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DIRECT INGUINAL HERNIA IN WOMEN
found to have steatorrhoea. In the last six months I have seen 3 such cases, 1 with " idiopathic " steatorrhoea and 2 with enterocolitis. And I suspect from the second paragraph of Dr. Henderson’s letter that some may have been seen but not recognised at St. Mark’s.
subsequently
Queen Elizabeth Hospital, Birmingham.
B. N. BROOKE.
DIRECT INGUINAL HERNIA IN WOMEN
SiR,-Mr. Brown (Jan. 23) asks why direct inguinal hernia is very rate in women. I have reviewed my hernia register of people over 50 years on whom a radical cure has been performed. It totals 404 : of these, 36 are women, and of these 36, 5 had direct hernial sacs, 3 of them having both a direct and an indirect sac. I always look upon a direct hernia as a degenerative condition or the result of a strain which stretches or tears the transversalis fascia guarding the posterior wall of the inner inguinal canal. Amongst the men patients, the incidence of a single direct hernial sac was 15% and that of two sacs-i.e., indirect and direct-was also 15%. So the 5 direct sacs in 36 women represents about half the incidence in men : but, if the traumatic factor is accepted as a cause, then the reduced occurrence in women would be in accord with expectation. En passant, the detection and removal of a second hernial sac is essential for the cure of the hernia ; for instance had the second one not been detected, there would have been at least three recurrences in 36 patients.
The graph can be used for prescribing any proportion. For example, if it is desired to decrease the proportion of i.z.s.(A) to 20%, without alteration of the total dose, then the point where the 20% line cuts the ordinate of the current total dose indicates the- amount of I.Z.S.(A) required in this new proportion.. By following this abscissa horizontally to the left until it intersects the 30% line, the amount of i.z.s. lente which contains this reduced quantity of I.Z.S.(A) is found. The balance between this and the current dose is made up with i.z.s.(c). Where it is desired to decrease the proportion of i.z.s.(c), a similar method is used. In this case the intersection of the abscissa (determined, for example, by the 60% line) with the 70% line is used and the balance is made up with I.z.s.(A). Victoria Infirmary,
Glasgow.
IAN WANG.
SEXING SKIN 1 SIR,—A report from London, Ontario, last year surprised many people by describing differences between the nuclei of male and female epidermis, and indicated that the method hadvalue in determining the true chromosomal sex of pseudohermaphrodites. Encouraged by Mr. Duncan Murdoch, and happening to have avarable a suitable series of skin biopsies, we tried out this method of sexing skin, and were agreeably surprised to find that, given good fixation and good staining, male and female could be easily distinguished. We know of several people who have been interested in HAEOLD DODD. the W.l. London, possibilities of the method, but who have been deterred by the prospect of error in inexperienced hands. LENTE INSULIN We are writing this letter with two principal objects: SIR,—Dr. Oakley (Jan. 30) seems to have missed the (a) We would assure doubters that the method works, point of our paper, which was deliberately entitled and that a few dozen samples of skin of known sex, taken from routine surgical material, will convince them that Transfer to Insulin Zinc Suspension." We were conthe difference is real. Good fixation is essential (we use cerned primarily with the immediate effect of the transfer, half-saturated mercuric chloride in 15 % formol-saline which may be dangerous if the total dose of insulin is solution) and, to any laboratory accustomed to the not increased ; the deterioration in the first few days periodic-acid-Schiff reaction, the Feulgen reaction will after transfer may occur even in those who are well be found not only better but easier than any adequate controlled on soluble insulin in doses of 40-50 units. hæmatoxylin stain. Many or most of these patients settle down later and can (b) We would welcome material from pseudohermareduce the dose to a level near to that before transfer. phrodites from other centres which would prefer to-avoid Our reason for including cases that had been poorly the trouble of establishing the method on their own account. controlled was simple : these are the patients in whom Skin, unembedded, in formalin or formolsublimate would be the most satisfactory material. a change to i.z.s. is likely to be suitable ; those who are would not be advised by us W. F. HUNTER already entirely to make any alteration in their treatment. BERNARD LENNOX Postgraduate Medical School of Webelieve that i.z.s. is a real advance in insulin M. G. PEARSON. W.12. London, treatment, but its position cannot yet be fully assessed. Within the limited scope of our present investigations, MEDICINE AND THE WELFARE STATE we cannot regard our results as disappointing or as SIR,—I have the greatest admiration generally, and indicating that the new insulins are inferior, as Dr. in very many cases affection, for members of the medical Oakley suggests. a so much so that I fear the end-result of profession ; J. M. MALINS modern trend to set up only the medical man as,ex officio, P. A. THORN. United Birmingham Hospitals. skilled and trained in every aspect of human life and behaviour. out in Dr. Thorn his article Why cannot a non-medical administrator SIR,—As (Jan. 23), pointed ever hope to cope " in the words of Dr. Gavin (Feb. 6), a graph can be of great assistance in the prescription of " with the multitude of human problems ... which insulin zinc suspension mixtures. In the diabetic clinic we are similar to crop up daily in the little world of the hospital "’? a here, using graph which, though very The less specialised his early academic background, Dr. Thorn’s, may have slight advantages. By using three differently coloured inks, the pairing of the lines-i.e., the more broad should be the administrator’s under20% and 80%, 30% and 70%, 40% and 60%-is more standing of a consultant, an " exuberant resident," a matron, an almoner, or a wardmaid. Noamount of obvious. We find that emphasis of the 30% and 70% theoretical training makes a good hospital administrator. lines by black ink is helpful as these lines represent the proportions in ’I.Z.S. Lente.’ Also we find it more He can only hope to become one if he has, as an apprentice, absorbed almost through his pores the atmosphere. convenient and less misleading to scale the ordinate with traditions, habits, and characteristics of every individual zero at the base. As the patient probably has already a stock of I.Z.S. type and department making up .the complex little world of hospitals. And even with this, he will fail if he does and as is the insulin at this zinc lente, only suspension not care for those inside the world he administers. if in the " 80 " it available, present -required, strength, whether patients or staff. is obviously desirable to use i.z.s. lente as the basis of any the lente of i.z.s. with mixture, replacing part I.Z.S.(A) 1. Moore, K. L., Grahame, M. A., Barr, M. L. Surg. Gynec. Obstet. or I.Z.S.(C) as indicated. 1953, 96, 641. "
.
satisfactory
subsequently
Queen Elizabeth Hospital, Birmingham.
B. N. BROOKE.
DIRECT INGUINAL HERNIA IN WOMEN
SiR,-Mr. Brown (Jan. 23) asks why direct inguinal hernia is very rate in women. I have reviewed my hernia register of people over 50 years on whom a radical cure has been performed. It totals 404 : of these, 36 are women, and of these 36, 5 had direct hernial sacs, 3 of them having both a direct and an indirect sac. I always look upon a direct hernia as a degenerative condition or the result of a strain which stretches or tears the transversalis fascia guarding the posterior wall of the inner inguinal canal. Amongst the men patients, the incidence of a single direct hernial sac was 15% and that of two sacs-i.e., indirect and direct-was also 15%. So the 5 direct sacs in 36 women represents about half the incidence in men : but, if the traumatic factor is accepted as a cause, then the reduced occurrence in women would be in accord with expectation. En passant, the detection and removal of a second hernial sac is essential for the cure of the hernia ; for instance had the second one not been detected, there would have been at least three recurrences in 36 patients.
The graph can be used for prescribing any proportion. For example, if it is desired to decrease the proportion of i.z.s.(A) to 20%, without alteration of the total dose, then the point where the 20% line cuts the ordinate of the current total dose indicates the- amount of I.Z.S.(A) required in this new proportion.. By following this abscissa horizontally to the left until it intersects the 30% line, the amount of i.z.s. lente which contains this reduced quantity of I.Z.S.(A) is found. The balance between this and the current dose is made up with i.z.s.(c). Where it is desired to decrease the proportion of i.z.s.(c), a similar method is used. In this case the intersection of the abscissa (determined, for example, by the 60% line) with the 70% line is used and the balance is made up with I.z.s.(A). Victoria Infirmary,
Glasgow.
IAN WANG.
SEXING SKIN 1 SIR,—A report from London, Ontario, last year surprised many people by describing differences between the nuclei of male and female epidermis, and indicated that the method hadvalue in determining the true chromosomal sex of pseudohermaphrodites. Encouraged by Mr. Duncan Murdoch, and happening to have avarable a suitable series of skin biopsies, we tried out this method of sexing skin, and were agreeably surprised to find that, given good fixation and good staining, male and female could be easily distinguished. We know of several people who have been interested in HAEOLD DODD. the W.l. London, possibilities of the method, but who have been deterred by the prospect of error in inexperienced hands. LENTE INSULIN We are writing this letter with two principal objects: SIR,—Dr. Oakley (Jan. 30) seems to have missed the (a) We would assure doubters that the method works, point of our paper, which was deliberately entitled and that a few dozen samples of skin of known sex, taken from routine surgical material, will convince them that Transfer to Insulin Zinc Suspension." We were conthe difference is real. Good fixation is essential (we use cerned primarily with the immediate effect of the transfer, half-saturated mercuric chloride in 15 % formol-saline which may be dangerous if the total dose of insulin is solution) and, to any laboratory accustomed to the not increased ; the deterioration in the first few days periodic-acid-Schiff reaction, the Feulgen reaction will after transfer may occur even in those who are well be found not only better but easier than any adequate controlled on soluble insulin in doses of 40-50 units. hæmatoxylin stain. Many or most of these patients settle down later and can (b) We would welcome material from pseudohermareduce the dose to a level near to that before transfer. phrodites from other centres which would prefer to-avoid Our reason for including cases that had been poorly the trouble of establishing the method on their own account. controlled was simple : these are the patients in whom Skin, unembedded, in formalin or formolsublimate would be the most satisfactory material. a change to i.z.s. is likely to be suitable ; those who are would not be advised by us W. F. HUNTER already entirely to make any alteration in their treatment. BERNARD LENNOX Postgraduate Medical School of Webelieve that i.z.s. is a real advance in insulin M. G. PEARSON. W.12. London, treatment, but its position cannot yet be fully assessed. Within the limited scope of our present investigations, MEDICINE AND THE WELFARE STATE we cannot regard our results as disappointing or as SIR,—I have the greatest admiration generally, and indicating that the new insulins are inferior, as Dr. in very many cases affection, for members of the medical Oakley suggests. a so much so that I fear the end-result of profession ; J. M. MALINS modern trend to set up only the medical man as,ex officio, P. A. THORN. United Birmingham Hospitals. skilled and trained in every aspect of human life and behaviour. out in Dr. Thorn his article Why cannot a non-medical administrator SIR,—As (Jan. 23), pointed ever hope to cope " in the words of Dr. Gavin (Feb. 6), a graph can be of great assistance in the prescription of " with the multitude of human problems ... which insulin zinc suspension mixtures. In the diabetic clinic we are similar to crop up daily in the little world of the hospital "’? a here, using graph which, though very The less specialised his early academic background, Dr. Thorn’s, may have slight advantages. By using three differently coloured inks, the pairing of the lines-i.e., the more broad should be the administrator’s under20% and 80%, 30% and 70%, 40% and 60%-is more standing of a consultant, an " exuberant resident," a matron, an almoner, or a wardmaid. Noamount of obvious. We find that emphasis of the 30% and 70% theoretical training makes a good hospital administrator. lines by black ink is helpful as these lines represent the proportions in ’I.Z.S. Lente.’ Also we find it more He can only hope to become one if he has, as an apprentice, absorbed almost through his pores the atmosphere. convenient and less misleading to scale the ordinate with traditions, habits, and characteristics of every individual zero at the base. As the patient probably has already a stock of I.Z.S. type and department making up .the complex little world of hospitals. And even with this, he will fail if he does and as is the insulin at this zinc lente, only suspension not care for those inside the world he administers. if in the " 80 " it available, present -required, strength, whether patients or staff. is obviously desirable to use i.z.s. lente as the basis of any the lente of i.z.s. with mixture, replacing part I.Z.S.(A) 1. Moore, K. L., Grahame, M. A., Barr, M. L. Surg. Gynec. Obstet. or I.Z.S.(C) as indicated. 1953, 96, 641. "
.
satisfactory