"laetrile" and then as "vitamin B17." It is two parts sugar, one part benzaldehyde, one part cyanide, and no parts vitamin.' Laetrile may actually cause cancer, since cyanogenetic glycosides ("laetriles") have been shown to be goitrogens in Africa, mutagenic in rats and pigs, and may give a positive Ames test result; while taking lae¬ trile, a second cancer developed in a patient with cancer.5 Thus, the "nutritional and metabol¬ ic" program of laetrile proponents is perhaps as unhealthy for cancer patients from the nutrition and metabolism standpoint as it is possi¬ ble for the mind of man to conceive. Victor Herbert, MD, JD Veterans Administration

Bronx, NY State



of New York

Downstate Medical Center

Brooklyn Dr Herbert is supported by a Veterans Administra¬ tion Medical Investigatorship and Public Health Service grant AM 20526. 1. Richardson J, Griffin P: Laetrile Case Histories. New

York, American

Media and Bantam


immediate improvement of her condi¬ tion was noted. A similar episode occurred 12 hours later. The presumption that the recurrent hypoglycémie attacks were related to some iatrogenic factor led us to inves¬ tigate the possibility that an absentminded pharmacist erred and instead of acetazolamide (Diamox) tablets,

supplied chlorpropamide (Diabinase) our patient. The similarity of names of both drugs (ie, "dia" prefix) is the reason these tablets lie side by side in the alphabetically arranged to

medicine chest. The enthusiasm pro¬ voked by this suspicion proved justi¬ fied: nine tablets of Diabinese were found in our patient's home. This batch was given to her three days before admission, and her troubles began after she started taking them. Since hypoglycemia due to inadver¬ tence is rare,2 one has to consider a similar circumstance in patients with

unexplained hypoglycemia.

Dan Aderka, MD Jack Pinkhas, MD Beilinson Medical Center Petah Tikva, Israel


2. Goodhart RS, Shils ME (eds): Modern Nutrition in Health and Disease. Philadelphia, Lea & Febiger, 1975. 3. Schmidt ES, Newton GW, Sanders SM, et al: Laetrile toxicity studies in dogs. JAMA 239:943-947,


4. Herbert V: Megavitamin therapy. J Am Pharm Assoc 17:764-766, 1977. 5. Herbert V: Laetrile: The cult of cyanide. Am J Clin

Nutr, to be published.

Inadvertently Induced Hypoglycemia To the Editor.\p=m-\Factitious hypoglycemia, induced by oral antidiabetic agents,1,2 should be suspected in diabetic or psychiatric patients and in subjects who have diabetic relatives or work in medical institutions.3 None of this was true in our patient, a 62-year-old housewife, who was admitted to our department because of unconsciousness. Her blood glucose level was 33 mg/dl. After intravenous (IV) administration of glucose, she promptly regained consciousness, and the blood glucose level rose to 96 mg/dl. The patient's past history was irrelevant, except for glaucoma, presently treated with acetazolamide (Diamox) and pilocarpine. Two days before admission the patient complained of an unusual weakness and vertigo; she became slightly confused and had a voracious appetite. A copious intake of sweet drinks and chocolate abated these symptoms. Six hours after admission, while receiving a 5% glucose infusion, the patient became noticeably confused. Her blood glucose level again dropped to 43 mg/dl. After IV administration of 20 ml of a 50% glucose solution, an

1. Scarlett JA, Mako

ME, Rubenstein AH, et al: Factihypoglycemia. N Engl J Med 297:1029-1032,1977. 2. Miller DR, Orson J, Watson D: Upjohn, down glucose. N Engl J Med 297:339,1977. 3. Jordan RM, Kammer H, Riddle MR: Sulfonylureainduced factitious hypoglycemia: A growing problem. tious

Arch Intern Med 137:390-393, 1977.

While physicians may not always have at their fingertips the exact information as to the cost of each item referred to in the commentary, they are sharply aware that most patients want to have done for them whatever is most likely to be helpful. Patients and their families do not want almost the best, but they want and expect the best and are prepared to go to court if they have reason to believe that they have not received it. They want no stone left unturned, the cost be damned, especially since someone else is paying the charges. Somehow the public manages to feel very cost conscious when insurance premiums are being discussed, but not when the discussion shifts to benefits. Third-party payers are not the innocent bystanders they would have us believe. They have a long tradition of opposing cost-saving ideas, eg,


testing, outpatient in-hospital diagnostic evaluation, outpatient surgery, and office care in general. That behavior is perhaps not too surprising, since carrier company profits are usually rather than

considered as a percentage of total business volume. In that circum¬ stance, why should the carriers seek to reduce cost and hence their own

profit? M. J.

Fiduciary Responsibility


The University


To the Editor.\p=m-\"WePhysicians Are



Hospital and Clinics

Fiduciary Failures" (239:1629, 1978) points up a most valuable concern,

but fails to take into account many other equally important aspects of the problem. Indeed, if we are to

Diagnosis of Carbon Monoxide

to the

(239:1515, 1978) Kelley and Sophocleus point out the difficulty in making the clinical diagnosis of carbon monoxide poisoning. They emphasize that ophthalmoscopy should always be performed in patients with nausea, headache, and dizziness, and

discharge our fiduciary relationship patient honorably, we should consider only that individual's physical, mental, and financial well-being

rather than that of some third party. Obviously the latter is inappropriate, but if we are going to play a perfectly open game with the patient in terms of cost, should we not also explain to the patient the cost-effectiveness ratio of each given test or procedure, the role of the sequence in which these are done, including delays that may be introduced as a result of sequence (eg, a small-bowel contrast study can be done almost immediately after intravenous pyelography but not vice versa)? Furthermore, the patients would have to assume some liability for consequences of their decisions, since it would seem unreasonable to hold the physician alone responsible for the consequences of decisions other than those that he recommended.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015


To the Editor.\p=m-\Ina recent article

that retinal hemorrhages should suggest the possibility of CO poisoning. Following their recommendations will certainly add to the clinical examination of such patients, but I believe several statements in their article are confusing regarding the laboratory diagnosis of CO poison-


In several places the authors refer serum CO measurements. Clearly, anticoagulated whole blood, rather than a clotted serum tube, is the proper specimen to submit to the laboratory, since virtually all the CO in the blood is tightly bound to the to



Furthermore, the authors report that "blood gas analysis showed a carbon monoxide saturation value of 27%." The implication of this statement, though perhaps not intentional,

is that routine blood gas analysis is useful in diagnosing CO poisoning. This is not the case. Routine blood gas determination involves only measure¬ ment of pH, Po2, and Pco2. Neverthe¬ less, many laboratories report an oxygen saturation with their routine blood gas results. It is important to realize that this 02 saturation is merely a calculated value based on the Po2 and pH assuming a normal oxyhemoglobin dissociation curve. In CO poisoning, the Po2 shows no corre¬ lation to the true percent of 02 satu¬ ration. In general, the blood gas values are relatively normal in a CO poisoning patient until tissue hypoxia becomes severe enough to produce a lactic acidosis. Even in this extreme case, the Po2 and thus the calculated 02 saturation may be near normal. To measure CO or 02 saturation, one must examine the hemoglobin visible absorption spectrums. Instru¬ ments are available that use interfer¬ ence filters to measure absorbance at several different wavelengths and then display the 02 and CO saturation calculated from these determinations. If only CO saturation is of interest, one does not need such specialized instrumentation, and any laboratory with a visible spectrophotometer hav¬

ing a relatively narrow bandpass can

determine CO saturation.1 Using a spectrophotometer method, I have found the Instrumentation Laborato¬ ries CO-Oximeter Control material particularly useful. This material is a solution of CO-saturated bovine he¬ moglobin and has spectral properties

essentially identical

to human CO-

hemoglobin. It is supplied in sealed ampuls and eliminates the inconve¬ nience and potential hazard of using CO gas cylinders for setting up and controlling the quality of the spectrophotometric method.

"to find out the cause of his proximal amyotrophy and weight loss." Very

complete laboratory investigations were carried out (including the fatal intravenous pyelogram), but the single, most important investigation

necessary in any neuromuscular inwas not done. I refer to


electrodiagnostic evaluation. If the patient indeed had diabetic amyotrophy, the electrodiagnositc findings might have been of diagnostic importance.1 Certainly, there is no apparent justification to have labeled the disorder a "profound myopathy" when the involvement more probably was neuropathic in nature. Joseph B. Rogoff, MD New York Medical College New York

1. Thomas

PK, Eliasson SG: Diabetic neuropathy, in Peripheral Neuropathy. Philadelphia, WB Saunders Co, vol 1975, 2, pp 963-964.


Reply.\p=m-\Professor Rogoff correctly out the value of electrodiagnostic testing in the diagnosis of strictly neuropathic vs myopathic disease states. While electrodiagnostic tests may differentiate pathogenesis points


patients with muscle weaktests may not clearly sepathese ness, rate those patients with diabetic amyotrophy from those with the multiplicity of neurologic, muscular, and end-plate abnormalities seen in patients with neoplasms. Therefore, use of the provisional term myopathy was justified by the clinical picture of profound proximal muscle weakness in an elderly man with a pancreatic mass. Subsequent events of the hospital course, as described, did not allow for performance of elective muscle biopsy or electromyography. Nevertheless, concern over the presence of an underlying malignant neoplasm would have made tumor search the primary goal, regardless of interpretation of electromyographic pattern. some

Larry A. Weinrauch, MD W. Scott Robertson, MD John A. D'Elia, MD

Joslin Clinic Boston


of Clinical Chemistry. Philadelphia, WB Saunders Co, 1976, pp 1105-1109.

Diagnosis of Neuropathic Myopathic Disease


To the Editor.\p=m-\A CLINICAL


(239:2018,1978) concerning renal failure following intravenous pyelography describes a patient with apparent diabetic amyotrophy. The workup is described as having been undertaken


reflex gag


be sufficient to

provoke complete airway obstruction1,2 (229:671, 1974). Although many patients may be successfully examined by careful tongue depression and direct visualization of the epiglottis, and some may tolerate laryngoscopy (230:821, 1974), it is rarely possible to predict the lability of the airway, and therefore the safety of examination, in the individual patient. Although it

is natural to wish to use a tongue blade to examine a patient who may be complaining of a severe sore throat, the use of this simple tool, let alone a laryngoscope, may be lethal when done without adequate prepara¬ tion. Instrumentation of the pharynx should not be performed unless the physician is prepared for resuscita¬ tion and immediate intubation or tracheostomy, preferably in the oper¬ ating room" (229:671, 1974). In this institution, as in others,34 residents are taught to take a child with suspected epiglottitis directly to the intensive care unit, accompanied by a nurse and emergency equipment. In the intensive care unit lateral-neck roentgenograms (as recommended by Dr Rivers) are taken immediately for primary confirmation of the diagno¬ sis, and, if the films are abnormal, the child is taken next door to the oper¬ ating room for direct examination and intubation, under controlled con¬ ditions. I strongly discourage exami¬ nation with a tongue blade or other instruments in the absence of such precautions. The physician who sus¬ pects epiglottitis should accompany the patient to the intensive care unit, whether from the office or from the emergency room,


the airway's patency at notice.

John H. Eckfeldt, MD, PhD University of Minnesota Hospitals

1. Tietz NW: Fundamentals

In the sixth paragraph, Dr Rivers is quoted as recommending laryngoscopy (direct or indirect) to confirm the diagnosis of epiglottitis. To the inexperienced, this advice, if not further qualified, could lead to a disaster. The airway is unstable in epiglottitis; a minor stimulus such as

Examination for Epiglottitis To the Editor.\p=m-\Afeature story in the MEDICAL NEWS section (239:94, 1978), "Misdiagnosis of Acute Epiglottitis Can Be Fatal," deserves further comment. Although I agree with the general thrust of the story and am pleased to see this potentially lethal problem brought to the attention of the general medical audience, one portion of the text is misleading and

potentially dangerous.

Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/03/2015





Gerald A. Ahronheim, MD Montreal Children's Hospital Montreal

1. Baxter J: Acute


in children.


77:1358-1368,1967. 2. McCracken GH Jr, Eichenwald HF: Acute infections of the larynx and the trachea, in Vaughan VC, McKay RJ (eds): Nelson Textbook of Pediatrics, ed 10. Philadelphia, WB Saunders Co, 1975, pp 961-962. 3. Johnson GK, Sullivan JL, Bishop LA: Acute epiglottitis: Review of 55 cases and suggested protocol. Arch Otolaryngol 100:333-337, 1974. 4. Weber ML, Desjardins R, Perreault G, et al: Acute epiglottitis in children: Treatment with nasotracheal scope



57:152-155, 1976.

of 14 consecutive



Diagnosis of carbon monoxide poisoning.

"laetrile" and then as "vitamin B17." It is two parts sugar, one part benzaldehyde, one part cyanide, and no parts vitamin.' Laetrile may actually cau...
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