sometimes rapidly. He should describe to the patient the usual repetitive periods of rejection requiring adjust¬ ment of dosage of immunosuppressive
drugs.
Neither should the patient be spared the details of the expected physio¬ logical and psychological course of dial¬ ysis. Usually, however, the patient is familiar with peritoneal or hemodial¬ ysis as a result of treatment provided before he is presented with a choice. In my previous article (237:2532, 1977) I noted that dialysis patients are vulner¬ able to active or passive (allowing them¬ selves to die) suicide. Usually the dial¬ ysis patient knows that he must receive prolonged, frequent, and often unpleas¬ ant, periods of dialysis. Too often, however, the transplant patient is not prepared for rejection of the trans¬
planted organ. Certainly neither treatment restores the patient to a normal life. Those of us who prefer one or the other of these modes of treatment probably eventually reach a point where we are unsure of their value. Both prolong life, but the quality of that prolongation must largely be determined by the patient. With regard to the statements made by Howard et al about living donors having a normal life expectancy, he is of course correct, statistically. However, let me ask a few questions. Who is responsible for the lack of renal function
that occurs when a person who has donated a kidney loses the other through trauma? Furthermore, if donating kid¬ neys is such a happy event, why are we not flooded with a host of people wanting to donate their kidneys? How many of the transplant team members around the country have given their kidneys, or even been cross-matched, eagerly await¬ ing the opportunity to serve as a donor at the earliest opportunity? If it is indeed so benign, no person is entitled to keep two kidneys as long as there is another person who needs one of them. During the last 15 years I have attended more than 100 patients while they were dying of end-stage renal disease in three different medical schools. All of these patients had received dialysis or transplant or both. Most of them were allowing themselves to die because life had little meaning or attraction. At such a time death becomes less feared, almost welcome. Therefore, I wish to suggest the following approach: At the time when the patient must decide what course to take, we should present three alterna¬ tives (transplant, dialysis, or death) with sympathetic candor, describing the details of each of the three, including the type of death he may expect. It is the
patient's decision to make. His decision may partially depend on his knowledge of his ability to maintain hope in the face of great adversity or on his ability to live a different kind of life only for the
immediate future. The main point I wish to make with regard to end-stage renal disease is this: let us take stock of our massive invest¬ ment in renal transplant and dialysis. Of
these procedures home dialysis is the least expensive. Are they worth the investment to the patient and to society? Let us, as physicians, not oversell these
procedures. Transplant or dialysis or death should be the patient's decision, not the physician's. The patient may ask the physician to make the decision, but he can only provide the necessary infor¬ mation, unbiased, to allow the patient to make his own decision. Since people vary widely in their private thoughts and wishes, varying types and amounts of intervention will probably be required by different people. The wish to die should be expected of people at different times along the course of intervention, in some cases possibly before initiating any procedures. This lack of a wish to live as a dialysis or transplant patient may be considered as a naturally evolving phenomenon, not necessarily a complication of illness or treatment. John P. Kemph, MD Medical Toledo
College of Ohio
Application of Diethyl Ether Herpes Simplex Lesions
to
To the Editor.\p=m-\Formany years, I have used an excellent, practical, safe solution to the problem of the application of diethyl ether to herpes simplex lesions (238:1631, 1977) and have had no complaints from patients concerning the safety of the following method. I advise them to purchase an aerosol container of engine-starting fluid and warn them as to the directions on the container about its explosive nature. Inasmuch as this product has been used by millions of people over the years, including myself for other purposes, the safety rules concerning its use are well documented. The instructions to the patient concerning application to the herpes lesions involves early detection of the recurrence by means of the pain that exists. This always precedes the emergence of the lesions. At this time, the patient takes a cotton-tipped applicator, places it at the orifice in the head of the aerosol can, releases some of the ether to soak the cotton, and applies this to the painful area six to ten times
daily.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/14/2015
In my experience over many years, with excellent reports from most of the patients involved, there are three bene¬ fits to be acquired from this technique. The first is dramatic and obvious—an almost immediate relief of the pain for appreciable lengths of time. The second is a slowing of the eruption and a faster regression of the lesions, and the third is the always hoped for destruc¬ tion of the virus deep in the tissues, perhaps preventing future recurrence of the herpes simplex lesions. I have kept no statistics, but I am acquainted over the years with hundreds of patients who have found the foregoing method a tremendous help to them in their herpes simplex virus dermatitis problems. H. D. Mintun, Jr, MD
Walnut
Gnathology and
Creek, Calif
Tinnitus
To the Editor.\p=m-\Relating to the reply of H. D. Peterson, MD (238:2072,1977), to the question whether the onset of tinnitus in a 48-year-old man might be related to myelography or one of the several drugs he was taking, it might be helpful to know that this symptom is often seen by dentists in persons suffering from chronic headache patterns or recent trauma. The source of the dental cause is a dysfunctional relationship between the temperomandibular joint and the dentition or dental prosthesis. The dysfunction (which may have been asymptomatic) is then exacerbated by a behavioral pattern. The usual pattern is simply clenching the teeth in response to pain elsewhere in the body. There are many modifications to this pattern, including biting the incisal edge of the front teeth, grinding the teeth, and biting two particular teeth
(eg, cuspids).
Where other sources of tinnitus, such as aspirin, have been ruled out, a gnathologically aware dentist may provide relief by correcting the underlying
dysfunction.
Kenneth W. Hicks, DDS Kailua, Hawaii
Improved Radionuclide of the Pancreas
Imaging
To the Editor.\p=m-\Withthe advent of ultrasound and body computerized tomography (CT) scanning, radionuclide imaging of the pancreas is rapidly being replaced. However, there are still many hospitals where CT scanning or newer Grey-scale ultrasound is not available and where pancreatic radionuclide imaging is still being per-
drugs.
Neither should the patient be spared the details of the expected physio¬ logical and psychological course of dial¬ ysis. Usually, however, the patient is familiar with peritoneal or hemodial¬ ysis as a result of treatment provided before he is presented with a choice. In my previous article (237:2532, 1977) I noted that dialysis patients are vulner¬ able to active or passive (allowing them¬ selves to die) suicide. Usually the dial¬ ysis patient knows that he must receive prolonged, frequent, and often unpleas¬ ant, periods of dialysis. Too often, however, the transplant patient is not prepared for rejection of the trans¬
planted organ. Certainly neither treatment restores the patient to a normal life. Those of us who prefer one or the other of these modes of treatment probably eventually reach a point where we are unsure of their value. Both prolong life, but the quality of that prolongation must largely be determined by the patient. With regard to the statements made by Howard et al about living donors having a normal life expectancy, he is of course correct, statistically. However, let me ask a few questions. Who is responsible for the lack of renal function
that occurs when a person who has donated a kidney loses the other through trauma? Furthermore, if donating kid¬ neys is such a happy event, why are we not flooded with a host of people wanting to donate their kidneys? How many of the transplant team members around the country have given their kidneys, or even been cross-matched, eagerly await¬ ing the opportunity to serve as a donor at the earliest opportunity? If it is indeed so benign, no person is entitled to keep two kidneys as long as there is another person who needs one of them. During the last 15 years I have attended more than 100 patients while they were dying of end-stage renal disease in three different medical schools. All of these patients had received dialysis or transplant or both. Most of them were allowing themselves to die because life had little meaning or attraction. At such a time death becomes less feared, almost welcome. Therefore, I wish to suggest the following approach: At the time when the patient must decide what course to take, we should present three alterna¬ tives (transplant, dialysis, or death) with sympathetic candor, describing the details of each of the three, including the type of death he may expect. It is the
patient's decision to make. His decision may partially depend on his knowledge of his ability to maintain hope in the face of great adversity or on his ability to live a different kind of life only for the
immediate future. The main point I wish to make with regard to end-stage renal disease is this: let us take stock of our massive invest¬ ment in renal transplant and dialysis. Of
these procedures home dialysis is the least expensive. Are they worth the investment to the patient and to society? Let us, as physicians, not oversell these
procedures. Transplant or dialysis or death should be the patient's decision, not the physician's. The patient may ask the physician to make the decision, but he can only provide the necessary infor¬ mation, unbiased, to allow the patient to make his own decision. Since people vary widely in their private thoughts and wishes, varying types and amounts of intervention will probably be required by different people. The wish to die should be expected of people at different times along the course of intervention, in some cases possibly before initiating any procedures. This lack of a wish to live as a dialysis or transplant patient may be considered as a naturally evolving phenomenon, not necessarily a complication of illness or treatment. John P. Kemph, MD Medical Toledo
College of Ohio
Application of Diethyl Ether Herpes Simplex Lesions
to
To the Editor.\p=m-\Formany years, I have used an excellent, practical, safe solution to the problem of the application of diethyl ether to herpes simplex lesions (238:1631, 1977) and have had no complaints from patients concerning the safety of the following method. I advise them to purchase an aerosol container of engine-starting fluid and warn them as to the directions on the container about its explosive nature. Inasmuch as this product has been used by millions of people over the years, including myself for other purposes, the safety rules concerning its use are well documented. The instructions to the patient concerning application to the herpes lesions involves early detection of the recurrence by means of the pain that exists. This always precedes the emergence of the lesions. At this time, the patient takes a cotton-tipped applicator, places it at the orifice in the head of the aerosol can, releases some of the ether to soak the cotton, and applies this to the painful area six to ten times
daily.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/14/2015
In my experience over many years, with excellent reports from most of the patients involved, there are three bene¬ fits to be acquired from this technique. The first is dramatic and obvious—an almost immediate relief of the pain for appreciable lengths of time. The second is a slowing of the eruption and a faster regression of the lesions, and the third is the always hoped for destruc¬ tion of the virus deep in the tissues, perhaps preventing future recurrence of the herpes simplex lesions. I have kept no statistics, but I am acquainted over the years with hundreds of patients who have found the foregoing method a tremendous help to them in their herpes simplex virus dermatitis problems. H. D. Mintun, Jr, MD
Walnut
Gnathology and
Creek, Calif
Tinnitus
To the Editor.\p=m-\Relating to the reply of H. D. Peterson, MD (238:2072,1977), to the question whether the onset of tinnitus in a 48-year-old man might be related to myelography or one of the several drugs he was taking, it might be helpful to know that this symptom is often seen by dentists in persons suffering from chronic headache patterns or recent trauma. The source of the dental cause is a dysfunctional relationship between the temperomandibular joint and the dentition or dental prosthesis. The dysfunction (which may have been asymptomatic) is then exacerbated by a behavioral pattern. The usual pattern is simply clenching the teeth in response to pain elsewhere in the body. There are many modifications to this pattern, including biting the incisal edge of the front teeth, grinding the teeth, and biting two particular teeth
(eg, cuspids).
Where other sources of tinnitus, such as aspirin, have been ruled out, a gnathologically aware dentist may provide relief by correcting the underlying
dysfunction.
Kenneth W. Hicks, DDS Kailua, Hawaii
Improved Radionuclide of the Pancreas
Imaging
To the Editor.\p=m-\Withthe advent of ultrasound and body computerized tomography (CT) scanning, radionuclide imaging of the pancreas is rapidly being replaced. However, there are still many hospitals where CT scanning or newer Grey-scale ultrasound is not available and where pancreatic radionuclide imaging is still being per-
