986 mation becomes available. A national network would provide the disinterested source required by the health profession. School of Pharmacy and University of Bath, Claverton Down, Bath BA2 7AY.
Pharmacology,
J. M. PADFIELD S. H. Moss D. A. NORTON
DISCHARGE OF VIOLENT PATIENTS
SiR,—Iwas surprised to learn that Dr Newcombe (Oct. 25,
820) supports muddled anxieties expressed by the public and in the media. He cites two anecdotes and implies that the once dangerous mentally disordered patient will always be so. Sadly, no mention is made of the possibility of good faith and conscientiousness on the part of the psychiatrists concerned. Nor does Dr Newcombe admit that he might have himself agreed with these clinical decisions. Many mentally disordered offenders on whom the courts impose a sentence of psychiatric treatment under Section 60 of the 1959 Mental Health Act are not a danger to others. Lay involvement in limiting any discharge and further treatment plans can only be justified if the public interest is significantly involved. Conditional discharge and supervision decisions about restricted Section-65 patients are taken by the Home Office. Mental health review tribunals have only an advisory role like that of the consultant psychiatrist (the responsible medical officer). Among other possible results, the universal application of Section-65 restrictions in addition to Section-60 Orders could increase the regrettable reluctance of area psychiatric services to treat the mentally disordered offender. His nuisance value and criminal associations alone already deter hospitals from providing appropriate containment and treat-
p.
ment.
Whatever the limitations of psychiatric evaluations and pre-
dictions, it is improbable that the reliability of decisions will
improved by investing the responsibility for assessment in independent body such as a mental health review tribunal. If the view of a predominantly lay body is to replace the psychiatrist’s assessment of his patient, he will be encouraged to relinquish responsibility for subsequent supervision in the community. If he does not profoundly influence the time of the patient’s discharge, he can scarcely be expected to advise the patient to accept custodial care which he considers un-
be
an
necessary and
even harmful. The public will always tend to be anxious about patients with records of violence and will assume that they remain dangerous until persuaded otherwise. Absolutely no risk to the public equals absolutely no discharges, however unjustifiable continued detainment may be to the psychiatrist involved.
Broadmoor
Hospital,
Crowthorne, Berks RG11 7EG.
JAMES MACKEITH
proportion is rather alarming and, as far asI am systematic investigation into the factors responsible
tions. This aware,
no
has been undertaken. This exercise is overdue and urgent, because these patients challenge the functioning of the opendoor policy and improved therapeutic care. The establishment of secure units will do little to improve the resources for the management and the actual care of such patients which should be a priority above the establishment of secure units, especially since resources are limited. As most of the patients recommended for secure units would be those in whom mental illness and criminality are causally related, would it not be more efficient and economic to improve the therapeutic potential of psychiatric facilities in prison, where provision for physical security already exists? This could also benefit other prisoners with psychiatric problems. In times of financial stringency, would it not be more economical to improve the existing services and the milieu in which people can be treated rather than embark on something new and
expensive? St. Christophers Day 52 Hurst Road, Horsham RH12 2EP.
Hospital, N. H. RATHOD
SELECT COMMITTEE UNDER THE ABORTION LAW
SIR,-The Secretary of State is reported in your columns (Nov. 1, p. 879) as being under obligation to Parliament to
provide an abortion service at least as far as conscientious objection (Section 4 of the 1967 Act) will permit. I have read the Act many times but I can see no reference to "providing an abortion service". Certainly the N.H.S. or private doctor can offer his opinion in good faith and the law requires that two registered practitioners should agree to abortion. No doctor is obliged to provide a service, only an opinion. This is important in 1975 since abortion on request for social economic pressure accounts for most of Britain’s 200,000 yearly abortions. Uniformity of opinion on the abortion issue is an impossible target even allowing that the D.H.S.S. do put pressure on selection committees with a view to excluding from consultant appointments any with conscientious or other objections to abortion. The D.H.S.S. achieves this by using a job description despite the "out" clause Section 4 in the 1967 Abortion Act. The Secretary of State confessed in Parliament that 9 obstetricians in 70 appointments were barred by the N.H.S. during the past six months. As far as I know this is the first time that a test act has been applied to candidates applying for a public post in the profession of medicine. However, the profession and the nation may carry its head high. It seems that Parliament is going to insist that before givine an ooinion a doctor must examine a orernant oatient! Birmingham & Midland Hospital for Women, Showell Green Lane, Birmingham B11 4HL.
H. C. MCLAREN
SECURE UNITS FOR MENTALLY ILL
SIR,-Following recommendations’ from the D.H.S.S. regional authorities are giving consideration to the establishment of secure units for mentally ill and mentally handicapped patients needing such an environment. The patients in such units would be those who cannot be treated in general psychiatric units and, at the same time, do not qualify for admission or stay in special units - e.g., Broadmoor or Rampton. Although few would argue against the need for such facilities, the question of security and treatment of disturbed and disturbing patients, with or without involvement in criminal behaviour, raises certain problems. In 1971, 7.6%, (i.e., approximately 13 000 patients) in psychiatric hospitals were said to be housed in wards with locked doors, there being considerable variation between hospitals and regions in the proportion of people needing such restric1. Circular
no.
HSC (IS
61) July,
1974.
JUNIOR DOCTORS’ CONTRACT SIR,-We, representing the junior doctors of the Royal Marsden Hospital, which incorporates two specialist cancer centres in London and Surrey, wish to present our proposals to all colleagues. As junior hospital doctors we find ourselves increasingly at odds with the philosophy now pervading negotiations for a new contract. Discussions with our colleagues in many parts of the country convince us that our views are widely held and may even be those of the "silent majority" and therefore it THE
would appear that our present negotiating body is non-representative of the majority view. Our proposals are as follows: (1) The National Health Service and ill people should be separated from direct political interference which has resulted in the present conflict. It should have an independent govern-
987
ing body, who represent
a
in it.
(2) There should be a return to a contract for an adequate basic salary in which overtime plays no part. (3) There should be sufficient staffing to reduce the grossly excessive hours that some doctors ’work at present. In areas where this cannot be met, there should be a supplemented salary for those with an above average workload and where understaffing exists. (4) Every doctor should have the opportunity for time-off duty from his clinical responsibilities. (5) There should be no difference in salary between doctors of the same grade in different specialties. Any new contract should shift the emphasis in the direction of a basic salary and adequate staffing. Until new basic salaries can be negotiated which meet the needs of doctors depending heavily on overtime payments, we should respect our present contracts. Any step which confirms overtime payment as a permanent feature of the system in a profession such as medicine is obviously a step backwards. We therefore suggest that those in sympathy with our views reject the principle of a 40-hour week with overtime which the ballot recommends. We are greatly concerned about the future of medicine in this country and hope that the Royal Commission set up by the Government will be unbiased and examine all aspects of the National Health Service and lay down the foundations for a better organised system of medical care. P. R. S. TASKER
Royal Marsden Hospital, Fulham Road, London SW3 6JJ.
C. S. FOSTER J. P. GLEES P. F. HOWARD for the Royal Marsden Hospital Junior Doctors Committee
ADVISERS IN CONTROL OF INFECTIOUS DISEASE
SiR,—The amount of experience in this country in the practical aspects of infectious-disease control is gradually diminishing. A realisation of this, reinforced by the proposal for establishing regional epidemiologists put forward by the committee of inquiry into the smallpox outbreak in London in 1973,’ has encouraged the D.H.S.S. to consider the need for experts to be readily accessible at any time to assist medical officers for environmental health in instituting the practical measures that should be taken to control outbreaks of serious infectious disease such as smallpox, Lassa fever, and other unusual imported infections. It is interesting to speculate whether another epidemic like the encephalitis of the 1920s would find us any better prepared than we were then. These advisers would provide an increasingly valuable concentration of practical experience, and by supplying advice rather than direction, need pose no threat to the independence of the local authorities responsible for controlling an outbreak. It is important however, that they should be called regional "infectious disease advisers" and not regional "epidemiologists" : it was some years ago that epidemiologists ceased to confine their attention to communicable disease, and began to study chronic conditions and contribute information relevant to the planning of health services in general. In addition, epidemiologists may have little experience of implementng practical control procedures. The appointment of at least a few infectious-disease advisers should be welcomed. Kensington and Chelsea and Westminster Area Health Authority (Teaching), North-East District Management Team Offices, Middlesex Hospital, London W1N 8AA
1. in
BROMOCRIPTINE IN PARKINSONISM
cross-section of all those who work
PAUL A. KITCHENER
Report of the Committee of Inquiry into the Smallpox Outbreak in London March and April 1973; p 116. Cmnd 5626. H.M. Stationary Office, 1974.
SIR,-Dopamine agonists (drugs that stimulate dopamine receptors) are an important advance in the treatment of Parkinson’s disease. They have several theoretical advantages over levodopa. Firstly, their effect may last longer; secondly, if the on-off effect that develops in 10% of patients treated with levodopa is due to toxic metabolites of the compound, response swings may not occur with drugs such as bromocriptine; and thirdly, patients who do not respond to levodopa, possibly because of insufficient striatal dopa decarboxylase, may respond to dopamine agonists. In addition, if a specific nigrostriatal dopamine agonist can be developed, it may have specific antiparkinsonian effects without the adverse reactions resulting from altered function Iin other dopamine systems both inside and outside the brain.’ Bromocriptine, a drug which stimulates dopamine receptors appears to have considerable potency in Parkinson’s disease and may be as active as levodopa.’-3 Some patients unresponsive to or unable to tolerate levodopa have improved on bromocriptine, as have patients who have not been treated previously with levodopa.4 The response was striking in some patients on a high dosage of bromocriptine (>40 mg/day).4 Our own experience with bromocriptine has not yet proved so encouraging, although it seems more active than anticholiner-
gic drugs. 31 patients with Parkinson’s disease have been treated so far-11I with bromocriptine (2-5-40 mg/day, mean 27.5 mg) alone and 20 with bromocriptine in addition to levodopa or ’Sinemet’. The 20 latter patients were still disabled despite optimum dosage. 11 patients could not be established on bromocriptine because of nausea, vomiting, neuropsychiatric disorders, hallucinations and anxiety, or neck stiffness. The remaining 20 patients (12 on levodopa and 8 not) subsequently took part in a double-blind controlled crossover trial of bromocriptine (in optimum dosage up to a maximum of 40 mg daily) and placebo treatment. 16 patients completed the two 2-week trial periods, of whom 10 improved on bromocriptine compared with placebo and 6 did not. No patient showed a dramatic response, but bromocriptine caused a useful degree of improvement in otherwise untreated patients, and overall there was a 23% reduction in mean total disability score. The less disabled patients, those taking bromocriptine as a single treatment, and those on the highest dosages responded best. Higher bromocriptine dosages than used in this trial would probably have given greater improvement, but side-effects similar to those caused by levodopa occurred in the majority of patients.’
Bromocriptine, like levodopa, causes a rise in the plasmaconcentration of growth hormone in normal subjects, probably owing to stimulation of dopamine-sensitive hypothalamicpituitary mechanisms.6 2 out of 7 patients with Parkinson’s disease showed an increase in plasma-growth-hormone concentration after oral bromocriptine 2.5 mg. There was no significant relationship between the change in growth-hormone concentration after 2.5 mg bromocriptine and the clinical response to long-term treatment with this drug in higher dosage. Small doses of bromocriptine may be insufficient, in patients with Parkinson’s disease, to stimulate hypothalamic dopamine receptors. Larger doses are probably required to cause this effect and also for a therapeutic response in parkinsonism. Attempts to overcome the on-off effect resulting from chronic levodopa treatment by replacement of this drug with bromocriptine have been only partially successful. Despite total replacement of sinemet, 4 and 6 tablets daily, in 2 patients by bromocriptine in a total daily dosage of 40 and 300 mg respectively, the clinical response to bromocriptine was not as great as to sinemet, although response swings were less Calne, D. B., Teychenne, P. F., Claveria, L. E., Eastman, R., Greenacre, J. K., Petrie, A. Br. med.J, 1974, iv, 442. 2. Teychenne, P. F., Calne, D. B., Leigh, P. N., Bamji, A. N., Greenacre, J. K. Lancet, 1974, ii, 1355. 3. Teychenne, P. F., Calne, D. B., Leigh, P. N., Greenacre, J. K., Reid, J. L., Petrie, A., Bamji, A. N. ibid. 1975, ii, 473. 4. Lees, A. J., Shaw, K. M., Stern, G. M. ibid. p. 709. 5. Parkes, J. D., Marsden, C. D., Donaldson, I., Galea Debono, A., Walters, J., Kennedy, G., Asselman, P. J. Neurol. Neurosurg. Psychiat (in the Press). 6. Camanni, F., Massara, F., Belforte, L., Molinatti, G. M. J. clin. Endocr. Metab. 1975, 40, 363. 1.
Pharmacology,
J. M. PADFIELD S. H. Moss D. A. NORTON
DISCHARGE OF VIOLENT PATIENTS
SiR,—Iwas surprised to learn that Dr Newcombe (Oct. 25,
820) supports muddled anxieties expressed by the public and in the media. He cites two anecdotes and implies that the once dangerous mentally disordered patient will always be so. Sadly, no mention is made of the possibility of good faith and conscientiousness on the part of the psychiatrists concerned. Nor does Dr Newcombe admit that he might have himself agreed with these clinical decisions. Many mentally disordered offenders on whom the courts impose a sentence of psychiatric treatment under Section 60 of the 1959 Mental Health Act are not a danger to others. Lay involvement in limiting any discharge and further treatment plans can only be justified if the public interest is significantly involved. Conditional discharge and supervision decisions about restricted Section-65 patients are taken by the Home Office. Mental health review tribunals have only an advisory role like that of the consultant psychiatrist (the responsible medical officer). Among other possible results, the universal application of Section-65 restrictions in addition to Section-60 Orders could increase the regrettable reluctance of area psychiatric services to treat the mentally disordered offender. His nuisance value and criminal associations alone already deter hospitals from providing appropriate containment and treat-
p.
ment.
Whatever the limitations of psychiatric evaluations and pre-
dictions, it is improbable that the reliability of decisions will
improved by investing the responsibility for assessment in independent body such as a mental health review tribunal. If the view of a predominantly lay body is to replace the psychiatrist’s assessment of his patient, he will be encouraged to relinquish responsibility for subsequent supervision in the community. If he does not profoundly influence the time of the patient’s discharge, he can scarcely be expected to advise the patient to accept custodial care which he considers un-
be
an
necessary and
even harmful. The public will always tend to be anxious about patients with records of violence and will assume that they remain dangerous until persuaded otherwise. Absolutely no risk to the public equals absolutely no discharges, however unjustifiable continued detainment may be to the psychiatrist involved.
Broadmoor
Hospital,
Crowthorne, Berks RG11 7EG.
JAMES MACKEITH
proportion is rather alarming and, as far asI am systematic investigation into the factors responsible
tions. This aware,
no
has been undertaken. This exercise is overdue and urgent, because these patients challenge the functioning of the opendoor policy and improved therapeutic care. The establishment of secure units will do little to improve the resources for the management and the actual care of such patients which should be a priority above the establishment of secure units, especially since resources are limited. As most of the patients recommended for secure units would be those in whom mental illness and criminality are causally related, would it not be more efficient and economic to improve the therapeutic potential of psychiatric facilities in prison, where provision for physical security already exists? This could also benefit other prisoners with psychiatric problems. In times of financial stringency, would it not be more economical to improve the existing services and the milieu in which people can be treated rather than embark on something new and
expensive? St. Christophers Day 52 Hurst Road, Horsham RH12 2EP.
Hospital, N. H. RATHOD
SELECT COMMITTEE UNDER THE ABORTION LAW
SIR,-The Secretary of State is reported in your columns (Nov. 1, p. 879) as being under obligation to Parliament to
provide an abortion service at least as far as conscientious objection (Section 4 of the 1967 Act) will permit. I have read the Act many times but I can see no reference to "providing an abortion service". Certainly the N.H.S. or private doctor can offer his opinion in good faith and the law requires that two registered practitioners should agree to abortion. No doctor is obliged to provide a service, only an opinion. This is important in 1975 since abortion on request for social economic pressure accounts for most of Britain’s 200,000 yearly abortions. Uniformity of opinion on the abortion issue is an impossible target even allowing that the D.H.S.S. do put pressure on selection committees with a view to excluding from consultant appointments any with conscientious or other objections to abortion. The D.H.S.S. achieves this by using a job description despite the "out" clause Section 4 in the 1967 Abortion Act. The Secretary of State confessed in Parliament that 9 obstetricians in 70 appointments were barred by the N.H.S. during the past six months. As far as I know this is the first time that a test act has been applied to candidates applying for a public post in the profession of medicine. However, the profession and the nation may carry its head high. It seems that Parliament is going to insist that before givine an ooinion a doctor must examine a orernant oatient! Birmingham & Midland Hospital for Women, Showell Green Lane, Birmingham B11 4HL.
H. C. MCLAREN
SECURE UNITS FOR MENTALLY ILL
SIR,-Following recommendations’ from the D.H.S.S. regional authorities are giving consideration to the establishment of secure units for mentally ill and mentally handicapped patients needing such an environment. The patients in such units would be those who cannot be treated in general psychiatric units and, at the same time, do not qualify for admission or stay in special units - e.g., Broadmoor or Rampton. Although few would argue against the need for such facilities, the question of security and treatment of disturbed and disturbing patients, with or without involvement in criminal behaviour, raises certain problems. In 1971, 7.6%, (i.e., approximately 13 000 patients) in psychiatric hospitals were said to be housed in wards with locked doors, there being considerable variation between hospitals and regions in the proportion of people needing such restric1. Circular
no.
HSC (IS
61) July,
1974.
JUNIOR DOCTORS’ CONTRACT SIR,-We, representing the junior doctors of the Royal Marsden Hospital, which incorporates two specialist cancer centres in London and Surrey, wish to present our proposals to all colleagues. As junior hospital doctors we find ourselves increasingly at odds with the philosophy now pervading negotiations for a new contract. Discussions with our colleagues in many parts of the country convince us that our views are widely held and may even be those of the "silent majority" and therefore it THE
would appear that our present negotiating body is non-representative of the majority view. Our proposals are as follows: (1) The National Health Service and ill people should be separated from direct political interference which has resulted in the present conflict. It should have an independent govern-
987
ing body, who represent
a
in it.
(2) There should be a return to a contract for an adequate basic salary in which overtime plays no part. (3) There should be sufficient staffing to reduce the grossly excessive hours that some doctors ’work at present. In areas where this cannot be met, there should be a supplemented salary for those with an above average workload and where understaffing exists. (4) Every doctor should have the opportunity for time-off duty from his clinical responsibilities. (5) There should be no difference in salary between doctors of the same grade in different specialties. Any new contract should shift the emphasis in the direction of a basic salary and adequate staffing. Until new basic salaries can be negotiated which meet the needs of doctors depending heavily on overtime payments, we should respect our present contracts. Any step which confirms overtime payment as a permanent feature of the system in a profession such as medicine is obviously a step backwards. We therefore suggest that those in sympathy with our views reject the principle of a 40-hour week with overtime which the ballot recommends. We are greatly concerned about the future of medicine in this country and hope that the Royal Commission set up by the Government will be unbiased and examine all aspects of the National Health Service and lay down the foundations for a better organised system of medical care. P. R. S. TASKER
Royal Marsden Hospital, Fulham Road, London SW3 6JJ.
C. S. FOSTER J. P. GLEES P. F. HOWARD for the Royal Marsden Hospital Junior Doctors Committee
ADVISERS IN CONTROL OF INFECTIOUS DISEASE
SiR,—The amount of experience in this country in the practical aspects of infectious-disease control is gradually diminishing. A realisation of this, reinforced by the proposal for establishing regional epidemiologists put forward by the committee of inquiry into the smallpox outbreak in London in 1973,’ has encouraged the D.H.S.S. to consider the need for experts to be readily accessible at any time to assist medical officers for environmental health in instituting the practical measures that should be taken to control outbreaks of serious infectious disease such as smallpox, Lassa fever, and other unusual imported infections. It is interesting to speculate whether another epidemic like the encephalitis of the 1920s would find us any better prepared than we were then. These advisers would provide an increasingly valuable concentration of practical experience, and by supplying advice rather than direction, need pose no threat to the independence of the local authorities responsible for controlling an outbreak. It is important however, that they should be called regional "infectious disease advisers" and not regional "epidemiologists" : it was some years ago that epidemiologists ceased to confine their attention to communicable disease, and began to study chronic conditions and contribute information relevant to the planning of health services in general. In addition, epidemiologists may have little experience of implementng practical control procedures. The appointment of at least a few infectious-disease advisers should be welcomed. Kensington and Chelsea and Westminster Area Health Authority (Teaching), North-East District Management Team Offices, Middlesex Hospital, London W1N 8AA
1. in
BROMOCRIPTINE IN PARKINSONISM
cross-section of all those who work
PAUL A. KITCHENER
Report of the Committee of Inquiry into the Smallpox Outbreak in London March and April 1973; p 116. Cmnd 5626. H.M. Stationary Office, 1974.
SIR,-Dopamine agonists (drugs that stimulate dopamine receptors) are an important advance in the treatment of Parkinson’s disease. They have several theoretical advantages over levodopa. Firstly, their effect may last longer; secondly, if the on-off effect that develops in 10% of patients treated with levodopa is due to toxic metabolites of the compound, response swings may not occur with drugs such as bromocriptine; and thirdly, patients who do not respond to levodopa, possibly because of insufficient striatal dopa decarboxylase, may respond to dopamine agonists. In addition, if a specific nigrostriatal dopamine agonist can be developed, it may have specific antiparkinsonian effects without the adverse reactions resulting from altered function Iin other dopamine systems both inside and outside the brain.’ Bromocriptine, a drug which stimulates dopamine receptors appears to have considerable potency in Parkinson’s disease and may be as active as levodopa.’-3 Some patients unresponsive to or unable to tolerate levodopa have improved on bromocriptine, as have patients who have not been treated previously with levodopa.4 The response was striking in some patients on a high dosage of bromocriptine (>40 mg/day).4 Our own experience with bromocriptine has not yet proved so encouraging, although it seems more active than anticholiner-
gic drugs. 31 patients with Parkinson’s disease have been treated so far-11I with bromocriptine (2-5-40 mg/day, mean 27.5 mg) alone and 20 with bromocriptine in addition to levodopa or ’Sinemet’. The 20 latter patients were still disabled despite optimum dosage. 11 patients could not be established on bromocriptine because of nausea, vomiting, neuropsychiatric disorders, hallucinations and anxiety, or neck stiffness. The remaining 20 patients (12 on levodopa and 8 not) subsequently took part in a double-blind controlled crossover trial of bromocriptine (in optimum dosage up to a maximum of 40 mg daily) and placebo treatment. 16 patients completed the two 2-week trial periods, of whom 10 improved on bromocriptine compared with placebo and 6 did not. No patient showed a dramatic response, but bromocriptine caused a useful degree of improvement in otherwise untreated patients, and overall there was a 23% reduction in mean total disability score. The less disabled patients, those taking bromocriptine as a single treatment, and those on the highest dosages responded best. Higher bromocriptine dosages than used in this trial would probably have given greater improvement, but side-effects similar to those caused by levodopa occurred in the majority of patients.’
Bromocriptine, like levodopa, causes a rise in the plasmaconcentration of growth hormone in normal subjects, probably owing to stimulation of dopamine-sensitive hypothalamicpituitary mechanisms.6 2 out of 7 patients with Parkinson’s disease showed an increase in plasma-growth-hormone concentration after oral bromocriptine 2.5 mg. There was no significant relationship between the change in growth-hormone concentration after 2.5 mg bromocriptine and the clinical response to long-term treatment with this drug in higher dosage. Small doses of bromocriptine may be insufficient, in patients with Parkinson’s disease, to stimulate hypothalamic dopamine receptors. Larger doses are probably required to cause this effect and also for a therapeutic response in parkinsonism. Attempts to overcome the on-off effect resulting from chronic levodopa treatment by replacement of this drug with bromocriptine have been only partially successful. Despite total replacement of sinemet, 4 and 6 tablets daily, in 2 patients by bromocriptine in a total daily dosage of 40 and 300 mg respectively, the clinical response to bromocriptine was not as great as to sinemet, although response swings were less Calne, D. B., Teychenne, P. F., Claveria, L. E., Eastman, R., Greenacre, J. K., Petrie, A. Br. med.J, 1974, iv, 442. 2. Teychenne, P. F., Calne, D. B., Leigh, P. N., Bamji, A. N., Greenacre, J. K. Lancet, 1974, ii, 1355. 3. Teychenne, P. F., Calne, D. B., Leigh, P. N., Greenacre, J. K., Reid, J. L., Petrie, A., Bamji, A. N. ibid. 1975, ii, 473. 4. Lees, A. J., Shaw, K. M., Stern, G. M. ibid. p. 709. 5. Parkes, J. D., Marsden, C. D., Donaldson, I., Galea Debono, A., Walters, J., Kennedy, G., Asselman, P. J. Neurol. Neurosurg. Psychiat (in the Press). 6. Camanni, F., Massara, F., Belforte, L., Molinatti, G. M. J. clin. Endocr. Metab. 1975, 40, 363. 1.
