- Email: [email protected]
MEDICAL EDUCATION AND PLAIN ENGLISH
567
individuals, those with pharmacologically altered colonic function, and those with diarrhoea] diseases. With the possible exception of the rare childhood disease, acrodermatitis enteropathica,4,5 there is little data to suggest that any of the halogenated hydroxyquinolines is the drug of choice for conditions other than the " carrier " state (asymptomatic cyst passer) of amoebiasis. There is no convincing data to support the use of this class of drugs to treat any of the diarrhoeal diseases, including symptomatic amoebic colitis, for which metronidazole seems to be the drug of choice. There is certainly no indication for these drugs in any type of inflammatory bowel disease or so-called non-specific diarrhoea. In fact, since it now seems almost certain that large doses of halogenated hydroxyquinolines produce severe clinically obvious neurological damage, it must be suspected that the accepted smaller dosage schedules may cause subclinical neurological damage. Until this latter possibility has been ruled out by careful studies in laboratory animals, it seems wise to use the halogenated hydroxyquinolines only when they are unequivocally indicated, and when other acceptable treatment is not available-and then only with extreme caution. This work
supported by grants from the John A. Hartford Foundation, New York; the National Institutes of Health general research support grant RR05420 to the Medical University of South Carolina; the South Carolina State Appropriations for Research; and the Veterans Administration. was
Department of Medicine,
Gastroenterology Division, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina 29401, U.S.A.
FRED E. PITTMAN
MILTON WESTPHAL.
THE PILL, THROMBOEMBOLISM, AND GALLBLADDER DISEASE
SiR,—The statement by Tuerck and Comer (August 11, p. 317) that we excluded pregnant women from the cases but not the controls is incorrect: they were excluded from both comparison groups. Their suggestion that inclusion exclusion of certain age-groups could have led to exaggeration of the differences between the cases and the controls is also incorrect since adjustment was made for the influence of varying pill use with age. We have no data on women below the age of 20 years. or
Boston Collaborative Drug Surveillance Program, 400 Totten Pond Road,
Waltham, Massachusetts 02154, U.S.A.
SAMUEL SHAPIRO.
MEDICAL EDUCATION AND PLAIN ENGLISH
SIR,-Professor Dudley writes (July 28, p. 195): " In that the graduate will have to use plain English to express himself about problems to be communicated from one to another, it can be argued that giving up essays completely is a retreat from the reality around which the examination should test." Shades of Fowler! Is this plain English ? Does this mean that since physicians discourse with one another in English, getting rid of the essay-type question might make such communication more difficult ? Why do those who write about medical education resort to a vocabulary which is both arcane and incomprehensible ? 4. 5. 6.
Cash, R., Berger, C. K. J. Pediat. 1969, 74, 717. Powell, S. J. Bull. N. Y. Acad. Med. 1971, 47, 269. Lancet, 1973, i, 1399.
" strucDoes everything in medical education have to be " formulated " ? Cannot we be spared from tured " or " factual bases ", " problem solving ", " heuristic apIf proaches ", " data banks ", " feed-back loops ", &c.? medical educators write so that they can only be understood by one another, they will suffer the fate of the Mandarins.
School of Medicine, West Virginia University, West
Morgantown, Virginia 26506, U.S.A.
W. K. C. MORGAN.
TREATMENT OF ERYTHEMA NODOSUM LEPROSUM WITH THALIDOMIDE p.
SIR, The letter by Dr Levy and his colleagues (Aug. 11, 324) and the use of thalidomide in the management of
erythema following
nodosum
leprosum (E.N.L.) necessitate the
comments.
How serious a complication is E.N.L.? The following conclusions are drawn from personal observation of 14 patients (7 from Zaria, Northern Nigeria, and 7 from Dar es Salaam, Tanzania) and from the literature on the
subject: (1) 6 of the Nigerian patients came from an area where 180 lepromatous patients were being treated as outpatients, giving a frequency of the complication of about 3%. (2) All 14 had at some time recurrent bouts of fever, with generalised subcutaneous nodules, lasting 48 hours. In those taking once-weekly dapsone this occurred at weekly intervals. (3) In 10, clinical examination of the peripheral nervous system showed no motor or sensory loss, although there was thickening of the nerves in some of them. 4 had a sensory polyneuropathy typical of late lepromatous leprosy. In 2 it was mild, while in the other 2 it was severe; 1 had an ulcer on the foot, and the second had extensive involvement of the legs and hands and the tips of the fingers were lost. 3 of these same 4 also had recurrent bouts of pain and tenderness in the ulnar nerve at the elbow with the same time sequence as the E.N.I. (4) No patients were observed with iritis, arthritis, or orchitis. These complications are also not reported in trials assessing the efficacy of drugs against E.N.L. (5) Clofazimine was not available for the Nigerian patients, and they were managed with low-dosage dapsone (12-5-75 mg. 1 patient was once weekly) and prednisone (2-5-7-5 mg. daily). given 15 mg. daily. Occasional small doses of ’Fantorin’ (antimony compound) were also given. E.N.L. was not completely suppressed but there was little discomfort and the patients were able to be discharged to the huts in the leprosarium. 1 patient was admitted with an ulcerating E.N.L. and this was the only episode seen. Thus, low-dosage dapsone does seem to reduce the severity of E.N.L., and this view is supported by Davey and Jopling. No patient showed any increase in skin infiltration or rise in the bacillary index on this regimen. The most difficult problem in management was the ulnar mononeuritis. In 1 patient local injections of cortisone were given round the nerve at the beginning of treatment. The symptoms then disappeared and there was no functional loss. Another patient, however, had persistent pain and tenderness in the nerve with progressive motor and sensory loss. 5 of the 7 Tanzanian group were changed from dapsone and prednisone to clofazimine with suppression of the E.N.L. All were managed as outpatients. None had ulnar mononeuritis. The effectiveness of clofazimine in suppressing E.N.L. is well documented.3-5 In the remaining 2 all chemo-
therapy was stopped.6 (6) E.N.L. occurs commonly
in the absence of a mononeuritis. also occur in both lepromatous and nonlepromatous patients while taking dapsone. Dr Levy and his colleagues also point out that thalidomide had little effect on ulnar neuritis in 1 patient compared to the E.N.L. The cause of the mononeuritis is therefore probably different. Sensory poly-
Mononeuritis
can
1. 2. 3. 4. 5.
Crawford, C. L. Lep. Rev. 1969, 40, 159. Davey, T. F., Jopling, W. H. ibid. 1965, 26, 186. Hastings, R. C., Trautman, J. R. ibid. 1968, 39, 3. Imkamp, F. M. J. H. ibid. p. 119. Helmy, H. S., Pearson, J. M. H., Waters, M. F. R. ibid. 1971, 42,
6.
Crawford, C. L. Lancet, 1973, i, 1247.
167.
individuals, those with pharmacologically altered colonic function, and those with diarrhoea] diseases. With the possible exception of the rare childhood disease, acrodermatitis enteropathica,4,5 there is little data to suggest that any of the halogenated hydroxyquinolines is the drug of choice for conditions other than the " carrier " state (asymptomatic cyst passer) of amoebiasis. There is no convincing data to support the use of this class of drugs to treat any of the diarrhoeal diseases, including symptomatic amoebic colitis, for which metronidazole seems to be the drug of choice. There is certainly no indication for these drugs in any type of inflammatory bowel disease or so-called non-specific diarrhoea. In fact, since it now seems almost certain that large doses of halogenated hydroxyquinolines produce severe clinically obvious neurological damage, it must be suspected that the accepted smaller dosage schedules may cause subclinical neurological damage. Until this latter possibility has been ruled out by careful studies in laboratory animals, it seems wise to use the halogenated hydroxyquinolines only when they are unequivocally indicated, and when other acceptable treatment is not available-and then only with extreme caution. This work
supported by grants from the John A. Hartford Foundation, New York; the National Institutes of Health general research support grant RR05420 to the Medical University of South Carolina; the South Carolina State Appropriations for Research; and the Veterans Administration. was
Department of Medicine,
Gastroenterology Division, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina 29401, U.S.A.
FRED E. PITTMAN
MILTON WESTPHAL.
THE PILL, THROMBOEMBOLISM, AND GALLBLADDER DISEASE
SiR,—The statement by Tuerck and Comer (August 11, p. 317) that we excluded pregnant women from the cases but not the controls is incorrect: they were excluded from both comparison groups. Their suggestion that inclusion exclusion of certain age-groups could have led to exaggeration of the differences between the cases and the controls is also incorrect since adjustment was made for the influence of varying pill use with age. We have no data on women below the age of 20 years. or
Boston Collaborative Drug Surveillance Program, 400 Totten Pond Road,
Waltham, Massachusetts 02154, U.S.A.
SAMUEL SHAPIRO.
MEDICAL EDUCATION AND PLAIN ENGLISH
SIR,-Professor Dudley writes (July 28, p. 195): " In that the graduate will have to use plain English to express himself about problems to be communicated from one to another, it can be argued that giving up essays completely is a retreat from the reality around which the examination should test." Shades of Fowler! Is this plain English ? Does this mean that since physicians discourse with one another in English, getting rid of the essay-type question might make such communication more difficult ? Why do those who write about medical education resort to a vocabulary which is both arcane and incomprehensible ? 4. 5. 6.
Cash, R., Berger, C. K. J. Pediat. 1969, 74, 717. Powell, S. J. Bull. N. Y. Acad. Med. 1971, 47, 269. Lancet, 1973, i, 1399.
" strucDoes everything in medical education have to be " formulated " ? Cannot we be spared from tured " or " factual bases ", " problem solving ", " heuristic apIf proaches ", " data banks ", " feed-back loops ", &c.? medical educators write so that they can only be understood by one another, they will suffer the fate of the Mandarins.
School of Medicine, West Virginia University, West
Morgantown, Virginia 26506, U.S.A.
W. K. C. MORGAN.
TREATMENT OF ERYTHEMA NODOSUM LEPROSUM WITH THALIDOMIDE p.
SIR, The letter by Dr Levy and his colleagues (Aug. 11, 324) and the use of thalidomide in the management of
erythema following
nodosum
leprosum (E.N.L.) necessitate the
comments.
How serious a complication is E.N.L.? The following conclusions are drawn from personal observation of 14 patients (7 from Zaria, Northern Nigeria, and 7 from Dar es Salaam, Tanzania) and from the literature on the
subject: (1) 6 of the Nigerian patients came from an area where 180 lepromatous patients were being treated as outpatients, giving a frequency of the complication of about 3%. (2) All 14 had at some time recurrent bouts of fever, with generalised subcutaneous nodules, lasting 48 hours. In those taking once-weekly dapsone this occurred at weekly intervals. (3) In 10, clinical examination of the peripheral nervous system showed no motor or sensory loss, although there was thickening of the nerves in some of them. 4 had a sensory polyneuropathy typical of late lepromatous leprosy. In 2 it was mild, while in the other 2 it was severe; 1 had an ulcer on the foot, and the second had extensive involvement of the legs and hands and the tips of the fingers were lost. 3 of these same 4 also had recurrent bouts of pain and tenderness in the ulnar nerve at the elbow with the same time sequence as the E.N.I. (4) No patients were observed with iritis, arthritis, or orchitis. These complications are also not reported in trials assessing the efficacy of drugs against E.N.L. (5) Clofazimine was not available for the Nigerian patients, and they were managed with low-dosage dapsone (12-5-75 mg. 1 patient was once weekly) and prednisone (2-5-7-5 mg. daily). given 15 mg. daily. Occasional small doses of ’Fantorin’ (antimony compound) were also given. E.N.L. was not completely suppressed but there was little discomfort and the patients were able to be discharged to the huts in the leprosarium. 1 patient was admitted with an ulcerating E.N.L. and this was the only episode seen. Thus, low-dosage dapsone does seem to reduce the severity of E.N.L., and this view is supported by Davey and Jopling. No patient showed any increase in skin infiltration or rise in the bacillary index on this regimen. The most difficult problem in management was the ulnar mononeuritis. In 1 patient local injections of cortisone were given round the nerve at the beginning of treatment. The symptoms then disappeared and there was no functional loss. Another patient, however, had persistent pain and tenderness in the nerve with progressive motor and sensory loss. 5 of the 7 Tanzanian group were changed from dapsone and prednisone to clofazimine with suppression of the E.N.L. All were managed as outpatients. None had ulnar mononeuritis. The effectiveness of clofazimine in suppressing E.N.L. is well documented.3-5 In the remaining 2 all chemo-
therapy was stopped.6 (6) E.N.L. occurs commonly
in the absence of a mononeuritis. also occur in both lepromatous and nonlepromatous patients while taking dapsone. Dr Levy and his colleagues also point out that thalidomide had little effect on ulnar neuritis in 1 patient compared to the E.N.L. The cause of the mononeuritis is therefore probably different. Sensory poly-
Mononeuritis
can
1. 2. 3. 4. 5.
Crawford, C. L. Lep. Rev. 1969, 40, 159. Davey, T. F., Jopling, W. H. ibid. 1965, 26, 186. Hastings, R. C., Trautman, J. R. ibid. 1968, 39, 3. Imkamp, F. M. J. H. ibid. p. 119. Helmy, H. S., Pearson, J. M. H., Waters, M. F. R. ibid. 1971, 42,
6.
Crawford, C. L. Lancet, 1973, i, 1247.
167.