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INFARCT THROUGH THE LOOKING-GLASS
266 lowest income per head and the lowest doctor to patient ratio-I can say that the situation is improving year by year, and although there are a few pockets of inadequate medical care these are being filled in. One can predict that there will be no lack of general practitioners or specialists in any area, with probably minor exceptions, in the United States within the next ten years if things are left alone. To use such grand generalisations and comments as those of Professor Beeson as a basis for gleefully saying that what happened to medicine in Great Britain should happen in the United States is agonising and smacks of facile intellectuality that is unnecessary and possibly harmful. Let Professor Beeson come to Mississippi and go with us to one of our out-State clinics some Monday morning and judge the quality of care himself. Division of Neurology, University of Mississippi Medical Center, Jackson, Mississippi 39216, U.S.A.
ROBERT D. CURRIER.
INFARCT THROUGH THE LOOKING-GLASS
SIR,-Few doctors could not diagnose the electrocardiogram in fig. 1 with confidence as of an anterior myocardial infarction. Many, however, might find the one in fig. 2 more troublesome. It is widely appreciated that if leads are placed at diametrically opposite positions over the heart, then the one will be the " reciprocal " of the other. Leads I and aVR, for example, are frequently described as showing reciprocal changes. The reciprocal of a strip may be demonstrated by turning it upside-down (to reverse the positive and negative deflections) and turning it back to front (to put the PQRST deflections back in the correct order). In practice this can easily be done by holding the strip upside-down in front of a mirror and reading it in the mirror. The point of all this is that fig. 1 is not in fact the E.C.G. of an anterior infarction (the P wave was the give-away for obsessionals), but merely the reversed and inverted (reciprocal) leads of fig. 2, the original. The doubters may like to look through from the other side of the paper. a strip, produced in the mirror Thus, if the reciprocal of " as above, is apparently of true anterior infarction ", then the original must by definition be of a " true posterior infarction ". 64 Mallinson Road, London SW11.
GEORGE MEREDITH.
NEUROLOGICAL EXAMINATION AND HEPATITIS B SIR,-A medical student reported to one of us that he had accidentally pricked his finger with the needle which he used during physical examinations to test tactile sensation and that the last patient, examined the previous day, had been positive for hepatitis-B antigen (HBAg). The student had been using this needle routinely for approximately 6 weeks and had tested about 25 patients without 4 of the patients examined once sterilising the needle. had been positive for HBAg and he remembered occasionally drawing trace amounts of blood with the needle, but could not be certain which patients had bled. When one considers that a substantial number of patients admitted to hospital each year are HBAg-positive; that testing tactile sensation by pin-prick is commonly part of a full physical examination; that during such testing one may occasionally draw blood, especially in patients with hepatitis who may be somewhat obtunded and may have a tendency to bleed readily; that even very small amounts of blood can be infective; and that needles used to test tactile sensation are commonly used serially from patient to patient without sterilisation, we regard this procedure as potentially capable of transmitting hepatitis-B virus. The remedy is as simple as the procedure. A separate, disposable needle or pin should be used for each patient, or, if one’s favourite needle must be used, it should be sterilised between patients-preferably by heating to red heat. of Pediatrics and Pathology, McMaster University,
Departments
Hamilton, Ontario, Canada.
R. P. B. LARKE I. O. STEWART.
UREA TREATMENT OF SKIN MALIGNANCIES
SIR,-Professor Danopoulos and Dr Danopolou (Jan. 26, 115) state that this technique " presents some advantages especially when the lesion occurs in certain sites such as the eyelids, canthi, nose, and auricles. Surgery is often ineffective in such cases and radiotherapy is not infrequently followed by complications." I submit that their results49% of histologically proved basal-cell carcinomata cured by the urea technique with an additional 31 % showing a great improvement "-are simply not good enough. The anatomical sites in which they particularly recommend the p.
"
urea
treatment
Fig. l-E.C.G. leads VI-4.
Fig. 2-E.C.G. leads Vl-4.
are
precisely
those where the basal-cell
ROBERT D. CURRIER.
INFARCT THROUGH THE LOOKING-GLASS
SIR,-Few doctors could not diagnose the electrocardiogram in fig. 1 with confidence as of an anterior myocardial infarction. Many, however, might find the one in fig. 2 more troublesome. It is widely appreciated that if leads are placed at diametrically opposite positions over the heart, then the one will be the " reciprocal " of the other. Leads I and aVR, for example, are frequently described as showing reciprocal changes. The reciprocal of a strip may be demonstrated by turning it upside-down (to reverse the positive and negative deflections) and turning it back to front (to put the PQRST deflections back in the correct order). In practice this can easily be done by holding the strip upside-down in front of a mirror and reading it in the mirror. The point of all this is that fig. 1 is not in fact the E.C.G. of an anterior infarction (the P wave was the give-away for obsessionals), but merely the reversed and inverted (reciprocal) leads of fig. 2, the original. The doubters may like to look through from the other side of the paper. a strip, produced in the mirror Thus, if the reciprocal of " as above, is apparently of true anterior infarction ", then the original must by definition be of a " true posterior infarction ". 64 Mallinson Road, London SW11.
GEORGE MEREDITH.
NEUROLOGICAL EXAMINATION AND HEPATITIS B SIR,-A medical student reported to one of us that he had accidentally pricked his finger with the needle which he used during physical examinations to test tactile sensation and that the last patient, examined the previous day, had been positive for hepatitis-B antigen (HBAg). The student had been using this needle routinely for approximately 6 weeks and had tested about 25 patients without 4 of the patients examined once sterilising the needle. had been positive for HBAg and he remembered occasionally drawing trace amounts of blood with the needle, but could not be certain which patients had bled. When one considers that a substantial number of patients admitted to hospital each year are HBAg-positive; that testing tactile sensation by pin-prick is commonly part of a full physical examination; that during such testing one may occasionally draw blood, especially in patients with hepatitis who may be somewhat obtunded and may have a tendency to bleed readily; that even very small amounts of blood can be infective; and that needles used to test tactile sensation are commonly used serially from patient to patient without sterilisation, we regard this procedure as potentially capable of transmitting hepatitis-B virus. The remedy is as simple as the procedure. A separate, disposable needle or pin should be used for each patient, or, if one’s favourite needle must be used, it should be sterilised between patients-preferably by heating to red heat. of Pediatrics and Pathology, McMaster University,
Departments
Hamilton, Ontario, Canada.
R. P. B. LARKE I. O. STEWART.
UREA TREATMENT OF SKIN MALIGNANCIES
SIR,-Professor Danopoulos and Dr Danopolou (Jan. 26, 115) state that this technique " presents some advantages especially when the lesion occurs in certain sites such as the eyelids, canthi, nose, and auricles. Surgery is often ineffective in such cases and radiotherapy is not infrequently followed by complications." I submit that their results49% of histologically proved basal-cell carcinomata cured by the urea technique with an additional 31 % showing a great improvement "-are simply not good enough. The anatomical sites in which they particularly recommend the p.
"
urea
treatment
Fig. l-E.C.G. leads VI-4.
Fig. 2-E.C.G. leads Vl-4.
are
precisely
those where the basal-cell