724 S.-A. MEDIESE TYDSKRIF

TABLE V. DEGREE OF MAL 'UTRITlON PER COMEZ CRITERIA, RELATED TO MORTALITY

3 Ju1ie 1971

'-1'

ExpeCledAge ill WeiNlu weigh!

mOnlhs Sex in kg for age10 M 6·6 9·59 M 4·3 9·2

15 M 7·6 13-848 M 9·0 16·1

6 F 6·3 7-612 M 7·0 9·818 F 8-4 9'411 F 7-4 9-2

%of expectedweight for age

6948545583747981

Degree23331211

AntibioticDoxycyclineDoxycyclineDoxycyclineAmpicillinDoxycyclineDoxycyclineAmpicillinAmpicillin

On comparing the duration of pyrexia and consolidationof the two groups the following results were obtained:

DISCUSSION

De Buse et al.' comparing the usefulness of doxycyclinewith nonsynthetic penicillin in outpatient children sufferingfrom measles and bronchopneumonia found no majordifference between the two groups.

Fabre et at: found that the effective concentration ofdoxycycline in the body persisted much longer than theother tetracyclines. This is in keeping with the findings ofJacobs and Robinson. ' Barrettini5 comparing tonsillar tissuelevels between doxycycline and ampicillin showed levels of1·56 - 4·30 mg/ g in the former after 24 hours while no levelswere detected with ampicillin.

From this trial, an attempt is made to evaluate the clini­cal response to the 2 antibiotics by comparing the durationof pyrexia and consolidation in the 2 groups. When con­sidering the X-ray findings one must allow for the factthat the viral process of measles can be the cause of a largepart of the X-ray findings which is usually interpreted asbronchopneumonia, as assessed by Kahn and Koiransky"

Although a double-blind trial was not conducted, it issignificant that there is a difference of an average of 5 daysin the duration of the respiratory consoEdation which, infact, resulted in a shorter stay in hospital for those patientstreated with doxycycline. No side-effects were encounteredin either group.

Duralion of pyrexiaDuration of consolidation

TABLE VI. AVERAGE DURATIO:'< IN DAYS

Doxycycline5·5

16-4

Ampicillin7-3

21·3

Of the 8 deaths in this series, 4 of the 5 patients treatedwith doxycycline were admitted in congestive cardiac fail­ure and 3 of these were further complicated with gastro­enteritis. The 5th patient had been ill 14 days before ad­mission. Of the 3 patients treated with ampicillin, 2 wereadmitted in congestive cardiac failure and gastro-enteritisand one with gastro-enteritis only.

Doxycycline is therefore as effective as ampicillin intreating bronchopneumonia complicating measles. Further­more, the fact that it may be given once daily may be anadvantage over penicillin. From Table I and its final resultin Table VI, it is possible to assume that the organismswere more sensitive to doxycycline than tetracycline as awhole; and furthermore, that unless sensitivity tests areconducted for doxycycEne independently of tetracyclinethey are of little value.

Penicillins are often preferred to tetracyclines becausestaining of teeth does not occur. This appears to be lesscommon with doxycyclines than with other tetracyclinesdue to the reduced calcium bindings and low dosage.

I wish to thank Dr J. N. Sher, Medical Officer of Health forPort Elizabeth, for allowing me to conduct this trial and forpermission to publish; the staff of Empilweni Hospital FeverWard for their co-operation; and the South African Institutefor Medical Research for their assistance.

REFERENCES1. Jacobs, P. and Robinson, R. (1969): S. Afr. Med. J., 43, 209.2. Aitchison, W. R., Grant, 1. W., and Gould, J. C. (1968): Brit. J.

Clin. Pract., 22, 345.3. De Buse, P. J., Jones, G. and Naidoo, A. (1969): E. Afr. Med. J., 46,

52.4. Fabre. J., Kunz, 1. P., Pitton. J. S., Laurencet, F. and Vivieux, C.

(1968): Chemotherapy (Basel), 13, suppi., 28.5. Barrettini, B. (1968): Tbid., 13, 363.6. Kahn, J. 1.. and Koiransky H. (1933): Amer. J. Dis. Child .. 46, 40.

THE mSTORY OF GROIN HERNIA*SIMO I WAPNICK, M.D., FR.C.S., Lecturer in Surgery, University of Rhodesia, Salisbury

SUMMARY

In The first century AD Cefsus described a method ofrecognition of groin hernia. It was not until CasperStromayr (16th century) published his work on herniathat the distinction between a direct and indirect inguinalhernia was appreciated. Stromayr also introduf:ed a herniaTruSS II'hich was designed to prevent a groin hernia fromappearing. It is now almost lOO years since EduQl'doBassfni revo'utionized the surgery of hernia repair when he*Dare received: 23 February 1971.

introduced the operation of herniorrhaphy. This operation(in a slightly modified form) is still advocated by mostsurgeons as the ideal form of treatment for most patientsII'ho have an inguinal hernia.

Repair of a hernia is one of the commonest of surgicaloperations and can now be performed with low morbidityand mortality rates. It is only relatively recently, however,that any surgical operation could be undertaken withoutundue risk. In the distant past most operations were per-

3 July 1971 S.A. MEDICAL JOURNAL 725

(

formed by people who did not possess adequate medicaltraining, lacked technical skill, and were often unscrupu­lous. Furthermore, the importance of asepsis was notappreciated, and anaesthesia was a hazardous undertakinl>The purpose of this paper is to present a review of th~principles of management of groin hernias throughout thepast 2 000 years.

The first accurate account of the anatomy of the inguinalcanal appears to have been that of Celsus' in the firstcentury AD, who showed a clear understanding of thefeatures of groin hernias. Celsus belonged to the schoolof Encyclopaedists, and was not a physician as such. Helived in Rome and documented his knowledge of medicinein De Attiblls between 25 and 35 AD.

Celsus surmised that a defect in the layers covering thespermatic cord would permit the intestine or omentum toenter the scrotum and thus produce a hernia (enterocoele).He noted that a hernia could be made prominent bystraining, over-eating or shouting, and that at times itc-ould become irreducible, its contents red, green or black.He also appreciated the need for treating certain cases ofgroin hernia by surgery. He described a method wherebythe hernial sac could be identified, its contents returned tothe abdominal cavity and the possibility of severe haemor­rhage reduced by ligating the larger vessels with flaxthread. In dealing with the management of groin hernias,CelSU5 does not mention any form of herniorrhaphy at thetime of operation, but does describe a method whereby thetestis and its vascular supply could be preserved.

One of the most prolific and outstanding medicalwriters following Celsus was Claudius Galen,' who wasborn in Pergamon in Asia Minor in 130 AD. Galen refersbriefly to 'enterocoele' in his erudite discussion on patho­logical swellings. He chided the younger physicians whoused the term hernia for any type of swelling of thescrotum. He maintained that this term should be used forthose conditions where bowel contents or omentum passeddown towards the scrotum.

After the Galenic period, medical knowledge in theWestern Empire declined and the further progress wasmainly confined to the Byzantine Empire. Much of thisknowledge was documented by the Encyclopaedists: PaUlof Aegira' (7th century) compiled an excellent account ofsurgical principles of past and contemporary authors. Thedescription of hernia operations differed from that ofCelsus as it was cons:dered essential to remove the testiclein their procedure.

In the era soon after the Middle Ages, surgery as anart was devoted almost entirely to wounds, and the practiceof other forms of operative surgery was as a rule avoided.Most of the attempts at surgery were made by charlatans,unscrupulous 'specialists' who passed from place to placeclaiming to have particular knowledge in the care ofmultiple surgical conditions. Pierre Franco' (J 6th century)was an outstanding exception. He was a modest, religiousman, and devoted much of his time to perfecting his skillas a surgeon. He modified an operation to treat groinhernia and performed it on over 200 patients. He alsodescribed the clinical picture of strangulated hernia andthe surgical method of its cure. The operation was facili­tated by introducing a rounded, grooved probe to preventaccidental incision of the bowel wall. As in the case of

Celsus, the surgeons of this period carried out herniotomy,but made no attempt to devise a herniorrhaphy procedure.

In the 16th century, a relatively unknown Germansurgeon, Caspar Stromayr: made a valuable contributionto the understanding of hernia in his manuscript PraclicaCapiosa. It is beautifully illustrated;- witlr Imrnrdiagram .describing the procedure of hernia surgery. PracticaCapiosa contains the first record of a clear differentiationbetween indirect and direct hernias. The indirect herniafollows the spermatic cord, whereas the direct variety doesnot. Stromayr recommended the following procedure todetermine whether a patient's hernia wa of the direct orindirect variety: 'stand the patient upright, push thetesticle on the side of the rupture upward between the skinand thigh to the groin as high as you can, then you willsee that the testicle makes a separate swelling from thatof a direct rupture, which otherwise does not occur, forwhenever a rupture accompanies the I'era didymi [epidy­dimus] when it is out, and you push the testis upwards, asdescribed, there wou'd be no special swelling next to therupture for it wou:d go into the same swelling, wh:chotherwise would not be the case'. It is interesting to notethis simple test is omitted from the section on hernias inmost of the general surgical textbooks published in recenttimes. I have used this test in 12 patients with groinhernias and found it true in all of them.

Stromayr also designed a truss to keep a groin herniareduced. His truss was, in fact, very similar to those in usetoday. In the surgical management of hernia he advisedtbat the testicle should not be removed if it was of thedirect variety, but should be removed if it was an indirecthernia. He emphasized the importance of removing thehernial sac and ligating its neck at the level of the internalring. His advice that a groin incision should be used ratherthan a scrotal incision was a cons:derable advance in thesurgical treatment of hernias.

In the 19th century the operation of herniorrhaphy wasintroduced. The inguinal and femoral canals had beenaccurately described by previous anatomists such asPoupart, Gimbernat, Astley Cooper and Hesselbach. Themore reputable surgeons reserved hernia operations forthose cases in which the contents of the hernia could notbe reduced spontaneously, or where strangulat;on ofbowel contents was anticipated. The recurrence rate, re­ported by Bull' of New York in 1890, was given as 40°[,during the first year and 100°[, within the first four yearsfollowing surgery.

The high recurrence rate following hernia operationswas of great concern to surgeons in different parts of theworld, and in particular, to the famous Italian surgeon,Bassini.' Eduardo Bass:ni had fought for tbe liberation andunification of Italy in 1866, and developed a faecal fistulain the groin as the result of a bullet wound sustainedduring the war. When he recovered he pent some timein England before returning to Italy in 1875. In 1884, hewas one of the first surgeons to introduce antiseptic tech­niques into Italian surgery. In 1888 he was appointedProfessor of Clinical Surgery at Padua University, and inthe same year reported to the Italian Surgical Society theresults of hernia operations on 102 patients using hismethod of repair.

726 S.-A. MEDIESE TYDSKRIF 3 Julie 1971

Fig. 1: Bassini's original description of herniorrhaphy.(A) subcutaneous tissue, (B) external oblique, (C) fasciatransversalis, (E) spermatic cord, (F) transversus, internaloblique and fascia transversus, (G) hernia sac. (FromBassini's (j ber die Behandlung des Leisten-bruches,Langenbecks Arch. klin. Chir., Vo\. 40.)

Bassini appreciated the importance of strengthening theposterior abdominal wall. He advised that the hernia sacshould be excised and ligated as high as possible. The nextstep in the operation was to separate the external obliquefrom the internal oblique, and the transversus muscle andfascia transversalis from the preperitoneal fat. The hernior­rhaphy consisted of uniting the three layers (internaloblique, transversus and fascia transversalis) to the inguinal

G.P. Review Al'lide

ligament below with interrupted black silk sutures. Thesutures located at the most medial part also passed throughthe outer edge of the rectus sheath. The internal ring wasreconstituted so that it was situated lateral to the externalring to ensure that the obliquity of the inguinal canalwas maintained (Fig. I).

In 1890, Bassini reported his experience with 262 con­secutive cases who had had a hernia repaired accordingto the new method he described. Out of 251 cases wherestrangulation had not occurred, all survived the operation.The recurrence rate was less than 3% of those cases whohad been followed up for between one month and fouryears.

The operation described by Bassini has made a greatimpact on the surgery of inguinal herniae, and althoughmany different procedures have been described, none hashad a similar world-wide acceptance. The Bassini opera­tion has withstood the test of time, and proof of its valuelies in the fact that it is still used today by many surgeonsin different parts of the globe.

I wish to thank Professor J. M. Mynors and Mrs P. Fergusonfor assistance in preparing this paper, and Mr G. Davie, forthe photograph.

REFERENCES

1. Celsus, 1st Century, AD (1938): De Medicine. Vo!. Ill, Book VIT. TheLoeb Classical Library. Cambridge: Harvard University Press.

2. Galen, 2nd Century AD (1929): Greek Medicine. London: T. M. Dent& Sons.

3. Paul of Aegira, 7th Century AD (1844): Seven books, translated fromthe Greek. Vo!. 1. Printed for the Sydenham Society. London: FrancisAdams.

4. Pierre Franco, 16th Century AD 0895): Irate des Hernies. Paris:Librairie Germer Bailliere.

5. Stromayr, 16th Century AD in Van Brunn, W., ed. (1925): PracticaCapiosa. Berlin: Idra-Verlagsanstalt.

6. Bull, W. T. ill Zimrnerman, L. 1. and 1. Keith, ed,. (1890): GreatIdeas in {he History of Surgery. Baltimore: Williams & \Vilkins.

7. Bassini, E. (1890): Arch. Klin. Chit., 40, 429.

FLAT FOOT: II*G. F. DOMMISSE, F.R.C.S. (EDIN.), Pretoria

SUMMARY

The most important varieties of 'flat foot' are describedand are classified into the 'congenital' and the 'acquired'groups.

A foot which on casual inspection appears to be 'flat'will on careful examination prove to be within the limitsof normal in the majority of cases. The hasty labelling ofa patient as 'flat-footed', whether child or adult, is severelycondemned and is generally not justified. Both knowledgeand skill are required in the diagnosis of a condition whichis as important to the individual as wheels to a carriageand wings to a bird.

General rules in the choice of footwear suitable fOI;children and adults in their various daily activities are laiddown. Pedicure is strongly urged, so that the humble feetmay enjoy the same degree of fragrance and pride ofownership as the hands. Let our motto be: 'Pale feet,pink-tipped, [loved beside sweet Shalimar' (with apologies).* Date received: 4 February 1971.

'Flat-foot' is a generic term which covers a number of con­ditions involving the feet, conditions which differ in degree,in aetiology, in pathology, in prognosis, in treatment andin incidence as well as in age of incidence. The use of theterms 'pes planus' or 'pes plana-valgus' offers no particularadvantage over 'fiat-foot', and in either event assumessignificance only when suitably qualified, e.g. 'congenitalrigid flat-foot with vertical talus', or 'congenital rigid pesplanus with vertical talus'. There are many kinds of flat­foot, of which only the most important are briefly des­cribed below. They are classified under two main groups,namely congenital and acquired fiat-foot.

The term 'fiat-foot' is deceptive because of its simplicity,and has led to a faulty diagnosis in countless normal indi­vidua:Is whose feet merely appeared to be flat. Worse, thereare those individuals who, although they suffer from flat­foot in the incipient stages, are denied treatment on thegrounds that the arches of the feet have not yet fallen.

I! would be illogical to attempt a definition in the know-