Tropical Doctor, October 1992 due to simple errors or omissions in care in the first 6 months. This fell to 1111/0 for the last 6 months following similar interventions as described above. The annual perinatal mortality was 29.411000. The key to such improvements in care is specific intervention measures developed from analysis of avoidable deaths. There are three groups of such avoidable deaths. The first includes deaths caused by error or omission, such as omitting to take antenatal blood, not referring high risk cases, inappropriate labour ward activity, etc. As indicated above this may account for 20-30% of all perinatal deaths. The implication is that there is scope for intervention and significant reduction in perinatal mortality. The second group of deaths includes those where there is scope for improvement but blame does not lie directly at the door of the health worker, eg late bookers, born before arrival. Here cultural practices and major infrastructural deficiencies may make improvements less easy. Finally, a third group includes the unexpected still birth in otherwise normal pregnancies, congenital abnormalities etc where it is difficult to envisage intervention at any level being successful. I find that formally classifying deaths in this way helps me and the midwives to target our resources to areas where maximum benefit may be gained. It allows the development of a plan: to eliminate all group 1 deaths through education and training and protocols and standing orders. Then to improve community access to services, and acceptability of services etc. Expressing perinatal mortality in this way also allows regional planners to direct their energies to where they are most needed. D WILKINSON
Hlabisa Hospital PlBag X500J, Hlabisa 3937 Zululand, South Africa
REFERENCE
1 Wilkinson D. Perinatal mortality - an intervention study. S Afr Med J 1991;79:552-3
Helicobacter pylori and non-ulcer dyspepsia In their letter about Helicobacter pylori and non-ulcer dyspepsia in Zambia, Watters and Gilmour (Tropical Doctor, April 1992, p 85) ask if others have also found a marked disparity between the endoscopic and histological findings of gastritis. In a prospective study of 192 patients with dyspepsia in the northern savannah of Nigeria 176 (92%) had histological gastritis while macroscopic gastritis at endoscopy was present in only 28 (15%). We have also conducted a trial of H. pylori clearance for the treatment of non-ulcer dyspepsia'. One hundred and thirty patients were randomized to receive either bismuth and amoxycillin or antacid. There was a significantly greater improvement in symptoms in those who received bismuth and amoxycillin than in those who had received antacid, but this was not related to H. pylori clearance. The initial clearance rate of H. pylori was poor,
175 whilethe recrudescence rate of infection was high, strongly suggesting the possibility of rapid re-infection. The evidence now available in the literature for an aetiological role for H. pylori in non-ulcer dyspepsia is so thin as to be almost non-existent. We therefore feel strongly that anti-H. pylori regimens should not be prescribed in nonulcer dyspepsia, although a double blind controlled trial of bismuth in non-ulcer dyspepsia would be worthwhile. C HOLCOME
University Department of Surgery, University College of Wales, Heath Park, Cardiff
REFERENCE
1 Holcome C, Thorn C, Kaluba J, Lucas SB. Helicobacter pylori clearance in the treatment of non-ulcer dyspepsia. Aliment Pharmacal Ther 1992;6:119-23
Unwanted pregnancy I was disturbed to read the implied conclusion in the report from Ile-Ife in Nigeria (Tropical Doctor, April 1992, p 75), where after a study of 74 cases of illegal induced abortion, the high mortality and morbidity rates seem to suggest to the authors that there should be a change in the policy of the abortion law in their country. The fact that legalizing abortion will reduce the mortality and the morbidity rates of illegal practices is manifestly evident, just as the use of qualified surgeons in hygienic conditions will reduce the terrible consequences and complications of such practices as female circumcision where this is still carried out as I found it was in some parts of East Africa. However, I would suggest the first consideration of any medical practice is not what the outcome of that practice is, but is the practice or procedure itself right or wrong? The end can never justify the use of wrong means. This is, of course, a simple moral dilemma and abortion is just such an issue where what is desired (ie the drop in numbers of deaths and septic complications of incompetent and illegal abortions) is a valid and good outcome, but is the means (ie the introduction of legalized and therefore technically competent abortion) also valid and morally correct? This question cannot be answered by a doctor any better than anyone else, as it all depends on what the individual believes is happening in the practice of abortion. Intrauterine photography leaves little room for doubt as to the recognition of the early fetus as very much a human life albeit very dependent on maternal support. It was interesting that in this paper 90% of the women knew by implication that the abortion they had had was wrong - (even though sadly, they presumably felt there was no other option) and that this was related to their understanding of where morality originates, ie in the will of God. The problem for all societies is how do we deal with the unwanted pregnancy? To simply say that widespread contraception is the answer (as advocated by family planning clinics in the UK) belies the statistical facts that since the introduction of widespread availability and use
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
I
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
Hlabisa Hospital PlBag X500J, Hlabisa 3937 Zululand, South Africa
REFERENCE
1 Wilkinson D. Perinatal mortality - an intervention study. S Afr Med J 1991;79:552-3
Helicobacter pylori and non-ulcer dyspepsia In their letter about Helicobacter pylori and non-ulcer dyspepsia in Zambia, Watters and Gilmour (Tropical Doctor, April 1992, p 85) ask if others have also found a marked disparity between the endoscopic and histological findings of gastritis. In a prospective study of 192 patients with dyspepsia in the northern savannah of Nigeria 176 (92%) had histological gastritis while macroscopic gastritis at endoscopy was present in only 28 (15%). We have also conducted a trial of H. pylori clearance for the treatment of non-ulcer dyspepsia'. One hundred and thirty patients were randomized to receive either bismuth and amoxycillin or antacid. There was a significantly greater improvement in symptoms in those who received bismuth and amoxycillin than in those who had received antacid, but this was not related to H. pylori clearance. The initial clearance rate of H. pylori was poor,
175 whilethe recrudescence rate of infection was high, strongly suggesting the possibility of rapid re-infection. The evidence now available in the literature for an aetiological role for H. pylori in non-ulcer dyspepsia is so thin as to be almost non-existent. We therefore feel strongly that anti-H. pylori regimens should not be prescribed in nonulcer dyspepsia, although a double blind controlled trial of bismuth in non-ulcer dyspepsia would be worthwhile. C HOLCOME
University Department of Surgery, University College of Wales, Heath Park, Cardiff
REFERENCE
1 Holcome C, Thorn C, Kaluba J, Lucas SB. Helicobacter pylori clearance in the treatment of non-ulcer dyspepsia. Aliment Pharmacal Ther 1992;6:119-23
Unwanted pregnancy I was disturbed to read the implied conclusion in the report from Ile-Ife in Nigeria (Tropical Doctor, April 1992, p 75), where after a study of 74 cases of illegal induced abortion, the high mortality and morbidity rates seem to suggest to the authors that there should be a change in the policy of the abortion law in their country. The fact that legalizing abortion will reduce the mortality and the morbidity rates of illegal practices is manifestly evident, just as the use of qualified surgeons in hygienic conditions will reduce the terrible consequences and complications of such practices as female circumcision where this is still carried out as I found it was in some parts of East Africa. However, I would suggest the first consideration of any medical practice is not what the outcome of that practice is, but is the practice or procedure itself right or wrong? The end can never justify the use of wrong means. This is, of course, a simple moral dilemma and abortion is just such an issue where what is desired (ie the drop in numbers of deaths and septic complications of incompetent and illegal abortions) is a valid and good outcome, but is the means (ie the introduction of legalized and therefore technically competent abortion) also valid and morally correct? This question cannot be answered by a doctor any better than anyone else, as it all depends on what the individual believes is happening in the practice of abortion. Intrauterine photography leaves little room for doubt as to the recognition of the early fetus as very much a human life albeit very dependent on maternal support. It was interesting that in this paper 90% of the women knew by implication that the abortion they had had was wrong - (even though sadly, they presumably felt there was no other option) and that this was related to their understanding of where morality originates, ie in the will of God. The problem for all societies is how do we deal with the unwanted pregnancy? To simply say that widespread contraception is the answer (as advocated by family planning clinics in the UK) belies the statistical facts that since the introduction of widespread availability and use
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
I
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
