46 EXCISION OF PILONIDAL SINUS
SIR,-Bosel advocates operative treatment of pilonidal sinus by excision and Z plasty rather than wide excision and removal of the coccyx. Others have performed excision of the sinus with or without primary sutureincision of the sinus followed by marsupialisation,3 or various kinds of plastic closure.4It has always seemed unnecessary to me to treat a benign condition with the excision of a quantity of tissue appropriate for a malignancy. Nor does it seem ideal to make use of an operative technique which requires the patient to be in hospital for a long time or which has an appreciable complication-rate. For several years I have merely incised the sinus over a probe or grooved director, removed any hair or debris present, and vigorously scraped the sinus tract with a sharp curette. It is crucial to open the entire tract as well as any lateral extensions that may be present. The wound is packed open, and any remaining bits of sinus tract can be cauterised with phenol 48 h later when the packing is removed. Patients are discharged from the hospital two days after operation and instructed to wash the open wound daily in the shower. They may return to work immediately and may anticipate healing of the wound within several weeks. No recurrences have been noted in a group of 40 patients so treated. The procedure could be performed on an outpatient basis if necessary. Department of Surgery, University of Wisconsin Hospitals,
FREDRIC JARRETT
APPENDICITIS AND MIMICKING CONDITIONS
StR,—Eales suggests adding acute porphyria to the list of conditions which may be confused with acute appendicitis. An even more important condition, which he does not mention and which should be considered in the differential diagnosis, is periodic peritonitis (familial Mediterranean fever). This is especially applicable to the group of 24 patients in the report by Gilmore et al.6 in whom no identifiable cause was found. In cases of porphyria a simple screening test of porphobilinogen in the urine is available. Unfortunately there is no test to establish the diagnosis of periodic peritonitis, which has to be purely a clinical one. This disorder is not confined to the Mediterranean region. It has been reported from all parts of the world.’ M. MURTADHA F. BAKIR
TESTING PAIN SENSATION seems that sensory testing is too often done badly all in clinical practice. I suspect that the main reason is lack of time or patience, but the unpleasantness of testing pain sensation with pin or needle, preferably sterile, may also be a factor. I have found that the end of an unfolded small paper clip delivers a suitable, mildly painful stimulus well tolerated by the patient. There is no danger of puncturing the epidermis and hence no need for sterility. A pin or needle is still required for testing palms and soles.
S!R,—It
or not at
Institute of Neurological Sciences, Southern General Hospital, Glasgow G15 4TF
is
common
in the urban
African,’ yet
cardiac failure and cerebrovascular accident as a result of hypertension. A 10-year postmortem study (1965-74) among 434 African patients with hypertension at King Edward VIII Hospital, Durban, showed that 41.9% had cerebrovascular complications, 25.0% had renal complications, 32.9%, had cardiovascular complications in the form of congestive cardiac failure, whilst only 10 patients (2.2%) had myocardial infarction. The average of the patients at necropsy was 45 (range 7-89) whilst the average age of the hypertensive patients with myocardial infarction was 54. Intracranial haemorrhage was responsible for 212 (95%) of the 223 cases of cerebrovascular accident, and cerebral thrombosis contributed only 11 cases
(5%). One of us (Y.K.S.) has studied 1000 hypertensive patients who were followed up for 13 years.2 The frequency of cardiac
changes was as follows: Cardiac
Africans %
change
Ventricular hypertrophy Clinical cardiomegaly Ischaemic heart-disease Chest X-ray, left Ventricular hypertrophy Normal chest X-ray Congestive heart-failure
Indians %
23
22
29 0
26 12
30 70 16
35 65 8
cardiac failure due to hypertension occurred in 16% of the Africans ischaemic heart-disease did not; in the Indian population infarction or angina developed in 12%. King Edward VIII Hospital has 2000 beds and serves 2 million people; some 800 000 patients attending as outpatients and about 99 000 are admitted each year (Africans 83%, Indians 17%). Whilst myocardial infarction is common in
Although congestive
or angina in Africans do exceed 10 per year. The frequency of coronary atheroma in Africans at necropsy is far less than in the European or Indian population in Durban. However, hypertension is not uncommonly associated with cerebral atheroma and atheroma in
Indians, cases of myocardial infarction
not
the aorta.3
Department of Medicine,
College of Medicine, University of Bagdad, Bagdad, Iraq
SiR,—Hypertension
myocardial infarction is rare. One of the striking features at necropsy among hypertensive patients is the rarity of myocardial infarction and the not infrequent occurrence of congestive
E.c.c., left
Madison, Wisconsin 53706, U.S.A.
RARITY OF MYOCARDIAL INFARCTION IN AFRICAN HYPERTENSIVE PATIENTS
W. F. DURWARD
1. Bose, B. Lancet, 1976, i, 1131. 2. Cherry, J. K. Surgery Gynec. Obstet. 1968, 126, 1263. 3. Abramson, D. J. Ann. Surg. 1960, 158, 261. 4. Hirschowitz, B., Mahler, D., Kaufmann-Friedmann, K. Surgery Gynec. Obstet. 1970, 131, 119. 5. Eales, L. Lancet, 1976, i, 704. 6. Gilmore, O. J. A., and others ibid. 1975, ii, 421. 7. Bakir, F., Murtadha, M. Trans. Roy. Soc. trop. Med. Hyg. 1975, 69, 111.
At the Mama Yemo
Hospital
in
Kinshasa, Zaire,
one
of
us
(H.M.-F.) studied cardiac patients attending as outpatients. In 1972, of 1193 new cardiac patients 413 (35%) were hypertensive ; there were no cases of myocardial infarction. In University College Hospital, Ibadan, in 1961-70 only 26 Africans with myocardial infarction were seen.4 In 412 middleaged and elderly persons living at Kasangati (Uganda) hypertension was the dominant cardiovascular disorder occurring in 33.7% of the study population.’ A history of angina was elicited in a significant proportion of individuals with obscure cardiomegaly when compared with a control group without cardiomegaly. Myocardial infarction was rare, however. At the non-European Hospital, Johannesburg, the story was much the same.6 Yet at Hammersmith Hospital, London,1 in New Zealand,8 and in the American Negro9 coronary-artery disease and hypertension commonly went hand in hand. Seftel, H. C. Medicine and Society in South Africa: Some Plain Thinking Johannesburg, 1973. 2. Seedat, Y. K., Reddy, J. A. S. Afr. med. J. 1974, 48, 816. 3. Wainwright, J. Lancet, 1961, i, 366. 4. Falase, A. O., Cole, T. O., Osuntokun, B. O. Trop. geogr. Med. 1972, 25 1.
147. 5. Ikeme, A. C., Bennett, F. J., Somers, K. E. Afr. med. J. 1974, 51, 409. 6. 7. 8. 9.
Seftel,
H.
C., Kew, M. C., Bersohn, I. S. Afr. med. J. 1970, 44,
8
Breckenridge, A., Dollery, C. T., Parry, E. H. O. Q. Jl Med. 1970, 39, 411 Smirk, F. H., Hodge, J. V. Br. med. J. 1963, ii, 1221. Anderson, R. S., Ellington, A., Gunter, L. M. Diabetes, 1961, 10, 114.
SIR,-Bosel advocates operative treatment of pilonidal sinus by excision and Z plasty rather than wide excision and removal of the coccyx. Others have performed excision of the sinus with or without primary sutureincision of the sinus followed by marsupialisation,3 or various kinds of plastic closure.4It has always seemed unnecessary to me to treat a benign condition with the excision of a quantity of tissue appropriate for a malignancy. Nor does it seem ideal to make use of an operative technique which requires the patient to be in hospital for a long time or which has an appreciable complication-rate. For several years I have merely incised the sinus over a probe or grooved director, removed any hair or debris present, and vigorously scraped the sinus tract with a sharp curette. It is crucial to open the entire tract as well as any lateral extensions that may be present. The wound is packed open, and any remaining bits of sinus tract can be cauterised with phenol 48 h later when the packing is removed. Patients are discharged from the hospital two days after operation and instructed to wash the open wound daily in the shower. They may return to work immediately and may anticipate healing of the wound within several weeks. No recurrences have been noted in a group of 40 patients so treated. The procedure could be performed on an outpatient basis if necessary. Department of Surgery, University of Wisconsin Hospitals,
FREDRIC JARRETT
APPENDICITIS AND MIMICKING CONDITIONS
StR,—Eales suggests adding acute porphyria to the list of conditions which may be confused with acute appendicitis. An even more important condition, which he does not mention and which should be considered in the differential diagnosis, is periodic peritonitis (familial Mediterranean fever). This is especially applicable to the group of 24 patients in the report by Gilmore et al.6 in whom no identifiable cause was found. In cases of porphyria a simple screening test of porphobilinogen in the urine is available. Unfortunately there is no test to establish the diagnosis of periodic peritonitis, which has to be purely a clinical one. This disorder is not confined to the Mediterranean region. It has been reported from all parts of the world.’ M. MURTADHA F. BAKIR
TESTING PAIN SENSATION seems that sensory testing is too often done badly all in clinical practice. I suspect that the main reason is lack of time or patience, but the unpleasantness of testing pain sensation with pin or needle, preferably sterile, may also be a factor. I have found that the end of an unfolded small paper clip delivers a suitable, mildly painful stimulus well tolerated by the patient. There is no danger of puncturing the epidermis and hence no need for sterility. A pin or needle is still required for testing palms and soles.
S!R,—It
or not at
Institute of Neurological Sciences, Southern General Hospital, Glasgow G15 4TF
is
common
in the urban
African,’ yet
cardiac failure and cerebrovascular accident as a result of hypertension. A 10-year postmortem study (1965-74) among 434 African patients with hypertension at King Edward VIII Hospital, Durban, showed that 41.9% had cerebrovascular complications, 25.0% had renal complications, 32.9%, had cardiovascular complications in the form of congestive cardiac failure, whilst only 10 patients (2.2%) had myocardial infarction. The average of the patients at necropsy was 45 (range 7-89) whilst the average age of the hypertensive patients with myocardial infarction was 54. Intracranial haemorrhage was responsible for 212 (95%) of the 223 cases of cerebrovascular accident, and cerebral thrombosis contributed only 11 cases
(5%). One of us (Y.K.S.) has studied 1000 hypertensive patients who were followed up for 13 years.2 The frequency of cardiac
changes was as follows: Cardiac
Africans %
change
Ventricular hypertrophy Clinical cardiomegaly Ischaemic heart-disease Chest X-ray, left Ventricular hypertrophy Normal chest X-ray Congestive heart-failure
Indians %
23
22
29 0
26 12
30 70 16
35 65 8
cardiac failure due to hypertension occurred in 16% of the Africans ischaemic heart-disease did not; in the Indian population infarction or angina developed in 12%. King Edward VIII Hospital has 2000 beds and serves 2 million people; some 800 000 patients attending as outpatients and about 99 000 are admitted each year (Africans 83%, Indians 17%). Whilst myocardial infarction is common in
Although congestive
or angina in Africans do exceed 10 per year. The frequency of coronary atheroma in Africans at necropsy is far less than in the European or Indian population in Durban. However, hypertension is not uncommonly associated with cerebral atheroma and atheroma in
Indians, cases of myocardial infarction
not
the aorta.3
Department of Medicine,
College of Medicine, University of Bagdad, Bagdad, Iraq
SiR,—Hypertension
myocardial infarction is rare. One of the striking features at necropsy among hypertensive patients is the rarity of myocardial infarction and the not infrequent occurrence of congestive
E.c.c., left
Madison, Wisconsin 53706, U.S.A.
RARITY OF MYOCARDIAL INFARCTION IN AFRICAN HYPERTENSIVE PATIENTS
W. F. DURWARD
1. Bose, B. Lancet, 1976, i, 1131. 2. Cherry, J. K. Surgery Gynec. Obstet. 1968, 126, 1263. 3. Abramson, D. J. Ann. Surg. 1960, 158, 261. 4. Hirschowitz, B., Mahler, D., Kaufmann-Friedmann, K. Surgery Gynec. Obstet. 1970, 131, 119. 5. Eales, L. Lancet, 1976, i, 704. 6. Gilmore, O. J. A., and others ibid. 1975, ii, 421. 7. Bakir, F., Murtadha, M. Trans. Roy. Soc. trop. Med. Hyg. 1975, 69, 111.
At the Mama Yemo
Hospital
in
Kinshasa, Zaire,
one
of
us
(H.M.-F.) studied cardiac patients attending as outpatients. In 1972, of 1193 new cardiac patients 413 (35%) were hypertensive ; there were no cases of myocardial infarction. In University College Hospital, Ibadan, in 1961-70 only 26 Africans with myocardial infarction were seen.4 In 412 middleaged and elderly persons living at Kasangati (Uganda) hypertension was the dominant cardiovascular disorder occurring in 33.7% of the study population.’ A history of angina was elicited in a significant proportion of individuals with obscure cardiomegaly when compared with a control group without cardiomegaly. Myocardial infarction was rare, however. At the non-European Hospital, Johannesburg, the story was much the same.6 Yet at Hammersmith Hospital, London,1 in New Zealand,8 and in the American Negro9 coronary-artery disease and hypertension commonly went hand in hand. Seftel, H. C. Medicine and Society in South Africa: Some Plain Thinking Johannesburg, 1973. 2. Seedat, Y. K., Reddy, J. A. S. Afr. med. J. 1974, 48, 816. 3. Wainwright, J. Lancet, 1961, i, 366. 4. Falase, A. O., Cole, T. O., Osuntokun, B. O. Trop. geogr. Med. 1972, 25 1.
147. 5. Ikeme, A. C., Bennett, F. J., Somers, K. E. Afr. med. J. 1974, 51, 409. 6. 7. 8. 9.
Seftel,
H.
C., Kew, M. C., Bersohn, I. S. Afr. med. J. 1970, 44,
8
Breckenridge, A., Dollery, C. T., Parry, E. H. O. Q. Jl Med. 1970, 39, 411 Smirk, F. H., Hodge, J. V. Br. med. J. 1963, ii, 1221. Anderson, R. S., Ellington, A., Gunter, L. M. Diabetes, 1961, 10, 114.
