BRITISH MEDICAL JOURNAL
5 MARCH 1977
643
infants in the home. With respect, we suggest molarity than 015 M (015 mmol HCl/l) for Thus the students learnt that the diagnosis of leprosy is easy and deformity can be that you read our paper again and then ask this intravenous use. S E WILLIAMS prevented. question: Would I be prepared to expose an The capital and running costs of leprosaria infant or a pregnant woman in my care to a University of Manchester Department of Medicine, like Garkida are enormous and this approach to drinking water lead level of 800 ftg/l ? Hope Hospital, leprosy is now completely outmoded. What is Salford, Lancs required is low-cost, effective, and practical A GOLDBERG management of the disease, and Ross was M R MOORE one of the few leprologists in the world to Department of Materia Medica, Patients' awareness of melaena Stobhill General Hospital, provide such measures. The decline in Glasgow leprosy after 10-15 years of dapsone adminisSIR,-During the past two months I have tration as shown by the figures from northern Beattie, A D, et al, Lancet, 1975, 1, 589. have who had three patients elderly seen 2 Bacon, A P C, et al, Lancet, 1967, 1, 264. Zaria is a good example of successful pre3Beattie, A D, et al, British Medical J7ournal, 1972, 1, melaena while taking fenoprofen. One pre- ventive medicine. It is therefore a strange 488. Campbell, B C, et al, British Medical Jrournal, 1977, sented with abdominal pain, the second with decision by the Faculty of Medicine of shortness of breath, and the third with short- Ahmadu Bello University, Zaria, not to 1, 482. Parry, W H, Lancet, 1967, 2, 1207. ness of breath and palpitations; their haemo- demonstrate these findings to the students, globin concentrations were 13-1, 7, and 9 g/dl especially as the clinics are in the immediate respectively. They had had black stools for vicinity of the medical school. between two and four days but none of them and molar Molar solutions complained of this and had continued to take C L CRAWFORD doncentrations the drug. The bleeding was discovered only Department of Anatomy and when the patients were specifically asked Embryology, SIR,-An article by Dr S E Williams (15 May about their stools. University College, London WC1 1976, p 1189) concerning the use of hydroPatients often complain of two or three chloric acid for the correction of severe loose stools but it appears that few realise the metabolic alkalosis perpetuates a small but significance of change in colour. I would significant error originally contained within suggest that all patients being given drugs CMV retinitis one of the references.' The author states that which might cause gastrointestinal bleeding 150 ml of 1-M HCI in one litre of sterile water should be made aware of the significance of SIR,-We are very grateful to Dr H W Murray yields 300 mmol of H+ and Cl per litre. By black stools and given advice regarding the for his letter (30 October, 1976, p 1071) drawing attention to the various reported definition a 1-M solution of any preparation action to take. episodes of the ocular manifestations of contains 1000 mmol of solute. Therefore MELVIN Ross cytomegalo inclusion disease and we look 150 ml of the 1-M HCl solution will contain forward to reading his article when it is 150 mmol of H+ and Cl-. When the 150-ml London N19 published. We apologise if we failed to make aliquot is added to the sterile water the sufficiently clear that the patient we reported molarity of the final solution is 015 M, not (31 July 1976, p 281) had a retinitis without 0 3 M as would be calculated using the Teaching leprosy to medical students visible choroidal involvement. Pure cyto300 mmol figure. Such miscalculations may be critical when SIR,-Professor H Scarborough (5 February, megalovirus (CMV) retinitis was not the one is attempting rapidly to correct severe p 379), in defending the teaching of leprosy in lesion in five of the 19 patients that Dr Murray metabolic alkalosis. Furthermore, while the leprosaria such as Garkida, Nigeria, states that cites'-5 and the diagnosis of cytomegalo author, as well as others,' 2confirms the safety physiotherapy, occupational therapy, and inclusion disease was no more than presumpof dilute solutions of HCl (0 1-0 2 M), several surgery are therapeutic measures. Instead, tive in three patients.t 3 5 In particular we reports2 '1 indicate that HCl in 0 3 M concen- patients receiving such measures should be agree with Dr M E Smith6 that the diagnosis trations or greater may precipitate acute seen as examples of a tragic failure to prevent in the otherwise asymptomatic patient with a haemolysis of red blood cells. Thus great care irreversible nerve damage, usually as a result unilateral uveitis briefly described by Dr should be directed toward ordering and pre- of late diagnosis. Thus students taught in Helen Foersterl must remain unproved and paring intravenous hydrochloric acid solutions leprosaria may well conclude that deformity speculative. Indeed, Dr Foerster herself in leprosy is inevitable and that its management presented her patient as a diagnostic problem. for reasons both of efficacy and of safety. is time-consuming, needs expensive equipIt may well be that our patient is not the JAMES CLOYD ment, and is not very rewarding. If students first reported case of CMV retinitis in an are taught that the diagnosis of leprosy is otherwise healthy adult but we remain unable College of Pharmacy, difficult or that it is desirable to do skin smears to find a similar patient in the English University of Minnesota, Minneapolis, Minnesota to establish a definitive diagnosis they may literature. H B CHAWLA lAbouna, G M, Adrete, J A, and Stangl, T E, Surgery, lose interest in the subject, and it is not surprising that leprosy continues to be neglected 1974, 75, 139. M J FORD 2 Shavelle, H G, and Parke, R, Surgery, 1975, 78, 439. by the medical profession. J F MUNRO 3 Whelton, 0, Lancet, 1974, 1, 1055. In 1970 the Faculty of Medicine at the R E SCORGIE Unit, ***We sent a copy of this letter to Dr Williams, University of Dar-es-Salaam, Tanzania, car- Medical ried out a teaching and health survey for two Eastern General Hospital, whose reply is printed below.-ED, BMJ. weeks on Mafia Island. The students were to Edinburgh detect cases of leprosy and tuberculosis, Foerster, H W, Survey in Ophthalmology, 1959, 4, 296. W A, American J7ournal of vaccinate the population of 14 000 against 2Maler, G H, and Disker, Surgery, 1970, 119, 334. SIR,-I am indebted to Dr Cloyd for pointing smallpox, and immunise the children against Madge, G E, Medical College of Virginia Quarterly, 1972, 8, 251. out a possible source for confusion in my poliomyelitis and measles. There were no 4Porter, R, et al, British Medical_Journal, 1972, 3, 133. article concerning the use of intravenous registered cases of leprosy on the island. None Coulson, A S, et al, Western Journal of Medicine, 1974, 120, 1. hydrochloric acid for correcting severe meta- of the students had previously seen a case of Smith, M E, Archives of Ophthalmology, 1964, 72, 44. leprosy. I gave one illustrated lecture followed bolic alkalosis. One hundred and fifty millilitres of 1-M HCI by a clinical demonstration. The current made up to one litre with sterile water will classification of the disease was not mentioned. produce a solution containing 300 mmol of The students were instructed to screen the Hip fractures up to date H+ and Cl-- (that is, 150 mmol of each ion). In population for hypopigmented skin lesions, retrospect this may have been ambiguous and I nodulation, and infiltration of the face and SIR,-Congratulations on an excellent series ears. Those having these signs were then of orthopaedic articles over the past few am sorry if it has caused confusion. In the patient described the calculated Cl- referred on a later day to the WHO leprologist weeks, among which I particularly enjoyed deficit and H ± deficit suggested that a total of and the leprosy specialist for Tanzania, who Mr P A Ring's on hip fractures (11 December, 300 mmol of H+ was required-that is, 2 1 of made a definitive diagnosis. Seventy-one p 1429). I should, however, like to endorse newly diagnosed cases of leprosy were detected, Mr E H J Smyth's comments (5 February, solution as made up above. I would again emphasise the dangers of an estimated 80",, of the leprosy on the island, p 377) regarding the displaced subcapital using solutions of hydrochloric acid of higher and many were at an early, curable stage. fractures which he describes as "the problem-
5 MARCH 1977
643
infants in the home. With respect, we suggest molarity than 015 M (015 mmol HCl/l) for Thus the students learnt that the diagnosis of leprosy is easy and deformity can be that you read our paper again and then ask this intravenous use. S E WILLIAMS prevented. question: Would I be prepared to expose an The capital and running costs of leprosaria infant or a pregnant woman in my care to a University of Manchester Department of Medicine, like Garkida are enormous and this approach to drinking water lead level of 800 ftg/l ? Hope Hospital, leprosy is now completely outmoded. What is Salford, Lancs required is low-cost, effective, and practical A GOLDBERG management of the disease, and Ross was M R MOORE one of the few leprologists in the world to Department of Materia Medica, Patients' awareness of melaena Stobhill General Hospital, provide such measures. The decline in Glasgow leprosy after 10-15 years of dapsone adminisSIR,-During the past two months I have tration as shown by the figures from northern Beattie, A D, et al, Lancet, 1975, 1, 589. have who had three patients elderly seen 2 Bacon, A P C, et al, Lancet, 1967, 1, 264. Zaria is a good example of successful pre3Beattie, A D, et al, British Medical J7ournal, 1972, 1, melaena while taking fenoprofen. One pre- ventive medicine. It is therefore a strange 488. Campbell, B C, et al, British Medical Jrournal, 1977, sented with abdominal pain, the second with decision by the Faculty of Medicine of shortness of breath, and the third with short- Ahmadu Bello University, Zaria, not to 1, 482. Parry, W H, Lancet, 1967, 2, 1207. ness of breath and palpitations; their haemo- demonstrate these findings to the students, globin concentrations were 13-1, 7, and 9 g/dl especially as the clinics are in the immediate respectively. They had had black stools for vicinity of the medical school. between two and four days but none of them and molar Molar solutions complained of this and had continued to take C L CRAWFORD doncentrations the drug. The bleeding was discovered only Department of Anatomy and when the patients were specifically asked Embryology, SIR,-An article by Dr S E Williams (15 May about their stools. University College, London WC1 1976, p 1189) concerning the use of hydroPatients often complain of two or three chloric acid for the correction of severe loose stools but it appears that few realise the metabolic alkalosis perpetuates a small but significance of change in colour. I would significant error originally contained within suggest that all patients being given drugs CMV retinitis one of the references.' The author states that which might cause gastrointestinal bleeding 150 ml of 1-M HCI in one litre of sterile water should be made aware of the significance of SIR,-We are very grateful to Dr H W Murray yields 300 mmol of H+ and Cl per litre. By black stools and given advice regarding the for his letter (30 October, 1976, p 1071) drawing attention to the various reported definition a 1-M solution of any preparation action to take. episodes of the ocular manifestations of contains 1000 mmol of solute. Therefore MELVIN Ross cytomegalo inclusion disease and we look 150 ml of the 1-M HCl solution will contain forward to reading his article when it is 150 mmol of H+ and Cl-. When the 150-ml London N19 published. We apologise if we failed to make aliquot is added to the sterile water the sufficiently clear that the patient we reported molarity of the final solution is 015 M, not (31 July 1976, p 281) had a retinitis without 0 3 M as would be calculated using the Teaching leprosy to medical students visible choroidal involvement. Pure cyto300 mmol figure. Such miscalculations may be critical when SIR,-Professor H Scarborough (5 February, megalovirus (CMV) retinitis was not the one is attempting rapidly to correct severe p 379), in defending the teaching of leprosy in lesion in five of the 19 patients that Dr Murray metabolic alkalosis. Furthermore, while the leprosaria such as Garkida, Nigeria, states that cites'-5 and the diagnosis of cytomegalo author, as well as others,' 2confirms the safety physiotherapy, occupational therapy, and inclusion disease was no more than presumpof dilute solutions of HCl (0 1-0 2 M), several surgery are therapeutic measures. Instead, tive in three patients.t 3 5 In particular we reports2 '1 indicate that HCl in 0 3 M concen- patients receiving such measures should be agree with Dr M E Smith6 that the diagnosis trations or greater may precipitate acute seen as examples of a tragic failure to prevent in the otherwise asymptomatic patient with a haemolysis of red blood cells. Thus great care irreversible nerve damage, usually as a result unilateral uveitis briefly described by Dr should be directed toward ordering and pre- of late diagnosis. Thus students taught in Helen Foersterl must remain unproved and paring intravenous hydrochloric acid solutions leprosaria may well conclude that deformity speculative. Indeed, Dr Foerster herself in leprosy is inevitable and that its management presented her patient as a diagnostic problem. for reasons both of efficacy and of safety. is time-consuming, needs expensive equipIt may well be that our patient is not the JAMES CLOYD ment, and is not very rewarding. If students first reported case of CMV retinitis in an are taught that the diagnosis of leprosy is otherwise healthy adult but we remain unable College of Pharmacy, difficult or that it is desirable to do skin smears to find a similar patient in the English University of Minnesota, Minneapolis, Minnesota to establish a definitive diagnosis they may literature. H B CHAWLA lAbouna, G M, Adrete, J A, and Stangl, T E, Surgery, lose interest in the subject, and it is not surprising that leprosy continues to be neglected 1974, 75, 139. M J FORD 2 Shavelle, H G, and Parke, R, Surgery, 1975, 78, 439. by the medical profession. J F MUNRO 3 Whelton, 0, Lancet, 1974, 1, 1055. In 1970 the Faculty of Medicine at the R E SCORGIE Unit, ***We sent a copy of this letter to Dr Williams, University of Dar-es-Salaam, Tanzania, car- Medical ried out a teaching and health survey for two Eastern General Hospital, whose reply is printed below.-ED, BMJ. weeks on Mafia Island. The students were to Edinburgh detect cases of leprosy and tuberculosis, Foerster, H W, Survey in Ophthalmology, 1959, 4, 296. W A, American J7ournal of vaccinate the population of 14 000 against 2Maler, G H, and Disker, Surgery, 1970, 119, 334. SIR,-I am indebted to Dr Cloyd for pointing smallpox, and immunise the children against Madge, G E, Medical College of Virginia Quarterly, 1972, 8, 251. out a possible source for confusion in my poliomyelitis and measles. There were no 4Porter, R, et al, British Medical_Journal, 1972, 3, 133. article concerning the use of intravenous registered cases of leprosy on the island. None Coulson, A S, et al, Western Journal of Medicine, 1974, 120, 1. hydrochloric acid for correcting severe meta- of the students had previously seen a case of Smith, M E, Archives of Ophthalmology, 1964, 72, 44. leprosy. I gave one illustrated lecture followed bolic alkalosis. One hundred and fifty millilitres of 1-M HCI by a clinical demonstration. The current made up to one litre with sterile water will classification of the disease was not mentioned. produce a solution containing 300 mmol of The students were instructed to screen the Hip fractures up to date H+ and Cl-- (that is, 150 mmol of each ion). In population for hypopigmented skin lesions, retrospect this may have been ambiguous and I nodulation, and infiltration of the face and SIR,-Congratulations on an excellent series ears. Those having these signs were then of orthopaedic articles over the past few am sorry if it has caused confusion. In the patient described the calculated Cl- referred on a later day to the WHO leprologist weeks, among which I particularly enjoyed deficit and H ± deficit suggested that a total of and the leprosy specialist for Tanzania, who Mr P A Ring's on hip fractures (11 December, 300 mmol of H+ was required-that is, 2 1 of made a definitive diagnosis. Seventy-one p 1429). I should, however, like to endorse newly diagnosed cases of leprosy were detected, Mr E H J Smyth's comments (5 February, solution as made up above. I would again emphasise the dangers of an estimated 80",, of the leprosy on the island, p 377) regarding the displaced subcapital using solutions of hydrochloric acid of higher and many were at an early, curable stage. fractures which he describes as "the problem-
