actually an increase in complexity, as evidenced by a reduction in predictability. Although this contradicts the idea that disease is brought on by a reduction in complexity, it does not necessarily negate the hypothesis that physiological complexity is lost in a disease state. Maybe normal interactions are halted but overall complexity is increased—either by the emergence of new links between systems or by augmented communication along preestablished paths. The activity of the immune system triggered by acute pancreatitis seems to illustrate this point. But one way or the other, chaos remains.

Thank you for publishing this provocative piece.

Edgar Guzman Arrieta, M.D.
Chicago, Ill.

Admirable account

I immediately purchased a copy of Constance Putnam's history of DMS as soon as it was available. [A feature in our Summer 2004 issue—"A Question of Balance," about a contentious period in DMS's history in the 1960s—was adapted from this book.] How well does her account of the sorry mess rate? Excellent. It gave me a better view of both sides' stands, as well as admiration for the grace of her writing.

Kenneth W. Cooper, Ph.D.
Riverside, Calif.

Cooper was a professor of cytology and genetics at DMS in the 1960s and is now retired from the University of California at Riverside.

Powerful lesson

I thought the article by Deborah Schiff in your Summer 2004 issue—" Telling Johnny's Story"—was fabulous! I am a nursing student at Rivier College in Nashua, N.H., and my classmates and I rarely get to see pediatric oncology patients.

This story was powerful and moving. I am going to share it with my fellow nursing students. Some of us are very interested in working at Dartmouth-Hitchcock—especially in pediatrics.

Two features from our Summer 2004 issue—including the cover article, based on a newly published history of DMS—are still inspiring readers.

Thanks for this wonderful glimpse into the emotional relationship between the patient and care-providers. It is truly special when you are able to both care for patients in this way and meet their medical needs.

Kellie DeCalogero
Pelham, N.H.

Rural rotations

I enjoyed the article on the "Medical Student for a Day" program in your Fall 2004 issue and wanted to pass on some information about a rural health opportunity within three hours' drive of DHMC. The Dartmouth- Hitchcock Clinic-Indian Stream in Colebrook, N.H., is a federally designated Rural Health Clinic. All physicians in our clinic are on staff at the local 16-bed hospital, which is designated a Critical Access Hospital.

We have, in the past, had the pleasure of having Dartmouth residents in general internal medicine rotating through our clinic and working with our grateful and needy population. We are preparing to leave the DHMC system, but we intend to strengthen our ties to DMS and to the DHMC family practice and internal medicine residency programs. I encourage Rural Scholars at DMS to

contact our clinic if they're interested in working in a rural setting.

Thank you for a great article about the importance of preparing doctors for rural practice!

Christine E. Charman
Colebrook, N.H.

Second look at smears

Your article about Dr. Brenda Sirovich's study of useless Pap smears in patients with a prior hysterectomy [Fall 2004] was very timely. Unfortunately and interestingly, many women don't remember they've had a hysterectomy—or if they do they can't remember if it was for cancer or not. In fact, many women don't remember if they've ever had an abnormal Pap smear, and many clinicians don't remember or communicate to the laboratory that a patient had a prior abnormal Pap result.

Today, routine Pap smears on the same patient may be sent to different laboratories—depending on the physician or insurance contract—and none of these laboratories may have or receive any information on the patient's gynecological history, previous abnormal smears, or even a history of cervical cancer.

So it's almost meaningless that most if not all laboratories that process Pap smears have built into their quality-control systems patient-history identifiers which target samples from high-risk women to receive automatic double screening or review by a pathologist or both.

Given that one of the top plaintiff lawyers in the country ran for vice president in 2004, I don't think doctors are going to give up doing routine yearly Pap smears on women who have had a hysterectomy—even if we get Hillary-care.

William J. Frable, M.D.
Dartmouth College '56
Richmond, Va.

Frable is a professor of pathology at Virginia Commonwealth University.