The American College of Obstetri¬ cians and Gynecologists has recog¬ nized our role as primary physicians, as illustrated by Dr Willis Brown's inaugural address in 1968, as well as by subsequent presentations and writings of his successors (Drs Keith Russell, Fred Hofmeister, and Roy
Parker).
Lastly, I might quote from a letter recently received from one who rep¬ resents a more objective and impar¬ tial view of the subject and certainly is recognized as an authority on the subject of medical care in the United States. Dr John S. Mills stated, "It has always been my opinion that the obstetrician is the ideal example of the "primary physician." I
Jack W. Pearson, MD Indiana University\p=m-\Purdue
University Indianapolis
Chymopapain Chemonucleolysis In Lumbar Disk Disease
To the Editor.\p=m-\Wiltse et al have given us an excellent review of chymopapain chemonucleolysis in lumbar disk disease (231:474, 1975). Although they themselves have performed this procedure in 1,200 cases of lumbar disk disease, it is disappointing that all they can conclude is that "chemonucleolysis appears to be as good as laminectomy in properly selected cases." It is unfortunate to find that despite the many thousands of patients treated with this agent, Wiltse et al cannot quote a single example where the correct study has been performed, ie, comparison of the effect of therapy with the active agent, chymopapain, to that of either no treatment at all or an appropriate placebo. In their study, Wiltse and co-workers note that 48.2% of the patients treated did not achieve their optimal result until at least four months after therapy. This looks remarkably like the natural history of lumbar disk disease. The few studies that have been performed to try and compare a conservative approach to lumbar disk disease with surgical therapy have not shown any clear benefit for the surgical procedures. To suggest, therefore, that chymopapain treat¬ ment may be as effective as laminec¬ tomy may be—until proved other¬ wise—to state that it is no more effective than routine conservative
management.
It can still be argued that the time off work with this procedure is shorter than is usual in a standard conserva-
tive program. Unfortunately, it still requires to be shown that the stan¬ dard conservative programs used are in themselves useful or optimal proce¬ dures. A. S. Russell, FRCP(C) University of Alberta
Edmonton, Canada
Reply.\p=m-\Dr.Russell is absolutely correct in that the ideal study to termine the efficacy of a drug to relieve pain is a double-blind study with an appropriate placebo. We considered this but came to the conclusion that injection of the disk with a placebo in alternate patients was not feasible in our practice at that time. Such a study is now being done in two centers in the United States, but it will be some time before reports of the results are available. It is true that there is a time lag between the chymopapain injection and achievement of optimal results and that the relief of pain reported by the patient could be due to natural recovery. This is true with any treatment, whether it be laminectomy for a herniated disk or antibiotics for In
de-
pneumonia.
It is also true, as Dr. Russell says, that some studies indicate that if one could assemble two identical groups of patients each with herniated disks and treat one group with laminec¬ tomy and the other conservatively without surgery, in six or seven years each group would be symptomatically about the same. However, in one such study the operated group became
symptom-free sooner. It is simply not practical to tell the patient with se¬
sciatica that if he waits six or years, his condition will be the same whether or not he has surgery. Every patient in our series was treated conservatively for an ade¬ quate period of time, the same period as has been traditionally used in our practice before resorting to laminec¬ vere
seven
tomy.
The
enough
symptoms had
to be
severe
and of
to warrant
nucleolysis
long enough duration laminectomy, or chemo¬
was
not done.
L. L. Wiltse, MD
Long Beach, Calif
Disseminated Intravascular Coagulation in Heat Stroke To the Editor.\p=m-\Aneditorial by Knochel (231:496, 1975) comments on a case report of heat stroke in the same issue (231:480, 1975) that deals with the disseminated intravascular coag-
Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/03/2015
ulation (DIC) that developed as a complication of the heat stroke. There is
no
reference in the editorial to
a
report published earlier in The Journal (216:1195,1971) in which this hemorrhagic diathesis, as well as the other complications of heat stroke, case
were accounted for by an endotoxemia of intestinal origin that is the result of acute hepatic failure. Endotoxemia has since been documented in hepatic damage not only by heat stroke, but also in viral hepatitis, advanced cirrhosis, and drug poisoning. The striking uniformity of the clinical picture in all these disorders (brain damage, congestion and edema of the lungs, and renal failure in addition to DIC), and their resemblance to those produced by endotoxemia in advanced Gram-negative sepsis, points to the need for therapy that comes to grips with the endotoxemia, ie, reduc¬ tion of the absorption of endotoxin from the gut (by inducing bacteriostasis of the colon and lower ileum),
repeated peritoneal washings (to re¬ move endotoxin that enters by transmural transfer into the peritoneal cavity), continuous intra-aortic (ab¬
dominal) infusion of corticosteroids (to block the action of endotoxin on the splanchnic viscera), and anti-aadrenergic measures (to suppress the release of norepinephrine without which the endotoxin cannot inflict in¬
jury). Jacob Fine, MD Stanford, Calif
In Reply.\p=m-\Allof us are indebted to Dr Fine for his dedicated and persistent efforts to elucidate the pathophysiology and treatment of bacteremic and endotoxic shock. Dr Fine suggests that death in acute heat stroke could be mediated by acute disseminated intravascular coagulation (DIC) emanating from hepatic failure and absorption of endotoxin from the bowel. He further postulates that measures to interrupt this process could be life-saving. Laboratory evidence of DIC in patients with heat stroke is extremely common and in most instances resolves spontaneously after cooling and other supportive measures. If
damage occurs by this mechanism, it seems quite likely that it has already occurred by the time the patient is initially seen. It has been suggested, therefore, but not proved that heparin therapy might be useful to prevent further DIC.
Dr Fine
implies
that the
initialing
Parker).
Lastly, I might quote from a letter recently received from one who rep¬ resents a more objective and impar¬ tial view of the subject and certainly is recognized as an authority on the subject of medical care in the United States. Dr John S. Mills stated, "It has always been my opinion that the obstetrician is the ideal example of the "primary physician." I
Jack W. Pearson, MD Indiana University\p=m-\Purdue
University Indianapolis
Chymopapain Chemonucleolysis In Lumbar Disk Disease
To the Editor.\p=m-\Wiltse et al have given us an excellent review of chymopapain chemonucleolysis in lumbar disk disease (231:474, 1975). Although they themselves have performed this procedure in 1,200 cases of lumbar disk disease, it is disappointing that all they can conclude is that "chemonucleolysis appears to be as good as laminectomy in properly selected cases." It is unfortunate to find that despite the many thousands of patients treated with this agent, Wiltse et al cannot quote a single example where the correct study has been performed, ie, comparison of the effect of therapy with the active agent, chymopapain, to that of either no treatment at all or an appropriate placebo. In their study, Wiltse and co-workers note that 48.2% of the patients treated did not achieve their optimal result until at least four months after therapy. This looks remarkably like the natural history of lumbar disk disease. The few studies that have been performed to try and compare a conservative approach to lumbar disk disease with surgical therapy have not shown any clear benefit for the surgical procedures. To suggest, therefore, that chymopapain treat¬ ment may be as effective as laminec¬ tomy may be—until proved other¬ wise—to state that it is no more effective than routine conservative
management.
It can still be argued that the time off work with this procedure is shorter than is usual in a standard conserva-
tive program. Unfortunately, it still requires to be shown that the stan¬ dard conservative programs used are in themselves useful or optimal proce¬ dures. A. S. Russell, FRCP(C) University of Alberta
Edmonton, Canada
Reply.\p=m-\Dr.Russell is absolutely correct in that the ideal study to termine the efficacy of a drug to relieve pain is a double-blind study with an appropriate placebo. We considered this but came to the conclusion that injection of the disk with a placebo in alternate patients was not feasible in our practice at that time. Such a study is now being done in two centers in the United States, but it will be some time before reports of the results are available. It is true that there is a time lag between the chymopapain injection and achievement of optimal results and that the relief of pain reported by the patient could be due to natural recovery. This is true with any treatment, whether it be laminectomy for a herniated disk or antibiotics for In
de-
pneumonia.
It is also true, as Dr. Russell says, that some studies indicate that if one could assemble two identical groups of patients each with herniated disks and treat one group with laminec¬ tomy and the other conservatively without surgery, in six or seven years each group would be symptomatically about the same. However, in one such study the operated group became
symptom-free sooner. It is simply not practical to tell the patient with se¬
sciatica that if he waits six or years, his condition will be the same whether or not he has surgery. Every patient in our series was treated conservatively for an ade¬ quate period of time, the same period as has been traditionally used in our practice before resorting to laminec¬ vere
seven
tomy.
The
enough
symptoms had
to be
severe
and of
to warrant
nucleolysis
long enough duration laminectomy, or chemo¬
was
not done.
L. L. Wiltse, MD
Long Beach, Calif
Disseminated Intravascular Coagulation in Heat Stroke To the Editor.\p=m-\Aneditorial by Knochel (231:496, 1975) comments on a case report of heat stroke in the same issue (231:480, 1975) that deals with the disseminated intravascular coag-
Downloaded From: http://jama.jamanetwork.com/ by a Oakland University User on 06/03/2015
ulation (DIC) that developed as a complication of the heat stroke. There is
no
reference in the editorial to
a
report published earlier in The Journal (216:1195,1971) in which this hemorrhagic diathesis, as well as the other complications of heat stroke, case
were accounted for by an endotoxemia of intestinal origin that is the result of acute hepatic failure. Endotoxemia has since been documented in hepatic damage not only by heat stroke, but also in viral hepatitis, advanced cirrhosis, and drug poisoning. The striking uniformity of the clinical picture in all these disorders (brain damage, congestion and edema of the lungs, and renal failure in addition to DIC), and their resemblance to those produced by endotoxemia in advanced Gram-negative sepsis, points to the need for therapy that comes to grips with the endotoxemia, ie, reduc¬ tion of the absorption of endotoxin from the gut (by inducing bacteriostasis of the colon and lower ileum),
repeated peritoneal washings (to re¬ move endotoxin that enters by transmural transfer into the peritoneal cavity), continuous intra-aortic (ab¬
dominal) infusion of corticosteroids (to block the action of endotoxin on the splanchnic viscera), and anti-aadrenergic measures (to suppress the release of norepinephrine without which the endotoxin cannot inflict in¬
jury). Jacob Fine, MD Stanford, Calif
In Reply.\p=m-\Allof us are indebted to Dr Fine for his dedicated and persistent efforts to elucidate the pathophysiology and treatment of bacteremic and endotoxic shock. Dr Fine suggests that death in acute heat stroke could be mediated by acute disseminated intravascular coagulation (DIC) emanating from hepatic failure and absorption of endotoxin from the bowel. He further postulates that measures to interrupt this process could be life-saving. Laboratory evidence of DIC in patients with heat stroke is extremely common and in most instances resolves spontaneously after cooling and other supportive measures. If
damage occurs by this mechanism, it seems quite likely that it has already occurred by the time the patient is initially seen. It has been suggested, therefore, but not proved that heparin therapy might be useful to prevent further DIC.
Dr Fine
implies
that the
initialing
