526 Since the interior of the small bowel was not directly visualised in this case, the presence or absence of other non-perforating ulcerative lesions cannot be established. It is distinctly possible that, in this patient, hypertension, chronic proctitis, and necrotising angiitis indicate the presence of a collagen disorder. The concluding statement of Thompson and Jackson2-"All that is abdominal pain is not sclerosing peritonitis"--could be expanded to "All that is peritonitis in patients receiving beta blockers is not the practolol syndrome." Research Laboratories, Merck Sharp & Dohme, West Point, Pennsylvania
19486, U.S.A.
JOHN F. NANCARROW
HALOTHANE HEPATITIS
tious hepatitis from the ingestion of infected shellfish was present in the area." Third, they did not mention the fact that during the same epidemic 41 cases of jaundice had been reported after intravenous barbiturate anaesthesia for psychiatric procedures and 15 of them died from massive liver necrosis-a tragic example of the immunodepression of anxsthetic drugs." Finally, the two physicians did not appear to know that fever, rashes, myalgia, arthralgia, and so on are manifestations of the virxmic phase of infectious hepatitis.9 It is not improbable that the suggestion that halothane may cause allergic liver necrosis may come to be regarded as one of the silliest in the history of anaesthesia if not of medicine. In the meantime physicians would be well advised to stop meddling in anaesthetics and devote their attention to the search for reliable serological tests for all forms of viral hepatitis. Department of Anaesthetics,
SIR,-Professor Sherlock (Aug. 12, p. 364) gives the impression that she thinks that halothane confers immunity to all forms of viral hepatitis in people exposed to its vapour. She
Royal Infirmary, Manchester M13 9WL
MICHAEL
JOHNSTONE
may be
right, but I do not think she is because I am reasonably certain that the immunodepression of surgery and anaesthesia increases the severity of all infections. 12 Fatal liver necrosis from a herpes-type virus has occurred in a patient after surI gery under enflurane anaesthesia.3 in not a are Physicians position to prescribe anaesthetic that halothane should be Sherlock’s recommendation drugs. avoided in "minor" surgery is irresponsible. Halothane is usually the safest and best anaesthetic in these circumstances. If possible all anaesthetic drugs should be avoided in surgical patients with viral infections unrelated to the surgical pathology. A second anaesthetic should not be given until recovery from the immunodepression of the first operation is complete. Hepatitis B (serum hepatitis) is not an uncommon complication in patients after surgery and it may also afflict the surgical staff. The recognition and the control of the infection in these circumstances has been well described, and anaesthetists are advised to read carefully the published reports.4-6 Hepatitis A (infectious hepatitis) is a more difficult problem because there is no reliable serological test for it.’ In the early stages of the first clinical trial of halothane it was anticipated that sooner or later patients in the asymptomatic incubation phase of infectious hepatitis would be anaathetised with this agent, and anaesthetists were warned that the jaundice which subsequently appeared might be wrongly ascribed to the anoesthetic.8 With the cooperation of the Office of Morbidity Statistics for General Practice in the United Kingdom and the department of anaathetics in the University of Cardiff it was estimated that out of every million patients anaathetised with any anaesthetic agent jaundice might appear in about 100 of them some days or weeks postoperatively as the result of coincidental infectious hepatitis.9 This figure does not include transmitted hepatitis B. Despite the warning the hepatitis controversy was precipitated by two physicians who reported 8 cases of transient postoperative jaundice and suggested that the cause was an allergic reaction to halothane.’" In presenting their opinion they ignored four important facts. First, the fact that most of the cases occurred over a period of a few weeks should have alerted them to the possibility of an infectious origin. Second, they did not refer to the fact that a widely publicised epidemic of infec1. 2.
Munster, H. M. Lancet, 1976, i, 1329. Duncan, P. G., Cullen, B. F. Anesthesiology, 1976, 45, 522. 3. Douglas, H. J., Eger, E. I., Biava, C. G., Renzi, C. New Engl. J. Med. 1977, 296, 553. 4. Rimland, D., Parkin, W. E., Miller, G. B., Schrack, W. D. ibid. 1977, 296, 955.
5. 6.
Grady, G. F. ibid. 1977, 296, 996. Naulty, J. S., Reves, J. G., Tobey, R. E., Schultz, W. W. curr. Res. 1977, 56, 366. 7. Woolf, I., Williams, R. Br. J. Hosp. Med. 1977, 17, 117. 8. Johnstone, M. Anesthesiology, 1961, 22, 591. 9. Johnstone, M. Br.J. Anæsth. 1964, 36, 718. 10. Lindenbaum, J., Leifer, E. New Engl. J. Med. 1963, 268, 525.
Anesth.
PHARMACOLOGY AND THE MOLE
SiR,—Your normally thoughtful columns developed a regrettable entrenched tone on June 17.’ While it must be accepted that we do not yet possess an understanding of the molecular action of drugs which demands that drug concentrations should be expressed in molar units, there are a number of other considerations which justify a change to these units. My experience over the past seven years of running a quality-control scheme for antiepileptic drugs, in which 200 laboratories in many countries participate, has led me to conclude that a major source of error stems from the inability of many laboratories to make up working standards. One important oversight is failure to correct for the fact that standards are usually made up by weighing in the salt, whereas it is the acid or base which is measured in serum. For example, phenytoin is usually added as the sodium salt, and failure to allow for the sodium atom will produce an approximately 10% error in the result. This oversight is not confined to the laboratory amateur-one of the leading producers of quality-control serum was guilty of this error when it introduced drug control sera. Some laboratories express their serum levels as the salt—e.g., lignocaine hydrochloride2-but this could cause confusion. In our not yet published study of the bioavailability of lignocaine hydrochloride and monohydrate, for example, it would be nonsensical if we expressed our results in anything but the base. In many publications it is, not made clear just what has been measured. How many disagreements in clinical pharmacology are due to simple confusions of this sort? Precision in medicine, often difficult, can be achieved in drug measurement. The use of molar units does not automatically overcome these problems, but when an analyst has to convert from gravimetric to molar units he has to think about what he is measuring.
Further problems arise when metabolites of drugs are being measured. Some drugs, for instance, have active metabolites, and in relating serum level to effect it is tempting to add the concentrations of parent compound and. metabolite together. But to do so on a gravimetric basis, as did Carr and Hobson did for tricyclic antidepressants3 is incorrect. On a molar basis, however, this makes more sense. Similarly, it is logical to use molar units in studies of the metabolic pattern of drugs, when it may be necessary to compare yields of metabolites through different pathways. You are right in saying that drugs are measured only occasionally, but it is reasonable to assume that as progress is made in clinical pharmacology, the indications for drug level moni-
Analg. 11. Dougherty, W. J., Altman, R. Am. J. Med. 1962, 32, 704. 1. Lancet, 1978, i, 1297. 2. Rowland, M., Thomson, P. D., Guichard, A., Melmon, K. L. Ann. N.Y. Acad. Sci. 1971, 179, 383. 3. Carr, A. C., Hobson, R. P. Br. med. J. 1977, ii, 1151.
527
toring will become clear and the need for a routine service will increase. Why not, then, allow the clinician to get used to molar units now rather than make the inevitable, but painful, change later? The argument that drug dosing is normally on a gravimetric basis has little relevance to the question of what units should be used for drug levels. In fact, there is only one drawback to the discrepancy in units-namely, that a conversion factor must be used when the apparent volume of distribution and clearance of a drug is calculated-not an exercise which the clinician is likely to be involved in very often. While noting your quip about molar weighing machines, I consider that dosing in molar units is the logical outcome in the rationalisation of units. As was pointed out in a more thoughtful British Medical 3’ournal editorial,4 drugs may be given in the form of the base itself or of a salt or other compound of the base, and this may lead to confusion in dosing. How many of your readers know that the yield of theophylline from a 200 mg choline theophyllinate (’Choledyl’) tablet is only 127 mg, and is therefore therapeutically equivalent to a 125
tablet (plain theophylline)? Furthermore, how that a 192 mg ’Heminevrin’ capsule is equivamany lent in potency to a 500 mg heminevrin tablet (the former contains chlormethiazole base while the latter contains the edisylate). Perhaps readers of the small print in data sheets know this, but it did not prevent an editorial error5 in conversion of gravimetric to molar units. If all drug doses were given in moles of the active substance this source of confusion would be eliminated. Perhaps the change will be difficult, but as drugs become more potent there is no longer a place for a system which encourages their imprecise use.
mg ’Nuelin’
are aware
of Clinical Pharmacology, St. Bartholomew’s Hospital, London EC1A 7BE
Department
ALAN RICHENS
ETHICAL PROBLEMS OF SCREENING FOR NEURAL-TUBE DEFECTS
SIR,-We are conducting a pilot screening programme for neural-tube defects and find the comments by the Bishop of Durham (July 15, p. 148) and Dr Gould (July 29, p. 265) very timely. We agree that women should be made aware of the implications of screening before the first test, even though this takes considerable effort. Besides ethical issues, we have found that anxiety plays a major role in a woman’s choosing whether to participate in the screening programme. For a small, but significant, percentage of pregnant women, the anxiety appears so intense as to negate any possible benefits that testing might offer. There have been instances in our programme where an informed woman has elected to have screening done even though she would not agree to abortion. This has occurred because the physician felt that knowledge of a neural-tube defect would help to plan for delivery, including anticipation of possible breech presentation and consideration of csesarean section. Home deliveries would be strongly advised against, and fathers discouraged from attending in such circumstances. Foundation for Blood Research,
P.O. Box 426,
Scarborough, Maine 04074, U.S.A.
JAMES
E. HADDOW
RELEVANCE OF HOMOEOPATHY
SIR,-It was surprising to read in your commentary from Westminster (July 15, p. 166) that the Postgraduate Medical Education Council feels that homoeopathy is not "of sufficient relevance to modern medical practice" to warrant financial support for training. "Modern medical practice" refers to all the possible effective and ethical ways in which a doctor manages his patients. To an open-minded observer homoe-
seems highly relevant to present-day medical practice in this sense. A large number of patients present in general practice and in hospital clinics with disorders not attributable to any demonstrable structural or biochemical lesion and which may come to be classified as "psychosomatic". Those whose symptoms include a disorder of the nasal mucosa, some pattern of vasomotor rhinitis, frequently finish their hospital pilgrimage at an allergy clinic. The ordinary resources of allergy study and management may be useful for some but the majority have no specific allergy or any other precisely determinable disease. When I followed up a few allergy-clinic failures who subsequently had homoeopathic treatment I was very favourably impressed. Some were no better but about half of them had become much fitter and happier people. There was more partial improvement than from any previous treatment. I would say that homoeopathy can be of very great value for this difficult group of patients and, from another point of view, offers the prospect of reducing the national drug bill for the tranquilisers and antihistamines which these patients generally receive. Allergy Clinic, Radcliffe Infirmary, Oxford OH2 6HE R. M. MORRIS OWEN
opathy
SCHOOL-TEACHERS AND HEALTH IN DEVELOPING COUNTRIES to congratulate Dr Ahmed (Aug. 5, p. his article on the potential contribution of primaryschool teachers to the health of a developing country, and to record some of our experience. In cooperation with the Government of Bangladesh, the Norwegian Red Cross is running a comprehensive health project, a thana health complex, for approximately 150 000 people living in Joydebpur Thana. In 1975, we appointed a female primary-school teacher and gave her some months’ training in basic pathology, hygiene, sanitation, nutrition, and family planning. A teaching programme was worked out, and she went out to the primary schools in the villages to give basic health education. We soon realised that her efficacy would be much increased if she started out by instructing the teachers, who would then carry the course to the classes. In cooperation with one or two of our paramedics, smallpox and B.C.G. vaccinations -are given. A-D vitamin capsules, anthelminthics, and scabies treatment are given according to needs (periodic deworming has a positive effect on nutritional status of ascaris-infected children1). The school tube-wells are kept in order, and a latrine building programme for the schools has been started. All eighty primary schools in the thana have now been covered, most of them several times. The programme is enthusiastically received by pupils and teachers alike, and the cooperation with school authorities has been very smooth. Steps are now being taken to introduce similar activities in other thanas in Bangladesh. We have not had the capacity to evaluate the programme scientifically. However, the children seem to be healthier and cleaner, and there has been a notable decline in the number of children treated for scabies and worms at our clinics. Although there has been some general improvement of the nutritional status at the same time in this area, it is tempting to give some credit to the school health programme as well. There are two limitations to such programmes: the greatest toll of child mortality is borne by preschool children, and some of the children who are worst off never come to school. However, the schoolchildren may have a positive influence on their families. Also, the programme is attractive in that it takes advantage of an already existing and effective infrastructure. Thus, I think the idea deserves to be an integral part of a comprehensive primary health care system in developing countries.
SiR,—Iwould like
307)
on
Krohgstötten Hospital, FINN WISLÖFF
Oslo, Norway 4. British Medical Journal, 1978, 5. Slessor,I. M. ibid. p. 716.
i, 668. 1.
Gupta,
M.
C., Mithal, S., Arora, K. L., Tandon,
B. N.
Lancet, 1977, ii, 108.
19486, U.S.A.
JOHN F. NANCARROW
HALOTHANE HEPATITIS
tious hepatitis from the ingestion of infected shellfish was present in the area." Third, they did not mention the fact that during the same epidemic 41 cases of jaundice had been reported after intravenous barbiturate anaesthesia for psychiatric procedures and 15 of them died from massive liver necrosis-a tragic example of the immunodepression of anxsthetic drugs." Finally, the two physicians did not appear to know that fever, rashes, myalgia, arthralgia, and so on are manifestations of the virxmic phase of infectious hepatitis.9 It is not improbable that the suggestion that halothane may cause allergic liver necrosis may come to be regarded as one of the silliest in the history of anaesthesia if not of medicine. In the meantime physicians would be well advised to stop meddling in anaesthetics and devote their attention to the search for reliable serological tests for all forms of viral hepatitis. Department of Anaesthetics,
SIR,-Professor Sherlock (Aug. 12, p. 364) gives the impression that she thinks that halothane confers immunity to all forms of viral hepatitis in people exposed to its vapour. She
Royal Infirmary, Manchester M13 9WL
MICHAEL
JOHNSTONE
may be
right, but I do not think she is because I am reasonably certain that the immunodepression of surgery and anaesthesia increases the severity of all infections. 12 Fatal liver necrosis from a herpes-type virus has occurred in a patient after surI gery under enflurane anaesthesia.3 in not a are Physicians position to prescribe anaesthetic that halothane should be Sherlock’s recommendation drugs. avoided in "minor" surgery is irresponsible. Halothane is usually the safest and best anaesthetic in these circumstances. If possible all anaesthetic drugs should be avoided in surgical patients with viral infections unrelated to the surgical pathology. A second anaesthetic should not be given until recovery from the immunodepression of the first operation is complete. Hepatitis B (serum hepatitis) is not an uncommon complication in patients after surgery and it may also afflict the surgical staff. The recognition and the control of the infection in these circumstances has been well described, and anaesthetists are advised to read carefully the published reports.4-6 Hepatitis A (infectious hepatitis) is a more difficult problem because there is no reliable serological test for it.’ In the early stages of the first clinical trial of halothane it was anticipated that sooner or later patients in the asymptomatic incubation phase of infectious hepatitis would be anaathetised with this agent, and anaesthetists were warned that the jaundice which subsequently appeared might be wrongly ascribed to the anoesthetic.8 With the cooperation of the Office of Morbidity Statistics for General Practice in the United Kingdom and the department of anaathetics in the University of Cardiff it was estimated that out of every million patients anaathetised with any anaesthetic agent jaundice might appear in about 100 of them some days or weeks postoperatively as the result of coincidental infectious hepatitis.9 This figure does not include transmitted hepatitis B. Despite the warning the hepatitis controversy was precipitated by two physicians who reported 8 cases of transient postoperative jaundice and suggested that the cause was an allergic reaction to halothane.’" In presenting their opinion they ignored four important facts. First, the fact that most of the cases occurred over a period of a few weeks should have alerted them to the possibility of an infectious origin. Second, they did not refer to the fact that a widely publicised epidemic of infec1. 2.
Munster, H. M. Lancet, 1976, i, 1329. Duncan, P. G., Cullen, B. F. Anesthesiology, 1976, 45, 522. 3. Douglas, H. J., Eger, E. I., Biava, C. G., Renzi, C. New Engl. J. Med. 1977, 296, 553. 4. Rimland, D., Parkin, W. E., Miller, G. B., Schrack, W. D. ibid. 1977, 296, 955.
5. 6.
Grady, G. F. ibid. 1977, 296, 996. Naulty, J. S., Reves, J. G., Tobey, R. E., Schultz, W. W. curr. Res. 1977, 56, 366. 7. Woolf, I., Williams, R. Br. J. Hosp. Med. 1977, 17, 117. 8. Johnstone, M. Anesthesiology, 1961, 22, 591. 9. Johnstone, M. Br.J. Anæsth. 1964, 36, 718. 10. Lindenbaum, J., Leifer, E. New Engl. J. Med. 1963, 268, 525.
Anesth.
PHARMACOLOGY AND THE MOLE
SiR,—Your normally thoughtful columns developed a regrettable entrenched tone on June 17.’ While it must be accepted that we do not yet possess an understanding of the molecular action of drugs which demands that drug concentrations should be expressed in molar units, there are a number of other considerations which justify a change to these units. My experience over the past seven years of running a quality-control scheme for antiepileptic drugs, in which 200 laboratories in many countries participate, has led me to conclude that a major source of error stems from the inability of many laboratories to make up working standards. One important oversight is failure to correct for the fact that standards are usually made up by weighing in the salt, whereas it is the acid or base which is measured in serum. For example, phenytoin is usually added as the sodium salt, and failure to allow for the sodium atom will produce an approximately 10% error in the result. This oversight is not confined to the laboratory amateur-one of the leading producers of quality-control serum was guilty of this error when it introduced drug control sera. Some laboratories express their serum levels as the salt—e.g., lignocaine hydrochloride2-but this could cause confusion. In our not yet published study of the bioavailability of lignocaine hydrochloride and monohydrate, for example, it would be nonsensical if we expressed our results in anything but the base. In many publications it is, not made clear just what has been measured. How many disagreements in clinical pharmacology are due to simple confusions of this sort? Precision in medicine, often difficult, can be achieved in drug measurement. The use of molar units does not automatically overcome these problems, but when an analyst has to convert from gravimetric to molar units he has to think about what he is measuring.
Further problems arise when metabolites of drugs are being measured. Some drugs, for instance, have active metabolites, and in relating serum level to effect it is tempting to add the concentrations of parent compound and. metabolite together. But to do so on a gravimetric basis, as did Carr and Hobson did for tricyclic antidepressants3 is incorrect. On a molar basis, however, this makes more sense. Similarly, it is logical to use molar units in studies of the metabolic pattern of drugs, when it may be necessary to compare yields of metabolites through different pathways. You are right in saying that drugs are measured only occasionally, but it is reasonable to assume that as progress is made in clinical pharmacology, the indications for drug level moni-
Analg. 11. Dougherty, W. J., Altman, R. Am. J. Med. 1962, 32, 704. 1. Lancet, 1978, i, 1297. 2. Rowland, M., Thomson, P. D., Guichard, A., Melmon, K. L. Ann. N.Y. Acad. Sci. 1971, 179, 383. 3. Carr, A. C., Hobson, R. P. Br. med. J. 1977, ii, 1151.
527
toring will become clear and the need for a routine service will increase. Why not, then, allow the clinician to get used to molar units now rather than make the inevitable, but painful, change later? The argument that drug dosing is normally on a gravimetric basis has little relevance to the question of what units should be used for drug levels. In fact, there is only one drawback to the discrepancy in units-namely, that a conversion factor must be used when the apparent volume of distribution and clearance of a drug is calculated-not an exercise which the clinician is likely to be involved in very often. While noting your quip about molar weighing machines, I consider that dosing in molar units is the logical outcome in the rationalisation of units. As was pointed out in a more thoughtful British Medical 3’ournal editorial,4 drugs may be given in the form of the base itself or of a salt or other compound of the base, and this may lead to confusion in dosing. How many of your readers know that the yield of theophylline from a 200 mg choline theophyllinate (’Choledyl’) tablet is only 127 mg, and is therefore therapeutically equivalent to a 125
tablet (plain theophylline)? Furthermore, how that a 192 mg ’Heminevrin’ capsule is equivamany lent in potency to a 500 mg heminevrin tablet (the former contains chlormethiazole base while the latter contains the edisylate). Perhaps readers of the small print in data sheets know this, but it did not prevent an editorial error5 in conversion of gravimetric to molar units. If all drug doses were given in moles of the active substance this source of confusion would be eliminated. Perhaps the change will be difficult, but as drugs become more potent there is no longer a place for a system which encourages their imprecise use.
mg ’Nuelin’
are aware
of Clinical Pharmacology, St. Bartholomew’s Hospital, London EC1A 7BE
Department
ALAN RICHENS
ETHICAL PROBLEMS OF SCREENING FOR NEURAL-TUBE DEFECTS
SIR,-We are conducting a pilot screening programme for neural-tube defects and find the comments by the Bishop of Durham (July 15, p. 148) and Dr Gould (July 29, p. 265) very timely. We agree that women should be made aware of the implications of screening before the first test, even though this takes considerable effort. Besides ethical issues, we have found that anxiety plays a major role in a woman’s choosing whether to participate in the screening programme. For a small, but significant, percentage of pregnant women, the anxiety appears so intense as to negate any possible benefits that testing might offer. There have been instances in our programme where an informed woman has elected to have screening done even though she would not agree to abortion. This has occurred because the physician felt that knowledge of a neural-tube defect would help to plan for delivery, including anticipation of possible breech presentation and consideration of csesarean section. Home deliveries would be strongly advised against, and fathers discouraged from attending in such circumstances. Foundation for Blood Research,
P.O. Box 426,
Scarborough, Maine 04074, U.S.A.
JAMES
E. HADDOW
RELEVANCE OF HOMOEOPATHY
SIR,-It was surprising to read in your commentary from Westminster (July 15, p. 166) that the Postgraduate Medical Education Council feels that homoeopathy is not "of sufficient relevance to modern medical practice" to warrant financial support for training. "Modern medical practice" refers to all the possible effective and ethical ways in which a doctor manages his patients. To an open-minded observer homoe-
seems highly relevant to present-day medical practice in this sense. A large number of patients present in general practice and in hospital clinics with disorders not attributable to any demonstrable structural or biochemical lesion and which may come to be classified as "psychosomatic". Those whose symptoms include a disorder of the nasal mucosa, some pattern of vasomotor rhinitis, frequently finish their hospital pilgrimage at an allergy clinic. The ordinary resources of allergy study and management may be useful for some but the majority have no specific allergy or any other precisely determinable disease. When I followed up a few allergy-clinic failures who subsequently had homoeopathic treatment I was very favourably impressed. Some were no better but about half of them had become much fitter and happier people. There was more partial improvement than from any previous treatment. I would say that homoeopathy can be of very great value for this difficult group of patients and, from another point of view, offers the prospect of reducing the national drug bill for the tranquilisers and antihistamines which these patients generally receive. Allergy Clinic, Radcliffe Infirmary, Oxford OH2 6HE R. M. MORRIS OWEN
opathy
SCHOOL-TEACHERS AND HEALTH IN DEVELOPING COUNTRIES to congratulate Dr Ahmed (Aug. 5, p. his article on the potential contribution of primaryschool teachers to the health of a developing country, and to record some of our experience. In cooperation with the Government of Bangladesh, the Norwegian Red Cross is running a comprehensive health project, a thana health complex, for approximately 150 000 people living in Joydebpur Thana. In 1975, we appointed a female primary-school teacher and gave her some months’ training in basic pathology, hygiene, sanitation, nutrition, and family planning. A teaching programme was worked out, and she went out to the primary schools in the villages to give basic health education. We soon realised that her efficacy would be much increased if she started out by instructing the teachers, who would then carry the course to the classes. In cooperation with one or two of our paramedics, smallpox and B.C.G. vaccinations -are given. A-D vitamin capsules, anthelminthics, and scabies treatment are given according to needs (periodic deworming has a positive effect on nutritional status of ascaris-infected children1). The school tube-wells are kept in order, and a latrine building programme for the schools has been started. All eighty primary schools in the thana have now been covered, most of them several times. The programme is enthusiastically received by pupils and teachers alike, and the cooperation with school authorities has been very smooth. Steps are now being taken to introduce similar activities in other thanas in Bangladesh. We have not had the capacity to evaluate the programme scientifically. However, the children seem to be healthier and cleaner, and there has been a notable decline in the number of children treated for scabies and worms at our clinics. Although there has been some general improvement of the nutritional status at the same time in this area, it is tempting to give some credit to the school health programme as well. There are two limitations to such programmes: the greatest toll of child mortality is borne by preschool children, and some of the children who are worst off never come to school. However, the schoolchildren may have a positive influence on their families. Also, the programme is attractive in that it takes advantage of an already existing and effective infrastructure. Thus, I think the idea deserves to be an integral part of a comprehensive primary health care system in developing countries.
SiR,—Iwould like
307)
on
Krohgstötten Hospital, FINN WISLÖFF
Oslo, Norway 4. British Medical Journal, 1978, 5. Slessor,I. M. ibid. p. 716.
i, 668. 1.
Gupta,
M.
C., Mithal, S., Arora, K. L., Tandon,
B. N.
Lancet, 1977, ii, 108.
