Tricyclic antidepressants.

Correspondence BRiTISH 301 Tricyclic Antidepressants SIR,-I am worried by one sentence in the article on tricyclic antidepressants (13 April, p. 102): "Jaundice, which is very uncommon , is of the cholestatic type similar to that found in chlorpromazine." This is misleading. Jaundice is one of the more frequent side-effects reported from imipramine and imitrip-tyline, the most widely used members of the group. Its incidence is probably related to the amount of drug prescribed, and is only likely to be "very uncommon" with the newer compounds. I doubt, too, if the jaundice is always of the chlorpromazine type; this implies a cholestatic reaction which is usually benign. Some patients almost certainly have a far more serious hepatic reaction , and death can result from liver-cell SIR,-The summary of Dr. E. Sowton's admirable paper (6 April, p. 11) on pacemakers is misleading. As is clear from the text he has reviewed only implantable pacemakers. His report presumably includes the data which were sent to him describing the experience of the Sheffield Cardiothoracic Unit. With the implanted type of pacemaker we have had failures from wire fractures, pacemaker failure (causing a death), and sepsis. For the past three years we have used the induction type of pacemaker, described by Abrams and his colleagues,' manufactured by Lucas Ltd. This instrument consists of an implanted coil and electrodes, the battery-operated stimulator and primary coil being carried externally. We have had no failure of the implanted unit. The stimulator and its lead are accessible at all times, and all patients carry a spare set in case of failure. They learn a simple drill in the ward after the internal unit is inserted, and are encouraged to regard themselves independent of the centre. All patients living at a distance either consult their own doctor if in difficulties or return faulty components to Lucas themselves. In a region in which patients may live more than 80 miles from the special centre this is important. Other advantages of the induction unit are the controllable rate which is used by our more physiologically minded patients, and the ease with which it can be stopped. Sinus rhythm has returned in two patients while being paced by the induction unit, and a possibly fatal competition between the natural and implanted pacing units has been avoided by removing the artificial stimulus. In the present state of electronic miniature stimulators (Dr. Sowton's survey revealed …