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moment a visiting senior thoracic surgeon walked in from ourother theatre. External cardiac massage was immediatelystarted while the visitor monitored the patient and his anses-thetist passed an endotracheal tube and administered oxygenthrough the Boyle’s machine.

After rather more than one minute of what our experiencedvisitors agreed was correctly performed external massage, nosigns of life had returned. The chest was opened, asystoleconfirmed, the pericardium slit, and massage performed. Aradial pulse and good colour were restored, but the unaidedheart slowly dilated and blood-pressure fell. 3 ml. of 1/40,000adrenaline was injected into the left ventricular cavity, afterwhich no further assistance was required. The chest was closedwith under-water drainage and the patient returned to theward. Six hours later he was able to recognise relatives.During the first night his systolic blood-pressure fell to

70 mm. Hg, and, after a rapid infusion of dextrose had raisedhis venous pressure without any effect on arterial pressure,noradrenaline was added to the infusion, and was required foreighteen hours.On the third day it was clear that physiotherapy was making

no progress against his retained sputum, and tracheotomy wasperformed. Thereafter his progress was unimpeded, and heleft hospital in good health.

This man stated that he was fully grown with a family whenthe Germans left New Guinea in 1914, which would make himmore than seventy years old when he came to us.On a previous occasion I lost a child following a cleft-

palate repair, death occurring without warning at themoment of extubation. External massage was carried outfor almost five minutes before I opened the chest withoutavail. I resolved to make an early decision as to the effec-tiveness of external massage in any future case, and I haveno doubt that this man owes his life to this policy.

J. K. A. CLEZY

Schieffelin LeprosyResearch Sanatorium,Karigiri, (Via) Katpadi,North Arcot, South India.

UROSCREEN AS A DIAGNOSTIC AID IN

URINARY-TRACT INFECTION

S. I. HNATKO.Department of Laboratory Medicine,

Royal Alexandra Hospital,Edmonton, Alberta, Canada.

SiR,ņI have followed with interest the articles and

correspondence 1-7 on the tests used to detect significantbacteriuria. The triphenyltetrazolium-chloride test (T.T.c.)was found the most valuable. I should like to present ourresults on the ’ Uroscreen ’ test (T.T.C.) in support of theuse of this test to determine significant bacteriuria.The uroscreen test (T.T.C. test) (Chas. Pfizer and Co., Inc.,

New York) consists simply of adding 2 ml. of a urine specimen,whether it is the " midstream ", the " clean catch ", or catheterspecimen, into the uroscreen tube which contains a dry,buffered tetrazolium reagent for in-vitro testing of urine. Thespecimen is shaken well until the uroscreen agent is dissolved,and is then incubated at 37°C for four hours. A pink-to-reddeposit denotes a positive test and significant bacteriuria

(100,000 per ml. or more), and a negative test is indicatedeither by absence of a precipitate, or by absence of colour in theprecipitate.

725 specimens of urine were examined under identicalconditions by the uroscreen, pour-plate, and calibrated-loopmethods: 30% yielded counts of greater than 100,000 per ml.Of 218 urines containing more than 100,000 bacteria, 213(97-2%) gave a positive T.T.c. test. Bacterial counts of less than

100,000 per ml. were found in 117 urines, and of these only 2(1-7°0) gave a positive test. Of 66 urines in which the bacterialcounts were between 10,000 and 100,000 per ml., 2 (3%) werepositive.100% correlation was found in urines infected with gram-

1. Simmons, N. A., Williams, J. D. Lancet, 1962, i, 1377.2. Steers, E., Jackson, F. W. ibid. 1963, i, 1267.3. Williams, J. D., Simmons, N. A. ibid. p. 1373.4. Chard, T., Cole, P. G. ibid. 1963, ii, 326.5. Kincaid-Smith, P., Bullen, M., Mills, J., Fussell, U., Huston, N., Goon,

F. ibid. July 11, 1964, p. 61.6. Guze, L. B., Kalmanson, G. M. Amer. J. med. Sci. 1963, 246, 691.7. Deutch, M., Jespersen, H. G. Acta med. scand. 1964, 175, 191.

negative bacilli, whether this was with one species or more thanone. Correlation with bacterial counts was less precise withgram-positive organisms, notably with Staphylococcus aureusand Streptococcus faecalis. There were 7 uroscreen-positivetests where the bacterial count was negative.The tests were easy to read and gave a clear-cut positive or

negative result. Judged by our results, the uroscreen test issuitable for screening the urine of large numbers of patients forsignificant bacteriuria, and should be routinely used in thebacteriological investigation of the urine. The evidence that

only 30% of the urines yielded significant bacteriuria, and thatthe test was accurate and simple, showed the value of this testand the amount of time and money that could be saved by notusing the pour-plate technique.We recommend the test as a diagnostic aid for the

detection of urinary-tract infection. Further results willbe published shortlv.

WHY DON’T WE TELL?

SIR,-I do not remember reading a Leader anywhere-least of all in The Lancet-as smugly hypocritical asyours (Oct. 10). Surely you, Sir, are not so cut off fromthe ways of the world that you do not know why themedical profession-and the public in general-are so

suspicious of the Press.It cannot be coincidence that twice in the past few weeks at

widely different gatherings I have heard the following story.A Bishop travelling abroad was met by reporters at the airport." What do you think of our strip-tease clubs, Bishop ?

" hewas asked. " Do you have strip-tease clubs ?

" was the some-

what naive reply. Next morning the national dailies carriedthe banner headline: " Bishop’s first question: Are there strip-tease clubs in ? "

My purpose in writing is not to defend the actions ofthe Birmingham and Midland Eye Hospital, but to ques-tion the specious implications of your final paragraph.Do you seriously believe that the " intentions of the Pressare almost always good " ? The job of the Press-as weare constantly reminded when it oversteps the bounds ofdecency and privacy-is to sell newspapers. Where

money is concerned truth is hardly a saleable commodity.It is distortion, whether intentional or mistaken, that wefear, and your last sentence should surely have read:

" Asolution must be found: it will come more readily whenthe Press are prepared to give doctors and administrators(and private individuals) the trust-and the true informa-tion-they deserve."

Birmingham, 18. A. PATON.

SiR,ņI agree entirely with Mr. Qvist (Oct. 17). Whatshould be done is to use the Press to drive home to the

public the things that really matter about the hospitalservice.At present the teaching hospitals are turning suitable girls

away because they have not got five 0-level passes, while at thedistrict hospitals nursing recruitment falls, and the situation atmany hospitals is frankly dangerous because of the nursingshortage. Is this the time to introduce nationally a 42-hourweek for nurses, or for schemes for nursing training which willkeep girls away from contact with patients for two years-forthe sake of turning them into inferior doctors ? And why notlet them start at 17 years ?The public ought to be told. Management committees

and regional boards are terrified of publicity. As a

consultant I am getting a little tired of having to spendtime defending the professional reputation of the hospitalover such relative trivia as delays in outpatient clinics orcasualty departments when really serious matters, such

965

E. A. DEVENISH.West Middlesex Hospital,

Isleworth, Middlesex.

as the nursing shortage, obsolete theatres, and non-

existent accident centres, are left unmentioned. Let us usethe power of the Press in a worth-while cause.

CONGENITAL CARDIAC ARRHYTHMIA

INGRID GAMSTORPR. NILSÉNH. WESTLING.

Lasarettet,Lund,Sweden.

SiR,ņYour annotation (July 4) with the ensuingcorrespondence (Sept. 5 and 19) was of great interest tous, because we have had a patient with similar symptoms.A woman, aged 35, was referred to us by Dr. K. Linde-

Andersen, of Hudiksvall, on account of severe syncopalattacks. At the age of 5 or 6 she had had a few syncopal attacks.They came on when she was bathing at the beach, and were sosevere that she needed resuscitation. Thereafter she was in goodhealth until the age of 35, when she began to have syncopalattacks, beginning with vague chest pain and a faint feelingbefore she lost consciousness. The first three attacks occurredwithin 2 days; 3 months then elapsed before the next attack.The patient was at this time overworked, but no other provok-ing factors were apparent. She was seen by a physician in herfourth attack; she was deeply unconscious, pulseless, andcyanotic, but recovered spontaneously. An electrocardiogram(E.C.G.), recorded within an hour of the attack, showed low Twaves and " u " waves. Her serum-potassium, determinedshortly after the attack, was 3-2 mEq. per litre. The attack wasdiagnosed as cardiac arrest due to spontaneous hypopotassxmia,and the patient was given potassium salts. During the following3 months before her admission to the university hospital inLund, she had only mild, infrequent attacks.One of her two sons had died 5 years earlier at the age of 9.

When he was 3 years old the boy began to have sudden attacksof unconsciousness. Physical examination and electroencephalo-graphy revealed no abnormalities. An E.C.G., recorded for thefirst time when the boy was 5 years old, showed low and" broad " T waves. The boy was given potassium chloride,which considerably diminished the frequency and severity ofhis attacks. But, the potassium chloride caused nausea andepigastric pain and was therefore reduced, and finally dis-continued. About a year later the boy died suddenly whilerunning in play.The examination of our patient did not include an audiogram;

but no loss of hearing was apparent, or reported by the patient.The only abnormal findings were a serum-potassium at or

below the lower normal limit (3-0-3-8 mEq. per litre) andabnormal E.C.G. tracings. The E.C.G. recorded at rest (duringpotassium therapy) was usually normal, but sometimes showedflattened or slightly negative T waves and a pronounced positiveafterpotentiall 11 after the second heart-sound. Previousobservations indicate that E.c.G. changes in normal personswith hypopotassxmia due to administration of saluretics canbecome accentuated during exercise. In our patient the E.c.G.during and after exercise became distinctly abnormal, evenwhen the E.C.G. at rest was within normal limits. The E.C.G.

pattern after exercise was similar to that recorded at rest

in the fig. 2 of Fraser et a1.3 and fig. 6b of Jervell and Lange-Nielsen.4 E.C.G. changes during exercise were less pronounced30 minutes after the administration of 5 g. potassium chlorideby mouth.When the patient was admitted she was on continuous

potassium medication, which was slowly reduced. When itwas completely withdrawn the patient had a mild attack, duringwhich unfortunately no E.C.G. was recorded. The E.c.G.

recorded half an hour later showed flattened T waves and

after-potentials, as described above.The patient was discharged and given a mixture of organic

potassium salts, containing 40 mEq. of potassium and 1-2 g.ammonium chloride, four times daily. She has now beenfollowed up for almost 2 years and has remained completelyfree of attacks; but E.C.G. abnormalities, though mild at rest,are still conspicuous during exercise.

1. Cannon, P., Sjostrand, T. Acta med. scand. 1953, 146, 191.2. Christensson, B., Gustafson, A., Westling, H. ibid. 1964, 175, 727.3. Fraser, G. R., Froggatt, P., James, T. N. Quart. J. Med. 1964, 33, 361.4. Jervell, A., Lange-Nielsen, F. Amer. Heart J. 1957. 54, 59.

Meagre as the evidence may be, we regard the findingsin this patient as possible signs of disturbed potassiummetabolism and/or an abnormal sensitivity of the heart toa slight drop in serum-potassium. This is against thegeneral rule that skeletal muscles are more sensitive thanthe heart-muscle to hypopotassaemia. But, since treatmentwith potassium salts and ammonium chloride seemed tobenefit our patient, we suggest that it should be tried inother patients with the same type of symptoms andE.C.G. abnormalities. Our findings also suggest that

E.c.G.-recording during and after exercise may be moresensitive than E.c.-.s at rest in disclosing this type ofabnormality.

TOO MUCH WORK?

NEVILLE JONESHonorary Secretary,

General Practitioners’ Association147, Manor Road,London, E.10.

SIR,-May I add a comment on the article by Dr. Fryand Dr. Dillane (Sept. 19).

Their summing-up states: " A fifteen-year analysis of thework-load of a single general practice shows that the volumeof work has remained remarkably constant, with an averageannual rate of 3-5 attendances per patient." This conclusion

would, from their figures, appear to be perfectly correct asregards doctor-patient contacts per patient per year. Strictlyspeaking, this is the rate of work per patient. Surely, thevolume of work would be more clearly defined as the productof rate of doctor-patient contacts per patient per year and thenumber of patients.The article gave list sizes only in 1947 and in 1964, so we

cannot work out any intermediate figures. What we can say isthat, with the addition of a second doctor to the practice in1955 and of a third in 1961-63, there are bound to have beenvery sharp fluctuations in the volume of work for each. Sinceno details of list size are given for any of the intermediate yearsone cannot show to what extent the authors’ volume of workhas fluctuated.

I do most heartily state, however, that a misleadingimpression of the general practitioner’s work is given ifone talks only of contacts per patient per year and not ofcontacts per patient per year times the number on the list.

INFECTION OF THE EYE

SiR,ņThe reported statement 1 that the loss of an eyeby each of six patients in the Birmingham Eye Hospitalwas due to infection from Pseudomonas pyocyanea indistilled water used for eye irrigation must cause alarm;for distilled water is not synonymous with sterile water.

In Adelaide, in years gone by, a steady trickle of patientssuffered because insufficient attention was paid to asepsis. In1957 proof was obtained that one infection by pyocyanea wasdue to eyedrops contaminated in the hospital pharmacy. Nowall eyedrops are supplied sterile: this is achieved by the use ofthe autoclave, but a few drugs, such as eserine (physostigmine)are steamed to avoid breakdown. Water for injection B.P. isused in the preparation of all drops. Chlorhexidine 0-005%bacteriostatic for Ps. pyocyanea, proteus and Staphylococcuspyogenes, is included where compatible; but for a few eyedrops,such as methyl cellulose, it appears that an effective bacterio-static has yet to be found.2 Sulphate radicals are changed toavoid incompatibility with chlorhexidine and thus permit theinclusion of this drug. Fluorescein solution incorporatesphenylmercuric nitrate 0-004%. Eyedrops are supplied in

1. Daily Telegraph, Sept. 30, 1964.2. Anderson, K. F., Lillie, S., Crompton, D. O. Pharm. J. 1964, i, 593.3. Jeffs, P. L. Sterile Eye Drop Dispensing, Queen Elizabeth Hospital

Formulary, Adelaide, 1962.