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RUPTURE OF THE INTERVENTRICULAR SEPTUM ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION
404 The theoretical advantage of increased venous return from the lower part of the body is obviously nullified by other factors. The slight decrease in arterial blood-pressure may be secondary to interference with the respiratory pump,10 or due to the carotid baroreceptors interpreting " the total intravascular pressure at that site as representative of the general vis a tergo. Department of Pediatrics, WARREN G. GUNTHEROTH University of Washington School of Medicine, MÜFIT M. ARCASOY. Seattle, U.S.A.
started by the patient if there are premonitory twinges of pain. I associate myself strongly with the view of Braham and Saia that no patient should be submitted to radical treatment without an adequate trial of phenytoin. With this first major advance in the drug therapy of tic douloureux it is to be hoped that alcohol injection and surgical extirpation of the trigeminal nerve will soon be
DIAGNOSIS OF ACUTE APPENDICITIS: THREE PHYSICAL SIGNS
RUPTURE OF THE INTERVENTRICULAR SEPTUM ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION
"
SIR,-In the hope of making this diagnosis more certain, the three following physical signs are offered, because they have been found to be very reliable in practice. I have not found them described in textbooks or elsewhere, and they have proved valuable in cases of doubt. Caecal gurgling.-Sometimes palpation of the right iliac fossa leads to palpable gurgling of the underlying caecum. When this is present it has been found that there has never been acute inflammation in the appendix. Acute appendicitis seems to be associated with conditions either in the cxcum itself, or in the overlying abdominal wall, preventing any gurgling in the caecum. Tenderness on movement.-In the case of children with suspected acute "appendicitis it is helpful to stand them up and get them to jump on the spot". If there is no increase in the pain in the right iliac fossa nor stabs of pain occurring at each jump, acute appendicitis is not present. Stethoscope tenderness.-When a patient is examined for the first time, tenderness in the right iliac fossa is a frequent finding and not necessarily indicative of underlying inflammation. Even when all the usual measures are taken to relax the abdominal wall, such as bending the knees, warming the hands of the examiner, and feeling through a layer of clothing, tenderness may sometimes persist when there is no underlying organic cause. On such an occasion palpating the abdomen by means of pressing the bell of the stethoscope on the abdomen is often a help. Tenderness revealed by such a method is real tenderness, indicating inflammation. Another advantage of the method is that it enables any real tenderness present to be accurately localised. This sign is a great help in children and infants, particularly those who are crying when first seen. Dudley Road Hospital, P. GILROY BEVAN. Birmingham.
PHENYTOIN IN THE TREATMENT OF TRIGEMINAL NEURALGIA SIR,-The paper by Dr. Braham and Dr. Saia 11 is a welcome addition to the British literature on this subject, which has been well reviewed in Continental and American
publications. Credit is due to some earlier reports.12-1õ The use of phenytoin (’ Epanutin ’,Dilantin ’, diphenylhydantoin) was pioneered in Germany by Albrecht and Krump 13 and Winiker-Blank,12 and later in America by Ende 14 and King.ls King also commented on the use of mephenesin alone and in combination with phenytoin. Ianone et al.16 pointed out the latent period of 24-36 hours before the drug achieves its full therapeutic effect. My experience of 9 cases of tic douloureux and 4 of postherpetic neuralgia dates from August, 1958, and parallels that of Braham and Saia. Phenytoin in combination with phenobarbitone seems to increase drug toxicity with no increase in therapeutic effect. The dose may be at least double that suggested by Braham and Saia, with a corresponding increase in effect, which is particularly useful in bringing a bad attack under control. Continuous therapy for months on end is not necessary; treatment may be 10. Altschule, M. D. Anesthesiology, 1943, 4, 385. 11. Braham, J., Saia, A. Lancet, 1960, ii, 892. 12. Winiker-Blank, E. Dtsch. Stomatol. 1955, 5, 321. 13. Albrecht, K., Krump, J. Münch. Med. Wschr. 1954, 96, 1037. 14. Ende, M. Virgin. med. Mon. 1957, 84, 358. 15. King, R. B. J. Neurosurg. 1958, 15, 290. 16. Ianone, A., Baker, A. B., Morrell, F. Neurology, 1958, 8, 126.
eliminated. HOWARD S. REEVE, REEVE.
London, S.E.10.
SIR,-Iread Dr. Schiller’s paperwith interest. We published a paper on the same subject some years ago,2 One of our conclusions was that the systolic murmur pathognomonic of ruptured interventricular septum can be heard until the last moment of the patient’s life, even when heart. be discerned. Since then I have seen and confirmed this observation in all. This finding may be a diagnostic feature of rupture of the inter. ventricular septum associated with acute myocardial infarction, Department of Internal Medicine A, Rambam Government Hospital, HARRY BASSAN. Haifa, Israel.
sounds several
can no
longer
more cases
Parliament Undermining
or
Underpinning ?
ON Feb. 8 Mr. GEORGE BROWN moved a vote of censure deploring the proposed increases in N.H.S. charges and contribution because they indicated the Government’s determination " to undermine the National Health Service and to place heavy burdens on those least able to bear them".", Mr. Brown described the service as a noble edifice that needed a great and imaginative architect for its improvement and continuation. Instead we had a quantity surveyor. As a result we had descended from the real problems to fiddling about with quantities and bills of cost. The Minister rested his case on the rising cost of the service, If it went higher, we should have to stop having desirable things. But Mr. Brown pointed out that at a round E860 million it was only a little over half what the nation spent Furthermore by itself a sum of money was no on defence. It had to be looked at as a proportion of the national guide. income, and, as a percentage of the national income, expenditure on the N.H.S. rested almost exactly where it was in 1950. In real terms, allowing for changes in the value of money, the expenditure in the service had only risen 2% a year since 1948. Was that too much for us ? Was that a disaster?1 According to the figures for 1953 given in the I.L.O. report’ we were only spending 4% of our national income in health. Even at that time only two developed countries (Holland and Denmark) were spending so little. Since then most other Continental countries had moved forward in their social services, but seven years later we were still spending only 4%, and when the next comparison was published it would look even worse. The Minister had also said that we could not have the new hospital building programme unless expenditure was curbed. But what did the programme, Mr. Brown asked, amount to ? An increase of E5 million a year from now until 1965-66, yet the Minister proposed to take back through his charges and contribution E65 million a year. The Minister had suggested that the increases were needed to curb waste-Mr. Brown presumed in the drug bill. But it was not the patient who was wasting money. We should have a full inquiry into the cost of drugs and the state of the phamaceutical industry. Mr. Brown also deplored dearer welfare foods. They were preventive medicine and a really sensible method of avoiding waste. The extra prescription charge would 1. Schiller, K. F. R. Lancet, 1960, ii, 1322. 2. Heichmann, Y., Bassan, H., Gellei, B. Harefuah, 3. See Lancet, 1959, ii, 655.
1955, 49, 160.
started by the patient if there are premonitory twinges of pain. I associate myself strongly with the view of Braham and Saia that no patient should be submitted to radical treatment without an adequate trial of phenytoin. With this first major advance in the drug therapy of tic douloureux it is to be hoped that alcohol injection and surgical extirpation of the trigeminal nerve will soon be
DIAGNOSIS OF ACUTE APPENDICITIS: THREE PHYSICAL SIGNS
RUPTURE OF THE INTERVENTRICULAR SEPTUM ASSOCIATED WITH ACUTE MYOCARDIAL INFARCTION
"
SIR,-In the hope of making this diagnosis more certain, the three following physical signs are offered, because they have been found to be very reliable in practice. I have not found them described in textbooks or elsewhere, and they have proved valuable in cases of doubt. Caecal gurgling.-Sometimes palpation of the right iliac fossa leads to palpable gurgling of the underlying caecum. When this is present it has been found that there has never been acute inflammation in the appendix. Acute appendicitis seems to be associated with conditions either in the cxcum itself, or in the overlying abdominal wall, preventing any gurgling in the caecum. Tenderness on movement.-In the case of children with suspected acute "appendicitis it is helpful to stand them up and get them to jump on the spot". If there is no increase in the pain in the right iliac fossa nor stabs of pain occurring at each jump, acute appendicitis is not present. Stethoscope tenderness.-When a patient is examined for the first time, tenderness in the right iliac fossa is a frequent finding and not necessarily indicative of underlying inflammation. Even when all the usual measures are taken to relax the abdominal wall, such as bending the knees, warming the hands of the examiner, and feeling through a layer of clothing, tenderness may sometimes persist when there is no underlying organic cause. On such an occasion palpating the abdomen by means of pressing the bell of the stethoscope on the abdomen is often a help. Tenderness revealed by such a method is real tenderness, indicating inflammation. Another advantage of the method is that it enables any real tenderness present to be accurately localised. This sign is a great help in children and infants, particularly those who are crying when first seen. Dudley Road Hospital, P. GILROY BEVAN. Birmingham.
PHENYTOIN IN THE TREATMENT OF TRIGEMINAL NEURALGIA SIR,-The paper by Dr. Braham and Dr. Saia 11 is a welcome addition to the British literature on this subject, which has been well reviewed in Continental and American
publications. Credit is due to some earlier reports.12-1õ The use of phenytoin (’ Epanutin ’,Dilantin ’, diphenylhydantoin) was pioneered in Germany by Albrecht and Krump 13 and Winiker-Blank,12 and later in America by Ende 14 and King.ls King also commented on the use of mephenesin alone and in combination with phenytoin. Ianone et al.16 pointed out the latent period of 24-36 hours before the drug achieves its full therapeutic effect. My experience of 9 cases of tic douloureux and 4 of postherpetic neuralgia dates from August, 1958, and parallels that of Braham and Saia. Phenytoin in combination with phenobarbitone seems to increase drug toxicity with no increase in therapeutic effect. The dose may be at least double that suggested by Braham and Saia, with a corresponding increase in effect, which is particularly useful in bringing a bad attack under control. Continuous therapy for months on end is not necessary; treatment may be 10. Altschule, M. D. Anesthesiology, 1943, 4, 385. 11. Braham, J., Saia, A. Lancet, 1960, ii, 892. 12. Winiker-Blank, E. Dtsch. Stomatol. 1955, 5, 321. 13. Albrecht, K., Krump, J. Münch. Med. Wschr. 1954, 96, 1037. 14. Ende, M. Virgin. med. Mon. 1957, 84, 358. 15. King, R. B. J. Neurosurg. 1958, 15, 290. 16. Ianone, A., Baker, A. B., Morrell, F. Neurology, 1958, 8, 126.
eliminated. HOWARD S. REEVE, REEVE.
London, S.E.10.
SIR,-Iread Dr. Schiller’s paperwith interest. We published a paper on the same subject some years ago,2 One of our conclusions was that the systolic murmur pathognomonic of ruptured interventricular septum can be heard until the last moment of the patient’s life, even when heart. be discerned. Since then I have seen and confirmed this observation in all. This finding may be a diagnostic feature of rupture of the inter. ventricular septum associated with acute myocardial infarction, Department of Internal Medicine A, Rambam Government Hospital, HARRY BASSAN. Haifa, Israel.
sounds several
can no
longer
more cases
Parliament Undermining
or
Underpinning ?
ON Feb. 8 Mr. GEORGE BROWN moved a vote of censure deploring the proposed increases in N.H.S. charges and contribution because they indicated the Government’s determination " to undermine the National Health Service and to place heavy burdens on those least able to bear them".", Mr. Brown described the service as a noble edifice that needed a great and imaginative architect for its improvement and continuation. Instead we had a quantity surveyor. As a result we had descended from the real problems to fiddling about with quantities and bills of cost. The Minister rested his case on the rising cost of the service, If it went higher, we should have to stop having desirable things. But Mr. Brown pointed out that at a round E860 million it was only a little over half what the nation spent Furthermore by itself a sum of money was no on defence. It had to be looked at as a proportion of the national guide. income, and, as a percentage of the national income, expenditure on the N.H.S. rested almost exactly where it was in 1950. In real terms, allowing for changes in the value of money, the expenditure in the service had only risen 2% a year since 1948. Was that too much for us ? Was that a disaster?1 According to the figures for 1953 given in the I.L.O. report’ we were only spending 4% of our national income in health. Even at that time only two developed countries (Holland and Denmark) were spending so little. Since then most other Continental countries had moved forward in their social services, but seven years later we were still spending only 4%, and when the next comparison was published it would look even worse. The Minister had also said that we could not have the new hospital building programme unless expenditure was curbed. But what did the programme, Mr. Brown asked, amount to ? An increase of E5 million a year from now until 1965-66, yet the Minister proposed to take back through his charges and contribution E65 million a year. The Minister had suggested that the increases were needed to curb waste-Mr. Brown presumed in the drug bill. But it was not the patient who was wasting money. We should have a full inquiry into the cost of drugs and the state of the phamaceutical industry. Mr. Brown also deplored dearer welfare foods. They were preventive medicine and a really sensible method of avoiding waste. The extra prescription charge would 1. Schiller, K. F. R. Lancet, 1960, ii, 1322. 2. Heichmann, Y., Bassan, H., Gellei, B. Harefuah, 3. See Lancet, 1959, ii, 655.
1955, 49, 160.