self-support, the ultimate desire, assuming that there is a reasonable degree of remission at the time of discharge. "Dubious distinction" or not, what better reminder is there of our shortcomings in any branch of medicine - or in penology - than the number of readmissions for the same complaint? Recurrent hospitalization will remain, as will revolving doors, until better treatment is forthcoming. Fortunately, in the final paragraph of this enlightening article a suggestion is made that seems to show greater foresight. Though some might disagree, many will share my enthusiasm for this thoughtful statement: "A medical disease model of effectiveness, analogous for instance to diabetes mellitus or coronary artery disease, would be more beneficial to psychiatrists and their patients." What evidence would be needed to support such a bold belief? WILLIAM D. PANTON, MD
Eastvan Medical Centre Vancouver, BC
References 1. ROSENBLATT A, MEYER JE: The reci-
divism of mental patients: review of past studies. Am J Orthopsychiatry 44: 697, 1974 2. SHEDLETSKY R, VOINESKOS G: Rehabilitation of chronic psychiatric patient - beyond hospital-based token economy system. Soc Psychiatry 11: 145, 1976
Protection des droits du patient au Quebec Au r&iacteur: C'est avec .tonnement que la Corporation professionnelle
des m.decins du Qu6bec a constat6 que le Journal avait publi6 l'article "L'Association qu6becoise de protection des malades . la d6fense du droit . la sante" r.dig6 par Claire Lalonde (Can Med Assoc J 117: 1342, 1977) et fasse ainsi de la publicit6 . cette organisation. Get article laisse croire en l'inefficacite du travail accompli par le Coll.ge des m6decins et chirurgiens de l'Ontario et la Corporation professionnelle des m.decins du Qu6bec, sans que l'auteur n'ait pris les in-
formations n6cessaires aupr.s des autorites de ces corporations, du moms celles du Quebec. La Corporation des m6decins, cr. par le gouvernement du Quebec pour prot6ger le public en cc qui concerne la qualit6 de l'exercice de la
medecine, proc&le . 1'6tude de toutes les plaintes qu'elle re.oit et le comit6 charge de cette 6tude donne suite . chacune d'elles selon la decision prise. AUGUSTIN Roy, MD
Pr.sident-secr6taire g.n&a1 Corporation professionelle des m6decins du Quebec
[La section des nouvelles et reportages du Journal a la responsabilit. de faire connaitre les nouvelles de la sc?ne m&licale et les opinions qui y sont e.mises; elle s'int.resse donc . une grande vari.t. de sujets d'int.r.t g.n.ral pour les mc.decins. Il lui est done permis, nous semble-t-il, de ne pas se limiter . la presentation d'artides conformes aux opinions m.dicales courantes. On demande aux auteurs d'.mettre une opinion ou de rapporter celles qui ont cours dans diffrfrents secteurs de la socMt. actuelle, qu'elles coincident ou non avec la philosophie du m6decin ou celle de son association. - R.dacteur]
Screening for breast cancer To the editor: Dr. T.J. Muckle's recent letter (Can Med Assoc 1 118: 119, 1978) was entertaining but he glosses over the most crucial issue in screening for breast cancer. He asks several questions sequentially and suggests that if the answer to any question in sequence is No, the whole subject of screening for breast cancer should be forgotten. I shall do as he suggests: 1. "Do the techniques of screening for breast cancer ever detect any form of cancer?" Yes. Therefore we proceed to question 2. 2. "Do these mass screening techniques offer any advantage over clinical examination?" Yes. Therefore we proceed to question 3. 3. "Does the advantage of mass screening over clinical examination confer on the patient or on the delivery of medical services any form of benefit whatever?" Yes. No. Maybe. Question 3 is the most important, and Dr. Muckle, while making an emotional appeal on behalf of mass screening, does not answer it. He seems to assume that the answer is Yes because he proceeds to his next question. In the very wording of question 3 he prejudges the issue that mass screening is an "advantage".
1486 CMA JOURNAL/JUNE 24, 1978/VOL. 118
B econase Nasal Spray
®(beclomethasone
Prescribing Information Indications and clinical uses Beconase is indicated for the treatment of perennial and seasonal allergic rhinitis unresponsive to conventional treatment. Contraindicatlons Active or quiescent tuberculosis or untreated fungal, bacterial and viral infections. Children under six years of age. Warnings In patients previously on high doses of systemic steroids, transfer to Beconase may cause withdrawal symptoms such as tiredness, aches and pains, and depression. In severe cases adrenal insufficiency may occur, necessitating the temporary resumption of systemic steroids. The safety of Beconase in pregnancy has not been established. If used, the expected benefits should be weighed against the potential hazard to the fetus, particularly during the first trimester of pregnancy. Precautions The replacement of a systemic steroid with Beconase has to be gradual and carefully supervised by the physician. The guidelines under "Administration" should be followed in all such cases. Unnecessary administration of drugs during pregnancy is undesirable. Corticosteroids may mask some signs of infection and new infections may appear. A decreased resistance to localized infection has been observed during corticosteroid therapy. During long-term therapy, pituitary-adrenal function and hematological status should be periodically assessed. Fluorocarbon propellants may be hazardous if they are deliberately abused. Inhalation of high concentrations of aerosol sprays has brought about cardiovascular toxic effects, and even death, especially under conditions of hypoxia. However, evidence attests to the relative safety of aerosols when used intranasally and with adequate ventilation. There is an enhanced effect of corticosteroids on patients with hypothyroidism and in those with cirrhosis. Acetylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. During Beconase therapy, the possibility of atrophic rhinitis and/or pharyngeal candidiasis should be kept in mind. Adverse reactions No major side effects attributable to Beconase have been reported. Occasional sneezing attacks have followed immediately after the use of the intranasal aerosol. A few patients have complained of burning sensation and irritation in the nose after Beconase nasal inhalation. When patients are transferred to Beconasefrom a systemic steroid, allergic conditions such as asthma or eczema may be unmasked.
Dosage and administration The usual dosage for
patients of all ages who received no previous systemic steroid is one application (50 mcg of beclomethasone dipropionate) into each nostril three to four times daily. Maximum daily dose should not exceed twenty applications in adults and ten applications in children. If Beclovent is used concurrently, the maximum dose of each aerosol is ten applications in adults and five applications in children. Beconase should not be used under six years of age. Since the effect of Beconase depends on its regular use, patients must be instructed to take the nasal inhalations at regular intervals and not, as with other nasal sprays, as they feel necessary. They should also be instructed in the correct method, which is to blow the nose, then insert the nozzle firmly into the nostril, compress the opposite nostril and acuate the aerosol while inspiring through the nose, with the mouth closed. In the presence of excessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of action. In such cases it is advisable to uses nasal vasoconstrictor for two or three days prior to Beconase. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids when transferred to Beconase. Initially, Beconase and the systemic corticosteroid must be given concomitantly, while the dose of the latter is gradually decreased. The usual rate of withdrawal of the systemic steroid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close supervision. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of predriisone (or equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic steroid should be resumed for a week before further decrease is attempted. Dosage form Beconase is a metered-dose aerosol, delivering 50 micrograms of beclomethasone dipropionate with each depression of the valve. There are two hundred doses in a container. Official product monograph on request.
Allen & Hanburys A Glaxo Canada Ltd. Company Toronto, Canada
The results of the New York project of mass screening for breast cancer suggest that the mortality of breast cancer over a 7-year period in screened women was lower than that in controls.1'1 The difference, however, was only about 30% and benefit was limited to women over the age of 50 years. Doubts have been raised concerning the validity of this study, but even if the findings are substantiated by further reports a decision must be made about the value of mass screening, and somewhere along the line the dirty phrase "cost-benefit analysis" must be discussed. It is interesting to put the data from the much-quoted New York trial in a different form. There were 62 000 women aged 40 to 64 years in the program, of whom 31 000 were screened annually and 31 000 served as controls. As the authors were aware, the question of early diagnosis is irrelevant unless it results in fewer women dying of breast cancer. Of the screened group 70 women died in the 7-year follow-up period, while 108 of the control group died. In other words, the screening was of benefit to 38 of 31 000 women, or 1.23 per 1000. The morbidity of the screening process must also be considered. It is still an open question whether mammography causes breast cancer, and 12.47 per 1000 women screened had a lesion detected that was proved at operation to be benign. I too would like to be involved in the decision-making process but the "mad mathematics of the paramedical bureaucracy" to which Dr. Muckle refers may not be so mad on close examination. We are living in the real world, where all kinds of programs requiring tax dollars are competing for support. We do not inhabit a fairyland of limitless resources in which any expense is justified if it results in the saving (i.e., prolongation) of even one person's life. CHARLES J. WRIGHT, MB, CH B, M Sc, FRCS[C], FRCS (ENG), FRCS (EDIN) Department of surgery University Hospital Saskatoon, Sask.
References 1. S¶rRAx P, VENET L, SHAPIRO 5, et al: Mammography and clinical examination in mass screening for cancer of
the breast. Cancer 20: 2184, 1967 2. STRAX P: Control of breast cancer through mass screening. JAMA 235: 1600, 1976
Prognosis for survival in neonatal meningitis To the editor: I enjoyed reading the article by Bortolussi and colleagues (Can Med Assoc 1 118: 165, 1978). However, one item requires comment. There is a certain danger in switching from a well known unit of measurement to a less well known unit, particularly when the volumes are different. It will not be immediately apparent to many readers that 2.000 X 109/L is the same as 2 X 106/L. Also, when peripheral leukocyte counts are recorded in number per litre an error of plus or minus 5% must be considered, just as when leukocytes are counted per millimetre. I question the validity of prognostic criteria based on a laboratory test with a 5% standard error when the standard error is apparently not considered in the test for significance. Furthermore, if one is choosing the exponential form of numerical notation 100 X 109/L should really be written as 1011/L. These are minor points, and perhaps niggling, but they do detract from an otherwise interesting study. A.L. AMACHER, MD, FRCs[c]
Pediatric neurosurgery War Memorial Children's Hospital London, Ont.
To the editor: Dr. Amacher's question on the units used in our article can be answered briefly. The choice of units of measurement was made by the editorial staff of the Journal, presumably to follow the style recommended by the "Metric Practice Guide".1 Our original manuscript expressed counts of neutrophils as number per cubic millimetre. I share Dr. Amacher's confusion with the new system and hope the attention drawn to this change will alert other readers as well. A second area of concern deserved more comment. When the material for our article was compiled it was obvious to us that a depressed peripheral neutrophil count was associated with a high mortality. Some arbitrary lines were drawn to facili-
tion of intrinsic error of the estimate is of secondary concern. The most important point is that a depressed peripheral neutrophil count in a newborn infant with meningitis reflects severe infection and indicates that not only has the battle been lost, but also the war is almost over in this host-parasite confrontation. The four features outlined in our article should be used as general guidelines indicating the prognosis for survival and may be helpful for the attending physician in deciding on the need for supplementary modes of therapy. ROBERT A. BORTOLUSSI, MD
Department of pediatrics University of Minnesota Minneapolis, Minnesota
Reference 1. Metric Practice Guide, Can Stand Assoc, Rexdale, 1973
[Readers may be interested in a recent publication of the World Health Organization entitled "The SI for the Health Professions", which details the application of SI (Sysh.me international d'unit.s) in medical practice. This booklet may be obtained for $2.75 by writing to Elinor Lockhart, Canadian Public Health Association, 1335 Caning Ave., Ottawa, Ont. KJZ 8N8. In the absence of such a guide a simple rule of thumb for confused readers who wish to convert leukocyte count from number per litre to number per cubic millimetre is to subtract 6 from the exponent 9 (e.g., 2 X 109/L is equivalent to 2 X 103/mm3). - Ed.]
Unusual case of intestinal obstruction in late pregnancy To the editor: Having discovered that volvulus of the bowel has been reported in the past 90 years as a recognized, though rare, complication of pregnancy, I believe I am justified in offering an additional case for the record, especially as I believe it to be unique among the cases reported thus far.
tate statistical analysis of this inforA 26-year-old multiparous Micromation. However, our conclusions nesian whose first name, would have been the same if a count Asuncion,woman, suggested that her ancestry, of 1.500, 2.500 or even 2.318 neu- as with that of many of the islanders, trophils X 109/dL had been selected was partly Spanish, was admitted to the as the demarcation point. The ques- general ward of the hospital in Kolo-
1488 CMA JOURNAL/JUNE 24, 1978/VOL. 118
Eastvan Medical Centre Vancouver, BC
References 1. ROSENBLATT A, MEYER JE: The reci-
divism of mental patients: review of past studies. Am J Orthopsychiatry 44: 697, 1974 2. SHEDLETSKY R, VOINESKOS G: Rehabilitation of chronic psychiatric patient - beyond hospital-based token economy system. Soc Psychiatry 11: 145, 1976
Protection des droits du patient au Quebec Au r&iacteur: C'est avec .tonnement que la Corporation professionnelle
des m.decins du Qu6bec a constat6 que le Journal avait publi6 l'article "L'Association qu6becoise de protection des malades . la d6fense du droit . la sante" r.dig6 par Claire Lalonde (Can Med Assoc J 117: 1342, 1977) et fasse ainsi de la publicit6 . cette organisation. Get article laisse croire en l'inefficacite du travail accompli par le Coll.ge des m6decins et chirurgiens de l'Ontario et la Corporation professionnelle des m.decins du Qu6bec, sans que l'auteur n'ait pris les in-
formations n6cessaires aupr.s des autorites de ces corporations, du moms celles du Quebec. La Corporation des m6decins, cr. par le gouvernement du Quebec pour prot6ger le public en cc qui concerne la qualit6 de l'exercice de la
medecine, proc&le . 1'6tude de toutes les plaintes qu'elle re.oit et le comit6 charge de cette 6tude donne suite . chacune d'elles selon la decision prise. AUGUSTIN Roy, MD
Pr.sident-secr6taire g.n&a1 Corporation professionelle des m6decins du Quebec
[La section des nouvelles et reportages du Journal a la responsabilit. de faire connaitre les nouvelles de la sc?ne m&licale et les opinions qui y sont e.mises; elle s'int.resse donc . une grande vari.t. de sujets d'int.r.t g.n.ral pour les mc.decins. Il lui est done permis, nous semble-t-il, de ne pas se limiter . la presentation d'artides conformes aux opinions m.dicales courantes. On demande aux auteurs d'.mettre une opinion ou de rapporter celles qui ont cours dans diffrfrents secteurs de la socMt. actuelle, qu'elles coincident ou non avec la philosophie du m6decin ou celle de son association. - R.dacteur]
Screening for breast cancer To the editor: Dr. T.J. Muckle's recent letter (Can Med Assoc 1 118: 119, 1978) was entertaining but he glosses over the most crucial issue in screening for breast cancer. He asks several questions sequentially and suggests that if the answer to any question in sequence is No, the whole subject of screening for breast cancer should be forgotten. I shall do as he suggests: 1. "Do the techniques of screening for breast cancer ever detect any form of cancer?" Yes. Therefore we proceed to question 2. 2. "Do these mass screening techniques offer any advantage over clinical examination?" Yes. Therefore we proceed to question 3. 3. "Does the advantage of mass screening over clinical examination confer on the patient or on the delivery of medical services any form of benefit whatever?" Yes. No. Maybe. Question 3 is the most important, and Dr. Muckle, while making an emotional appeal on behalf of mass screening, does not answer it. He seems to assume that the answer is Yes because he proceeds to his next question. In the very wording of question 3 he prejudges the issue that mass screening is an "advantage".
1486 CMA JOURNAL/JUNE 24, 1978/VOL. 118
B econase Nasal Spray
®(beclomethasone
Prescribing Information Indications and clinical uses Beconase is indicated for the treatment of perennial and seasonal allergic rhinitis unresponsive to conventional treatment. Contraindicatlons Active or quiescent tuberculosis or untreated fungal, bacterial and viral infections. Children under six years of age. Warnings In patients previously on high doses of systemic steroids, transfer to Beconase may cause withdrawal symptoms such as tiredness, aches and pains, and depression. In severe cases adrenal insufficiency may occur, necessitating the temporary resumption of systemic steroids. The safety of Beconase in pregnancy has not been established. If used, the expected benefits should be weighed against the potential hazard to the fetus, particularly during the first trimester of pregnancy. Precautions The replacement of a systemic steroid with Beconase has to be gradual and carefully supervised by the physician. The guidelines under "Administration" should be followed in all such cases. Unnecessary administration of drugs during pregnancy is undesirable. Corticosteroids may mask some signs of infection and new infections may appear. A decreased resistance to localized infection has been observed during corticosteroid therapy. During long-term therapy, pituitary-adrenal function and hematological status should be periodically assessed. Fluorocarbon propellants may be hazardous if they are deliberately abused. Inhalation of high concentrations of aerosol sprays has brought about cardiovascular toxic effects, and even death, especially under conditions of hypoxia. However, evidence attests to the relative safety of aerosols when used intranasally and with adequate ventilation. There is an enhanced effect of corticosteroids on patients with hypothyroidism and in those with cirrhosis. Acetylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypoprothrombinemia. Patients should be advised to inform subsequent physicians of the prior use of corticosteroids. During Beconase therapy, the possibility of atrophic rhinitis and/or pharyngeal candidiasis should be kept in mind. Adverse reactions No major side effects attributable to Beconase have been reported. Occasional sneezing attacks have followed immediately after the use of the intranasal aerosol. A few patients have complained of burning sensation and irritation in the nose after Beconase nasal inhalation. When patients are transferred to Beconasefrom a systemic steroid, allergic conditions such as asthma or eczema may be unmasked.
Dosage and administration The usual dosage for
patients of all ages who received no previous systemic steroid is one application (50 mcg of beclomethasone dipropionate) into each nostril three to four times daily. Maximum daily dose should not exceed twenty applications in adults and ten applications in children. If Beclovent is used concurrently, the maximum dose of each aerosol is ten applications in adults and five applications in children. Beconase should not be used under six years of age. Since the effect of Beconase depends on its regular use, patients must be instructed to take the nasal inhalations at regular intervals and not, as with other nasal sprays, as they feel necessary. They should also be instructed in the correct method, which is to blow the nose, then insert the nozzle firmly into the nostril, compress the opposite nostril and acuate the aerosol while inspiring through the nose, with the mouth closed. In the presence of excessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of action. In such cases it is advisable to uses nasal vasoconstrictor for two or three days prior to Beconase. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids when transferred to Beconase. Initially, Beconase and the systemic corticosteroid must be given concomitantly, while the dose of the latter is gradually decreased. The usual rate of withdrawal of the systemic steroid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close supervision. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of predriisone (or equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic steroid should be resumed for a week before further decrease is attempted. Dosage form Beconase is a metered-dose aerosol, delivering 50 micrograms of beclomethasone dipropionate with each depression of the valve. There are two hundred doses in a container. Official product monograph on request.
Allen & Hanburys A Glaxo Canada Ltd. Company Toronto, Canada
The results of the New York project of mass screening for breast cancer suggest that the mortality of breast cancer over a 7-year period in screened women was lower than that in controls.1'1 The difference, however, was only about 30% and benefit was limited to women over the age of 50 years. Doubts have been raised concerning the validity of this study, but even if the findings are substantiated by further reports a decision must be made about the value of mass screening, and somewhere along the line the dirty phrase "cost-benefit analysis" must be discussed. It is interesting to put the data from the much-quoted New York trial in a different form. There were 62 000 women aged 40 to 64 years in the program, of whom 31 000 were screened annually and 31 000 served as controls. As the authors were aware, the question of early diagnosis is irrelevant unless it results in fewer women dying of breast cancer. Of the screened group 70 women died in the 7-year follow-up period, while 108 of the control group died. In other words, the screening was of benefit to 38 of 31 000 women, or 1.23 per 1000. The morbidity of the screening process must also be considered. It is still an open question whether mammography causes breast cancer, and 12.47 per 1000 women screened had a lesion detected that was proved at operation to be benign. I too would like to be involved in the decision-making process but the "mad mathematics of the paramedical bureaucracy" to which Dr. Muckle refers may not be so mad on close examination. We are living in the real world, where all kinds of programs requiring tax dollars are competing for support. We do not inhabit a fairyland of limitless resources in which any expense is justified if it results in the saving (i.e., prolongation) of even one person's life. CHARLES J. WRIGHT, MB, CH B, M Sc, FRCS[C], FRCS (ENG), FRCS (EDIN) Department of surgery University Hospital Saskatoon, Sask.
References 1. S¶rRAx P, VENET L, SHAPIRO 5, et al: Mammography and clinical examination in mass screening for cancer of
the breast. Cancer 20: 2184, 1967 2. STRAX P: Control of breast cancer through mass screening. JAMA 235: 1600, 1976
Prognosis for survival in neonatal meningitis To the editor: I enjoyed reading the article by Bortolussi and colleagues (Can Med Assoc 1 118: 165, 1978). However, one item requires comment. There is a certain danger in switching from a well known unit of measurement to a less well known unit, particularly when the volumes are different. It will not be immediately apparent to many readers that 2.000 X 109/L is the same as 2 X 106/L. Also, when peripheral leukocyte counts are recorded in number per litre an error of plus or minus 5% must be considered, just as when leukocytes are counted per millimetre. I question the validity of prognostic criteria based on a laboratory test with a 5% standard error when the standard error is apparently not considered in the test for significance. Furthermore, if one is choosing the exponential form of numerical notation 100 X 109/L should really be written as 1011/L. These are minor points, and perhaps niggling, but they do detract from an otherwise interesting study. A.L. AMACHER, MD, FRCs[c]
Pediatric neurosurgery War Memorial Children's Hospital London, Ont.
To the editor: Dr. Amacher's question on the units used in our article can be answered briefly. The choice of units of measurement was made by the editorial staff of the Journal, presumably to follow the style recommended by the "Metric Practice Guide".1 Our original manuscript expressed counts of neutrophils as number per cubic millimetre. I share Dr. Amacher's confusion with the new system and hope the attention drawn to this change will alert other readers as well. A second area of concern deserved more comment. When the material for our article was compiled it was obvious to us that a depressed peripheral neutrophil count was associated with a high mortality. Some arbitrary lines were drawn to facili-
tion of intrinsic error of the estimate is of secondary concern. The most important point is that a depressed peripheral neutrophil count in a newborn infant with meningitis reflects severe infection and indicates that not only has the battle been lost, but also the war is almost over in this host-parasite confrontation. The four features outlined in our article should be used as general guidelines indicating the prognosis for survival and may be helpful for the attending physician in deciding on the need for supplementary modes of therapy. ROBERT A. BORTOLUSSI, MD
Department of pediatrics University of Minnesota Minneapolis, Minnesota
Reference 1. Metric Practice Guide, Can Stand Assoc, Rexdale, 1973
[Readers may be interested in a recent publication of the World Health Organization entitled "The SI for the Health Professions", which details the application of SI (Sysh.me international d'unit.s) in medical practice. This booklet may be obtained for $2.75 by writing to Elinor Lockhart, Canadian Public Health Association, 1335 Caning Ave., Ottawa, Ont. KJZ 8N8. In the absence of such a guide a simple rule of thumb for confused readers who wish to convert leukocyte count from number per litre to number per cubic millimetre is to subtract 6 from the exponent 9 (e.g., 2 X 109/L is equivalent to 2 X 103/mm3). - Ed.]
Unusual case of intestinal obstruction in late pregnancy To the editor: Having discovered that volvulus of the bowel has been reported in the past 90 years as a recognized, though rare, complication of pregnancy, I believe I am justified in offering an additional case for the record, especially as I believe it to be unique among the cases reported thus far.
tate statistical analysis of this inforA 26-year-old multiparous Micromation. However, our conclusions nesian whose first name, would have been the same if a count Asuncion,woman, suggested that her ancestry, of 1.500, 2.500 or even 2.318 neu- as with that of many of the islanders, trophils X 109/dL had been selected was partly Spanish, was admitted to the as the demarcation point. The ques- general ward of the hospital in Kolo-
1488 CMA JOURNAL/JUNE 24, 1978/VOL. 118
