point of grammar. Dr Gitlitz, who admits "lack of reverence for [his] elders" and accuses me of "leading innocents astray," generates so much heat (and so little light) in his letter that I'm half afraid to try to set him straight. Take these two sentences: (1) Dr Gitlitz is not the only one who makes that mistake. (2) Dr Gitlitz is one of many who make that mistake. In each sentence, there is a main (independent or principal) clause and a subordinate (dependent, modifying, or qualifying) clause. In both sentences, the subject of the main clause is Dr Gitlitz and the subject of the subordinate clause is who. In sentence 1, the antecedent of who is one, a predicate noun. (No, the antecedent is not "the subject of the sentence.") The subject of the sentence does indeed "determine the form of the verb," or more precisely its number, but only for the main clause, in which it appears, and not for any subordinate clause. In sentence 2, the "who" clause modifies "many." True, "many" is merely the lowly object of a preposition and, in the Gitlitz sim¬ plification of grammar, something to be ignored along with the rest of the prepositional phrase; but that is easy for him, since he is prepared to go even further and, calling it a "pronoun phrase," eliminate the entire predicate of the main clause, leav¬ ing behind only its subject, which he is free to match up with whatever remains—in these examples, a stray, motherless sub¬ ordinate clause that (Gitlitz evidently believes) should be a good little dogie and suck any nearby teat. a
David Goldblatt, MD University of Rochester (NY) School of Medicine and Dentistry
Post-Pepper Pain, Perforation, and Peritonitis To the Editor.\p=m-\Spices have long been associated with gastric mucosal injury. We report a case of ruptured duodenal ulcer associated with eating chili peppers. A 23-year-old man was admitted to the casualty ward with excruciating abdominal pain and vomiting. Four hours before admission he had competed with his brother in eating 25 chili peppers within 12 minutes. The pain began 2 hours later. There was no history of dyspepsia or any other symptoms related to ulcer diathesis or recent stressful events. On physical examination, the patient was in pain and had overt peritoneal irritation. Routine tests including complete blood cell count and serum urea nitrogen, electrolyte, and amylase levels were within normal limits.
Plain abdominal roentgenogram demonstrated free air undiaphragm. On exploratory laparotomy, the duodenum was neither deformed nor scarred, but a free, round, 5-mm-diameter perforation of the anterior wall was found, together with mild peritonitis. Finney pyloroplasty was performed. Postoperative course and 2-year follow-up were uneventful. Capsaicin is the active ingredient of red peppers and pa¬ prika. Gastroscopy following ingestion of hot peppers has demonstrated gastric erythema and edema.1·2 A significant increase in parietal cell activity following ingestion of red and black pepper has been reported as well. Nevertheless, no significant difference has been demonstrated in the healing rate of duodenal ulcer in patients treated with cimetidine, whether they had eaten hot pepper or not.3 In our case report, a previously healthy, symptom-free young man suffered acute perforation of the duodenum fol¬ lowing ingestion of a large amount of chili peppers. The pos¬ sible pathophysiology of the perforation includes spontane¬ ous onset, mechanical injury of the duodenal wall, acute hy¬ peracidity, and direct irritation by capsaicin. Spontaneous perforation is the first clinical manifestation in 2% to 5% of patients with duodenal ulcer. Mechanical perfora¬ tion by ingested food has been reported, but in our case the per-
der the
foration was sharp and round and excluded the possibility of mechanical tear. Acute hyperacidity or direct effect of capsaicin on the duodenal wall are both possibilities here, and the prox¬ imity of events (pepper ingestion followed by perforation) places the peppers first as the suspected cause. Ofer Landau, MD Haim Gutman, MD Amit Ganor Israel Nudelman, MD
Eyal Rivlin, MD Rafael Reiss, MD
Tel Aviv (Israel)
University
1. Sanchez PE.
Concept of mucous barrier and its significance, changes in the gastric mucosa produced by local action of spices and other irritative agents. Gastroen-
terology. 1951;18:269-286. 2. Schneider MA, DeLuca Y, Gray SJ. The effect of spice ingestion upon the stomach. Am J Gastroenterol. 1956;26:722-732. 3. VandenBroucke J, Verheesen JHH, Bruin ADE, et al. Do chilis influence healing of duodenal ulcer? BMJ. 1984;288:1803-1804.
Nicotine Patches: Up in Smoke? To the Editor.\p=m-\Cigarette smoking is a well-identified risk factor for heart disease and lung cancer, and cessation of smoking results in a decline of risk.1 Smoking has also been identified by the Surgeon General as the No. 1 public health problem. Despite their importance, smoking cessation programs have generally not been popular with physicians because of the time involved, low success rate, and nonreimbursement. The recent introduction of nicotine patches is a watershed event in treating nicotine addiction. The patches are so popular with the public that the drug manufacturers cannot keep up with the demand.2 The 1-year success rates of 29% to 35%3 compare favorably with success rates for treatment of certain cancers and other chronic diseases. Few insurance companies will reimburse for the nicotine patches, and some of those are discontinuing their coverage.2 Instead, the insurance carriers continue to prefer to pay the extremely costly end-stage medical costs associated with cigarette smoking, and pass these costs onto the two thirds of adults who are nonsmokers in the form of higher premiums. Ironically, while the Surgeon General identifies smoking as the No. 1 public health problem in the United States, Medi¬ care will not reimburse for nicotine patches. Thus, the tax¬ payers will continue to subsidize the massive medical costs of the minority of cigarette smokers. Once again, a seed of prevention is choked by weeds. Mark Jameson, MD
Harmon, RD Washington County Health Department Hagerstown, Md Katherine
1. Rosenberg L, Palmer JR, Shapiro S. Decline in the risk of myocardial infarction among women who stop smoking. N Engl J Med. 1990;322:213-217. 2. Hwang SL, Valeriano LL. Marketers and consumers get the jitters over severe shortage of nicotine patches. Wall Street Journal. Eastern edition. May
(col 3).
3. Nicotine
22,1992:B1
patches. Med Lett Drugs Ther. 1992;34:37-38.
Incorrect Number. \p=m-\Inthe At Large With Dennis L. Breo article entitled "JFK's Death\p=m-\ThePlain Truth From the MDs Who Did the Autopsy," published in the May 27, 1992 (1992;267:2794-2803), issue of The JOURNAL, on page 2794 in the second column, the first complete sentence of the top paragraph indicates that James J. Humes, MD, was breaking a "29-year silence" in speaking on the events surrounding the autopsy of the assassinated President John F. Kennedy. Subsequent to publication, we learned that Dr Humes made a brief on-camera appearance with CBS News in June 1967 to discuss the autopsy. Thus, Humes was breaking only a 25-year silence in speaking with JAMA.
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015
David Goldblatt, MD University of Rochester (NY) School of Medicine and Dentistry
Post-Pepper Pain, Perforation, and Peritonitis To the Editor.\p=m-\Spices have long been associated with gastric mucosal injury. We report a case of ruptured duodenal ulcer associated with eating chili peppers. A 23-year-old man was admitted to the casualty ward with excruciating abdominal pain and vomiting. Four hours before admission he had competed with his brother in eating 25 chili peppers within 12 minutes. The pain began 2 hours later. There was no history of dyspepsia or any other symptoms related to ulcer diathesis or recent stressful events. On physical examination, the patient was in pain and had overt peritoneal irritation. Routine tests including complete blood cell count and serum urea nitrogen, electrolyte, and amylase levels were within normal limits.
Plain abdominal roentgenogram demonstrated free air undiaphragm. On exploratory laparotomy, the duodenum was neither deformed nor scarred, but a free, round, 5-mm-diameter perforation of the anterior wall was found, together with mild peritonitis. Finney pyloroplasty was performed. Postoperative course and 2-year follow-up were uneventful. Capsaicin is the active ingredient of red peppers and pa¬ prika. Gastroscopy following ingestion of hot peppers has demonstrated gastric erythema and edema.1·2 A significant increase in parietal cell activity following ingestion of red and black pepper has been reported as well. Nevertheless, no significant difference has been demonstrated in the healing rate of duodenal ulcer in patients treated with cimetidine, whether they had eaten hot pepper or not.3 In our case report, a previously healthy, symptom-free young man suffered acute perforation of the duodenum fol¬ lowing ingestion of a large amount of chili peppers. The pos¬ sible pathophysiology of the perforation includes spontane¬ ous onset, mechanical injury of the duodenal wall, acute hy¬ peracidity, and direct irritation by capsaicin. Spontaneous perforation is the first clinical manifestation in 2% to 5% of patients with duodenal ulcer. Mechanical perfora¬ tion by ingested food has been reported, but in our case the per-
der the
foration was sharp and round and excluded the possibility of mechanical tear. Acute hyperacidity or direct effect of capsaicin on the duodenal wall are both possibilities here, and the prox¬ imity of events (pepper ingestion followed by perforation) places the peppers first as the suspected cause. Ofer Landau, MD Haim Gutman, MD Amit Ganor Israel Nudelman, MD
Eyal Rivlin, MD Rafael Reiss, MD
Tel Aviv (Israel)
University
1. Sanchez PE.
Concept of mucous barrier and its significance, changes in the gastric mucosa produced by local action of spices and other irritative agents. Gastroen-
terology. 1951;18:269-286. 2. Schneider MA, DeLuca Y, Gray SJ. The effect of spice ingestion upon the stomach. Am J Gastroenterol. 1956;26:722-732. 3. VandenBroucke J, Verheesen JHH, Bruin ADE, et al. Do chilis influence healing of duodenal ulcer? BMJ. 1984;288:1803-1804.
Nicotine Patches: Up in Smoke? To the Editor.\p=m-\Cigarette smoking is a well-identified risk factor for heart disease and lung cancer, and cessation of smoking results in a decline of risk.1 Smoking has also been identified by the Surgeon General as the No. 1 public health problem. Despite their importance, smoking cessation programs have generally not been popular with physicians because of the time involved, low success rate, and nonreimbursement. The recent introduction of nicotine patches is a watershed event in treating nicotine addiction. The patches are so popular with the public that the drug manufacturers cannot keep up with the demand.2 The 1-year success rates of 29% to 35%3 compare favorably with success rates for treatment of certain cancers and other chronic diseases. Few insurance companies will reimburse for the nicotine patches, and some of those are discontinuing their coverage.2 Instead, the insurance carriers continue to prefer to pay the extremely costly end-stage medical costs associated with cigarette smoking, and pass these costs onto the two thirds of adults who are nonsmokers in the form of higher premiums. Ironically, while the Surgeon General identifies smoking as the No. 1 public health problem in the United States, Medi¬ care will not reimburse for nicotine patches. Thus, the tax¬ payers will continue to subsidize the massive medical costs of the minority of cigarette smokers. Once again, a seed of prevention is choked by weeds. Mark Jameson, MD
Harmon, RD Washington County Health Department Hagerstown, Md Katherine
1. Rosenberg L, Palmer JR, Shapiro S. Decline in the risk of myocardial infarction among women who stop smoking. N Engl J Med. 1990;322:213-217. 2. Hwang SL, Valeriano LL. Marketers and consumers get the jitters over severe shortage of nicotine patches. Wall Street Journal. Eastern edition. May
(col 3).
3. Nicotine
22,1992:B1
patches. Med Lett Drugs Ther. 1992;34:37-38.
Incorrect Number. \p=m-\Inthe At Large With Dennis L. Breo article entitled "JFK's Death\p=m-\ThePlain Truth From the MDs Who Did the Autopsy," published in the May 27, 1992 (1992;267:2794-2803), issue of The JOURNAL, on page 2794 in the second column, the first complete sentence of the top paragraph indicates that James J. Humes, MD, was breaking a "29-year silence" in speaking on the events surrounding the autopsy of the assassinated President John F. Kennedy. Subsequent to publication, we learned that Dr Humes made a brief on-camera appearance with CBS News in June 1967 to discuss the autopsy. Thus, Humes was breaking only a 25-year silence in speaking with JAMA.
Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/08/2015
