158 I have seen nurse anaesthetists throughout the world, and it would be idle to pretend that quite a number do not attain a high degree of proficiency, but it would be equally idle to conceal that occasionally a life is lost which could have been saved at the hands of a specialist. With the rising cost of the N.H.S. one cannot be but concerned, in one’s own specialty, at the highly trained consultant anarsthetist spending so much of his time on humdrum work. In surgery and anaesthetics impeccable technique is all-important. Practice and experience can accomplish much, and there is no doubt that an able and keen nurse can be trained " to give routine anaesthetics ". But if economics or the shortage of doctors makes this step worthy of serious consideration, is there not something to be said for training nurses specifically for dental con-
servation, dental extractions, tonsillectomy, cataract extraction, varicectomy ? And why stop there ? If the nurse anaesthetist is to be justified on grounds that she can be made technically adequate, why shouldn’t nurses " be brought to something like G.P.-surgeon standard " (to paraphrase Dr. Toner), and, under supervision, perform herniotomy and gastrectomy-to mention but two operations in which neat and accurate sewing is an asset. After special training from an expert surgeon, an intelligent nurse would undoubtedly do these jobs both more neatly and more economically than many a young registrar. That occasionally a patient will be sewn up the wrong way we will accept with the same equanimity as we now
accept the unnecessary death which occurs from time of the nurse anaesthetist.
to time at the hands Pembroke College, Oxford.
SIR,-Dr. Toner suggests the use of specially trained technicians to give safe adequate anaesthesia to wide range of cases, although the practice is looked on
nurses or a
here with the same disfavour as doctors in North America view the conduct of labour by nurses. Our system of anaesthesia by anxsthetists is spreading throughout Europe-for example, Austria, which before the late war could hardly afford the cost of anaesthetic drugs, let alone anaesthetists, now has a postgraduate diploma and trained anaesthetists. British anaesthesia is respected throughout the world, and our present standards should be maintained in the interests of patient and surgeon. The smoothness of expert anaesthesia is the result of years of study and practice, whereas the stormy anaesthesia of prewar days was due largely to the employment of untrained anaesthetists. In the U.S.A., where nurse-anaesthetists are still employed in diminishing numbers for economic reasons, the training they receive varies in duration from two weeks to two years. The overall anaesthetic mortality was estimated after an exhaustive survey1 at 5128 per annum-which I believe to be far higher proportionately than the corresponding British figure. Assuming that the shortage of doctors will become so acute that substitutes will have to be found for medical anaesthetists from the already insufficient numbers of nurses and other young people, what material would be available for training ? At present the educational requirements for entry into nursing are almost nil, and technicians would presumably start on the same footing. Can Dr. Toner suggest how to bring them up to D.A. standard ? Surgeons would once more become responsible for the minute-to-minute supervision of the anaesthetic, a responsibility which they were glad to drop, and which the majority would not now be fit to assume. Even if a medical anaesthetist were 1.
Beecher, H. K., Todd, D.
Surg. 1954, 140,
the theatres there would inevitably be occasions when he was not present when needed. One can anticipate difficulty in compiling lists suitable for the non-medical anaesthetist, and thorny problems of status and salary, rapid turnover, opposition from the nursing authorities, medicolegal responsibility, and addiction to dangerous drugs. If the principle of administration of anaesthesia by nonmedical personnel were accepted, no doubt this would pave the way for further economies in medical manpower by the employment of similar staff to perform standard operations, reduction of fractures, suturing of wounds, and so forth. Surely we want nurses to nurse, and to secure the doctors we need by making the practice of medicine more attractive than it is at present. Mayday Hospital, ERIC GODWIN. Thornton Heath, Surrey.
NYLON REPAIR IN INGUINAL HERNIA
SiR,ŅThe article by Mr. Leacock and Dr. Rowley (Jan. 6) calls, I feel, for some comment as to technique, follow-up, and recurrences. Technique.-Stage 3 of their standard method is to suture the conjoint tendon to the inguinal ligament using continuous monofilament nylon. This, surely, is Bassini all over again. In stage 4, the last stage of the repair, using the same suture, a reinforcing darn is placed between the conjoint tendon and the inguinal ligament. If this method is to be called nylon darn, then surely it must follow the principle of a darn-that is, a method of stitching without tension and filling in a gap. Stage 3 of that technique is merely suturing under tension; and stage 4, called a reinforcing darn, is not in fact a darn at all but merely a second layer of nylon suturing. The essential principle in any inguinal-hernia repair is the absence of tension. That is why Tanner devised the slide, and why I devised the release of the attachment of the fascia lata to the inguinal ligament in the thigh. If the principle of the darn is introduced, then no attempt should be made to draw the conjoint tendon down to the inguinal ligament. If these two structures are joined, then the method is not a darn. Follow-up.-Inguinal-hernia follow-up is a notoriously difficult procedure. It is fallacious to assume, as has been done on many occasions by different authors, that the group of cases, unexamined for various reasons (22% in the article in question), carries the same low percentage-rate of recurrence as a group that were examined at follow-up. Experience has shown that there may be a higher percentage of recurrence in the group not followed, for the following main reasons: (1) fear of a second operation; (2) a second operation elsewhere; (3) a kindly reticence in avoiding telling the surgeon that his operation has failed; (4) undisclosed acceptance of a recurrence, unknown even to the patient’s own practitioner, and the resumption of (or purchase of) the faithful truss. It is generally admitted with regard to recurrences that, of those repairs which are going to break down, 90% break down within the first two years; in this series, of 348 repairs, 72 had been followed up for only one year, and a second examination of these cases may reveal recurrences which would tend to spoil the excellent recurrence-rate reported. It is suggested that the variations in percentage-rates of recurrence cited by many surgeons are directly related to both the efficiency and the fullness of the follow-up examination. A follow-up is also more instructive when these figures are broken down into age-groups.
comprehensive review of the hernia
problem in the Liverpool region, Mr. A. J. Marsden has laid down certain principles related to the follow-up and recurrences. He feels, quite rightly, that it is important to record the type of hernia and the type of repair and the type of recurrence. Leacock and Rowley appear to have been fortunate in having no indirect recurrences, although the literature stresses that indirect recurrence of primary indirect hernia is a relatively common finding. Incredulity at the early appearance of a fresh indirect sac has often been explained away by the assumption
ligated high enough. Personal experience believe, however, that this type of recurrence is due to lax peritoneum on the medial side of the internal ring not being removed at the time of the first operation. Lax peritoneum, which I have termed " medial sac ", is found more often perhaps in herniae with wide necks. Mr. Maloney, in his original article of 1948, stressed that the
the need for
not suturing the conjoint tendon to the ligament ; and this article shows that the method inguinal used by Leacock and Rowley is a modified Bassini rather than a Maloney darn. In any case, the principle of the dam was enunciated by Sir Heneage Olgivie as long ago as
sac was not
So great is the problem of inguinal-hernia repair, both economically and surgically, that it may be well worth while to consider setting up a central hernia registry, based perhaps on the Liverpool scheme and designed in the first instance to discover present-day principles in use and present-day techniques and follow-up schemes. This suggestion may be countered by the surgical attitude of I’m all right Jack " (" My method suits me, therefore I will continue it "). But the problem is there; and it was brought home to me recently when a surgical colleague practising in London said, I do very few hernia repairs now; in fact only other people’s recurrences." "
D. W. BRACEY.
THE PREMATURE BABY’S DIET
SIR,-Iread that the Meacham quads, being two days old, were allowed their first feed-a few drops of sterile water. It seems an odd custom to require premature babies, who have hitherto been continuously succoured, to withstand a two-day fast and then to give them only water. Can someone explain the rationale ? F. D. BOSANQUET. London, S.E.23. ALLERGY TO LIGNOCAINE
SIR,-The demonstration by Mr. Noble and Dr. Pierce (Dec. 30) of allergy to lignocaine prompts me to report in which death may have been due mechanism.
A 72-year-old man had mild rheumatic aortic stenosis and mitral incompetence. When symptoms of prostatic obstruction developed, he refused surgery; catheterisation was occasionally required. This was done by various urologists, one of whom used lignocaine (’ Xylocaine ’ 2% urethral gel) for the first time in June, 1960. There was no untoward reaction, and the patient remained well until Jan. 6, 1961, when he had acute retention. Lignocaine was again used to lubricate the catheter. About 1 hour later the patient had tachycardia and dyspnoea, which soon passed off; he did not bother to report this. He was able to pass urine spontaneously next morning, but it was necessary to catheterise him that evening. Once again, lignocaine was used, a thin catheter was inserted, and about 12 oz. of urine was slowly removed. The patient remained well for 45 minutes, but then suddenly became dyspnceic, and soon lost consciousness. He could only briefly be revived, despite the use of adrenaline and intravenous and intracardiac hydrocortisone. Tachycardia (200 beats a minute) and loud wheezing were prominent features. Postmortem examination was not permitted, but the patient appears to have developed allergy to lignocaine. There was no trouble on the first occasion it was used, only a moderate reaction the second time, and, finally, fatal anaphylaxis. While definite proof is lacking, the circumstances seem very suggestive. Salisbury, D. M. D M KIRKLER.
SIR,-In his excellent very special article, Dr. Asher (Dec. 23) says that the witchcraft styles of treatment, such as eye of newt and toes of frog, wool of bat and tongue of dog " and glycerin of ichthyol, are based on no reasoning whatever. Is it not more likely that all treatment depends on some reasoning, however absurd, than on no reasoning ? I suggest that Dr. Asher underestimates the ability even of clever and learned men to devise incredibly tortuous a-priori arguments with fantastic conclusions, provided that they carefully avoid the practical testing of their beliefs. In the 18th century the celebrated philosopher, Bishop Berkeley, wrote a treatise on the virtues of tar-water, in which he hypothesised that the lime-trees "
accumulate the vital elements of the universe from the sunand air and concentrate them in the tar. This tarwater would cure smallpox, consumption, syphilis, ulcers, gravel, and other maladies. Berkeley’s reasoning proved so persuasive that his treatise was translated into many languages and barrels of tar were consumed all over
Europe. In Price’s Medicine (1937 edition) appears the following : " The form [of treatment for Graves’ disease] will depend upon the view taken as to the origin of the disease.
If it be assumed that Graves’ disease is the result of stimulation of the thyroid gland by substances formed in the intestines by a pathogenic microbe, the administration of antiseptics, such as thymol carbonate, salol, or fluorides is indicated ..." This is a striking example of apriority, since the author does not even suggest that the treatment mentioned works in practice. JOHN W. TODD. Farnham, Surrey. ALPORT’S SYNDROME
SIR,-Dr. Williamson (Dec. 16) reports the first 3 families with hereditary nephritis with deafness observed in Great Britain, bringing to a total of 22 the families reported since 1951. We should like to add to his geographical list the first family in Switzerland with Alport’s syndrome, hitherto unreported. The family’s history is easily traced since its members lived in the same village of Eastern Switzerland and dated records are available as far back as 1770. The old records kept by the minister of the village reveal in the last 5 out of 7 generations several deaths due to nephritis. Detailed data were obtained for 3 brothers from a family with 10 siblings in the last generation but one who died aged 17, 19, and 23 years from chronic renal disease with haematuria and albuminuria. In 1 of them, who was only 139 cm. (4 ft. 31/a in.) when he died, the renal disease was noted already at the age of 3, and in the others at 18 and 21 years. Raised blood-pressure was observed terminally in all of them. The hearing defect could be traced audiometrically as originating in the inner ear for the first time at age 11, 9, and 7 years respectively. An additional feature in the 3 brothers was debility. Each one had to repeat classes once or twice. In 1, at the age of 10, a cataract developed rapidly and necessitated operation: there was no apparent traumatic lesion. Necropsy records exist for 2 of the cases and describe the classical picture of chronic diffuse glomerulonephritis. We have tested the urine for erythrocytes in the 4 brothers and 3 sisters (ages 27 to 44 years), with a positive result in 1 brother only. Out of 14 children available in the last genera-
tion, however, 3 boys and 2 girls showed microscopic hxmaturia. One boy, born in 1952, had nephritis at the age of 2, and at 8 years difficulty in hearing was noted for the first time. In each urine specimen tested so far we found a microscopic haematuria and albumin (1-2 g. per 24 hours). An average hearing loss of 50 decibels within the speaking range without