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EFFECTIVE USE OF TEACHING TIME
682 it likely that the hypoglycæmic action of insulin accounted for my patient’s ulcer. Since then a strong possibility has arisen that there is a second pancreatic hormone-a hyperglycæmic glycogenolytic factor (glucagon). Abrahamson and Hinton ’7 suggested in 1943 that the gastric mucosa was an endocrine gland. Having re-read their paper and your leading article, I wonder whether at this stage even " a little imagination " is not just too much-in linking such complex physiological activities with morbid-anatomical
may be difficult to distinguish a small intetstitial inguinal hernia from the bulging of weak muscles, and diagnosis depmds
on feeling feeling rarefully carefully for adefinitecough cough impulse. impulse.
M.
LEVENE.
EFFECTIVE USE OF TEACHING TIME
SIR--In their article of March
14 Dr.
opinion this type of interstitial inguinal hernia is to a congenital sac curiously placed; after an ordinary inguinal hernia has been repaired its recurrence may be interstitial. It seems rather that a hernia which has entered the inguinal canal from the abdominal cavity is occasionally unable to escape through the superfku) inguinal ring, especially in females, and instead en. larges laterally and upwards under the external obliqueOccasionally an inguinal hernia is seen which has both escaped through the superficial inguinal ring and also extended a little interstitially. The treatment of interstitial inguinal hernia does not differ from that of ordinary
Joyce and
inguinal hernias.
of time spent in reading textbooks, other references, or their own notes ranged from 0 to 21 hours per student per week. Can this be taken as evidence that all spare-time reading is useless ? Were the efforts of the 21-hour student quite unrewarded? If so, I for one can think of many other ways of spending an evening, and if reading is of no value I am prepared to stop at once. TIMOTHY CHARD. London, S.E.l. INTERSTITIAL INGUINAL HERNIA
SIR,-Before coming to Nigeria I thought of interinguinal hernia as a rarity which one was unlikely to meet and less likely to diagnose before operation. Howstitial
we see so
many hernias of
different sites and sizes, interstitial inguinal hernias, in which the sac is spread out under the external oblique
aponeurosis, are fairly common; and, though they are of no particular importance, I should like to draw attention to their features, which. differ from those described in my textbooks. Of a personal series of 303 inguinal hernias operated on here in eighteen months 14 were interstitial-an incidence of nearly 5°o. These 14 were made up of 4 on the right, 4 on the left, and 3 bilateral. Some emerged from the abdomen lateral to the
deep epigastric
vessels, others medial to them. They varied in size, the largest extending almost to the flank and costal margin. None was
strangulated, and
associated with undescended testis; indeed, 10 out of the 14 were in females. The characteristic feature of these interstitial inguinal hernias is that the hernia does not
none was an
escape through the super-
ficial inguinal ring from between the the inguinal canal, but instead extends external oblique aponeurosis and the internal oblique muscle. Such a hernia appears therefore as a swelling in the groin above the inguinal ligament and lateral to the pubic tubercle (see figure, for which I am indebted to my colleague, Dr. M. L. Cox). If one is aware of the existence of this type of hernia, the diagnosis is usually obvious at a glance. But sometimes it
laterally
7.
definite
In my due
Professor Weatherall make the following statements: (1) the number of hours spent on private study did not correlate with the score in the final test; (2) the amount
ever, in this country, where
a
not
findings. Christie Hospital and Holt Radium Institute, Manchester.
for
on
Abrahamson, R. H., Hinton, J. W. Surg. Gynec. Obstet. 1943, 76, 147.
Methodist Hospital, Ituk Mbang, Uyo, Eastern Nigeria.
R. D. CUNDALL. HEPATIC AMŒBIASIS
SIR,-We appreciate the interest in our papershown by your annotation of Feb. 14. We feel, however, thata wrong impression may have been given and we should be grateful if you would allow us to clarify certain issue (1) In our paper we were at pains to point out that the term " amoebic hepatitis " is in our opinion a misnomer, and has no demonstrable pathological basis. The suggestion you mis. takenly ascribe to us that amoebic hepatitis and amœbic abscess differ only in degree was a direct quotation froma textbook of medicine.2 We used this quotation in out paper to illustrate the discrepancy between the clinician and the pathologist in their concepts of hepatic amœbiasis. (2) From our studies we concluded that the clinical entitr
current
traditionally described as amoebic hepatitis probably represents one or more deep-seated abscesses of small dimensions resolving on specific therapy without recourse to aspiration. (3) Your annotation fails to draw attention to our observation that it was only the smaller abscesses which responded promptly and strikingly to specific therapy alone. King
Edward VIII Durban.
Hospital,
N. MCE. LAMONT N. R. POOLER.
STREPTOKINASE IN CHRONIC BRONCHITIS
SIR,-Many bronchitics find great difficulty in coughing up their sputum owing to its stickiness. The commonly used expectorants are valuable in stimulating cough and bronchial secretion but have little or no effect on the viscosity of the sputum. I have recently been using a preparation of streptokinase given in tablet form which seems to have had a remarkable effect in reducing the tenacity of sputum. The tablets, each containing 10,000 units of strepicm and 2500 units of streptodornase, were given to three chMcx bronchitics who complained of very sticky sputum, the p3ticx being instructed to suck one tablet three or four times dh. All three patients, who had previously been taking compound sodium chloride mixture, B.N.F. in hot water twice dljt, reported considerable reduction in the stickiness of their s and consequent relief from episodes of severe and diqr,-m4 coughing and straining in order to bring up masses t ti3 mucoid phlegm.
The
subjective results in these few patients rr impressed me with the value of orally absorbed sut-M-kinase in selected
cases
of chronic bronchitis.
D. S. NACHSHEN. London, N.W.2. 1. Quart. J. Med. 1958, 27, 389. 2. Harrison, T. R. Principles of Internal Medicine; p. 1137. New York. 1954.
may be difficult to distinguish a small intetstitial inguinal hernia from the bulging of weak muscles, and diagnosis depmds
on feeling feeling rarefully carefully for adefinitecough cough impulse. impulse.
M.
LEVENE.
EFFECTIVE USE OF TEACHING TIME
SIR--In their article of March
14 Dr.
opinion this type of interstitial inguinal hernia is to a congenital sac curiously placed; after an ordinary inguinal hernia has been repaired its recurrence may be interstitial. It seems rather that a hernia which has entered the inguinal canal from the abdominal cavity is occasionally unable to escape through the superfku) inguinal ring, especially in females, and instead en. larges laterally and upwards under the external obliqueOccasionally an inguinal hernia is seen which has both escaped through the superficial inguinal ring and also extended a little interstitially. The treatment of interstitial inguinal hernia does not differ from that of ordinary
Joyce and
inguinal hernias.
of time spent in reading textbooks, other references, or their own notes ranged from 0 to 21 hours per student per week. Can this be taken as evidence that all spare-time reading is useless ? Were the efforts of the 21-hour student quite unrewarded? If so, I for one can think of many other ways of spending an evening, and if reading is of no value I am prepared to stop at once. TIMOTHY CHARD. London, S.E.l. INTERSTITIAL INGUINAL HERNIA
SIR,-Before coming to Nigeria I thought of interinguinal hernia as a rarity which one was unlikely to meet and less likely to diagnose before operation. Howstitial
we see so
many hernias of
different sites and sizes, interstitial inguinal hernias, in which the sac is spread out under the external oblique
aponeurosis, are fairly common; and, though they are of no particular importance, I should like to draw attention to their features, which. differ from those described in my textbooks. Of a personal series of 303 inguinal hernias operated on here in eighteen months 14 were interstitial-an incidence of nearly 5°o. These 14 were made up of 4 on the right, 4 on the left, and 3 bilateral. Some emerged from the abdomen lateral to the
deep epigastric
vessels, others medial to them. They varied in size, the largest extending almost to the flank and costal margin. None was
strangulated, and
associated with undescended testis; indeed, 10 out of the 14 were in females. The characteristic feature of these interstitial inguinal hernias is that the hernia does not
none was an
escape through the super-
ficial inguinal ring from between the the inguinal canal, but instead extends external oblique aponeurosis and the internal oblique muscle. Such a hernia appears therefore as a swelling in the groin above the inguinal ligament and lateral to the pubic tubercle (see figure, for which I am indebted to my colleague, Dr. M. L. Cox). If one is aware of the existence of this type of hernia, the diagnosis is usually obvious at a glance. But sometimes it
laterally
7.
definite
In my due
Professor Weatherall make the following statements: (1) the number of hours spent on private study did not correlate with the score in the final test; (2) the amount
ever, in this country, where
a
not
findings. Christie Hospital and Holt Radium Institute, Manchester.
for
on
Abrahamson, R. H., Hinton, J. W. Surg. Gynec. Obstet. 1943, 76, 147.
Methodist Hospital, Ituk Mbang, Uyo, Eastern Nigeria.
R. D. CUNDALL. HEPATIC AMŒBIASIS
SIR,-We appreciate the interest in our papershown by your annotation of Feb. 14. We feel, however, thata wrong impression may have been given and we should be grateful if you would allow us to clarify certain issue (1) In our paper we were at pains to point out that the term " amoebic hepatitis " is in our opinion a misnomer, and has no demonstrable pathological basis. The suggestion you mis. takenly ascribe to us that amoebic hepatitis and amœbic abscess differ only in degree was a direct quotation froma textbook of medicine.2 We used this quotation in out paper to illustrate the discrepancy between the clinician and the pathologist in their concepts of hepatic amœbiasis. (2) From our studies we concluded that the clinical entitr
current
traditionally described as amoebic hepatitis probably represents one or more deep-seated abscesses of small dimensions resolving on specific therapy without recourse to aspiration. (3) Your annotation fails to draw attention to our observation that it was only the smaller abscesses which responded promptly and strikingly to specific therapy alone. King
Edward VIII Durban.
Hospital,
N. MCE. LAMONT N. R. POOLER.
STREPTOKINASE IN CHRONIC BRONCHITIS
SIR,-Many bronchitics find great difficulty in coughing up their sputum owing to its stickiness. The commonly used expectorants are valuable in stimulating cough and bronchial secretion but have little or no effect on the viscosity of the sputum. I have recently been using a preparation of streptokinase given in tablet form which seems to have had a remarkable effect in reducing the tenacity of sputum. The tablets, each containing 10,000 units of strepicm and 2500 units of streptodornase, were given to three chMcx bronchitics who complained of very sticky sputum, the p3ticx being instructed to suck one tablet three or four times dh. All three patients, who had previously been taking compound sodium chloride mixture, B.N.F. in hot water twice dljt, reported considerable reduction in the stickiness of their s and consequent relief from episodes of severe and diqr,-m4 coughing and straining in order to bring up masses t ti3 mucoid phlegm.
The
subjective results in these few patients rr impressed me with the value of orally absorbed sut-M-kinase in selected
cases
of chronic bronchitis.
D. S. NACHSHEN. London, N.W.2. 1. Quart. J. Med. 1958, 27, 389. 2. Harrison, T. R. Principles of Internal Medicine; p. 1137. New York. 1954.