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While working with alcohol-dependent Native Americans (Indians as they are referred to in this book), I have wondered about the unbearable burden their culture and race have suffered. Ninety percent of the American Indian population had died before the American Revolution. Such decimation of their numbers by war, infectious disease, and alcohol since the arrival of Europeans is impossible to comprehend. While psychiatric and anthropological studies of Indian alcohol abuse provide valuable observations and theoretical discussions, a historical and economic review adds further depth to a cogent analysis. InDeadly Medicine, University of Kansas historian Peter Mancall supplies extraordinarily detailed documentation of colonial North American Indians' mostly ill-fated relationship to alcohol. His basic premise is as follows: Indians' responses to liquor reinforced colonists' notions about their cultural and racial inferiority; colonists' desire to maintain the trade [in alcohol] despite its all too apparent costs reinforced Indians' notions about deeply rooted

To the Editor.— We read with great interest the article by Hannan et al. 1 We commend the authors for the attempt to establish a risk stratification method by which hospitals can compare results. Several aspects of the article deserve comments and raise questions. The basic premise of the method is to define risk-stratified mortality rates. Yet in Table 5 of the Hannan et al article (p 2772), a risk-stratified column was left out, though it was included in a preliminary draft sent to all hospitals in New York State. The risk-adjusted mortality from that preliminary draft for Table 5 is depicted in the Table. The important emphasis of the article lies in the comparison of quality of care given by hospitals, using standardization of mortality rates. Ranking of hospitals by crude mortality rates is not only uninformative, but it is misleading in that it does not take into account

In Reply.— The claims of Nazarro-Porro and coworkers regarding the therapeutic properties and lack of toxicity of azelaic acid bring to mind the home-cleaning salesman who claims that his product not only can clean the oven, sink, floor, finest china, and commode, but also is nontoxic to humans and pets and can be used as fertilizer for plants. A basic premise of modern pharmacologic therapy is that most useful compounds have therapeutic windows below which they are ineffective and above which they are generally toxic. While these investigators appear to have stumbled on (quite literally) a useful compound due to a series of serendipitous observations, in their eagerness to promote it, they have made some claims that are difficult to accept on face value. Of primary interest is the fact that azelaic acid, even in cell cultures, is not active against any cell lines until one approaches the 10 -3 to

The vitreous implant is not to be confused with the vitreous transplant. The implant is a technique for adding new vitreous to cases of retinal detachment, while the vitreous transplant is an exchange of clear vitreous for cloudy or bloody vitreous. The basic premise of the use of vitreous in retinal detachment was that it hydraulically could pump the retina back in place, but so could air or saline. The second premise for its use was that vitreous seemed to be what kept the retina normally attached in the first place, for the retina has no attachments between its two extremities—the ora serrata and the disc. The final premise is that vitreous is the normal inhabitant of the vitreous chamber. Therefore, replacement by more vitreous seemed the logical procedure. This has been well expressed by Dr. Graham Clark, who feels that the retina is a membrane in the midst

Dr. von Noorden's letter was referred to Dr. Taylor, who offers the following reply: To the Editor: I would like to thank Dr. von Noorden for his comments. I have deliberately taken a strong stand on a somewhat controversial subject and therefore welcome criticism of this type. It is both constructive and healthy, and I frankly would have been somewhat disappointed if someone from the conservative camp had not risen to the occasion. We are actually in complete agreement on the basic premise that the eyes must be made straight as early as possible in order to permit or re-establish bifoveal stimulation. We depart company when it comes to assuming the awesome responsibility of attempting to achieve ocular parallelism by operating at a time in life when sensory motor components of the fusion phenomenon are actively developing. We are all aware of the fact that delayed management of constant congenital

To the Editor.— Marzuk et al 1 present a detailed report of the first epidemiologic investigation of suicide in persons with acquired immunodeficiency syndrome (AIDS). While they use careful ascertainment methods and have done an excellent job in reporting the study, the relative risk is expressed as a ratio of the incidence densities (number of events per 100 000 person-years of follow-up) between the patients with AIDS and the general population. The result is a staggeringly high value of 36.30 among men 20 to 59 years of age. While the relative - risk - estimate method is a common statistical tool in epidemiologic studies with long followup periods, its direct application without regard to the underlying assumptions is somewhat naive. The basic premise in using the ratio of incidence densities is that the potential personyears of follow-up in the two groups, if the events being studied did not occur , are comparable. The

FELLOWSHIP training is the final stage of formal medical education for a substantial number of physicians. Its influence, however, extends beyond those who undergo its rigors and is felt by the profession as a whole and the society it serves. The National Study of Internal Medicine Manpower1,2has studied the process by which physicians become fellows. Their reports are quite detailed and thoughtful but are unlikely to be of help to those wrestling with individual career decisions. The remarks that follow are intended to promote thought and discussion among fellowship candidates and the faculty members who train them. While based on observations of trainees in internal medicine training programs, these remarks may also be of interest to those in other fields who are forced to consider similar problems. My basic premise is that it is to the advantage of the applicant, the training program, the profession, and the patients

To the Editor.— Two cases of fatal aplastic anemia following the use of topical ocular chloramphenicol have been recently reported. 1,2 Regardless of dosage, systemic chloramphenicol can cause an idiosyncratic, usually fatal, hemopoietic event, with an incidence rate of one in 30,000 to 50,000 patients. This incidence is 13 times greater than the risk of idiopathic aplastic anemia in the population as a whole (1969;208:2045). To confirm a definite cause-and-effect relationship between ophthalmic chloramphenicol and aplastic anemia would require 1.5 million patient observations. 3 Nevertheless, a basic premise of clinical toxicology is that if there is sufficient suspicion and the adverse response is a major one, the suspected adverse drug reaction must be weighed as a side effect in therapeutic decision making until there is proof to the contrary. Therefore, we suggest the following: (1) Physicians should specifically question patients with aplastic anemia or marrow hypoplasia about their prior use

To the Editor. —I read with interest the article by Dillon et al entitled "Diagnostic Problem in Acute Myocardial Infarction: CK-MB in the Absence of Abnormally Elevated Total Creatine Kinase Levels" published in the JanuaryArchives(1982;142:33-38). I agree with the basic premise of the article; however, I would like to address their reliance on Technicon's reference values (calculated from 100 subjects) for total creatine kinase (CK) activity. If Dillon et al had used a reference range established by them for their institution rather than by someone else, I believe they would have found substantially fewer patients with increased CK and MB (its myocardial isozyme) levels with "normal" total CK levels than reported. They probably would have found that their reference range would have been substantially lower than the Technicon values. At the Methodist Medical Center of Illinois, Peoria, where I work, we have a Technicon automated multiple analysis system

THE KIND of life a patient lives is as important as the fact that he is living. Physicians seldom argue over this basic premise. The quality of life, after all, is the major reason there is a medical prefession—because pain, anxiety, and other forms of misery are not happily tolerated by mankind. Recently, as we have learned to use more aggressive therapy and to continue it with life-sustaining ancillary aids, criticism has been raised that aggressive treatment often ignores patient welfare in the interest of science. The criticism is that therapy that prolongs life at a great cost in suffering, hospitalization, and money is a failure, not a success. Therefore, it is essential that we grapple with a criterion of response to therapy that deals with quality of life, knowing in advance that such criteria do not lend themselves easily to measurement and that we will presumably end up with

To the Editor.— While the basic premise of the study by DiBisceglie et al in the July 1986 issue of theArchives, that pityriasis rotunda may be a paraneoplastic phenomenon, is plausible, there are serious problems with the study and its test data that lead to questioning its validity. 1 The authors suggested that the macular, scaling, arcuate lesions on the torso of ten patients, seven of whom had hepatocellular carcinoma, might be cutaneous markers of their underlying disease, but the suggestion was made without submitting data to show that another source of such lesions, dermatophytosis, was considered in their differential diagnosis. Where are the results of such basic studies as their potassium hydroxide preparations, Sabouraud's fungal cultures, or cutaneous biopsies with periodic acid-Schiff stain and diastase digestion? The published photomicrograph of a cutaneous biopsy specimen is compatible with tinea when only a hematoxylin-eosin stain is used; the legend

This book had its origins in courses given at Memorial Sloan-Kettering Cancer Center, New York, in 1980 and 1982. It is divided into two sections, with slightly more than half of the book devoted to the fundamental aspects of neoplasia and the inheritable factors that increase susceptibility to the disease. The latter part of the book concerns the applications of that basic knowledge to clinical aspects of oncology. The volume assumes that the reader has some degree of familiarity with basic genetic principles, oncology, cytogenetics, and the influence of environmental agents in the manifestation of certain neoplastic syndromes. The basic premise, to paraphrase Dr German, is that cancer cells are members of clones of somatic cells that have undergone one or several mutations. However, factors inherited from generation to generation influence the likelihood of such somatic mutations transforming into neoplasia. The varied elements that enter into the mechanism of cancer

To the Editor.— I wish to respond to the Letter to the Editor that appeared in the July 5 issue of JAMA 1 accusing physicians of every excuse ranging from illiteracy to being God in order to explain their poor handwriting. I have no quarrel with the basic premise that illegible writing is dangerous, time consuming, and frustrating. However, I believe there is a more plausible explanation for this problem than that sarcastically presented in the letter. Having noted a deterioration in my own handwriting, I would like to offer the most likely and apparently the most common cause of this deterioration—lack of time. The legibility of my handwriting began to decrease as I started medical school and attempted to take notes at the speed with which information was being dispensed. This note-taking process continued into the clinical training years, when there was never enough time, so my pace became

To the Editor.— While the basic premise expressed by Stenberg and Larko, in "Sunscreen Application and Its Importance for the Sun Protection Factor" in the November 1985 issue of theArchives 1 is plausible, there are serious problems with the study, the test data, and the interpretation, so much so that the report may mislead US physicians and consumers. Most important, the basic determination of application density is seriously flawed as follows: each volunteer was given only a 15-g sample of the product under test. A 15-g sample is just sufficient to cover an adult body at 1 mg/cm 2 . This irreparably biases the entire study and invalidates its conclusion. Further, each volunteer applied product to his own back. This also assured that less product was used, reducing the overall average application amount. The authors perform a sun protective factor test similar to the US Food and Drug Administration-proposed sunscreen

THE SUCCESS of the modern head and neck oncological surgeon in curing patients with head and neck cancer is due in large part to the principles that evolved from the astute clinical observations of George Crile, MD, and the truly imaginative and bold surgical concepts that he fostered. In his monumental article published in JAMA in 1906, he demonstrated the effectiveness of en bloc resection of regional lymph nodes and other lymphatic structures in the neck, including resection of the sternocleidomastoid muscle, the internal jugular vein, and the submaxillary salivary gland, in rendering patients free of disease. What led Crile to the surgical concepts he advocated was his observation that patients with head and neck cancer died primarily because the site of origin of the tumor was not controlled and/or the cancer had spread to regional neck structures. His basic premise was that each patient with cancer of the head

Dr. Midelfort has presented an account of his experiences in treating patients and family groups in the Lutheran Hospital in La Crosse, Wis. Theoretical aspects of his approach are illustrated with case material, including excerpts of interviews and their interpretation. Getting the family involved in the therapeutic effort is frequently facilitated by the custom of having family members remain in the hospital as aides and companions to the patient. This interesting procedure is unique in American hospitals. Discussion could have profitably been devoted to the implications of the therapeutic milieu, but the author chose to focus only on therapist-family-patient interactions. A basic premise of the work is that the family must be considered as the unit in which illness occurs and that only through melioration of the different psychopathologies in the family can mental health be achieved for any individual member. The author's attempt to offer a conceptual basis for

RADICAL extirpative cancer surgery in the head and neck occupies a unique position in the concepts of ablative surgery in the human body. The basic premise of total removal of the cancer is augmented by the qualifications for functional and esthetic rehabilitation of these wounds. In cancers of the lung, stomach, or intestines, the surgical interventions which deal with them are not confronted with the compelling need for esthetics, since the effects of this craftsmanship are concealed inside a body cavity. Other operative areas of the body have the advantage of camouflage and concealment by clothing. Radical surgery in the area of the head and neck, however, enjoys no such privilege. The framework of adequate surgery in this region must include not only extirpation, but a full concept of the possibilities of restoration for the purposes of function and grace. 1 To avoid a variety of surgical mutilations and distortions

To the Editor.— In my opinion, the basic premise of Dr. Charles Aring's article on the distribution of physicians into rural as opposed to urban practice is challengeable and derogatory to the medical profession ( 21 :606, 1972). Having spoken to many physicians who have left general practice to enter specialty training, it was not that they sought more income that they chose not to continue in rural practice. It was the constant "on-call" night and day, seven days a week, and the lack of educational and cultural opportunities for their families and themselves that influenced their decisions to seek further training. Young physicians do not choose isolated practices for similar reasons, and, in addition, they are more comfortable with the technological backup of the hospital medical center. Recommendations for regional primary care centers such as Dr. Bornemeier has proposed ( 219 :359, 1972) might be of significant importance in solving the

It has been suggested that "clinical normal values" can be estimated from routine laboratory records by purely statistical methods, so that accumulation of values for healthy persons is unnecessary. The basic premise for this view is that the routine laboratory values give a mixture of two gaussian (or "normal") distributions (one for the sick and one for the healthy) and that these can be identified. The results of the proposed method are compared with observed values for healthy persons tested in the same laboratories during the same period, and are found to be unsatisfactory. The distributions in healthy persons cannot be adequately described by a normal distribution. We propose that the misleading phrase "normal limits" be dropped, and that the phrase "clinical limits" be used to refer to the 2 1/2 and 97 1/2 percentage points of the distribution in healthy persons.

The authors offer a brief description of a psychotherapeutic method calledTechnique of Relaxation: Self-Relaxationas it has been practiced to their own satisfaction at the Medical Clinic of Jena in Thuringia. The core of the therapy amounts to verbal (symbolic?) control over autonomous organic function. The basic premise of such treatment, which avoids insight as well as drugs, appears to be related to J. H. Schultz'sAutogenic Training. Yet in a footnote to the preface of their first edition, the authors remark that "At the request of the Publishers, Georg Thieme, Stuttgart, who were anxious that there should be a distinction from the work of J. H. Schultz, we avoided the words 'Autogenes Training' in our title." To accomplish the results, the method seems to rely on the gradual absorption of verbal suggestions given by the doctor to individuals and to groups with the intention

The readers ofThe Journalwho are on the mailing list of Springer-Verlag of Berlin and New York are familiar with their current publications and the beautiful multicolored illustrations reprinted from the texts. Denecke and Meyer's monograph on rhinoplasty, which is volume 1 of two volumes on Plastic Surgery of the Head and Neck , is filled with similar accurate and vivid illustrations. The translator, Lowell Oxtoby, has been most successful in his basic premise to write in "American" English so that descriptions are very clear and readable. This volume is an encyclopedia of rhinoplasty. The authors make the point that they have included the tested methods of many surgeons, whereas most writers on the subject describe only their own procedures. A perusal of the bibliography will convince the reader that few, if any, of the writings in the world literature have been over-looked. For example, in 1898 the island flap

Activation, says Elizabeth Duffy, is ... " the arousal which occurs in the absence of physical exertion, or the arousal found when we subtract from measures of activation the effects of physical activity .... Activation is .... the extent of release of the stored energy of the organism through metabolic activity in the tissues." The author believes that contemporary psychological theory regards behavior as variable in only 2 fundamental aspects: direction and intensity. It is with the latter of these categories that activation theory is concerned ; and the basic premise of the activation theorist is clearly set forth at the beginning of this monograph: "A concept of intensity based on the measurement of internal processes appears to be a more useful psychological construct than one based on the force of overt response." Present-day activation theory has its historical roots in the early 1930's in the psychophysiological studies of Duffy, Freeman, Darrow, and R.