Tropical Doctor, October 1992

176 of oral contraception there has been an enormous paradoxical increase in the number of unwanted pregnancies, due to their inevitable inefficient use particularly by certain groups like young teenage girls. The fear of pregnancy was a providential way of keeping in check sexual licence which the suggestion of protection through easy access to contraceptive or abortion services has removed. Since the time of Hippocrates (4th century BC) and certainly since the introduction of the Judaeo-Christian ethic as the acceptable basis for law, abortion has been illegal. It is only in the last generation that there has been a widespread change in the law in many western countries reflecting the widespread rejection of the Christian ethic as the basis of morality. Sadly, this has led to dire consequences with huge numbers of abortions now being carried out in these countries (175000 approx per year in UK). I for one would be most saddened to see other countries follow the example set in western countries, as what appears to be the means of reducing one unwanted problem brings in its wake another infinitely more terrifying and sinister. This is always the scenario when morally incorrect methods are used to achieve good outcomes, and this is the practice of a utilitarian ethic which now predominates in western ethics and has replaced the limited but absolutist guidelines of the Judaeo-Christian ethic summarized in the ten commandments. The answer for the unwanted pregnancy must lie in the direction of better adoption services and the removal of financial and social hardships associated with the time of pregnancy and confinement all of which also need to be addressed by legal policies. N R

BEATSON

Montebello Hospital, PBX 506, Dalton 3470, Republic of South Africa

Anorectal fistulae and pulmonary tuberculosis in Ibadan An association between anorectal fistulae and pulmonary tuberculosis has often been suggested 1-3. However, only rarely is the tubercle bacillus actually identified in specimens excised from these fistulous tracts. To assess a possible relationship in an environment where TB is still prevalent, we studied two groups of consecutive patients: those with anorectal fistulae without clinical evidence of TB (group A, n = 66), and those with confirmed pulmonary TB only (group B, n = 71). The groups were matched for age, sex and duration of symptoms. Group A patients were evaluated to exclude evidence of tuberculosis. Fistulography in group A revealed a high fistula in four, intermediate in 10 and a low fistula in 52 patients. All group B patients were proctoscopically examined and sigmoidoscopy was achieved in 39 cases (550/0). Two patients had demonstrable fistulae on fistulography (one immediate, one low). All excised tracts were histologically examined.

Excised specimens from group A patients showed TB granulomata in two (one intermediate and one high). Thus 14% of intermediate and the high fistulae were tuberculous or 3% of fistulae of all levels. Among group B patients one intermediate level fistula had histological evidence of tuberculosis. These results suggest that anorectal fistulae, especially those of the intermediate or high level, may occasionally be of tuberculous origin. I suggest patients with anorectal fistula should be screened for tuberculosis. F N IHEKWABA

Department of Surgery University College Hospital, Ibadan, Nigeria

REFERENCES

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Mazier WP. The treatment and care of anal fistulas: a study of 1000 patients. Dis Colon Rectum 1971;14:134-40 2 Hanley PH. Ano-rectal abscess fistula. Surg Clin North Am 1978;58:487-94 3 Russel TR. Anorectum. In: Dumphy IE, Way LW, eds. Current Surgical Diagnosis and Treatment, 5th edn. Los Altos: Lang Med Publications, 1981:618 4 Ani AN, Solanke TF. Anal fistula: a review of 82 cases. Dis Colon Rectum 1976;19:51-5

Living retained second twin 6 days after first Reading Lester Dornan's letter in Tropical Doctor (January 1992, p 34) recalled to mind that some years ago we had delivered a retained second twin nearly a week after the first, so we searched our records and came up with the following: On 3 November at 11 am, a para-4, Zairois patient was admitted to the maternity unit, having been transported on a bicycle from an outlying village, approx. 100 miles away. The history was that on the 29 October 1984, she had delivered a male infant weighing now 1.600 kg, and that the second twin remained 'inside'. Abdominal examination confirmed this doubtful story, and a fetal heart was heard. Pelvic examination showed the cervix dilated, and rupturing membranes was immediately followed by the expulsion of the second male infant, weighing 2.050 kg and needing no resuscitation. There were two separate placentae. The postpartum period was completely uneventful (though a course of antibiotics was thought advisable), and she was discharged 9 days later with the twins both healthy and gaining weight. RUTH WILLIAMS

Mitwaba Hospital, Shaba, Zaire

Use of activated charcoal to treat poisoning Most physicians in Africa do not seem to appreciate the usefulness of activated charcoal in the treatment of poisoning, although this inexpensive powder is readily available in any poison control centre in Europe or America. In a survey of five hospitals in Nigeria I found that only 18% of the doctors and pharmacists had ever

Tropical Doctor, October 1992 prescribed activated charcoal for any of their poisoned patients. House officers and senior house officers stated that activated charcoal as an agent in poison management was only casually mentioned during their career as medical students. Activated charcoal was conspicuously omitted in a list of the requirements for a poisons unit, in a lecture recently delivered by a consultant physician in charge of accident and emergency at a major Nigerian teaching hospital. The editor of one African Journal states that activated charcoal has not been used in his hospital or any hospital known to him for the past 10 years. Some of the very few doctors who claim to know what activated charcoal is, do not prescribe it because they are unfamiliar with the correct technique of administration, the dose to be administered for various kinds of poison, and the possible interraction of activated charcoal with other drugs. I believe physicians need to be re-educated about the usefulness of this inexpensive and often effective treatment. Activated charcoal is best administered straight in 'slurries' without suspending agents or additives. It is most convenient if the powder is kept in single doses in opaque, wide mouth jars'. We have observed that often the patient's initial repugnance is ameliorated by persuasion and reassurance. A larger quantity can be taken in long straight gulps than in sips. Acceptability can be enhanced especially for children by the addition of a sweetening agent. The usual dose of activated charcoal required is 8-10 times that of the poisoning agent. However, if the amount and type of poison is unknown, 50-IOOg of the charcoal should be used", In severe poisoning and well controlled conditions, large daily doses (200-400 g) can be administered. The safety of activated charcoal is because it is a non-reactive substance and it is not absorbed systemically. Oral administration results only in occasional constipation. The administration of a saline cathartic prevents constipation, and may prevent the poison from being released from the charcoal surface. In comatose patients overdosed with phenobarbitone, nasogastric tube administration of activated charcoal reduces the elimination halflife of the drug and shortens the period of coma'. I consider that the neglect of activated charcoal by physicians is large due to lack of current information, a deficiency which should now be put right.

o

E

ORISAKWE

177 Inexpensive low vision aids Low vision is defined as a vision less than 0.3 (6/18) but equal to or better than 0.05 (3/60 or finger counting at 2.5 m). The information and the statistics available indicate that there are equal numbers of people suffering from low vision and blindness, ie around 30 million worldwide I . In developed countries optical aids, such as magnifying glassesand telescopiclenses, are given in order to obtain the best use of the residual vision. In developing countries optical aids, except regular spectacles, are not available. Nevertheless they can easily be made with inexpensive materials and simple technology. Near vision can be improved with a + 12 D (Dioptre) lens recovered from used spectacles prescribed as optical correction after cataract extraction. The low vision patient has to hold the lens between two fingers at about 8 cm from his eye and at about 8 em from the text or object he observes. The magnification is 3 x. Two + 12 D lenses can be fixed one on top of the other by means of a frame and the extension of the frame can keep the lens at 4 cm from the text. The frame is made with steel wire and has no welding points, the elements are fixed by binding them together with fine copper wire, such as can be recovered from a used dynamo'. The magnification is 6 x (Figure I). A binocular loupe, as the Beebe loupe, can easily be made with the same technology. It has the advantage of being fixed on a spectacle-frame, but the magnification is smaller'. Distance vision can be improved with a telescope. The Galilean telescope can easily be made. The materials needed are a negative lens of about - 4 D (as the one used for correction of myopia), a positive lens of about + 2 D (as the one used for correction of presbyopia), cardboard and tape or elastics. With the latter two, cylinders are made, gliding one into the

Toxicology Unit Department of Pharmacology, Nnamdi Azikiwe University, Nnewi Campus, Anambra State, Nigeria

KHERENCES

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Levy G, Soda OM, Lampman TA. Inhibitory by ice cream of the antidotal efficacy of activated charcoal. Am J Hosp Pharm 1975;32:289-91 2 Olkkola KT. Effect of charcoal drug ratio on antidotal efficacy of oral activated charcoal in man. Br J Clin Pharmacol 1985; 19:767 - 73 3 Goldbery MJ, Berlinger WG. Treatment of phenobarbital overdose with activated charcoal. JAMA 1982;247:2400-1

Figure J. A stand magnifier made with two positive lenses one on top of the other, recovered from spectacles used after cataract extraction, assembled with steel wire and fine copper wire

Use of activated charcoal to treat poisoning.

Tropical Doctor, October 1992 176 of oral contraception there has been an enormous paradoxical increase in the number of unwanted pregnancies, due to...
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