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NYLON-DARN REPAIRS OF HERNIÆ

CAMERON MACLEOD.

A. J. MARSDEN.

SIR,-Mr. Moloney in his excellent paper of Feb. 8implies inadvertently that the recurrence-rate of 14 3%for simple herniotomy (1940-45) in adult males which Irecorded referred to an operation which also includeda repair of the fascia transversalis at the internal ring.This was not so. Later in the same article I reported asmall series of 9 adult cases in all of whom success wasachieved by excision of the sac combined with suture of thering. This was first done by Marcy of Boston (1871) andsince 1951 I have continued to use it successfully in thosepatients who at operation are found to have entirelycongenital sacs with narrow necks.

London, W.1. CAMERON MACLEOD.

SiR,—I was much interested in Mr. Moloney’s article.The results are excellent by any standard, and must bea strong argument in favour of nylon as the most usefulsuture material. May I add one criticism and one

comment.

The results appear to have been ascertained by a postalquestionnaire. Many patients are unaware of a recurrence(or even of a primary hernia) until it strangulates. Further-

more, only 76% of the patients replied to the questionnaire,and there is no reference to the seeking of information fromthe general practitioners of the missing 24 °o. The figures forthe recurrence-rate cannot, therefore, be anything but veryapproximate, and cannot be compared satisfactorily with theresults of reviews obtained by actual examinations of the

patients. Is there no hope of obtaining the results of examina-tions of these patients ?

In the teaching hospitals of the Liverpool region all

inguinal-hernia repairs in adult males are registered, andreviewed after one and three years. Between 1951 and 1954,in 450 patients whose hernias were repaired with nylon, 17developed a sinus failing to heal within two months, 19 furtheroperations were effected to remove pieces of nylon, and 9 caseshad a discharge for a year or more=1 for five years. I havenot the figures available (as I write) to determine whether thenylon in the affected cases had been monofilament or braided,but I will check this; I think monofilament nylon was used inmost of the cases. Admittedly, the cases I quote were dealtwith in the main by registrars, whose results one would notexpect to equal the personal series of an experienced surgeon.Nevertheless, it cannot yet be accepted that nylon is free fromserious disadvantages as a suture material in the repair ofinguinal herniae.

St. Helens, Lancs. A. J. MARSDEN.

1. Lancet, 1955, ii, 106.

TECHNIQUE OF INTRA-ARTICULAR INJECTION

CYRIL KAPLAN.

SIR,-Mr. Grant Waugh’s letter of Dec. 28 is indeedtimely. Much relief can be given to patients by the useof intra-articular injections of hydrocortone, but there isno need for this to be associated with any pain or

discomfort.The knee-joint is treated most frequently and I feel that

more consideration should be paid to the injection route in anattempt to avoid pain during the procedure. The usual tech-niques of injecting on either side of the patellar tendon are tobe avoided because the needle does not necessarily enter thejoint space or even pierce the synovial membrane as the wholeof the apparent space between the femoral and tibial condylesis, in fact, occupied by the alar fat pad and if the hydrocortoneis deposited in this structure it causes severe pain.The method adopted in our practice is to displace the

patella laterally with the knee fully extended and insert a shortsmall-bore needle into the tense capsule at the " superolateralcorner " of the patella. This manoeuvre creates an artificial

space which is reached by piercing merely skin, subcutaneoustissue, capsule, and synovial membrane without having to

traverse any other tissues. This procedure is completelypainless and does not require the use of a local anaesthetic.It is also of great value in aspirating the knee-joint.Durban, South Africa. CYRIL KAPLAN.

1. Brown, E. H., Bailey, E. H. Lancet, 1957, ii, 1218.

ASSISTED RESPIRATION DURINGGALLAMINE ANÆSTHESIA

P. A. P. POMPA.St. Giles’ Hospital,London, S.E.5.

SIR,-In a number of patients who receive gallamineFlaxedil ’) in the course of anaesthesia induction, theinitial period of apnoea is followed by tracheal tug. Thismay persist for a varying length of time while spontaneousrespiration is becoming established again.

During the initial phase of tracheal tug, respiration is so

depressed that there is little or no movement of the rebreath-ing bag, to guide the anaesthetist in the timing of assistedrespiration.However, if a finger of one hand is placed over the patient’s

larynx whilst the other hand grasps the rebreathing bag it isnow possible to synchronise assisted respiration with the earlyefforts of the patient-i.e., with the tracheal tug.

Later, as respiratory efforts increase, it will be found thatthis method will give better timing of assisted respiration thanjudgment based upon the fluctuations of the rebreathing bagalone, since the anxsthetist’s own reaction time will beshortened.

INFANTILE GASTROENTERITIS

SiR,—I was interested to read the article by Dr. Brownand Dr. Bailey on the treatment of infantile gastro-enteritis.1 In my experience cortisone is often a life-

saving drug.In the tropics gastroenteritis is usually seen in a very

advanced stage. The infants are often practically moribund-dehydrated, cyanosed, and with dry staring eyes. It has

always been difficult to get this type of patient, with a sluggishperipheral circulation, to absorb and retain fluids, and inthose cases in which rehydration was established dehydrationrapidly recurred. But since we have adopted the followingroutine for the treatment of infantile gastroenteritis we havebeen able to overcome this difficulty and reduce the mortalityvery considerably.

(1) Intramuscular drip infusion, using hyaluronidase, of thissolution:

200 ml. is given into each leg simultaneously and repeated 4-hourlyif necessary.

(2) Cortisone intramuscularly 5 mg. 4-hourly.(3) Antibiotics: if the child is vomiting severely, 50 mg. oxytetra-

cycline is given 8-hourly intramuscularly; but the usual routine hasbeen to give streptomycin 0-25 g. 6-hourly by mouth, together withhalf a tablet of phthalylsulphathiazole.

(4) Water by mouth, until vomiting stops, then half-strengthmilk feeds.

Cortisone seems to assist in the rehydration of patientswith peripheral vascular failure, and prevents fluid lossonce rehydration has been established. It is possible towithdraw the cortisone suddenly about the fourth day,once the diarrhoea has stopped, without ill effects.

Unfortunately it has not been possible to establishscientific figures because staff is short and the patho-logical department is already overworked. I would addthat there is tremendous overcrowding in the wards;isolation is impossible, and very often two infants haveto be nursed in the cot. Cross-infection is practically