comparisons. We look forward to fur¬ study of this important issue to help delineate the importance of AIDS in residency program selection. ther
Ness, MD, MPH University of Pennsylvania Philadelphia Joyce V. Kelly, PhD Charles D. Killian, MA Roberta B.
Association of American Medical Colleges Washington, DC 1. Ness RB, Kelly JV, Killian CD. House staff recruitment to municipal and voluntary New York City residency programs during the AIDS epidemic. JAMA. 1991;266:2843-2846. 2. Clarke OW, Conley RB. The duty to 'attend upon the sick.' JAMA. 1991;226:2876-2877.
Infants at Risk for the
Acquired Immunodeficiency Syndrome To the Editor. \p=m-\TheAIDS Task Force of the American Academy of Pediatrics is distressed by the lack of understanding on the part of some personnel in neonatal intensive care units regarding the natural history offetuses exposed to the human immunodeficiency virus (HIV) during pregnancy. This is shown in the article by Levin et al.1 The therapeutic decisions recommended for HIV\x=req-\ seropositive neonates assumed that treatment of those infants was futile. This attitude could have deprived infants at risk for HIV infection of life-prolonging treatment and may have jeopardized care for uninfected infants who were seropositive owing to passive transfer of HIV antibody across the placenta. The true incidence of infection with HIV of seropositive newborns in the United States is approximately 30% and may be considerably less.2 Treatment has become more available and the mean survival of infected children is increasing.3 In any case, the diagnosis of infection in the newborn period is still fraught with difficulties.4 Thus, medical ethics dictate that therapeutic decisions for the infant should not be determined solely on the basis of the HIV serologie status of the mother or infant. The need for renewed and continuing efforts to educate health care workers is evident from this article.
Stanley A. Plotkin, MD American Academy of Pediatrics Marnes La Coquette, France Levin BW, Driscoll J, Fleischman A. Treatment
The Laparoscopic Dividend To the Editor. \p=m-\Thecost of laparoscopic cholecystectomy can be lowered. In the recent Letters section of JAMA,1 the hospital cost was $4633 and $6750 at two different centers. Our group has done more than 1200 laparoscopic cholecystectomies. A recent audit of 50 cases (age less than 60 years, elective cases) showed an average hospital charge of $1817. Here are the ways we lower costs. We use electrosurgical dissection instead of laser2: savings, $546 to $800. We use reusable cannulas with limited use trocars instead of completely disposable systems: savings, $400 to $650. We use reusable graspers, scissors, dissectors, suctionirrigators: savings, $250 to $600. We do operative cholangiograms only when indi-
cated, not routinely: savings, $300 to $500. There has been no reduction in quality of care; our morbidity, mortality, and operating efficiency compare favorably
with all reports.3 An increasing number of patients are treated as outpatients with additional savings of about $250. By making cost-responsible choices in technique and equipment, the sur¬ geon can greatly lower the cost of lap¬
aroscopie cholecystectomy.
Voyles, MD University of Mississippi
C. Randle Jackson
Financial Disclosure.—Dr Voyles holds stock, has received honoraria from, and has acted as a consultant for companies with an interest in lap¬
aroscopie equipment.
Hospital charges for laparoscopic and cholecystectomy. JAMA. 1991;266:3425. 2. Voyles CR, Meena AL, Petro AB, Haick AJ, Koury AM. Electrocautery is superior to laser for laparoscopic cholecystectomy. Am J Surg. 1990;160:457. 3. Voyles CR, Petro AS, Haick AJ, Koury AM. A practical approach to laparoscopic cholecystectomy. Am J Surg. 1991;161:365-370. 1. Jordan AM.
open
Hyperinsulinemia and Uric Acid Clearance To the Editor.\p=m-\I read with great interest the article by Facchini et al, 1 which correlated uric acid clearance with insulin resistance. Such an explanation fits with earlier studies in which the administration of antilipemic doses of nicotinic acid induced hyperglycemia, abnormal glucose tolerance, hyperinsulinemia, hyperuricemia, and apparent decreases in
Dis J. 1991;10:523-531.
the renal clearance of uric acid.2-5 At that time, nicotinic acid and/or one or more metabolites thereof were postulated to reduce the renal excretion of uric acid. In light of the Facchini study, changes in uric acid metabolism may have been induced by renal effects of the concomitant hyperinsulinemia. Zane N. Gaut, MD, PhD Warren, NJ
This letter ivas shown to Dr Levin, who declined to
1. Facchini
1. choice for infants in the neonatal intensive care unit at risk for AIDS. JAMA. 1991;265:2976-2981. 2. Oxtoby MJ. Perinatally acquired human immunodeficiency virus infection. Pediatr Infect Dis J.
1991;9:609-619.
3.
McKinney R, Maha M, Connor E, et al. A multicenter trial of oral zidovudine in children with advanced human immunodeficiency virus disease. N Engl J Med.
1991;324:1018-1025. Rogers M, Ou C, Kilbourne B, Schochetman G. Ad-
4.
and problems in the diagnosis of human immunodeficiency virus infection in infants. Pediatr Infect vances
reply.—Ed.
F, Chen I, Hollenbeck CB, Reaven GM. Relationship between resistance to insulin-mediated
glucose uptake, urinary uric acid clearance, and plasma uric acid concentration. JAMA. 1991;266:3008-3011. 2. Gaut ZN, Solomon HM, Miller ON. The influence of antilipemic doses of nicotinic acid on carbohydrate tolerance and plasma insulin levels in man. Diabetes. 1970;19:385. 3. Gaut ZN, Pocelinko R, Solomon HM, et al. Oral glucose tolerance, plasma insulin, and uric acid excretion in man during chronic administration of nicotinic acid. Metabolism. 1971;20:1031-1035. 4. Gaut SN, Solomon HM, Miller ON. The influence of antilipemic doses of nicotinic acid on carbohydrate tolerance in man. In: Gey KF, Carlson LA, eds. Metabolic Effects of Nicotinic Acid and Its Derivatives. Bern, Switzerland: Hans Huber Publishers; 1971:733. 5. Gaut ZN, Solomon HM, Miller ON. The influence of antilipemic doses of nicotinic acid on carbohydrate tolerance and plasma insulin levels in man. In: Gey KF, Carlson LA, eds. Metabolic Effects of Nicotinic Acid and Its Derivatives. Bern, Switzerland: Hans Huber Publishers; 1971:923-927. This letter was shown to the author, who declined to
reply.\p=m-\Ed.
Physicians and Patients Need an
Electronic Card To the Editor.\p=m-\As a physician and founder of a software development company, I was appalled to read in the recent issue of JAMA1 that a proposal by Louis Sullivan, secretary of the Department of Health and Human Services, for medical recordkeeping on a personal credit card has drawn such criticism. It has been suggested that this card "is to protect the special interests of those who are profiteering from the health care the consumsystem, as opposed to ers," and that it represents a "gimmick" whose principal purpose is to improve cash flow, not access. I have always assumed it to be evident that deciphering cryptic handwriting and requesting old medical records over and over again is a waste of a physician's time, as well as a health risk to the patient when errors occur in obtaining this vital information. I encourage critics of Dr Sullivan's proposal to visit the medical records office of an "ultra¬ modern" or "state-of-the-art" tertiary care hospital. While the person in the operating room ofthe same hospital com¬ plex may be having a central nervous system tumor lysed by a gamma beam that magnetically focuses high-energy protons at very precisely defined loca¬ tions, there are innumerable persons in the records office doing paperwork that could be done a minimum of a hundred times easier on an inexpensive computer, if a reasonable set of bookkeeping stan¬ dards existed. While such institutions aggressively try to be the first to offer a new form of laser therapy, not even a single hospital has been established in which all records are kept electronically. Enormous numbers ofworkers are hired to sort through and file mountains of paperwork, and months may be spent obtaining information that would oth¬ erwise be retrieved in milliseconds. Electronic standardization and auto¬ mation are perhaps the greatest actions
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/08/2015
.
.
.
that can be taken to increase efficiency in the short term and, unlike so many other proposed solutions (eg, socialized health care), is not exquisitely expen¬ sive to implement effectively. Removal of unnecessary bureaucracy would be helpful also, but traditionally such changes are long in coming. Indeed, elec¬ tronic automation is key and, unlike cer¬ tain other pie-in-the-sky ideas, is real¬ izable now. While it may not be the ul¬ timate solution in itself, its impact can be substantial and should not be under¬ estimated or ridiculed. Ahmed F. Ghouri, MD First Access Inc St Louis, Mo 1. Cotton P. Proposed card, intended to facilitate medical billing, record keeping, draws mixed reviews. JAMA. 1991;266:2804-2807. This letter was shown to the author, who declined to
reply.—Ed.
Fictive Ills: Literary Perspectives on Wounds and Disease To the Editor.\p=m-\Drs Richard and Enid Peschel's book review of Fictive Ills: Literary Perspectives on Wounds and Disease1 initially appears reasonable until their discussion ofthe essays on the fictive depiction of severe mental illness, which we are warned contain "fundamental and potentially disastrous deficiencies" because they allegedly utilize "late 19thand early 20th-century concepts" of severe mental illness. We are never told how these concepts\p=m-\froma time when there were many lasting contributions to psychiatry\p=m-\aredeficient. However, the essayists are chastised for ignoring the recent revolution in neuroscience research, which the Peschels claim has "documented that severe mental illness comprises biologically based brain disorder characterized by brain malfunctions or malformations" (p 2298). This claim implies a degree of scientific certitude that just does not exist as investigators seek to elucidate the neurobiological underpinnings of mental illness. Actually the Peschels commit several errors common to those unfamiliar with research in neuroscience. As Spiegel2 has pointed out about similar statements by the Peschels in the past,3 implicit in their conception of mind and brain is a Cartesian dualism that is now recog¬ nized to have hampered scientific un¬ derstanding of mind-brain functioning. Their view of severe mental illness is unifactorial, simplistic, and oblivious to what is known about the clinical heter¬ ogeneity of different diagnostic catego¬ ries, suggesting multiple causes, each of which is multifactorial. The Peschels also appear unaware of the limitations of .
.
The Peschels also attack both essay¬ ists for utilizing "late 19th- and early 20th-century Freudian concepts" and as an example of "quintessential Freudian analysis," they quote: "A self-absorbed mother deficient in mature empathy will be unable to respond to the child in ways, physical and vocal, that respect the child's being his own person" (p 2298). Nowadays this quotation would be con¬ sidered self-evident. To label it Freud¬ ian is like labeling the assertion of the earth revolving around the sun as Copernican. Such a label is antiquated. Their reproach of the nonscientific dis¬ cipline of literary criticism—with a habit for intellectual rigor the Peschels might emulate—for being nonscientific seems
especially egregious. Finally, one can¬ not help but wonder about the back¬ grounds of these reviewers. Dr Richard Peschel it turns out is a therapeutic radi¬ ologist. What irony, since it was in 1895 that Wilhelm Roentgen first detected "X rays."5 Surely Dr Peschel doesn't es¬ chew Roentgen's contribution because of his "late 19th- and early 20th-century" concept of "x-strahlen."
The readers of JAMA ought to know that the Peschels brazenly evince idiosyn¬ cratic opinions that do not constitute a valid criticism of the pertinent authors in this volume of Literature and Medicine. Would that they had taken greater pains in their review, which is riddled with fun¬ damental and disastrous deficiencies. Paul W. Ragan, MD National Naval Medical Center Bethesda, Md
.
purely neurobiological approach to un¬ derstanding complex mental functioning,
a
can be stated in terms of general living systems theory: "The most complex systems at higher levels have character¬ istics that cannot be described only in terms used for their lower subsystems and components without neglecting sig¬ nificant aspects of these systems."4
which
The opinions expressed herein are those of the author and do not reflect the views of the Depart¬ ment of the Navy, the Department of Defense, or the US government. 1. Peschel RE, Peschel E, reviewers. Review of: Graham PW, Sewell E, eds. Fictive Ills: Literary Perspectives on Wounds and Diseases. JAMA. 1991;266:
2298-2299. 2. Spiegel D. Minding the need for specialists in brain diseases. Percept Mot Skills. 1990;71:780-782. 3. Peschel R, Peschel E. The need for specialists in biologically-based brain diseases. Percept Mot Skills.
1990;70:624-626.
4. Miller JG, Miller JL. General living systems theory. In: Kaplan HI, Sadock BJ, eds. Comprehensive Text\x=req-\ book of Psychiatry, IV. Baltimore, Md: Williams &
Wilkins; 1985:13-24.
5. Ferris T. Coming of Age in the Milky York, NY: Anchor Books; 1989:248.
Way. New
In Reply.\p=m-\We are surprised that the critic of our review of Fictive Ills: Literary Perspectives on Wounds and Diseases claims that we "brazenly evince idiosyncratic opinions" when we criticize some of the authors of thatbook for interpreting severe mental illness based
late 19th- and early 20th-century conon modern scientific findings. We refer this critic to our forthcoming volume,1 which contains chapters by some of the foremost authorities in modern psychiatry and neuroscience. The authors who wrote chapters for this volume come from such renowned institutions as Stanford University, Yale University, the University of Pittsburgh, Albert Einstein College of Medicine, the University of California at Los Angeles and at San Diego, and the National Institute of Mental Health. Our views merely reflect the extraordinary progress that has been made in neurobiology at these outstanding institutions. As for Spiegel's criticisms of one of our articles to which this critic refers, we have responded to Spiegel in a subsequent pub¬ lication.2 We pointed out that our empha¬ sis on the neurobiochemical model of such serious, chronic neurobiological disorders as bipolar disorder, major depressive dis¬ order, schizophrenia, autism and perva¬ sive developmental disorders, obsessivecompulsive disorder, Tourette's disor¬ der, attention deficit hyperactivity disorder, and anxiety and panic disorders is based on two issues. Findings from the neuroscience revolution have docu¬ mented reproducible, scientifically verifi¬ able abnormalities in brain chemistry, anatomy, and function that help explain these biologically based brain disorders. Second, scientific clinical trials have proved the efficacy of many neuropharmacological medications for treating these neurobiological disorders. This critic's comments about Roent¬ gen's detecting X rays in 1895 actually add support to our point of view. Of course, we recognize that Roentgen made fundamental contributions to the field of therapeutic radiology. In 1992, however, it would be malpractice to treat cancer patients with Roentgen rays, which are low-energy X rays. As sci¬ entific knowledge advances, so must medical practice and understanding. In sum, it is unacceptable to ignore re¬ cent neuroscientific findings. In the last decade of the 20th century, it is impera¬ tive that all fields of medicine must be based on science, empirical evidence, and efficacy. Any medical field that ignores the revolution in neurobiology and molec¬ ular biology will not endure. Richard E. Peschel, MD, PhD on
cepts, instead of
Enid Peschel, PhD Yale University School of Medicine New Haven, Conn 1. Peschel E, Peschel R, Howe C, Howe J, eds. Neurobiological Disorders in Children and Adolescents: A Guide to Research and Policy on Schizophrenia, Bipolar Disorder, Autism, and More, for Professionals and Families. San Francisco, Calif: Jossey-Bass. In press. 2. Peschel RE, Peschel E. A medical model for specialists in biologically based brain disease. Percept Mot
Skills. 1991;72:96-98.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/08/2015
Ness, MD, MPH University of Pennsylvania Philadelphia Joyce V. Kelly, PhD Charles D. Killian, MA Roberta B.
Association of American Medical Colleges Washington, DC 1. Ness RB, Kelly JV, Killian CD. House staff recruitment to municipal and voluntary New York City residency programs during the AIDS epidemic. JAMA. 1991;266:2843-2846. 2. Clarke OW, Conley RB. The duty to 'attend upon the sick.' JAMA. 1991;226:2876-2877.
Infants at Risk for the
Acquired Immunodeficiency Syndrome To the Editor. \p=m-\TheAIDS Task Force of the American Academy of Pediatrics is distressed by the lack of understanding on the part of some personnel in neonatal intensive care units regarding the natural history offetuses exposed to the human immunodeficiency virus (HIV) during pregnancy. This is shown in the article by Levin et al.1 The therapeutic decisions recommended for HIV\x=req-\ seropositive neonates assumed that treatment of those infants was futile. This attitude could have deprived infants at risk for HIV infection of life-prolonging treatment and may have jeopardized care for uninfected infants who were seropositive owing to passive transfer of HIV antibody across the placenta. The true incidence of infection with HIV of seropositive newborns in the United States is approximately 30% and may be considerably less.2 Treatment has become more available and the mean survival of infected children is increasing.3 In any case, the diagnosis of infection in the newborn period is still fraught with difficulties.4 Thus, medical ethics dictate that therapeutic decisions for the infant should not be determined solely on the basis of the HIV serologie status of the mother or infant. The need for renewed and continuing efforts to educate health care workers is evident from this article.
Stanley A. Plotkin, MD American Academy of Pediatrics Marnes La Coquette, France Levin BW, Driscoll J, Fleischman A. Treatment
The Laparoscopic Dividend To the Editor. \p=m-\Thecost of laparoscopic cholecystectomy can be lowered. In the recent Letters section of JAMA,1 the hospital cost was $4633 and $6750 at two different centers. Our group has done more than 1200 laparoscopic cholecystectomies. A recent audit of 50 cases (age less than 60 years, elective cases) showed an average hospital charge of $1817. Here are the ways we lower costs. We use electrosurgical dissection instead of laser2: savings, $546 to $800. We use reusable cannulas with limited use trocars instead of completely disposable systems: savings, $400 to $650. We use reusable graspers, scissors, dissectors, suctionirrigators: savings, $250 to $600. We do operative cholangiograms only when indi-
cated, not routinely: savings, $300 to $500. There has been no reduction in quality of care; our morbidity, mortality, and operating efficiency compare favorably
with all reports.3 An increasing number of patients are treated as outpatients with additional savings of about $250. By making cost-responsible choices in technique and equipment, the sur¬ geon can greatly lower the cost of lap¬
aroscopie cholecystectomy.
Voyles, MD University of Mississippi
C. Randle Jackson
Financial Disclosure.—Dr Voyles holds stock, has received honoraria from, and has acted as a consultant for companies with an interest in lap¬
aroscopie equipment.
Hospital charges for laparoscopic and cholecystectomy. JAMA. 1991;266:3425. 2. Voyles CR, Meena AL, Petro AB, Haick AJ, Koury AM. Electrocautery is superior to laser for laparoscopic cholecystectomy. Am J Surg. 1990;160:457. 3. Voyles CR, Petro AS, Haick AJ, Koury AM. A practical approach to laparoscopic cholecystectomy. Am J Surg. 1991;161:365-370. 1. Jordan AM.
open
Hyperinsulinemia and Uric Acid Clearance To the Editor.\p=m-\I read with great interest the article by Facchini et al, 1 which correlated uric acid clearance with insulin resistance. Such an explanation fits with earlier studies in which the administration of antilipemic doses of nicotinic acid induced hyperglycemia, abnormal glucose tolerance, hyperinsulinemia, hyperuricemia, and apparent decreases in
Dis J. 1991;10:523-531.
the renal clearance of uric acid.2-5 At that time, nicotinic acid and/or one or more metabolites thereof were postulated to reduce the renal excretion of uric acid. In light of the Facchini study, changes in uric acid metabolism may have been induced by renal effects of the concomitant hyperinsulinemia. Zane N. Gaut, MD, PhD Warren, NJ
This letter ivas shown to Dr Levin, who declined to
1. Facchini
1. choice for infants in the neonatal intensive care unit at risk for AIDS. JAMA. 1991;265:2976-2981. 2. Oxtoby MJ. Perinatally acquired human immunodeficiency virus infection. Pediatr Infect Dis J.
1991;9:609-619.
3.
McKinney R, Maha M, Connor E, et al. A multicenter trial of oral zidovudine in children with advanced human immunodeficiency virus disease. N Engl J Med.
1991;324:1018-1025. Rogers M, Ou C, Kilbourne B, Schochetman G. Ad-
4.
and problems in the diagnosis of human immunodeficiency virus infection in infants. Pediatr Infect vances
reply.—Ed.
F, Chen I, Hollenbeck CB, Reaven GM. Relationship between resistance to insulin-mediated
glucose uptake, urinary uric acid clearance, and plasma uric acid concentration. JAMA. 1991;266:3008-3011. 2. Gaut ZN, Solomon HM, Miller ON. The influence of antilipemic doses of nicotinic acid on carbohydrate tolerance and plasma insulin levels in man. Diabetes. 1970;19:385. 3. Gaut ZN, Pocelinko R, Solomon HM, et al. Oral glucose tolerance, plasma insulin, and uric acid excretion in man during chronic administration of nicotinic acid. Metabolism. 1971;20:1031-1035. 4. Gaut SN, Solomon HM, Miller ON. The influence of antilipemic doses of nicotinic acid on carbohydrate tolerance in man. In: Gey KF, Carlson LA, eds. Metabolic Effects of Nicotinic Acid and Its Derivatives. Bern, Switzerland: Hans Huber Publishers; 1971:733. 5. Gaut ZN, Solomon HM, Miller ON. The influence of antilipemic doses of nicotinic acid on carbohydrate tolerance and plasma insulin levels in man. In: Gey KF, Carlson LA, eds. Metabolic Effects of Nicotinic Acid and Its Derivatives. Bern, Switzerland: Hans Huber Publishers; 1971:923-927. This letter was shown to the author, who declined to
reply.\p=m-\Ed.
Physicians and Patients Need an
Electronic Card To the Editor.\p=m-\As a physician and founder of a software development company, I was appalled to read in the recent issue of JAMA1 that a proposal by Louis Sullivan, secretary of the Department of Health and Human Services, for medical recordkeeping on a personal credit card has drawn such criticism. It has been suggested that this card "is to protect the special interests of those who are profiteering from the health care the consumsystem, as opposed to ers," and that it represents a "gimmick" whose principal purpose is to improve cash flow, not access. I have always assumed it to be evident that deciphering cryptic handwriting and requesting old medical records over and over again is a waste of a physician's time, as well as a health risk to the patient when errors occur in obtaining this vital information. I encourage critics of Dr Sullivan's proposal to visit the medical records office of an "ultra¬ modern" or "state-of-the-art" tertiary care hospital. While the person in the operating room ofthe same hospital com¬ plex may be having a central nervous system tumor lysed by a gamma beam that magnetically focuses high-energy protons at very precisely defined loca¬ tions, there are innumerable persons in the records office doing paperwork that could be done a minimum of a hundred times easier on an inexpensive computer, if a reasonable set of bookkeeping stan¬ dards existed. While such institutions aggressively try to be the first to offer a new form of laser therapy, not even a single hospital has been established in which all records are kept electronically. Enormous numbers ofworkers are hired to sort through and file mountains of paperwork, and months may be spent obtaining information that would oth¬ erwise be retrieved in milliseconds. Electronic standardization and auto¬ mation are perhaps the greatest actions
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/08/2015
.
.
.
that can be taken to increase efficiency in the short term and, unlike so many other proposed solutions (eg, socialized health care), is not exquisitely expen¬ sive to implement effectively. Removal of unnecessary bureaucracy would be helpful also, but traditionally such changes are long in coming. Indeed, elec¬ tronic automation is key and, unlike cer¬ tain other pie-in-the-sky ideas, is real¬ izable now. While it may not be the ul¬ timate solution in itself, its impact can be substantial and should not be under¬ estimated or ridiculed. Ahmed F. Ghouri, MD First Access Inc St Louis, Mo 1. Cotton P. Proposed card, intended to facilitate medical billing, record keeping, draws mixed reviews. JAMA. 1991;266:2804-2807. This letter was shown to the author, who declined to
reply.—Ed.
Fictive Ills: Literary Perspectives on Wounds and Disease To the Editor.\p=m-\Drs Richard and Enid Peschel's book review of Fictive Ills: Literary Perspectives on Wounds and Disease1 initially appears reasonable until their discussion ofthe essays on the fictive depiction of severe mental illness, which we are warned contain "fundamental and potentially disastrous deficiencies" because they allegedly utilize "late 19thand early 20th-century concepts" of severe mental illness. We are never told how these concepts\p=m-\froma time when there were many lasting contributions to psychiatry\p=m-\aredeficient. However, the essayists are chastised for ignoring the recent revolution in neuroscience research, which the Peschels claim has "documented that severe mental illness comprises biologically based brain disorder characterized by brain malfunctions or malformations" (p 2298). This claim implies a degree of scientific certitude that just does not exist as investigators seek to elucidate the neurobiological underpinnings of mental illness. Actually the Peschels commit several errors common to those unfamiliar with research in neuroscience. As Spiegel2 has pointed out about similar statements by the Peschels in the past,3 implicit in their conception of mind and brain is a Cartesian dualism that is now recog¬ nized to have hampered scientific un¬ derstanding of mind-brain functioning. Their view of severe mental illness is unifactorial, simplistic, and oblivious to what is known about the clinical heter¬ ogeneity of different diagnostic catego¬ ries, suggesting multiple causes, each of which is multifactorial. The Peschels also appear unaware of the limitations of .
.
The Peschels also attack both essay¬ ists for utilizing "late 19th- and early 20th-century Freudian concepts" and as an example of "quintessential Freudian analysis," they quote: "A self-absorbed mother deficient in mature empathy will be unable to respond to the child in ways, physical and vocal, that respect the child's being his own person" (p 2298). Nowadays this quotation would be con¬ sidered self-evident. To label it Freud¬ ian is like labeling the assertion of the earth revolving around the sun as Copernican. Such a label is antiquated. Their reproach of the nonscientific dis¬ cipline of literary criticism—with a habit for intellectual rigor the Peschels might emulate—for being nonscientific seems
especially egregious. Finally, one can¬ not help but wonder about the back¬ grounds of these reviewers. Dr Richard Peschel it turns out is a therapeutic radi¬ ologist. What irony, since it was in 1895 that Wilhelm Roentgen first detected "X rays."5 Surely Dr Peschel doesn't es¬ chew Roentgen's contribution because of his "late 19th- and early 20th-century" concept of "x-strahlen."
The readers of JAMA ought to know that the Peschels brazenly evince idiosyn¬ cratic opinions that do not constitute a valid criticism of the pertinent authors in this volume of Literature and Medicine. Would that they had taken greater pains in their review, which is riddled with fun¬ damental and disastrous deficiencies. Paul W. Ragan, MD National Naval Medical Center Bethesda, Md
.
purely neurobiological approach to un¬ derstanding complex mental functioning,
a
can be stated in terms of general living systems theory: "The most complex systems at higher levels have character¬ istics that cannot be described only in terms used for their lower subsystems and components without neglecting sig¬ nificant aspects of these systems."4
which
The opinions expressed herein are those of the author and do not reflect the views of the Depart¬ ment of the Navy, the Department of Defense, or the US government. 1. Peschel RE, Peschel E, reviewers. Review of: Graham PW, Sewell E, eds. Fictive Ills: Literary Perspectives on Wounds and Diseases. JAMA. 1991;266:
2298-2299. 2. Spiegel D. Minding the need for specialists in brain diseases. Percept Mot Skills. 1990;71:780-782. 3. Peschel R, Peschel E. The need for specialists in biologically-based brain diseases. Percept Mot Skills.
1990;70:624-626.
4. Miller JG, Miller JL. General living systems theory. In: Kaplan HI, Sadock BJ, eds. Comprehensive Text\x=req-\ book of Psychiatry, IV. Baltimore, Md: Williams &
Wilkins; 1985:13-24.
5. Ferris T. Coming of Age in the Milky York, NY: Anchor Books; 1989:248.
Way. New
In Reply.\p=m-\We are surprised that the critic of our review of Fictive Ills: Literary Perspectives on Wounds and Diseases claims that we "brazenly evince idiosyncratic opinions" when we criticize some of the authors of thatbook for interpreting severe mental illness based
late 19th- and early 20th-century conon modern scientific findings. We refer this critic to our forthcoming volume,1 which contains chapters by some of the foremost authorities in modern psychiatry and neuroscience. The authors who wrote chapters for this volume come from such renowned institutions as Stanford University, Yale University, the University of Pittsburgh, Albert Einstein College of Medicine, the University of California at Los Angeles and at San Diego, and the National Institute of Mental Health. Our views merely reflect the extraordinary progress that has been made in neurobiology at these outstanding institutions. As for Spiegel's criticisms of one of our articles to which this critic refers, we have responded to Spiegel in a subsequent pub¬ lication.2 We pointed out that our empha¬ sis on the neurobiochemical model of such serious, chronic neurobiological disorders as bipolar disorder, major depressive dis¬ order, schizophrenia, autism and perva¬ sive developmental disorders, obsessivecompulsive disorder, Tourette's disor¬ der, attention deficit hyperactivity disorder, and anxiety and panic disorders is based on two issues. Findings from the neuroscience revolution have docu¬ mented reproducible, scientifically verifi¬ able abnormalities in brain chemistry, anatomy, and function that help explain these biologically based brain disorders. Second, scientific clinical trials have proved the efficacy of many neuropharmacological medications for treating these neurobiological disorders. This critic's comments about Roent¬ gen's detecting X rays in 1895 actually add support to our point of view. Of course, we recognize that Roentgen made fundamental contributions to the field of therapeutic radiology. In 1992, however, it would be malpractice to treat cancer patients with Roentgen rays, which are low-energy X rays. As sci¬ entific knowledge advances, so must medical practice and understanding. In sum, it is unacceptable to ignore re¬ cent neuroscientific findings. In the last decade of the 20th century, it is impera¬ tive that all fields of medicine must be based on science, empirical evidence, and efficacy. Any medical field that ignores the revolution in neurobiology and molec¬ ular biology will not endure. Richard E. Peschel, MD, PhD on
cepts, instead of
Enid Peschel, PhD Yale University School of Medicine New Haven, Conn 1. Peschel E, Peschel R, Howe C, Howe J, eds. Neurobiological Disorders in Children and Adolescents: A Guide to Research and Policy on Schizophrenia, Bipolar Disorder, Autism, and More, for Professionals and Families. San Francisco, Calif: Jossey-Bass. In press. 2. Peschel RE, Peschel E. A medical model for specialists in biologically based brain disease. Percept Mot
Skills. 1991;72:96-98.
Downloaded From: http://jama.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/08/2015
