the mind and the body are separate; the implication is that categories 1 (physical problems) and 2 (psychosocial problems) are mutually exclusive. It is this kind of thinking that we are trying to get away from today. Obviously this kind of classification is entirely arbitrary and highly dependent upon the classifiers' bias. What criteria were used to classify the diseases into those four categories? For example, asthma (no. 44); tiredness NOS (not otherwise specified) (no. 49); low back pain (no. 28); eczema and dermatitis (no. 23); abdominal pain NOS (no. 12); "nondisease" (no. 8); and the general medical examination (no. 1) have all been classified as physical problems those with physical origins and manifestations. This is ridiculous! Surely I don't need to explain the psychologic manifestations of asthma, low back pain and dermatitis! The fact that they may have psychologic origins is not entirely unlikely. However, by arguing this point, I am really indulging in dichotomy. The fact is that the symptom or disease is the person. A person who has an asthma attack is not suffering from asthma - he is asthma at that moment. As soon as we see him suffering from asthma or being afflicted with asthma we separate the disease from the person and introduce dichotomy. The largest percentage of visits (8.3 %) are classified under general medical examination. It is not clear whether these persons were well or sick and yet they are still included in category no. 1. Did they present with a specific symptom or for a check-up? Was the check-up just an excuse to talk about some personal problem, as is often the case? With respect to the classification "nondisease" (no. 8) I am not sure what this is. If the patients had no disease, then what were they doing in the physician's office? Surely this category implies that the physician is unable to find anything wrong with them, but clearly something was wrong or they wouldn't be there. This example highlights the limitations of the traditional medical model, a model that is entirely unacceptable to present-day medicine and therapeutics. The authors compound their bias when they state "as collective knowledge of disease process improves, it may be that some of the problems listed as purely physical will be found to have psychosocial origins (e.g., leukorrhea, low back pain, amenorrhea, menorrhagia, asthma and nonarticular rheumatism)." I don't think we need any further knowledge in some of these cases. Just ask an asthmatic patient how he produces his attacks and he
will often tell you far more than a thousand scientific studies. After all he is asthma. The authors maintain that their results refute the view that most problems a family physician encounters are psychosocial in origin, and that the main emphasis on training is correctly placed on the physical aspect of medicine. I maintain that this article shows only what they set out to show and anyone can do that. What they have also shown is their inability to view disease in a holistic manner and that they have tunnel vision with respect to health. Furthermore, they may have done a disservice to modern medicine by perpetuating the Cartesian model of mind! body duality, a concept we can no longer afford to rely on. I do not particularly look forward to the second phase of their study. EDWARD LEIGHTON, MD, B SC, CcFP Senior resident in family medicine Queen's University Kingston, Ont.
Cataracts in pediatric renal transplant recipients To the editor: We have encountered in our pediatric transplantation program ocular complications in adults similar to those recently described by Dr. C.R. Pavlin and his colleagues (Can Med Assoc J 117: 360, 1977). We studied 41 patients (16 males and 25 females) aged 3 to 20 years (mean, 12.5 years) at the time of transplantation. Treatment with prednisone, orally, or methyiprednisolone, intravenously, was started after transplantation at 3 mg/kg .d (maximum. 100 mg). By 3 to 6 months the maintenance dose of prednisone was reduced to approximately 15 mg q2d.1 Azathioprine, 3 mg/kg .d was given; dosage was adjusted according to the leukocyte count. Acute graft rejection was treated with one or more of the following regimens: (a) methylprednisolone, 10 mg/kg and cyclophosphamide, 6 mg/kg intravenously every 2 days for three or four doses; (b) prednisone, 500 mg orally
for 1 day, the dose then being reduced by 100 mg/d to 100 mg/d, then' quickly reduced to the previous maintenance dose; or (c) methyiprednisolone intravenously every 2 to 3 days for at least three or four doses. Preoperatively no patient had any evidence of cataracts. Ocular status was assessed subsequently at least once; the interval after transplantation ranged from 34 to 2182 days (mean, 776 days). Four male (25%) and 12 female (48%) patients had cataracts; the overall incidence was almost 40%. All cataracts were bilateral, symmetric and posterior subcapsular. Their extent ranged from isolated opacities and vacuoles (nine patients) to clumps of opacities (five patients), which in some instances were large and coalesced (two patients). No significant visual loss was detected; most patients admitted only to discomfort and glare in bright conditions. Perilimbal calcium deposits, a common finding before transplantation in patients with renal failure, were found in 34% of the subjects. Some patients had alterations in arterial calibre and retinal pigment epithelial defects, both late effects of acute hypertensive retinopathy. Two patients who had phorias had no obvious amblyopia. Electroretinograms in two patients with a clinical picture consistent with tapetoretinal degeneration showed no abnormality in one, who had pyelonephritis, but extinction in the other, who had glomerulonephritis. Two patients with cystinosis had prominent corneal crystals and a mottled fundus. The intraocular pressure in one patient was mildly elevated initially but normal on repeat examination. Highly significant correlations were found between cataract formation and both the total dose of steroid and the number of days on which the dose had been 100 mg or more (Table I). These findings agree with those of Paylin and associates and Berkowitz and colleagues2 in adult patients. In patients under 25 years of age, however, Berkowitz and colleagues were unable to correlate cataract formation with the
?MpI.f Eftptot
4mtara.ts
(P.
.
CMA JOURNAL/DECEMBER 3, 1977/VOL. 117
1257
424 40.3
t300 120 246
tt.#.twoi44.sagwpgrwtr than #requal ti. 140mg of
.AIdactazidd Summary of prescribing information: Pharmacology: Spi ronolactone effects diuresis by blocking through competitive inhibition, the sodium and water retaining and potassium excreting effects of aldosterone on the distal renal tubule. Hydrochlorothiazide promotes excretion of sodium and water primarily by inhibiting their reabsorption by the cortical diluting segment of the renal tubule. Thus the components of Aldactazide have different and complementary modes of action. In addition, spironolactone minimizes potassium loss characteristically induced by hydrochlorothiazide, thereby reducing the possible serious consequences of potassium depletion. Indications: The treatment of essential hypertension; the edema and ascites of congestive heart failure, cirrhosis of the liver, the nephrotic syndrome and idiopathic edema. Contraindications: Acute renal insufficiency; rapidly progressing impairment of renal function; anuria; hyperkalemia; patients known to be sensitive to thiazides or other sulfonamide-derived drugs; patients with severe or progressive liver disease at the discretion of the physician; nursing mothers; sensitivity to spironolact one. Warnings: Concurrent potassium supplementation is not indicated unless a glucocorticoid is also given. Aldactazide should not be used in conjunction with other potassium conserving agents. Precautions: The most potentially serious electrolyte disturbance is hyperkalemia which is more likely to occur in severely ill patients. If hyperkalemia occurs, discontinue Aldactazide. Hypokalemia may develop. Use cautiously in patients with sodium depletion. Check for signs of fluid or electrolyte imbalance. The most frequent electrolyte disturbance encountered is dilutional hyponatremia. Rarely a true low-salt syndrome may develop. Decrease dosage before diuresis is complete to avoid dehydration. Thiazide diuretics may precipitate hepatic coma. Use with caution in patients subjected to regional or general anesthesia. Discontinue 48 hours prior to elective surgery as both hydrochlorothiazide and spironolactone reduce vascular responsiveness to norepinephrine. Orthostatic hypotension may occur. Thiazides may increase responsiveness to tubocurarine. Pathological changes in the parathyroid glands have been observed. Consider the possibilities of sensitivity reactions in patients with a history of allergy or asthma as well as exacerbation of systemic lupus erythematosus. Thiazides may cause elevation of BUN. Aldactazide may potentiate the effect of other antihypertensives especially the ganglionic blocking agents. The dosage of such drugs should be reduced at least 50% when Aldactazide is added to the regimen. Spironolactone interferes with the assay of plasma cortisol but not the Ertel method. ASA may interfere with the action of spironolactone. Use with caution in patients with hyperuricemia or history of gout. Insulin requirements may be increased, decreased or unchanged in diabetics. Hyperglycemia and glycosuria may be manifested in latent diabetics. Use with caution in women of childbearing age and weigh benefits against the possible hazards to the fetus. Adverse Effects: Nausea or other gastrointestinal disturbances, gynecomastia or mild androgenic manifestations have been reported in some patients. Other side effects including those of hydrochlorothiazide occur less frequently. Overdose: Symptoms of Overdosage; Acute overdosage may be manifested by drowsiness, mental confusion, maculopapular or erythematous rash, nausea, vomiting, dizziness or diarrhea. Rare instances of hypokalemia, hyponatremia, hyperkalemia or hepatic coma may occur. Thrombocytopenic purpura and granulocytopenia have occurred with thiazide therapy. No specific antidote. Treat fluid depletion and electrolyte imbalances as indicated. Dosage: In essential hypertension, a daily dosage of 2 to 4 tables, in divided doses, will be adequate for most patients, provided the treatment is continued for 2 weeks or longer. Dosage may range from 2 to 8 tablets daily. Dosage should be adjusted according to the response of the patient. In endematous states, a daily dosage of 2 to 4 tablets, in divided doses, will be adequate for most patients but may range from 2 to 8 tablets daily. Dosage should be adjusted according to the response of the patient. Supply: Each round, ivory-coloured tablet contains, spironolactone, 25 mg and hydrochlorothiazide, 25 mg. Available in bottles of 100, 1,000 and 2,500 tablets. Complete prescribing information available on request
A.
Searle Pharmaceuticals Oakville, Ontario L6H iMS
duration of daily dose or the total dos- general questions about the respondent's treatment of hypertension, and age of steroid. The incidence of cataracts in our then focused on the use of 11 indipediatric renal transplant recipients vidual preparations, including several (39%) is much lower than the 60% mixtures, all referred to only by brand reported in another pediatric group3 but name; it carefully probed the respondnot significantly different from the ent's present and future use of each 48% reported in patients under 25 product. On checking with appropriate years of age.2 Since we found that a references, I discovered that the mahigh cumulative dosage of steroid con- nufacturers of these 11 products tributes to the development of catar- are Ayerst, Boehringer, Ciba-Geigy, acts, it is to be expected that the in- Hoechst, Merck and Searle,1 and that cidence of cataracts in these persons their annual sales range from $3 to $25 will increase. In trying to retard the million in Canada alone.2 development of cataracts it is important Of course this study is not scientific to strive for the lowest efficacious research in the usual sense of the word steroid dosage without compromising It is a marketing survey; a sampling graft viability. of the behaviour of physicians, the aim GB. WALMAN, MD of which is to help some manufacturLIONEL CHIsHoLM, MD, FRCP[C] er(s) better advertise, and hence better G.S. ARBUS, MD, FRCP[C] sell, their products. The phrases "a Departments of ophthalmology nationwide study", "scientifically seand pediatrics (nephrology division) Hospital for Sick Children lected random sample", "essential to Toronto, Ont. the accuracy of our research", and particularly the misleading statement "the References purpose... is to determine present atI. HODA Q, HAsINOFF DJ, ARsus GS: Growth titudes, opinions and practices in relafollowing renal transplantation in children and adolescents. Clin Nephrol 3: 6, 1975 tion to the treatment of hypertension.. are used deliberately to create a pseu2. BERKOWITZ JS, DAVID DS, SAKAI 5, et al: doscientific atmosphere to lull the Ocular complications in renal transplant recipients. Am I Med 55: 492, 1973 respondent into the belief that he is helping someone solve the enigma of 3. FINE RN, WILsON WA, MIcKEY MR, et al: Posterior subcapsular cataracts (PSC) in pehypertensive disease. The stated purdiatric renal allograft recipients (abstr 1030), in Abstracts of the Sixth International Conpose of the study is, in fact, a carefully gress of Nephrology, Florence, Italy, June 8-12, 1975, Intl Soc Nephrol, 1975 worded distortion; the true purpose of the questionnaire is to supply information to drug manufacturers, at a price, to allow them to plan better marketing Research or marketing survey? strategies for the selling of antihyperTo the editor: I recently received an tensive agents. undated letter at my office under the Having said this, I must emphasize letterhead "Institute of Communications that there is nothing wrong with marResearch" from H.A. Walter, pres- keting surveys: they do harm to no ident, that began as follows: one, they coerce no one and they increase the efficiency of business. On Dear Doctor, the other hand, I dislike conscious atWill you do us a favour? tempts to mislead the public; the study We are conducting a nationwide among Canadian physicians, the purpose design of this survey package with its of which is to determine present attitudes, carefully chosen phrases is clearly opinions and practices in relation to the meant to do that. treatment of hypertension. .. Since you To correct this situation I propose were drawn as one of a scientifically se- that the following measures be taken: lected random sample representing Cana1. In the future all marketing surdian physicians, your answers are essential to the accuracy of our research.., all veys or other commercially motivated answers are strictly confidential and will inquiries sent to physicians should inonly be used in combination with those clude a clear, explicit description of of other doctors from across Canada. their purpose. 2. The respondent should have the After further exhortations and a thank-you the letter closed. I called right to receive a copy of all data genMr. Walter a few days later and asked erated by such survey activity or a him for information about this "study". summary thereof. Mr. Walter would reveal only that it 3. The above regulations should be was conducted "for the ethical drug instituted by the Pharmaceutical Maindustry", and refused to say who was nufacturers Association of Canada or sponsoring it, whether the data col- the health protection branch of Health lected would be available to me or any and Welfare Canada as soon as posother physician, or to what specific use sible. the data would be put. WARREN BELL, MD The "study" consisted of a simple 220 Villeneuve St. W Montreal, PQ few a questionnaire that began with CMA JOURNAL/DECEMBER 3, 1977/VOL. 117
1259
will often tell you far more than a thousand scientific studies. After all he is asthma. The authors maintain that their results refute the view that most problems a family physician encounters are psychosocial in origin, and that the main emphasis on training is correctly placed on the physical aspect of medicine. I maintain that this article shows only what they set out to show and anyone can do that. What they have also shown is their inability to view disease in a holistic manner and that they have tunnel vision with respect to health. Furthermore, they may have done a disservice to modern medicine by perpetuating the Cartesian model of mind! body duality, a concept we can no longer afford to rely on. I do not particularly look forward to the second phase of their study. EDWARD LEIGHTON, MD, B SC, CcFP Senior resident in family medicine Queen's University Kingston, Ont.
Cataracts in pediatric renal transplant recipients To the editor: We have encountered in our pediatric transplantation program ocular complications in adults similar to those recently described by Dr. C.R. Pavlin and his colleagues (Can Med Assoc J 117: 360, 1977). We studied 41 patients (16 males and 25 females) aged 3 to 20 years (mean, 12.5 years) at the time of transplantation. Treatment with prednisone, orally, or methyiprednisolone, intravenously, was started after transplantation at 3 mg/kg .d (maximum. 100 mg). By 3 to 6 months the maintenance dose of prednisone was reduced to approximately 15 mg q2d.1 Azathioprine, 3 mg/kg .d was given; dosage was adjusted according to the leukocyte count. Acute graft rejection was treated with one or more of the following regimens: (a) methylprednisolone, 10 mg/kg and cyclophosphamide, 6 mg/kg intravenously every 2 days for three or four doses; (b) prednisone, 500 mg orally
for 1 day, the dose then being reduced by 100 mg/d to 100 mg/d, then' quickly reduced to the previous maintenance dose; or (c) methyiprednisolone intravenously every 2 to 3 days for at least three or four doses. Preoperatively no patient had any evidence of cataracts. Ocular status was assessed subsequently at least once; the interval after transplantation ranged from 34 to 2182 days (mean, 776 days). Four male (25%) and 12 female (48%) patients had cataracts; the overall incidence was almost 40%. All cataracts were bilateral, symmetric and posterior subcapsular. Their extent ranged from isolated opacities and vacuoles (nine patients) to clumps of opacities (five patients), which in some instances were large and coalesced (two patients). No significant visual loss was detected; most patients admitted only to discomfort and glare in bright conditions. Perilimbal calcium deposits, a common finding before transplantation in patients with renal failure, were found in 34% of the subjects. Some patients had alterations in arterial calibre and retinal pigment epithelial defects, both late effects of acute hypertensive retinopathy. Two patients who had phorias had no obvious amblyopia. Electroretinograms in two patients with a clinical picture consistent with tapetoretinal degeneration showed no abnormality in one, who had pyelonephritis, but extinction in the other, who had glomerulonephritis. Two patients with cystinosis had prominent corneal crystals and a mottled fundus. The intraocular pressure in one patient was mildly elevated initially but normal on repeat examination. Highly significant correlations were found between cataract formation and both the total dose of steroid and the number of days on which the dose had been 100 mg or more (Table I). These findings agree with those of Paylin and associates and Berkowitz and colleagues2 in adult patients. In patients under 25 years of age, however, Berkowitz and colleagues were unable to correlate cataract formation with the
?MpI.f Eftptot
4mtara.ts
(P.
.
CMA JOURNAL/DECEMBER 3, 1977/VOL. 117
1257
424 40.3
t300 120 246
tt.#.twoi44.sagwpgrwtr than #requal ti. 140mg of
.AIdactazidd Summary of prescribing information: Pharmacology: Spi ronolactone effects diuresis by blocking through competitive inhibition, the sodium and water retaining and potassium excreting effects of aldosterone on the distal renal tubule. Hydrochlorothiazide promotes excretion of sodium and water primarily by inhibiting their reabsorption by the cortical diluting segment of the renal tubule. Thus the components of Aldactazide have different and complementary modes of action. In addition, spironolactone minimizes potassium loss characteristically induced by hydrochlorothiazide, thereby reducing the possible serious consequences of potassium depletion. Indications: The treatment of essential hypertension; the edema and ascites of congestive heart failure, cirrhosis of the liver, the nephrotic syndrome and idiopathic edema. Contraindications: Acute renal insufficiency; rapidly progressing impairment of renal function; anuria; hyperkalemia; patients known to be sensitive to thiazides or other sulfonamide-derived drugs; patients with severe or progressive liver disease at the discretion of the physician; nursing mothers; sensitivity to spironolact one. Warnings: Concurrent potassium supplementation is not indicated unless a glucocorticoid is also given. Aldactazide should not be used in conjunction with other potassium conserving agents. Precautions: The most potentially serious electrolyte disturbance is hyperkalemia which is more likely to occur in severely ill patients. If hyperkalemia occurs, discontinue Aldactazide. Hypokalemia may develop. Use cautiously in patients with sodium depletion. Check for signs of fluid or electrolyte imbalance. The most frequent electrolyte disturbance encountered is dilutional hyponatremia. Rarely a true low-salt syndrome may develop. Decrease dosage before diuresis is complete to avoid dehydration. Thiazide diuretics may precipitate hepatic coma. Use with caution in patients subjected to regional or general anesthesia. Discontinue 48 hours prior to elective surgery as both hydrochlorothiazide and spironolactone reduce vascular responsiveness to norepinephrine. Orthostatic hypotension may occur. Thiazides may increase responsiveness to tubocurarine. Pathological changes in the parathyroid glands have been observed. Consider the possibilities of sensitivity reactions in patients with a history of allergy or asthma as well as exacerbation of systemic lupus erythematosus. Thiazides may cause elevation of BUN. Aldactazide may potentiate the effect of other antihypertensives especially the ganglionic blocking agents. The dosage of such drugs should be reduced at least 50% when Aldactazide is added to the regimen. Spironolactone interferes with the assay of plasma cortisol but not the Ertel method. ASA may interfere with the action of spironolactone. Use with caution in patients with hyperuricemia or history of gout. Insulin requirements may be increased, decreased or unchanged in diabetics. Hyperglycemia and glycosuria may be manifested in latent diabetics. Use with caution in women of childbearing age and weigh benefits against the possible hazards to the fetus. Adverse Effects: Nausea or other gastrointestinal disturbances, gynecomastia or mild androgenic manifestations have been reported in some patients. Other side effects including those of hydrochlorothiazide occur less frequently. Overdose: Symptoms of Overdosage; Acute overdosage may be manifested by drowsiness, mental confusion, maculopapular or erythematous rash, nausea, vomiting, dizziness or diarrhea. Rare instances of hypokalemia, hyponatremia, hyperkalemia or hepatic coma may occur. Thrombocytopenic purpura and granulocytopenia have occurred with thiazide therapy. No specific antidote. Treat fluid depletion and electrolyte imbalances as indicated. Dosage: In essential hypertension, a daily dosage of 2 to 4 tables, in divided doses, will be adequate for most patients, provided the treatment is continued for 2 weeks or longer. Dosage may range from 2 to 8 tablets daily. Dosage should be adjusted according to the response of the patient. In endematous states, a daily dosage of 2 to 4 tablets, in divided doses, will be adequate for most patients but may range from 2 to 8 tablets daily. Dosage should be adjusted according to the response of the patient. Supply: Each round, ivory-coloured tablet contains, spironolactone, 25 mg and hydrochlorothiazide, 25 mg. Available in bottles of 100, 1,000 and 2,500 tablets. Complete prescribing information available on request
A.
Searle Pharmaceuticals Oakville, Ontario L6H iMS
duration of daily dose or the total dos- general questions about the respondent's treatment of hypertension, and age of steroid. The incidence of cataracts in our then focused on the use of 11 indipediatric renal transplant recipients vidual preparations, including several (39%) is much lower than the 60% mixtures, all referred to only by brand reported in another pediatric group3 but name; it carefully probed the respondnot significantly different from the ent's present and future use of each 48% reported in patients under 25 product. On checking with appropriate years of age.2 Since we found that a references, I discovered that the mahigh cumulative dosage of steroid con- nufacturers of these 11 products tributes to the development of catar- are Ayerst, Boehringer, Ciba-Geigy, acts, it is to be expected that the in- Hoechst, Merck and Searle,1 and that cidence of cataracts in these persons their annual sales range from $3 to $25 will increase. In trying to retard the million in Canada alone.2 development of cataracts it is important Of course this study is not scientific to strive for the lowest efficacious research in the usual sense of the word steroid dosage without compromising It is a marketing survey; a sampling graft viability. of the behaviour of physicians, the aim GB. WALMAN, MD of which is to help some manufacturLIONEL CHIsHoLM, MD, FRCP[C] er(s) better advertise, and hence better G.S. ARBUS, MD, FRCP[C] sell, their products. The phrases "a Departments of ophthalmology nationwide study", "scientifically seand pediatrics (nephrology division) Hospital for Sick Children lected random sample", "essential to Toronto, Ont. the accuracy of our research", and particularly the misleading statement "the References purpose... is to determine present atI. HODA Q, HAsINOFF DJ, ARsus GS: Growth titudes, opinions and practices in relafollowing renal transplantation in children and adolescents. Clin Nephrol 3: 6, 1975 tion to the treatment of hypertension.. are used deliberately to create a pseu2. BERKOWITZ JS, DAVID DS, SAKAI 5, et al: doscientific atmosphere to lull the Ocular complications in renal transplant recipients. Am I Med 55: 492, 1973 respondent into the belief that he is helping someone solve the enigma of 3. FINE RN, WILsON WA, MIcKEY MR, et al: Posterior subcapsular cataracts (PSC) in pehypertensive disease. The stated purdiatric renal allograft recipients (abstr 1030), in Abstracts of the Sixth International Conpose of the study is, in fact, a carefully gress of Nephrology, Florence, Italy, June 8-12, 1975, Intl Soc Nephrol, 1975 worded distortion; the true purpose of the questionnaire is to supply information to drug manufacturers, at a price, to allow them to plan better marketing Research or marketing survey? strategies for the selling of antihyperTo the editor: I recently received an tensive agents. undated letter at my office under the Having said this, I must emphasize letterhead "Institute of Communications that there is nothing wrong with marResearch" from H.A. Walter, pres- keting surveys: they do harm to no ident, that began as follows: one, they coerce no one and they increase the efficiency of business. On Dear Doctor, the other hand, I dislike conscious atWill you do us a favour? tempts to mislead the public; the study We are conducting a nationwide among Canadian physicians, the purpose design of this survey package with its of which is to determine present attitudes, carefully chosen phrases is clearly opinions and practices in relation to the meant to do that. treatment of hypertension. .. Since you To correct this situation I propose were drawn as one of a scientifically se- that the following measures be taken: lected random sample representing Cana1. In the future all marketing surdian physicians, your answers are essential to the accuracy of our research.., all veys or other commercially motivated answers are strictly confidential and will inquiries sent to physicians should inonly be used in combination with those clude a clear, explicit description of of other doctors from across Canada. their purpose. 2. The respondent should have the After further exhortations and a thank-you the letter closed. I called right to receive a copy of all data genMr. Walter a few days later and asked erated by such survey activity or a him for information about this "study". summary thereof. Mr. Walter would reveal only that it 3. The above regulations should be was conducted "for the ethical drug instituted by the Pharmaceutical Maindustry", and refused to say who was nufacturers Association of Canada or sponsoring it, whether the data col- the health protection branch of Health lected would be available to me or any and Welfare Canada as soon as posother physician, or to what specific use sible. the data would be put. WARREN BELL, MD The "study" consisted of a simple 220 Villeneuve St. W Montreal, PQ few a questionnaire that began with CMA JOURNAL/DECEMBER 3, 1977/VOL. 117
1259
