Management of Painful Neuromas in the Hand* - Northwestern University

Managemenot f Painful Neuromasin the Hand*

BY JAMES H. HERNDON, M.D.S,

RICHARD G. EATON, M.D.S, NEW YORK, N.Y.

AND J. WILLIAM LITTLEI~,

From the Hand Service of The Roosevelt Hospital, New York City

M.D.S,

ABSTRACT: A new treatment for painful neuromas neuromasin the hand. Of these, thirty-three patients, with

in the handwasused on thirty-three patients. Fifteen of a total of fifty-seven painful neuromas,wereavailable for

them were partial amputees and the others had unre- follow-up.

pairable lesions. The treatment was transfer of the

The patients were divided into two groups: those who

stumps to an unscarred site where the neuromawould had had amputation and those whohad not. Of the fifty-

not be under pressure whenthe hand was used. Excel- seven neuromasthat were treated, thirty-eight werein am-

lent results wereachieved in 82 per cent of patients. putation stumpsof fingers and nineteen were the result of

other injuries. In the amputeegroup there were thirteen

Symptomaticneuromas are a frequent cause of major male and two female patients; in the non-amputeegroup

disability of the hand. Asingle hypersensitive neuromain there were twelve male and six female patients. The aver-

an amputationstumpof a finger mayimpair the function of age age in both groups was forty-one years (range, ten to

the wholehand. The hypersensitivity is generally attrib- sixty-one years). The duration of symptoms averaged

uted to the scar around the enlarged end of the nerve, twenty months(range, two to eighty-four months), and the

especially whenit is subjected to repeated local trauma. To average follow-up was thirty months(range, four to eighty

date, treatment of painful neuromas has not been com- months). pletely satisfactory. The methods described for prophylaxis or treatment of painful neuromasinclude embedding

Operative Technique

the nerve ends in bone3,11; injecting themwith alcohol 16,

Under tourniquet hemostasis, the neuroma with its

phenol3, steroids 17, formalin21, or cerebrospinalfluid 1.4; fibrous capsule is carefully isolated. Aproximalarea that

repeatedly percussing them; or crushing or cauterizing the is free fromscar and awayfromlocal pressure or trauma is

nerve end 12 and ligating it i3 (with or without alcohol in- selected, preferably deep to a muscle, in a webspace, or

jection 1s,~_1). Recentlydescribed techniques of treatment betweenshafts of the metacarpals. Adorsal site is prefera-

include injecting the neuroma site with triamcinolone ble to a volar location that mightlead to pressure on the

acetonide is, resecting the lacerated nerve iz, and having neuroma with manual activity such as the gripping of

the patient wearprotective devices 6. Prophylaxisincludes tools. "

covering the cut nerve endwith a silicone cap ~.~,~1, apply-

The neuromain continuity with its nerve is then care-

ing a Silastic cuff around a nerve repair 6, and applying fully dissected proximally until the neuromabulb can be

abdominalpedicle flaps to the scarred area 4

transferred to its newlocation without tension on___the

Thereis no constant correlation betweenthe size of a neuromaand its ability to cause symptoms.The majority

of published treatment techniques include resection or some modification of the symptomatic neuroma. All such

nerve. A 5-0 catgut suture is then placed through the capsule (not the neuroma)and tied. Asecondknot is tied three to four miIlimeters distal to the neuroma,creating a small obstruction in the otherwise smoothlength of the free su-

techniques, however, are subject to muchthe same un- ture end. The free ends of the suture are then tunneled

knowninfluences which resulted in the development of subcutaneouslyand passed through the skin with a straight

symptomsin the initial neuroma.

needle proximal to the location selected for the neuroma.

Since 1967we have used a technique of treatment in This suture is drawnthrough the skin until the obstructing

whichevery effort is madeto keep the neuromaintact with knot contacts the dermis. This maintains a three to four-

its matureencapsulating scar, while transposing it en bloc millimeter separation between dermis and neur0ma. The

to an adjacent area that is free of scar and not subjected to free end of the suture is then tied subcutaneously (Figs.

repeated trauma. The present report is an analysis of our 1-A through l-C). The nerve trunk is carefully examined

results.

to makecertain that no tension exists along its path. A

Methods and Material

similar technique 'is utilized whenthe neuromais buried in muscle. For neuromasin the finger stumpswe preferred to

Weoperated on fifty-four patients with painful transfer the nerve end int?~ the webspace; for ne~aremaisn

369

370

J. H. HERNDON,R. G. EATON, ANDJ. W. LITTLER

FIG. I-A

FIG. I-B

FIG. I-C

Figs. l-A, I-B, and I-C: Operative technique in whicha large neuromaof the radial digital nerve of the amputatedindex finger is transferred to the dorsum of the hand.

Fig. I-A: Theneuromain continuity with its nerve trunk is dissected proximally. Fig. I-B: A catgut suture is secured to the fibrous capsule of the neuroma. Fig. l-C: Apair of scissors is passed through the hand creating a tunnel through which to pass the neuroma.

the handas fully as possible, initially avoiding trauma to lacerations wereresponsible for sixteen nerve injuries.

the area of the relocated neuroma.

The dominanthand was injured in 53 per cent of the

Criteria for Evaluation

amputee group and 61 per cent of the non-amputeegroup. In the amputeegroup all of the neuromasinvolved digital

Each patient's result was rated both subjectively and nerves except one (which involved the radial sensory

objectively. Thesubjective criteria were pain, stumpanes- branchat the level of the thumbmetacarpal). Fifteen of the

thesia, and patient acceptance. The grading systems for thirty-eight neuromasinvolved the ring finger in this group

pain and stump anesthesia were the same: Grade 1 -- and multiple fingers wereinjured in 20 per cent. Thelong,

none; Grade 2 -- mild, no interference with daily ac- ring, and little fingers were most commonlyinjured; the

tivities; Grade3 -- moderate, patient worksbut has some thumbwasinj ~uredin only three cases. In the thumb,painlimitation in use of the hand because of pain or numbness; ful neuromasinvolved the radial digital nerve in twocases,

Grade 4 -- severe, cannot workor use hand. The grading the ulnar digital nerve in two cases, and the radial dorsal

system for patient acceptance was: Grade 1 -- improved, sensory branch in one case. In the index finger, the ulnar

no interference with daily activity, no disability; Grade2A digital nerve was involved in three cases and the radial

-- improved, interference but patient can work, mild dis- digital nerve, in twocases. In the long finger, the ulnar

ability; Grade 2B -- improved, interference and patient digital nerve was involved in three cases and the radial

unable to work, mild disability; Grade 3 -- no change; digital nerve, in four. In the ring finger, the ulnar digital

Grade4 -- worse. The patients were graded preoperatively nerve was involved in seven cases and the radial digital

and postoperatively.

nerve, in seven. In the little finger, the ulnar digital nerve

Theobjective criteria included Tinel's sign and func- wasinvolvedin three cases, the radial digital nervein three,

tion. Tinel's:'sign wasgradedas follows: Grade1 -- none; and the ulnar (digital) dorsal sensory branchin onecase.

Grade2 -- mild, sl.ight tingle; Grade3 -- moderate, very the non-amputeegroup the dorsal sensory branch of the uncomfortable; Grade 4 -- severe, patient unable to use radial nerve was the most commonlyinjured nerve (seven

hand because of any stimulation of the neuroma.Function cases). Theulnar sensory branch and the palmar cutaneous

was graded as follows: Grade 1 -- normal, no interference branch of the mediannerve were injured in one case each.

with activity, full range of motionand strength; Grade2 -- The palmar cutaneous branch was injured during a carpal-

interference with heavyor delicate worksecondaryto loca- tunnel release. The ulnar digital nerve of the thumbwas

tion of the neuroma; Grade 3 -- patient unable to use injured in three cases: two iatrogenically, one with a

hand. Pinch and grasp were measured on standard spring trigger-thumb release, and another during removal of a

gauges.

foreign body. The final iatrogenic lesion wasan injury to

Results

the radial digital nerve of the index finger in a patient who had had incision and drainage of an abscess. Wetreated no

All cases of neuromain the amputeegroup except one patient in this series with injury to the dorsal radial sensory

were the result of industrial accidents. Of the patients in nerve. This nerve can easily be lacerated during release of

the non-amputeegroup, fifteen (72 per cent) had had in- the first extensor compartmentfor de Quervain's tenosyn-

dustrial accidents and the other four had had iatrogenic ovitis. Onlyone patient in the non-amputeegroup had two

injuries; +,hat is, i~i~..'..ri~:s tb.at occurredat the ti,m.~ of ~ervesinjured: twobra~~.'::hes of the dorsal, radial sensory

surger7

THE JOURNALOF BONEAND.iOINT SURGERY

the

the up. ital ory the ~up rig, the ~in-

~es,

rsal mar dial nar :lial ;ital ',ital :rye tee, :. In the :yen

,~OUS

ach. palwas th a of a

7y to who d no

sory se of ~synl two ~sory

/.

:GERY

MANAGEMENTOF PAINFUL NEUROMASIN THE HAND

371

and the patient's opinion of the surgical result. Pain was per cent had no sensitivity even whenthe site of the transsignificantly relieved in twelve patients (thirty-two position was percussed. Nopatient in the amputee group

neuromas)in the amputeegroup and in seventeen patients and only one in the non-amputeegroup had severe discom-

(seventeen neuromas) in the non-amputee group. These fort (Grade 4), and six patients (fourteen neuromas)

patients said that they had no interference with their daily moderate sensitivity (Grade 3) when the neuroma was

activities (Grades 1 and 2 in function). In no patient was tapped.

the hypeisensitivity made worse by the operation. One

Two-point discrimination" did not change following

patient in the amputee group had relief of pain in five transposition. However,five patients in the amputeegroup

neuromas(Grade 1) but no relief in two others (Grade

(28 per cent of the neuromas)had two-point discrimination

This patient had a diffuse, moderately severe post- of five millimeters or less at the amputationstump, pre-

traumatic sympathetic dystrophy. He did not return to sumablydue to dorsal skin flaps included in the resurfac-

work and refused to use his hand even to eat; his wife ing. The remaining patients had two-point discrimination

helped himwith most daily activities. Onepatient with a of 1.5 centimeters or greater.

severe avulsion injury had no relief of pain and had two

Pinch and grasp strength determinations were not

additional operations of unknowntype by other surgeons considered pertinent. Mosthands had differing degrees of

without improvement. Twopatients, following successful tissue loss which mademeaningful comparison :impossi-

transfer of highly sensitive digital neuromas, became ble.

aware of moderate pain in the remaining neuromas.

There was improvementpostoperatively in hand func-

Neither patient, however, was troubled enoughto consider tion; that is, in such simple tasks as buttoning a shirt,

havingadditional operations. Thefinal patient initially had picking up coins and keys, and opening a door. Thirty of relief from preoperative stump pain. However, two the patients (fifty-two neuromas) showedthis improvemonthsafter the transfer, he noted sensitivity of a neuroma ment. One case demonstrates this particularly well: The distal to the original relocation site. It wasthought that patient had undergone amputation of the little finger

tension had been present in the nerve trunk at the time of through the base of the fifth metacarpal following a crush

surgery andthat with lysis of the catgut fixation suture, the injury. The resulting neuromaswere so sensitive that he neuromahad migrated. Suchtension is created if the nerve could not hold objects in the hand. Followingthe transpotrunk is looped around Cleland's ligament or any semi- sition operationhe wasoverjoyedto report that for the first

flexible strand in the path of transfer from the volar to time in two years he was able to hold a bar of soap and

dorsal compartments.

wash his hand.

In the non-amputeegroup, six patients had moderate hypersensitivity after neuromatransfer (Grade 4 preopera- Over-all Results

tively and Grade3 postoperatively). Of these, four cases

The conclusions based on the subjective and the ob-

were iatrogenic. The remaining two patients had neuromas jective evaluation were as follows: Results were con-

involving the dorsal sensory branch of the radial nerve, .sidered excellent whenthe test criteria were Grade2 or one following a severe crush injury. Five other patients better. Bythese criteria, results in 82per cent of cases in

with painful neuromas of this particularly troublesome the amputee group and 63 per cent in the non-amputee .nerve had goodor excellent results following transfer of group were excellent. Nopatient whoinitially had a suc-

the painful neuromas.

cessful transfer of the neuromahad recurrent-symptoms

Anesthesia distal to the neuroma,as expected, did not after prolonged follow-up.

change in any of the patients in the amputee group. All

In the amputeegroup fourteen of the fifteen patients

cases wererated as either Grade1 or Grade2. In no patient were Workmen'sCompensationcases and in this difficult

was anesthesia so bothersome that it limited daily ac- groupof patients all but three returned to work. In these tivities. In the non-amputeegroup fifteen patients had no three patients persisting neuromasymptomswere not the change and three felt that the numbnesswas improved. We reason for failure to return to work. All had suffered cannot explain this finding except to state that it wasthe mutilating injuries with extensive loss of tissue that prepatient's subjective opinion. It mayhave been the result of cluded return to their jobs. Eleven patients returned to

the proximal neurotysis that occurs with the transfer.

work within one or two months after .transfer of the

The over-all surgical result as evaluated by the pa- neuromas. Twenty-two per cent had returned to work

tients themselves (subjective patient acceptance) was within one monthafter surgery. The remaining patient re-

judgedexcellent in 86 per cent of the transposition proce- turned to different workone year after injury.

dures. Twopatients in the amputee group and two in the

In the ,non-amputeegroup of patients with industrial

non-amputeegroup felt that there had been no change with injuries the average time from neuromatransfer to return

surgery. Nopatient was madeworse.

to workwas three and a half months(range, two weeks to

thirteen months). ~o'./ ~d not returned to work at the

~;:. ;)7/~,;: >-~c.( ~ ;!.. . 7 >7:,:' ~ :2 J:.'~.~:: :~.d,'~.!c,; :~ ~:~: was

:: i..'.tii, :/:~d t>#:+,/:: o:: :n,_:~ :..;.v~ ; :.e p~:>g~a;:~xs7.:_,::, fourth

VOL5.5,4~,i'~?.). 3_ A.?RIL1976

372

J. H. HERNDON, R. G. EATON, AND J. W. LITTLER

branchof the radial nerve and had extensive scarring in the in general these patients did not do well after the transfer

area. This patient had an unsatisfactory result and a palpa- procedure. Bothgroupsof patients stated that the pain was

ble, sensitive neuromawasnoted just proximalto the scar. not madeworse by the surgery and the grading of patient

Anothernerve transfer wasplanned for this patient.

acceptance was similar in the two groups. The seven pa-

Discussion

tients with poor results included three with iatrogenic lesions: injury to the palmar cutaneous branch after carpal

Painful neuromas are frequently a cause of major ligament release, ulnar digital nerve injury during opera-

hand disability. Avariety of techniques have been de- tion for trigger thumb,and injury resulting froman opera-

scribed for their treatment, the most commonbeing resec- tion to removea foreign bodyfrom the thumb, There were

tion of the hypersensitive neuroma.The results have been twocases of injury to the radial sensory branch, a neuroma

unpredictable since the new neuroma, which must form knownto be difficult to treat. (Five other patients in this

inevitably, maybe as sensitive as the original. Recent use series had goodto excellent results.) Onepatient had con-

of silicone capping by Frackelton and associates, Biddulf, comitant symptomswith claudication. The patient was

and Swanson and co-workers has been demonstrated to relatively pain-free from the preoperative symptoms,but

minimize neuroma formation after a nerve has been di- had moderately severe limitation of hand function be-

vided, but the cap must fit well to prevent an outgrowthof cause of symptomssecondaryto arterial injury in the fore-

axons forming a neuroma proximal to the cap. A recent arm.If this last case and the iatrogenic lesions are elimi-

report on the use of triamcinolone injections by Smith and nated from the series, the good-to-excellent results are

Gomezwas encouraging, but manypatients required re- similar to those in the amputeegroup, that is, 86 per cent.

peat injections and the treatment failed in almost one-third One of the patients with injury to the dorsal sensory

of the patients.

branch of the radial nerve had the nerve sectioned more

Brownand Flynn recently reported a technique of proximally in the forearm on two different occasions with

using abdominalpedicle flaps to cover scarred areas and to no relief of pain.

create a soft-tissue bed for the involved nerves 4. They

Experience has shown that two details of technique

stressed the importance of placing the nerves in a bed are particularly important. In those digital amputation

whe:.: they will not be constricted or restrained by scar stumps which are diffusely dysesthetic, with one pre-

tissue. The same protection of the neuroma can be ac- dominantly palpable and sensitive digital neuroma and

complished more simply by the transposition described another that is not palpable, one should transfer both

here.

neuromas. Several patients in this series noted mild to

Our technique of atraumatic transfer of the mature moderate symptoms from the remaining neuroma even

encapsulated neuromaeliminates the unpredictability of though the predominant symptomsin the first neuroma

other operations and the formation of a second neuroma. were relieved. Secondly, particular care must be taken to

By relocating the bulbous nerve stumpin a well nourished, avoid tension on the nerve as the neuromais drawnproxi-

well padded, minimally traumatized area the previously mall3; to the site of relocation. Unless the nerve trunk

hypersensitive neuromaappears to undergo a change and is completely relaxed, the neuroma will either be

lose muchof its hypersensitivity. In 28 per cent of the drawn away from the optimumsite as the catgut suture neuromastransferred no sensitivity to percussion could be is absorbed or the persisting tension will cause traction

elicited and in 73 per cent there was absent to mild sen- on the neuroma, producing pain particularly with finger

sitivity to direct percussion at the newlocation. Seven motion.

patients had developed recurrent symptomatic neuromas

Weneed to know more about neuroma formation.

following previous resectionsl one patient having had Not all sectioned nerves form painful neuromas.It is not

three such procedures. Anadditional patient had been uncommotno find that in the same amputateddigit stump,

treated with narcotics in a pain-control clinic for twoyears one nerve, the ulnar digital nerve for example, maypro-

prior to havinga successful operation. Theseeight patients duce a painful neuromawhile the radial digital nerve does

were relieved of their symptomsand returned to work. not, even if both have received identical primary treat-

The discrepancy betweenthe results in the good-to- ment. Until we understand neuromasbetter the technique

excellent category in the amputeeas opposedto the non- of atraumatic neuromatransposition should be considered,

amputee group is difficult to explain. Both groups were having been shownto be successful in more than 75 per

composedmainly of industrial accident cases, but in the cent of a series of painful neuromasfound in the handsof

non-amputeegroup 21 per cent were iatrogenic lesions and predominantlyindustrial workers.

e transfer pain was )f patient ;even pa,genic leer carpal lg operam opera~ere were neuroma :s in this had conent was ~ms, but tion the fore:e elimiults are ~er cent. sensory ,~d more ~ns with

chnique ~utation ne prema and er both mild to la even euroma aken to t proxi.~ trunk ~er be suture raction finger

aation. : is not stump, ~y pro'e does ' treathnique dered, 75 per rids of

Unter-

:iation.

5-579,

RGERY

MANAGEMENTOF PAINFUL NEUROMASIN THE HAND

373

5. CARVALHOPINTO, V. A. DE, and UCH~A, L. C.: A Comparative Study of the Methods for the Prevention of Amputation Neuroma. Surg., Gynec. and Obstet., 99: 492-496, 1954.

6. DOBYNS, J. H.; O'BRIEN, E. Z.; LINSCHEID, R. L.; and FARROW, G. M.: Bowler's Thumb:Diagnosis and Treatment. A Review of Seventeen Cases. J. Boneand Joint Surg., S4-A: 751-755, June 1972.

7. DUCKERT,. B., and HAVESG, . J.: Experimental Improvementsin the Use of Silastic Cuff for Peripheral Nerve Repair. J. Neurosurg., 28: 582-587, 1968.

8. FARLEYH, . H.: Painful Stump Neuroma. Minnesota Med., 48: 347-350, 1965.. 9. FRACKELTOWN.,H.; TEASLE?J,. L.; and T.SU~AS,ARVYDANSe:uromasin the HandTreated by Nerve Trar~sposiiion and Silicone Capping. In

Proceedings of the AmericanSociety for Surgery of the Hand. J. Bone and Joint Surg., 53-A: 813, June 1971. 10. GARRITYR,. W.: The Use of Plastic and Rubber Tubing in the Managemenot f Irreparable Nerve Injuries. Surg. Forum, 6: 517-520, 1955. 11. G~EEND, . P., and CARROLL, R. E.: Sensory Nerve Injury at the Wrist. In Proceedings of the American Society for Surgery of the Hand.

J. Bone and Joint SurE.., 54-A: 898, June 1972. 12. GLUCKT,H.: Ueber Neuroplastik auf demWebeder Transplantation. Arch. f. klin. Chit., 25: 606-616, 1880. 13. Hu~E~,G. C., and LEw~s, DEAN:Amputation Neuromas. Their Development and Prevention. Arch. Surg., 1:85-113, 1920. 14. ISAAKYAIN. , G.: A Biological Methodof Treatment of Nerve Stumpsin Amputations.In Proceedings of the Socifitfi lntemationale de Chirurgie

Orthop~dique et de Traumatologie. J. Boneand Joint Surg., 43-A: 297, Marcht961. 15. KRO~E~U: eber Nervenquetschung zur Verhutung schmerzhafter Neuromenach Amputationen. Miinchen. med. Wchnschr., 63: 368, 1916. 16. SmARDJ., A.: Traitement des neurites douloureuses de guerre (causalgies) par l'alcoolisation nerveuse locale. Presse mdd., 24: 241, 1916. 17. SMITH, D. C.; Treatm6nt of Digital StumpNeuromata. In Proceedings of the North-West Metropolitan Regional and East Anglian Orthopaedic

Clubs. J: Bone and Joint Surg., 44-B: 227, Feb. 1962. 18. SNrrH, J. R, and GOMEZN,. H.: Local Injection Therapy of Neuromata of the Handwith Triamcinolone Acetonide. A Preliminary Study of

Twenty-twoPatients. J. Bone and Joint Surg., 52-A: 71-83, Jan. 1970. 19. SYYD~eC, . C., and KYOWLERS., P.: Traumatic Neuromas.In Proceedings of the AmericanSociety for Surgery of the Hand. J. Bone and Joint

Surg., 47-A: 641. April 1965. 20. Sv~yc~. P. S.: The Traumatic Neuromaand Proximal Stump. Bull. Hosp. Joint Dis.. 35: 85-102, 1974. 21. SWAySONA,. B.: Bo~vE. N. R.: and BIDDULPHS,. L.: Silicone-Rubber Capping of Amputation Neuromas. tnvestigational and Clinical

Experience. Inter-Clin. Inf. Bull., 11: 1, 1972.

Treatment of Kienb6ck's Disease Using a Silicone RubBerImplant

BY J. ROCA, M.D.*, J. E. BELTRAN,M.D., PH.D., M.R.C.S.*, M. F. FAIREN, M.D.*, AND A. ALVAREZ, M.D.*, BARCELONA, SPAIN

Fromthe Servicio de Cirurgia OrtopOdica. Ciudad Sanitaria Principes de Espatia. Barcelona

ABSTRACTT:en patients with Kienb6ck's disease related to compressionof the mediannerve whereit passes

treated by resection and replacement with a silicone under the carpal ligament.

rubber implant through a volar approach were re-

in 1972, Michonemphasizedthe importance of using

Viewed after follow-up ranging from twenty-four to a volar approach whichprevents dorsal dislocation of the

thirty months. The results were good in seven and un- implant and at the sametime permits decompressionof the

satisfac.tory in three: two patients had volar dislocation median nerve.

of the implant and one, median-nerve paresthesias of

Our purposes here are: (1) to describe our surgical

unexplained origin.

procedure for the replacement,of the carpal lunate with the

Silastic implant designed by Swanson,and (2) to report

KienNSck'sdisease significantly affects function of ten patients whowere followed for a minimumof two

the hand, but no standard treatment has been established years after operation.

and no general agreementexists regarding the indications for the manysurgical procedures described for this condi-

Surgical Technique

tion.

The operation is performed through agently curving

Recently Swanson described a new technique in palmar incision. Ans-shaped incision is avoided because

whichthe lunate is replaced by a silicone implant. Reports of its tendencyto producenecrosis of the skin.

oi~ the early results of this methodanda description of the

The transverse carpal ligament as well as the fascia

operative technique have been published ~,a. In this proce- are openedb~?a longitudinal incision. Bycarefui and gen-

dure the necrotic lunate is removedthrough a dorsal ap- tle dissection the median nerve and flexor tendons are

proach and replaced by a Silastic replica of the samesize mobilizedand retracted and the capsule of the radioc~{rpal

and shape. Certain ~roblem.,~associ:v~eCwi:~ ~i~ ~echr~que jointis i:~ev,tified~n,J.then.:,::::::.:/.. ?.a 1,-: ~ ~dirmilnci-

A>':~I,'~m~~.:.:.iera~ter'>;'d:,: ,.':," :2:i~c~:..':....~::~,~x;~~-,:andex-

VOL.58-A, NO.3, APRIL1976

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