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URINARY-TRACT INFECTIONS CAUSED BY SALMONELLÆ
1221
thought by Surawicz and Gettes2 to be different from that of hyperkalaemic arrest. Hitherto no instance of the phenomenon has been described in the intact animal or in man, but Dr. Swales’ case seems to fulfil, at least partially, the criteria. Sudden restitution of extracellular potassium in a myocardium with serious intracellular depletion, is the factor common to both-in the case " then, reported, heart-block and bradycardia appeared " instantaneous without warning ..." This parallels the arrest " noted by Surawicz and Gettes.2 was
The E.c.G. in Dr. Swales’
patient was understandably inadequate safeguard against over-rapid infusion ", if one realises the nature of the z.-L. phenomenon. It should not be implied, however, that the E.c.G. failed to "
an
forewarn the clinician of exist.
a
"
Sri Venkateswara Medical College, Tirupati, India.
hyperkalaemia
"
that did
not
R. N. SARMA.
" CHEAP " DRUGS SIR,-Iwas perplexed by the letter (May
22) from Dr. Kalinowski and Dr. Moyes, about tetracycline and chloramphenicol in use in hospitals. Since December, 1962, I have been the medical director in charge of the distribution of tetracycline to all National Health Service hospitals in the United Kingdom, and also to the three Armed Services of the Crown. Since that time some 50,000,000 tablets and capsules of tetracycline have been so distributed under my direction. None of this tetracycline has been of Italian origin. We have no records of any complaint being received from Dr. Moyes or Dr. Kalinowski, or any doctor in the hospital service, concerning an increase in the number of toxic reactions in patients treated with material supplied by us. In fact we have received no complaints whatsoever concerning the tetracycline supplied to hospitals and the Armed Services.
To define the prevalence of urinary infection in a general practice the whole population would need to be screened; such an investigation is at present in progress. It must be appreciated, however, that this is a separate problem, unrelated to the investigation already reported. N. C. MOND A. PERCIVAL Department of Pathology, J. D. WILLIAMS Edgware General Hospital, W. BRUMFITT. Edgware, Middlesex. STERILISATION IN GENERAL PRACTICE SIR,-May I suggest aluminium foil as a suitable wrapping for the sterilising of syringes and instruments
in
medical and surgical wards in the Hull hospitals. Over the past five years all coliform organisms have been checked to see whether any of them were salmonellae; none have been found. Urines from the Infectious Diseases Hospital are of course excluded from this survey. Western General Hull.
Hospital,
J. G. ALEXANDER.
URINARY-TRACT INFECTION IN GENERAL PRACTICE
SIR,-Dr. Stansfeld (March 20) is surprised that the patients studied by us in a general practice (March 6) did
not
include any children under 16 years of age.
We clearly stated that our object was to investigate the significance of symptoms, such as frequency and dysuria, which No are commonly associated with urinary-tract infection. children under the age of 16 complained of these symptoms, and children with non-specific symptoms such as those mentioned by Dr. Stansfeld were not included. In fact, urinary tract-infection commonly occurs in patients who have no symptoms at alp. 56 Furthermore, Kuninhas shown that the majority of children found to be infected on routine screening are symptom-free, although investigation reveals serious renal lesions in a significant proportion. During the course of our own study a child with anaemia was found to have not only bacteriuria but chronic pyelonephritis as well, and another child with enuresis also had bacteriuria. 5. 6. 7.
Kass, E. H. Trans. Ass. Am. Physns, 1956, 69, 56. Brumfitt, W., Percival, A. Br. J. clin. Pract. 1962, 16, 253. Kunin, C. M., Southall, C. I., Paquin, A. J. New Engl. J. Med. 1960, 263, 817.
domestic
pressure-cooker ?
For several years I have used a cooker exactly as Dr. Grahame (May 22) describes, with Browne’s tubes for checking. But I roll the syringes and instruments in a double layer of foil, leaving the ends slightly open; when the cooker is opened, I immediately twist the ends closed with clean fingers, keeping the roll horizontal (to avoid falling contaminants). These individually wrapped syringes and instruments go into soft cases, to prevent chafing and piercing of the foil. They mostly get used within a fortnight, and I have found the wrapping sufficiently durable. I now use nylon syringes, with a needle tucked into a rubber band, or with several needles stowed inside the piston (holes need to be bored to allow steam permeation). These have worked out about three times cheaper than bulk-bought disposables, even allowing for the occasional " bum up "E9 last time, when the cooker boiled dry during Bernard Braden. My wife buys the foil in heavy rolls from a bulkbuying concern. I have not discovered how to do surgical gloves satisfactorily, and I prefer to buy catheters and dressings
presterilised. B. DALTON.
M. C. SOLOMON. URINARY-TRACT INFECTIONS CAUSED BY SALMONELLÆ SIR,-Ihave read with interest the article by Dr. Mitchell (May 22). This laboratory sets up cultures on not less than 350 urines per week from patients in general
a
FLUID REQUIREMENTS IN ASIATIC CHOLERA
SIR,-Iread with interest the comments of Dr. Reid and of Dr. Yahr and Dr. Krakauer (May 22) on my recent joint article (April 3). In regard to Dr. Reid’s observations, I should like to point that the average cholera patient in our study received 4-11 litres of saline during the first 4 hours of treatment. The mean total intravenous fluid requirement was 26-3 litres (range 8-566-4 litres). Therefore, as judged by total intravenous fluid requirements as well as by admission plasma-specific-gravity values, this series represents as severe a group of cholera patients as any yet reported. In regard to the quality of the pulse before therapy, no radial pulse could be felt in 25 of the patients, and a very faint, thready pulse was palpable at the wrist in the remaining 17. Concerning the observations of Dr. Yahr and Dr. Krakauer, we heartily agree that serial measurements of central venous pressure would (as suggested earlier by Dr. Graham Bull 1) provide a more accurate method of determining intravenous fluid requirements in cholera patients. But such measurements would be difficult to obtain under the circumstances in which the majority of cholera patients must be managed. Our feeling is that clinical evaluation, albeit not so precise as serial plasma-specific-gravity determinations2 or measurements of central venous pressure, provides a consistently adequate assessment of fluid requirements for the treatment of adult cholera patients. We would like also to point out that the average weight, after rehydration, of the adult cholera patients included in our study was 42-8 kg. Consequently the mean initial isotonic fluid debt in these patients was considerably in excess of that predicted on the basis of a lean 70 kg. male. out
Department of Medicine, Johns Hopkins Hospital, Baltimore, 5, C. C. J. CARPENTER. Maryland, 21224. 1. Bull, G. SEATO Conference on Cholera; p. 57. Dacca, 1960. 2. Phillips, R. A. Bull. Wld Hlth Org. 1963, 28, 297.
thought by Surawicz and Gettes2 to be different from that of hyperkalaemic arrest. Hitherto no instance of the phenomenon has been described in the intact animal or in man, but Dr. Swales’ case seems to fulfil, at least partially, the criteria. Sudden restitution of extracellular potassium in a myocardium with serious intracellular depletion, is the factor common to both-in the case " then, reported, heart-block and bradycardia appeared " instantaneous without warning ..." This parallels the arrest " noted by Surawicz and Gettes.2 was
The E.c.G. in Dr. Swales’
patient was understandably inadequate safeguard against over-rapid infusion ", if one realises the nature of the z.-L. phenomenon. It should not be implied, however, that the E.c.G. failed to "
an
forewarn the clinician of exist.
a
"
Sri Venkateswara Medical College, Tirupati, India.
hyperkalaemia
"
that did
not
R. N. SARMA.
" CHEAP " DRUGS SIR,-Iwas perplexed by the letter (May
22) from Dr. Kalinowski and Dr. Moyes, about tetracycline and chloramphenicol in use in hospitals. Since December, 1962, I have been the medical director in charge of the distribution of tetracycline to all National Health Service hospitals in the United Kingdom, and also to the three Armed Services of the Crown. Since that time some 50,000,000 tablets and capsules of tetracycline have been so distributed under my direction. None of this tetracycline has been of Italian origin. We have no records of any complaint being received from Dr. Moyes or Dr. Kalinowski, or any doctor in the hospital service, concerning an increase in the number of toxic reactions in patients treated with material supplied by us. In fact we have received no complaints whatsoever concerning the tetracycline supplied to hospitals and the Armed Services.
To define the prevalence of urinary infection in a general practice the whole population would need to be screened; such an investigation is at present in progress. It must be appreciated, however, that this is a separate problem, unrelated to the investigation already reported. N. C. MOND A. PERCIVAL Department of Pathology, J. D. WILLIAMS Edgware General Hospital, W. BRUMFITT. Edgware, Middlesex. STERILISATION IN GENERAL PRACTICE SIR,-May I suggest aluminium foil as a suitable wrapping for the sterilising of syringes and instruments
in
medical and surgical wards in the Hull hospitals. Over the past five years all coliform organisms have been checked to see whether any of them were salmonellae; none have been found. Urines from the Infectious Diseases Hospital are of course excluded from this survey. Western General Hull.
Hospital,
J. G. ALEXANDER.
URINARY-TRACT INFECTION IN GENERAL PRACTICE
SIR,-Dr. Stansfeld (March 20) is surprised that the patients studied by us in a general practice (March 6) did
not
include any children under 16 years of age.
We clearly stated that our object was to investigate the significance of symptoms, such as frequency and dysuria, which No are commonly associated with urinary-tract infection. children under the age of 16 complained of these symptoms, and children with non-specific symptoms such as those mentioned by Dr. Stansfeld were not included. In fact, urinary tract-infection commonly occurs in patients who have no symptoms at alp. 56 Furthermore, Kuninhas shown that the majority of children found to be infected on routine screening are symptom-free, although investigation reveals serious renal lesions in a significant proportion. During the course of our own study a child with anaemia was found to have not only bacteriuria but chronic pyelonephritis as well, and another child with enuresis also had bacteriuria. 5. 6. 7.
Kass, E. H. Trans. Ass. Am. Physns, 1956, 69, 56. Brumfitt, W., Percival, A. Br. J. clin. Pract. 1962, 16, 253. Kunin, C. M., Southall, C. I., Paquin, A. J. New Engl. J. Med. 1960, 263, 817.
domestic
pressure-cooker ?
For several years I have used a cooker exactly as Dr. Grahame (May 22) describes, with Browne’s tubes for checking. But I roll the syringes and instruments in a double layer of foil, leaving the ends slightly open; when the cooker is opened, I immediately twist the ends closed with clean fingers, keeping the roll horizontal (to avoid falling contaminants). These individually wrapped syringes and instruments go into soft cases, to prevent chafing and piercing of the foil. They mostly get used within a fortnight, and I have found the wrapping sufficiently durable. I now use nylon syringes, with a needle tucked into a rubber band, or with several needles stowed inside the piston (holes need to be bored to allow steam permeation). These have worked out about three times cheaper than bulk-bought disposables, even allowing for the occasional " bum up "E9 last time, when the cooker boiled dry during Bernard Braden. My wife buys the foil in heavy rolls from a bulkbuying concern. I have not discovered how to do surgical gloves satisfactorily, and I prefer to buy catheters and dressings
presterilised. B. DALTON.
M. C. SOLOMON. URINARY-TRACT INFECTIONS CAUSED BY SALMONELLÆ SIR,-Ihave read with interest the article by Dr. Mitchell (May 22). This laboratory sets up cultures on not less than 350 urines per week from patients in general
a
FLUID REQUIREMENTS IN ASIATIC CHOLERA
SIR,-Iread with interest the comments of Dr. Reid and of Dr. Yahr and Dr. Krakauer (May 22) on my recent joint article (April 3). In regard to Dr. Reid’s observations, I should like to point that the average cholera patient in our study received 4-11 litres of saline during the first 4 hours of treatment. The mean total intravenous fluid requirement was 26-3 litres (range 8-566-4 litres). Therefore, as judged by total intravenous fluid requirements as well as by admission plasma-specific-gravity values, this series represents as severe a group of cholera patients as any yet reported. In regard to the quality of the pulse before therapy, no radial pulse could be felt in 25 of the patients, and a very faint, thready pulse was palpable at the wrist in the remaining 17. Concerning the observations of Dr. Yahr and Dr. Krakauer, we heartily agree that serial measurements of central venous pressure would (as suggested earlier by Dr. Graham Bull 1) provide a more accurate method of determining intravenous fluid requirements in cholera patients. But such measurements would be difficult to obtain under the circumstances in which the majority of cholera patients must be managed. Our feeling is that clinical evaluation, albeit not so precise as serial plasma-specific-gravity determinations2 or measurements of central venous pressure, provides a consistently adequate assessment of fluid requirements for the treatment of adult cholera patients. We would like also to point out that the average weight, after rehydration, of the adult cholera patients included in our study was 42-8 kg. Consequently the mean initial isotonic fluid debt in these patients was considerably in excess of that predicted on the basis of a lean 70 kg. male. out
Department of Medicine, Johns Hopkins Hospital, Baltimore, 5, C. C. J. CARPENTER. Maryland, 21224. 1. Bull, G. SEATO Conference on Cholera; p. 57. Dacca, 1960. 2. Phillips, R. A. Bull. Wld Hlth Org. 1963, 28, 297.