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CHLORHEXIDINE AND Proteus rettgeri INFECTION
1287 were correct at the time my letter was written and submitted last November. That these figures are now out of date for the British Heartyournal is attributable to a delay, albeit unavoidable, in publication ! San Francisco, U.S.A.
*** We add
our own
D. E. L. WILCKEN. apologies.-ED. L.
MEDICAL EMIGRATION
SIR,-In view of Dr. R. H. Davison’s article in your May 20, and the leading article in The Times of May 20, the following information may interest your readers. Between July 1, 1955, and June 30, 1960, 11,000 assisted British migrants and 19,000 alien migrants arrived in Western Australia. During this period about 150 doctors qualified in the British Isles registered in the State. British migrants who paid their own fares are not included in this total, and the alien migrant figure includes visitors. It is unlikely that more than a few doctors would come here for educational reasons during this period, and study of the State Register shows that the great majority are still in practice in this State. As it is necessary to re-register each year in Australia, it should not be difficult to discover the overall picture of medical migration to this country issue of
from careful studv of the State Registers. School of Medicine, University of Western Australia, Perth.
J. D. MARTIN.
CHLORHEXIDINE AND Proteus rettgeri INFECTION SIR,-We agree with Dr. Lubsen and his colleagues (April 29) that chlorhexidine is less active against proteus,
especially Pr. rettgeri, than against most other urinary pathogens. This may be related to the increase of proteus infections which they have observed. But we suggest that their experience is an indication for reviewing the methods of using chlorhexidine and not for abandoning it. No disinfectant is perfect. One of the shortcomings of chlorhexidine is its relatively slow action against proteus. But its action can be enhanced by mixing it with other agents. The finding that mercuric oxycyanide (itself a poor disinfectant) increased the bactericidal action of chlorhexidine against a variety of bacteria, including the few proteus strains which were tested, led us to recommend a mixed aqueous solution of chlorhexidine 1/5000 and mercuric oxycyanide 1/2000 for disinfecting non-boilable cystoscopes.1 Subsequently chlorhexidine 1/200 in 70% alcohol was found more convenient.2 Both methods have proved reliable in practice. Chlorhexidine is partly inhibited by organic matter (another shortcoming common to many disinfectants). Its bactericidal action in broth is therefore not a good indication of its value in disinfecting cystoscopes, which should first be rinsed in water. No disinfectant by itself can be relied on to prevent urinary infection after prostatectomy. An integrated scheme of precautions is necessary, as Dr. Stewart and his colleagues point out (May 13). The value of a disinfectant can best be judged by the results of such a scheme in which it is included. In the system introduced in Bristol in November, 1957, chlorhexidine is the principal disinfectant and is used in conjunction with aseptic drainage and irrigation of the bladder. Postoperative urinary infection fell from 83% to 6%.3 Moreover, we have not observed any increase of proteus in the few infections which still occur, and the incidence of Pr.rettgeri has actually diminished. Of 54 unselected proteus strains isolated before November, 1957, 21 (39%) were Pr. rettgeri, compared with 1 (3%) of 32 strains examined recently. 1. Miller, A., Gillespie, W. A., Linton, K. B., Mitchell, J. P., Slade, N.
Lancet, 1958, ii, 608. Miller, A., Gillespie, W. A., Linton, K. B., Mitchell, J. P., Slade, N. ibid. 1960, i, 310. 3. Gillespie, W. A., Linton, K. B., Miller, A., Slade, N. J. clin. Path. 1960, 13, 187. 2.
These results, and those obtained by Beeuwkes and de Vries4 and by Paterson et a1.,5 show chlorhexidine to be a valuable disinfectant in urology and gynaecology. It certainly should not be abandoned until something better is available and has been proved by thorough clinical trial. W. A. GILLESPIE K. B. LINTON A. MILLER Bristol Royal Infirmary, J. P. MITCHELL and N. SLADE. Southmead Hospital, Bristol. THE INCIDENCE AND CYTOLOGY OF DIFFERENT MYELOMA TYPES
SiR,—The preliminary communication from Waldenstrom, Paraskevas, and Heremans, drawing attention to the difference in age-incidence of their " ylA-globulin " type myeloma from the y myeloma, prompts me to draw attention to fig. 7 of my article 6 in The Lancet, an article to which they refer. This shows clearly that in our series the average ageincidence of patients showing an excess of P-globulin (probably the equivalent of the " YiA’glooulin " of Waldenstrom and his colleagues) is significantly lower than the age of patients showing excess of y-globulin. Indeed, of the P myelomata only four out of twenty-one were over 60 and nine were under 45. The general trend, therefore, seems to be in line with the Malmö findings. St.
Chemical Pathology Department, George’s Hospital Medical School, London, S.W.1.
NICHOLAS H. MARTIN.
AMITRIPTYLINE IN DEPRESSION
SIR,-Previous correspondence in your columns, on the difficulties and uncertainties surrounding the administration of the large and increasing numbers of psychotropic drugs, prompts me to report on amitriptyline hydrochloride (’ Tryptizol ’), a new antidepressant drug recently released to hospitals, which resembles imipramine hydrochloride (’ Tofranil ’) in its structure and action. These are the results of a preliminary uncontrolled study of the action, side-effects, and complications of the drug in 74 patients with depression. 49 women and 25 men were treated. Their ages ranged from 18 to 73 years, and the specific diagnoses were: endogenous depression (50), involutional depression (6), reactive depression (18). No schizophrenics were included. 22 depressed manic-depressives (44%), 5 (83%) of the involutional depressives, and 6 (33%) of the reactive depressives were definitely improved: symptoms of depression disappeared completely, and the patient resumed his normal activities. 11 patients who definitely improved had failed to respond satisfactorily to previous electroconvulsive therapy. Besides its antidepressive action amitriptyline has a strong sedative effect which relieves depressive insomnia and
agitation. An effective dose is 50 mg. three times a day by mouth, but it is probably advisable to start with a dose of 25 mg. t.d.s. for four or five days to reduce the side-effects. Depressive symptoms are not usually relieved until ten to fourteen days have passed. Many patients notice no side-effects, while others (mainly the reactive depressives) complain particularly of drowsiness, which led 10% of them to abandon the drug. This symptom abates rapidly if the patient can be persuaded to continue treatment. Dryness of the mouth is common, constipation and excessive perspiration less frequent. Blurring of vision, heartburn, and difficulty in micturition are rare complications. No hypotensive effects were observed, but giving more than 25 mg. t.d.s. to elderly patients is not recommended. Beeuwkes, H., de Vries, H. R. Lancet, 1956, ii, 913. Paterson, M. L., Barr, W., Macdonald, S. J. Obst. Gynœc. Brit. Commonw. 1960, 67, 394. 6. Lancet, Feb. 4, 1961, p. 237.
4. 5.
*** We add
our own
D. E. L. WILCKEN. apologies.-ED. L.
MEDICAL EMIGRATION
SIR,-In view of Dr. R. H. Davison’s article in your May 20, and the leading article in The Times of May 20, the following information may interest your readers. Between July 1, 1955, and June 30, 1960, 11,000 assisted British migrants and 19,000 alien migrants arrived in Western Australia. During this period about 150 doctors qualified in the British Isles registered in the State. British migrants who paid their own fares are not included in this total, and the alien migrant figure includes visitors. It is unlikely that more than a few doctors would come here for educational reasons during this period, and study of the State Register shows that the great majority are still in practice in this State. As it is necessary to re-register each year in Australia, it should not be difficult to discover the overall picture of medical migration to this country issue of
from careful studv of the State Registers. School of Medicine, University of Western Australia, Perth.
J. D. MARTIN.
CHLORHEXIDINE AND Proteus rettgeri INFECTION SIR,-We agree with Dr. Lubsen and his colleagues (April 29) that chlorhexidine is less active against proteus,
especially Pr. rettgeri, than against most other urinary pathogens. This may be related to the increase of proteus infections which they have observed. But we suggest that their experience is an indication for reviewing the methods of using chlorhexidine and not for abandoning it. No disinfectant is perfect. One of the shortcomings of chlorhexidine is its relatively slow action against proteus. But its action can be enhanced by mixing it with other agents. The finding that mercuric oxycyanide (itself a poor disinfectant) increased the bactericidal action of chlorhexidine against a variety of bacteria, including the few proteus strains which were tested, led us to recommend a mixed aqueous solution of chlorhexidine 1/5000 and mercuric oxycyanide 1/2000 for disinfecting non-boilable cystoscopes.1 Subsequently chlorhexidine 1/200 in 70% alcohol was found more convenient.2 Both methods have proved reliable in practice. Chlorhexidine is partly inhibited by organic matter (another shortcoming common to many disinfectants). Its bactericidal action in broth is therefore not a good indication of its value in disinfecting cystoscopes, which should first be rinsed in water. No disinfectant by itself can be relied on to prevent urinary infection after prostatectomy. An integrated scheme of precautions is necessary, as Dr. Stewart and his colleagues point out (May 13). The value of a disinfectant can best be judged by the results of such a scheme in which it is included. In the system introduced in Bristol in November, 1957, chlorhexidine is the principal disinfectant and is used in conjunction with aseptic drainage and irrigation of the bladder. Postoperative urinary infection fell from 83% to 6%.3 Moreover, we have not observed any increase of proteus in the few infections which still occur, and the incidence of Pr.rettgeri has actually diminished. Of 54 unselected proteus strains isolated before November, 1957, 21 (39%) were Pr. rettgeri, compared with 1 (3%) of 32 strains examined recently. 1. Miller, A., Gillespie, W. A., Linton, K. B., Mitchell, J. P., Slade, N.
Lancet, 1958, ii, 608. Miller, A., Gillespie, W. A., Linton, K. B., Mitchell, J. P., Slade, N. ibid. 1960, i, 310. 3. Gillespie, W. A., Linton, K. B., Miller, A., Slade, N. J. clin. Path. 1960, 13, 187. 2.
These results, and those obtained by Beeuwkes and de Vries4 and by Paterson et a1.,5 show chlorhexidine to be a valuable disinfectant in urology and gynaecology. It certainly should not be abandoned until something better is available and has been proved by thorough clinical trial. W. A. GILLESPIE K. B. LINTON A. MILLER Bristol Royal Infirmary, J. P. MITCHELL and N. SLADE. Southmead Hospital, Bristol. THE INCIDENCE AND CYTOLOGY OF DIFFERENT MYELOMA TYPES
SiR,—The preliminary communication from Waldenstrom, Paraskevas, and Heremans, drawing attention to the difference in age-incidence of their " ylA-globulin " type myeloma from the y myeloma, prompts me to draw attention to fig. 7 of my article 6 in The Lancet, an article to which they refer. This shows clearly that in our series the average ageincidence of patients showing an excess of P-globulin (probably the equivalent of the " YiA’glooulin " of Waldenstrom and his colleagues) is significantly lower than the age of patients showing excess of y-globulin. Indeed, of the P myelomata only four out of twenty-one were over 60 and nine were under 45. The general trend, therefore, seems to be in line with the Malmö findings. St.
Chemical Pathology Department, George’s Hospital Medical School, London, S.W.1.
NICHOLAS H. MARTIN.
AMITRIPTYLINE IN DEPRESSION
SIR,-Previous correspondence in your columns, on the difficulties and uncertainties surrounding the administration of the large and increasing numbers of psychotropic drugs, prompts me to report on amitriptyline hydrochloride (’ Tryptizol ’), a new antidepressant drug recently released to hospitals, which resembles imipramine hydrochloride (’ Tofranil ’) in its structure and action. These are the results of a preliminary uncontrolled study of the action, side-effects, and complications of the drug in 74 patients with depression. 49 women and 25 men were treated. Their ages ranged from 18 to 73 years, and the specific diagnoses were: endogenous depression (50), involutional depression (6), reactive depression (18). No schizophrenics were included. 22 depressed manic-depressives (44%), 5 (83%) of the involutional depressives, and 6 (33%) of the reactive depressives were definitely improved: symptoms of depression disappeared completely, and the patient resumed his normal activities. 11 patients who definitely improved had failed to respond satisfactorily to previous electroconvulsive therapy. Besides its antidepressive action amitriptyline has a strong sedative effect which relieves depressive insomnia and
agitation. An effective dose is 50 mg. three times a day by mouth, but it is probably advisable to start with a dose of 25 mg. t.d.s. for four or five days to reduce the side-effects. Depressive symptoms are not usually relieved until ten to fourteen days have passed. Many patients notice no side-effects, while others (mainly the reactive depressives) complain particularly of drowsiness, which led 10% of them to abandon the drug. This symptom abates rapidly if the patient can be persuaded to continue treatment. Dryness of the mouth is common, constipation and excessive perspiration less frequent. Blurring of vision, heartburn, and difficulty in micturition are rare complications. No hypotensive effects were observed, but giving more than 25 mg. t.d.s. to elderly patients is not recommended. Beeuwkes, H., de Vries, H. R. Lancet, 1956, ii, 913. Paterson, M. L., Barr, W., Macdonald, S. J. Obst. Gynœc. Brit. Commonw. 1960, 67, 394. 6. Lancet, Feb. 4, 1961, p. 237.
4. 5.