard hospital care. A reduction in the insurance pool would force up the premiums, which are expected to drop in response to the new Government contribution to all medical costs. If the lower rebates for operations and other medical fees do in fact keep the medically uninsured (uninsured, that is, for doctor’s fees) away from private hospitals, whether they have hospital insurance or not, then the public hospital system, which can only just cope with its workload, will be overburdened and the Commonwealth will be faced with sharing the extra bill. Perhaps the intention is to renounce the hospital cost-sharing agreement with the States —a move which would be quite in keeping with the Liberal Government’s attitude to election promises (which included a promise to maintain Medibank T) and to social welfare. The latest example, before the Budget, was to halve its dollar-fordollar contribution to home-care services, so forcing the States to double their contribution (from a much smaller tax base) in order to maintain the same standards of home care. It is to the credit of the States that they have accepted the extra costs. funds
Round the World From
our
Correspondents
Australia LITTLE LEFT OF MEDIBANK
WHEN the Budget was presented on Tuesday, Aug. 15, all the newspaper predictions of the previous week were confirmed. Along with higher taxes the demise of Medibank Standard was announced. Medibank I was the free universal health insurance scheme introduced by Labour in 1975. It was modified to Medibank IF in 1976 by the Liberal (or, in U.K. terms, Conservative) Government by the introduction of a levy (insurance contributions) set at a level which encouraged people to opt for private insurance, so reducing the cost to the Commonwealth Government. Levy payers were insured with Medibank Standard, the truncated remains of Medibank I. Medibank Standard covered all those who were not privately insured. They either paid premiums to Medibank Standard as a deduction from their wages, taken with P.A.Y.E., or had the levy added to their income tax at the end of the year if they could not produce proof of payment to some other fund. On July 1 last, with the introduction of Medibank III the medicalfees rebate was reduced from 85% of the fee, with a maximum
payment of$5, by the patient, to 75% (or$10).
,
At the same time "bulk-billing" (which enabled doctors to send bills direct to Medibank and saved the patient from any payment) was to be abolished, except for pensioners. The outcry from both the Australian Medical Association and the Doctors Reform Society (a group usually found in opposition to the A.M.A.) persuaded the Government that there were other deprived groups in the community. The A.M.A. also pointed out that the decrease in the refund from 85% to 75% would be hard on the incomes of those doctors whose practices were mainly pensioners. The Government, after considerable pressure, backed down and left pensioner benefits (for bulkbilling) at 85% of the Government fee (which is below the A.M.A. fee). Doctors caring for other poor people are less lucky. Though the Government agreed to continue bulk-billing for the "socially disadvantaged"* the rebate would be at the new 75% rate, amounting to a cut of about 12% in doctors’ incomes. Everyone else in Australia has had about 5% increase in income, through wage indexation, during the past year. The budget killed Medibank Standard. All that remains is Medibank Private, which is just like the Hospital Benefits Association, the Hospitals Contributory Fund, and 93 other health-insurance organisations. The Budget also ended compulsory health insurance for everyone-an odd move for a Government determined on forcing people to help themselves. The new scheme offers much reduced rebates for medical bills and free public (State-run) hospital care to all at no cost. There will no longer be any subsidy for the "hospital-only" type of health insurance, and people requiring private or shared rooms in public hospitals plus the doctor (or surgeon) of their choice will be required, as now, to pay directly for these privileges or seek insurance cover with one of the private health funds (including Medibank Private) in order to protect themselves against vast health-care bills for a serious illness. The new system will require an extra$305 million per annum, to be obtained by increasing present income-tax scales by 11 2 %. Hopes that the scheme will be administered by the health
*Our comment of Aug. 26 (p. 466) on the Australian Budget was wrong in suggesting that bulk-billing for the socially disadvantaged had not been retained.-ED. L.
seem
carrot or a
PEER REVIEW
IN May, 1976, Mr Ralph Hunt, Minister for Health, peakof the rapid increase in health-care costs, maintained that, because the decisions and recommendations of doctors on behalf of their patients had caused these costs, it was the duty of the medical profession as a whole to see to it that procedures were introduced which maintained the quality of health care, exerted control over costs, and eliminated superfluous servicing. He added that if such a workable system were not forthcoming from the profession within a few years it would have to be imposed by the Government. There was, needless to say, considerable reaction. Nevertheless, a month later, at its Federal Assembly the Aystralian Medical Association agreed to inquire into the possibility of introducing such a system on a national basis, to determine whether such action would be acceptable to the medical profession, to send two delegates to study schemes already functioning, overseas, and to discuss the different findings at a later seminar, provided that the Federal Government covered all the costs incurred. A national seminar widely representative of medical personnel was held in February, 1977. Mr Hunt attended one session and oiled the wheels by declaring: "My Government believes first and foremost in self-regulation and self-determination". Clearly it would not be easy to dictate to
ing
570
profession ing. a
whose members
were
accustomed
to
do the dictat-
Letters
At the 1978 Federal Assembly on May 29, the A.M.A. by resolution committed its 15 000 members to the concept of peer review, despite the uneasiness of some and the open opposition of others, including the General Practitioners Society. The passing of this resolution entailed explaining to doctors exactly what was to be meant in the Australian context by peer review. It was made quite clear that it would not mean "a review of the work of doctors by their peers or fellow doctors"; the need for such possible action, it was claimed, was already adequately catered for by ethical committees, committees of inquiry, disciplinary tribunals, and many other systems within and without hospitals. What was meant was that programmes and services in hospitals would be evaluated in terms of predetermined professional standards and operated on that basis. The evaluation would be made initially within a hospital by all the peers involved in a particular procedure, who, having made their "clinical audit," would in effect have to police it and ensure that their colleagues conformed within reason to the prescribed pattern. Well-kept records would of course be mandatory, enabling the "audit" to be reviewed as required. This type of procedure is said to be the only known method of evaluating the quality of hospital services, the appropriateness of admission to hospital, and the length of hospital stay. The A.M.A. was opposed to nationwide bureaucratic administration of peer-review systems, as in the "professional services review organisation" (P.S.R.O.) of the U.S. (the value of which is yet to be proven), and to the idea of Australian State Health Authority involvement, which would inevitably also lead to Government control. It was, however, in sympathy with the Canadian practice which had linked systems of medical-care evaluation to the requirements of hospital accreditation.
’
As long ago as the late ’50s an attempt had been made in New South Wales by Dr T. Y. Nelson and Dr E. F. Thomson to introduce to Australia this North American concept of hospital accreditation. Despite many frustrations, the Australian Council on Hospital Standards finally emerged, representative of all medical professional bodies, and as a voluntary and powerful organisation. Hospitals can now apply to the council for the status of accreditation if they have conformed to the standards demanded in the publication The Accreditation
Guide for Australian Hospitals. Other public-spirited members of the medical profession who are concerned about efficiency and costs have already suc-
cessfully introduced peer-review systems for their own hospital specialties, and in one large teaching hospital all medical trainees are required to learn the costs of the equipment used, and of each test carried out, as well as the reasons and justifi-
to
the Editor
LEGIONNAIRES’ DISEASE: RADIOLOGICAL RESOLUTION AND BRONCHOSCOPY
SIR,-Bronchoscopy is often asked for in a patient with delayed radiological resolution after pneumonia. In a previously fit patient with non-cavitating pneumonia radiological changes persist at 4 weeks in only 13% of cases, at eight weeks in less than 3%.’ In legionnaires’ disease, however, resolution is much slower, irrespective of the clinical severity. In thirteen survivors from legionnaires’ disease (L.D.) admitted to this hospital since 1977, radiological changes were seen at 4 weeks in 100% and at 8 weeks in 85%. In July three patients referred to us for bronchoscopy because of delayed resolution of pneumonia were found to have .D., as was a fourth bronchoscoped in February. All have returned to normal health. Case 1.-A 57-year-old man was admitted in 1977 with leftlower-lobe pneumonia, and discharged after 10 days. 3 months later persisting radiological changes were noted. Bronchoscopy was normal. The diagnosis of L.D. was then considered, and confirmed by an immunofluorescent antibody titre (LF.A.T.) of 1 :512 (previously less than 1 :32). Case 2.-A 60-year-old man was admitted in June with lobar pneumonia, confusion, lymphopenia, hyponatrxmia, and hypoalbuminxmia, a combination which suggested L.D.23 Erythromycin was given intravenously, with rapid clinical improvement. I.F.A.T. was only 1:32, and in view of persisting pyrexia and consolidation, bronchoscopy was requested. This was performed four weeks after admission, and was normal. A serum sample taken the next day now had I.F.A.T. 1:1024. Case 3.-A 57-year-old man was transferred from another hospital for bronchoscopy because of slow clinical and radiological resolution of lobar pneumonia. L.D. was considered, and confirmed by LF.A.T. rising to 1:512. The bronchoscopy cancelled. Case 4.-Bronchoscopy was requested in a 68-year-old woman with persisting left-lower-lobe consolidation. 3 months earlier she had had pneumonia while staying in the same Benidorm (Spain) hotel that has been implicated in other cases of L.D. in 19734 and 1977,5 and was admitted to hospital there for 2 weeks. I.F.A.T. was 1:256, so bronchoscopy was not done. Delayed resolution of acute pneumonia in a previously fit patient is a problem familiar to all physicians. We suggest that in such a case legionnaires’ disease should be considered before bronchoscopy is performed. A. C. MILLER Department of Thoracic Medicine, S. B. PEARSON City Hospital, W. H. RODERICK SMITH Nottingham NG5 1PB was
-
--
cations for the tests. The hospital industry of Australia now costs about$2.5 billion per annum, and it is estimated that if 10% of its public hospital beds were closed (many of which are not used and/or are in the wrong districts) a saving of$260 million would result. The bed ratio is high-6.8per 1000 population in N.S.W. Further, if for each patient the period in hospital was reduced by one day, the savings would run into millions of dollars. It seems reasonable, in view of the relative costs, to suggest that paramedical home care might be substituted for many patients in the later stages of a spell in hospital.
The new Guide to Clinical Review, published jointly by the Australian Council on Hospital Standards, the Australian Hospital Association, and the A.M.A., explains to doctors how criteria auditing is achieved and gives examples. It also quotes John Ruskin: "Quality is never an accident. It is always the result of intelligent effort. There must be a will to produce superior work"-to which might be added, at a reasonable cost.
SICKLE-CELL DISEASE: TWO NEW THERAPEUTIC STRATEGIES
SIR,-At the XVIIth Congress of the International Society of Hasmatology, held in Paris in July, M. Perutz noted that since 1970 more than sixty chemotherapeutic agents for sicklecell disease cued to molecular aspects of sickle haemoglobin have been proposed. At the same congress R. L. Nagel classified such agents as non-covalent, covalent, modifiers of high oxygen affinity (i.e., inducing left-shifted oxygen-dissociation curves, L.S.O.D.C., or membrane modifiers. Beutler has 1.
2. 3. 4. 5.
Israel, H. L., Weiss, W., Eisenberg, G. M., Strandness, D. E., Flippin, H. F.Med. Clins N.Am. 1956, 40, 1291. Miller, A. C., Pearson, S. B. Thorax, (in the press). Jenkins, P. F., Miller, A. C., Osman, J., Pearson, S. B., Rowley, J. M. Br. J. Dis. Chest, (in the press). Lawson, J. H., Grist, N. R., Reid, D., Wilson, T. S. Lancet, 1977, ii, 1083. Kerr, D. N. S., Brewis, R. A. L., Macrae, A. D. Br. med. J. 1978, ii, 538.
