UNDER THE GRASS ROOTS

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physiological dead space, a decline in meta-bolic rate with hypoxia, or failure to reach a

new steady state. Having personally experi-enced the periodic breathing of high

alti-tude, a benign phenomenon that vanishes

upon oxygen inhalation, I wonder whether

the periodicity of the premature infant has

a similar origin. The lowlander, acclimatiz-ing to altitude hyperventilates and has an

increased ventilatory response to carbon

dioxide, though the role of these changes in

causing Cheyne-Stokes breathing is not

known.

Testing of the hypothesis that hypoxia un-derlies periodicity would require correlation of periodicity with arterial Po, in a sufficient

population of prematures. Perhaps such a

study will determine whether severe apneic

spells are merely an extension along the

same spectrum or have some other etiology. Also the effect of oxygen in altering breath-ing pattern can be evaluated. The authors’

suggestions that judicious oxygen therapy

may be beneficial hinges on clearer

docu-mentation of the relationship of periodicity

to Pao, and on the demonstration that

pen-odicity itself is not a benign concomitant of

prematurity. Certainly the hazards of

oxy-gen overdosage dictate its use only where

benefit may be derived. The technical task

of gleaning such information from a

van-able population of tiny people vil1 be

diffi-cult, but seems to be only seasoning to the

challenge for those bent upon unraveling

the problems of ventilation of the newborn. The present papers by Drs. Rigatto and Brady represent a significant and provoca-tive step in that direction, and one can only wait expectantly to see where their next step

takes us.

THOMAS F. HORNBEIN, M.D.

Departments of Anesthesiology Physiology, and Biophysics University of Washington Seattle, Washington 98105

REFERENCES

1. Rigatto, H., and Brady, J. P.: Periodic breathing and apnea in preterm infants: Evidence for

hypoventilation possibly due to central

respi-ratory depression. PEDIATRICS, 50:202, 1972.

2. Rigatto, H., and Brady, J. P.: Periodic breathing

and apnea in preterm infants: Hypoxia as a

primary event. PEDIATRICS, 50:219, 1972.

3. Chernick, V., Heidrich, F., and Avery, M. E.:

Periodic breathing of premature infants. J. Pediat., 64:330, 1964.

4. Chernick, V., and Avery, M. E.: Response of

premature infants with periodic breathing to

ventilatory stimuli. J. Appl. Physiol., 21:434,

1966.

5. Kildeberg, P.: Clinical acid-base physiology:

studies in neonates, infants, and young

chil-dren. Baltimore: Williams & Wilkins Co., p. 132, 1968.

UNDER

THE

GRASS

ROOTS

I

N an extraordinarily prolonged

contro-versy1-9 over the use of corticosteroids in obstructive respiratory disorders (e.g.,

croup, bronchiolitis) pediatricians have

heard from “ivory tower,” from “ground

level,” and from “grass roots.” Perhaps it is

time to hear a brief word from under the

grass roots-from the grave. Although our

forebearers did not have corticosteroids

they faced self-same issues concerning

effectiveness of cupping, bleeding, and

purging.

Galen dominated medical thought for

more than 16 centuries and recent

corn-ments (“. . . the use of steroids should be

studied in the more severe cases . . .“) re-mind us that his spirit is not yet stilled:

All who drink of this remedy are cured, except those whom it does not help who all die. Therefore

it is clear that it works in all but incurable cases. -Calen

As we leave the age of empiricism in

medicine, it is fascinating to reflect on the

strong appeal of the phrase “my

experience.” There is a deep-seated

suspi-cion of planned investigation (“Most

con-trolled studies are misleading . . .“) and a

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concern-186 UNDER THE GRASS ROOTS

ing the

inherent superiority of unstructured

observation carried out by physicians

dur-ing the course of everyday practice. No one

has

examined this issue more incisively than

Claude Bernard, over 100 years ago, in his

celebrated classic “An Introduction to the

Study of Experimental Medicine.” In a

sec-tion of this treatise entitled “Gaining

Ex-penience and Relying on Observation is

Different from Making Experiments and

Making Observations” he noted,

. . . when we apply to a physician the word

experi-ence . . . it means the information which he has

gained in the practice of medicine. It is the same

with the other professions; and it is in this sense that we say that a man has gained experience, or that he has experience. . . . Experience may be

gained by empirical and unconscious reasoning: but the obscure and spontaneous movement of the

mind has been raised . . . (in) . . . science into a

clear and reasoned method. . . which. . . proceeds

consciously and more swiftly toward a definite goal. Such is the experimental method . . . by

which experience is always gained by virtue of

precise reasoning based on an idea born of obser-vation and indeed, there are three phases: an ob-servation made, a comparison established, and a

judgment rendered.

Reliance on unplanned experience

per-petuates a curious myth that empiric

“truth” is somehow absolute whereas

exper-imental “truth” is merely statistical (“.

[controlled studies] . . . require numbers

.“). Somehow the accumulation of

“num-bers” during the course of a lifetime of

practice is felt to be superior to the use of

“numbers” in a planned trial. Claude

Ber-nard commented:

There are only partial and provisional truths which are necessary to us as steps on which to rest so as to go on with investigation. Many physicians attack experimentation on human beings, believing that medicine should be a science of observation, but physicians make therapeutic experiments daily on their patients so this inconsistency cannot stand

The pediatrician faced with the problem of a croupy child in the middle of the night hears clangorous voices. The voice of expe-nience applauds the “. . . use of steroids to

avoid tracheostomy . . .,“ the voice from the

ivory tower cautions “. . . the practicing

physician

that

there is no scientific basis for

the routine administration of corticoste-roids. . . .“ The situation is reminiscent of

the one facing the South Sea Islander who,

for centuries, has been treating eclipse of

the

sun completely successfully with drums

and whistles to frighten the moon into

dis-gorging the sun which it has swallowed.

The suggestion for a controlled trial is not

very appealing since the consequences of

failure of an alternative approach are too

horrible to contemplate.

Perhaps the most important issue is the

one concerning the identity of persons

(vaguely identified as an unspoken “they”)

who must bear the burden of obtaining

fur-ther proof (“. . . the use of steroids should

be studied... [in patients] in whom it is

hoped

to

provide an alternative to

tracheos-tomy”). Advice, while waiting for this fur-ther proof is rarely withheld bashfully.

And there is always the old question of

deception, as Kroeber has pointed out:

Probably most shamans or medicine men, the world over, help along with sleight-of-hand that is sometimes deliberate; in many cases awareness is perhaps not deeper than the foreconscious. The at-titude, whether there has been repression or not,

seems to be as toward a pious fraud. Field ethnog-raphers seem quite generally convinced that even shamans who know that they add fraud neverthe-less also believe in their powers, and especially in

those other shamans: they consult them when they

themselves or their children are ill.

Would you

withhold

corticosteroids if

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COMMENTARIES

187

respiratory tract infections in children: A controlled study. Pimwrmcs, 34:851, 1961.

4. Dabbous, I. S., Tkachyk,

J.

S., and Stamm, S. M.: A double-blind study on the effects of

corticosteroids in the treatment of

bronchio-litis. Pimwrmcs, 37:477, 1966.

5. Leer, J. A., Green, J. L., Heimlich, E. M.,

Hyde,

J.

S., Moffett, H. L., Young, C. A., and Barron, B. A.: Corticosteroid treatment in bronchiolitis. Amer. J. Dis. Child., 117: 495, 1969.

6. Committee on Drugs: Should steroids be used in treating bronchiolitis? PEDIATRICS, 46:640,

1970.

7. Coffin, L. A., III: Corticosteroids in croup: Is

there a reply from the ivory tower?

PEDIAT-RICS, 48:493, 1971.

8. Menachof, L.: Corticosteroids in croup: Reply from ground level, PEDIATRICS, 49:154,

1972.

9. Shaw, E. B.: Corticosteroids and croup: Com-ments from a grass rooted ivory tower. PEDI-ATRICS, 49:312, 1972.

10. Bernard, C.: An Introduction to the Study of

Experimental Medicine (1865) Translated by Henry Copley Greene. New York: Henry

Schuman, Inc. 1949.

11. Kroeber, A. L.: The nature of culture.

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1972;50;185

Pediatrics