544

published on 33 patients.1 We used a titrimetric techniquewhich we consider better in many ways than the colorimetricmethod of de la Huerga et al. Out of 16 patients treated withecothiophate iodide, 9 developed general symptoms of intoxica-tion. It is important to emphasise that the mental and gastro-intestinal symptoms in particular may give rise to difficulties indifferential diagnosis if the pseudocholinesterase activity is notconsidered. Symptoms of intoxication usually do not appearuntil the level of pseudocholinesterase activity has decreased to20-30% of the initial value-it must be emphasised that notthe absolute but the relative value is the most important, andthat the speed of reduction of pseudocholinesterase activity isespecially important.

FINN SPIERSPER JUUL.

Departments of Ophthalmology andClinical Chemistry,

Central County Hospital,Nykøbing Falster, Denmark.

THE CARPAL-TUNNEL SYNDROME

SIR,-The Lancet has said that " when a disease has manydifferent treatments none of them are likely to be much good ".2 2

Despite your twenty-two authorities I have never seen apatient with a painful swollen hand who required operation onthe wrist. In every case the condition subsided as soon as I

splinted the wrist by the method I have illustrated before 4

which leaves the fingers free.I have seen patients whose acutely painful hands with numb

fingers were not immediately relieved by release of pressure.Often both wrists are involved; often operation on one wrist isfollowed by acute pain and swelling in the other; often thepatient gives a history of attacks of acute rheumatoid arthritisin other joints; often I see patients with rheumatoid arthritis ofknees, feet, fingers, or shoulders who have had one or bothwrists operated on.Rheumatoid arthritis is a common disease and the wrist is its

commonest site. The extreme pain is worse on movement andprevents the patient from using his fingers. The hand dropsand the fingers are held straight; the dropped wrist presses onthe median nerve. But this " pressure

" is not an acute surgicalemergency-operation means traumatising tissues alreadyinflamed and requiring rest.

MICHAEL KELLY.

Institute of Rheumatology,East Melbourne,

Victoria, Australia.

THE ADDICTION EPIDEMIC

SIR,-We have been treating the occasional heroin addictat Spelthorne St. Mary since the beginning of the century,using a technique of tapered withdrawal and long-termrehabilitation. We have been disquieted at the rapid increaseduring the past few years of the number of heroin addicts sentto us, and at the youthful age of most; it has been even moredisquieting to find that, without exception, all have obtainedsupplies from addicts who were getting heroin on prescriptionfrom a handful of sympathetic doctors, and that most have later" registered " with the same doctors and sold a surplus in theirturn. Quite recently two girls have said to me, without collusionbut in almost identical words: " But, Sister, there is no blackmarket, except us and the doctors we get it from ".We are still in touch with a number of ex-addicts who have

done well since leaving us years ago; but many of the youngsterswho have passed through our hands during these past yearshave absconded after their withdrawal, and have returned totheir former haunts-and practices.

It is greatly hoped that legislation may provide for a centrallyplaced clinic where alone addicts may obtain a necessaryminimal dose pending withdrawal and rehabilitation. Thiswould at least prevent addicts from going to several doctors atonce, and from forging prescriptions; moreover it should help

1. Spiers, F., Juul, P. Acta ophthal. 1964, 42, 696.2. Lancet, 1963, ii, 77.3. ibid. July 17, 1965, p. 118.4. Kelly, M. ibid. 1954, i, 1158; ibid. 1960, i, 1296.

to make it possible to find out whence new addicts had obtainedtheir supply, and to relieve private doctors of a very graveresponsibility.

PATRICIA, C.S.M.V.Sister Superior.

Spelthorne St. Mary,Egham, Surrey.

AMITRIPTYLINE POISONING

SIR,-We should like to add our own experience to the fewdocumented cases of amitriptyline poisoning, for we feel thatthere is a strong likelihood of this condition becoming morecommon in the future.

A married woman, aged 24, was brought into the casualtydepartment at 9.40 P.M. about 2 hours after swallowing a largenumber of amitriptyline tablets. The total dose was never

accurately established, but it was almost certainly between1000 and 1500 mg. She had been prescribed 25 mg. three timesa day by her doctor for recurrent bouts of depression which hadstarted some 6 years earlier and had recently become moresevere.

In casualty she was reported to be conscious, pulse 72 perminute, and blood-pressure 120/75 mm. Hg. Her stomach waswashed out, but no tablets were recovered. She was admittedto the ward at 10.30 P.M., when she became unconscious,responding only to painful stimuli. Axillary temperature was97°F, pulse 110 per minute, blood-pressure 135/80, and

respirations regular at 24 per minute. Pupils were equal,normal in size, and reactive to light. Reflexes were brisk, andboth plantar reflexes were extensor. During the initial 2-3hours she had frequent clonic spasms with considerable twitch-ing muscular activity. The bladder was catheterised, a

pharyngeal airway was inserted, and forced diuresis was

immediately instituted with 500 ml. of 10% mannitol intra-venously followed by rapid infusion of isotonic dextrose/physiological-saline solution. She was given a total of 3500 ml.of fluid in the lst 6 hours, but unfortunately total urine outputwas not recorded. 4 hours after the start of therapy her blood-pressure had fallen to 100/70 and her pulse had risen to 130 perminute; involuntary muscular activity had ceased, and herpupils were dilated and failed to react to light. Her blood-

pressure was corrected and maintained at 120 mm. systolic bythe addition of metaraminol to the intravenous infusion.

Despite this improvement her tachycardia persisted for somehours.

12 hours after admission she regained consciousness. Intra-venous fluids and vasopressors were discontinued, and shebegan taking oral fluids. 24 hours later she had fully recovered,apart from a moderately severe headache and a low-gradepyrexia which lasted for another day. At no time was her

respiration impaired or depressed to such an extent thatartificial assistance was thought to be necessary.The most interesting feature of this case was the atropine-

like effect of amitriptyline poisoning-central-nervous-systemirritability, tachycardia, and hypotension. The absence of thesefeatures, and the pronounced respiratory depression seen in thecase reported by Dr. Stark and Dr. Bethune (Aug. 21) mayhave been due to the barbiturate poisoning also present in theirpatient. In our case the very rapid onset of coma and the almostequally rapid response to forced diuresis instituted at an earlystage may be worth noting. It seems possible that the attemptto wash out the stomach may have accelerated the absorptionof amitriptyline.

Although recovery has been the rule among those casesalready reported we believe forced diuresis to be valuable.Death has occurred only in cases where it has not been used.

T. W. LLOYDD. R. HART.

Gloucestershire Royal Hospital,Gloucester.

SIR,-Dr. Stark and Dr. Bethune describe a case of

recovery following poisoning with amitriptyline (’Tryptizol’),four previous cases only having been recorded. The followingis a report of a similar case which came under our care recently.A 65-year-old man was admitted to this hospital in coma,