863

As- the internal ring is approached, the cord is pulledfirmly outwards and suture is continued until it can be feltthat an opening only the size of the tip of the little fingerremains. At one time we were in the habit of reinforcingthe internal ring by buttressing the cord on all sides withfloss-silk sutures in the manner used by Gallie in his fascialrepair operation ; but now we omit this step, preferring toplace the emerging cord between the soft yielding muscleslaterally and the silk wall that is built up on its medial

aspect (fig. 4).The suture is next continued back- towards the starting-

point, but this time with much wider traverse, taking on oneside a bite of the inguinal ligament between the stitches ofthe previous row, then on the other side the fibromuscularconjoined tendon. The stitches are once again insertedwithout the slightest degree of tension and are passed insuch a manner that the whole of the posterior- floor of theinguinal canal is effectively darned with a lattice of flosssilk (fig. 4).The stitch is completed by taking a good bite of the

periosteum over the pubic spine and the crest of the pubisand by tying the ends of the silk sutures together so that the

Fig. 4-Posterior lattice repair nearing completion. When this sutureagain reaches starting-point, it picks up a good bite of periosteumof pubic spine, and ends are tied together. External obliqueaponeurosis’is sutured behind cord to provide maximal reinforcementfor posterior wall of cord.

knot will lie beneath the aponeurosis of the external obliquedose to the pubic crest.

’

CLOSURE OF WOUND

With the cord elevated, the edges of the external obliqueaponeurosis are approximated with a series of interruptedsutures of fine silk ; or, if the aponeurosis has been muchstretched, the edges may be overlapped. The cord is finallylaid back on its new bed before the deep fascia and the sub-,cutaneous tissues are drawn together with interrupted stitchesof fine silk. The skin edges are sutured with vertical mattresssutures of fine black silk or ’ Deknatel.’

,

The wound is finally painted with merthiolate, and asmall gauze dressing is applied and kept in place by a broadstrip of elastic adhesive bandage. ’

ASSESSMENT OF OPERATION

In our last - 100 consecutive cases there has beensepsis in 2 cases ; but, on removal of the offending liga.tures and injection of penicillin 250,000 units six-hourlyfor a few days, the wounds have healed satisfactorilyand apparently strongly. No operation can be compared to this floss:-silk latticemethod for large herniae or recurrent hernise in enfeebledpatients. The all-round recurrence-rate following thismethod is not higher than 3%, and this includes casesin which the. operation has been performed in obesepatients, in, the aged, and in patients who have hadtwo or three, or even sometimes four, previous hernior-Thaphics. Sepsis most often develops in obese patients.We make a point now of operating on only one side ata time in cases of bilateral hernia, and we avoid supple-mentary operations, such as those for varicocele andhydrocele, when operating on a hernia.

Referenees ut foot of next column

MR. MAINGOT: REFERENCES

Brandon, W. J. M. (1945) Lancet, i, 167.Gallie, W. E. (1921) Canad. med. Ass. J. 11, 504.Halsted, W. S. (1893) Bull. Johns Hopk. Hosp. 4, 17.Handley, S. (1918) Practitioner, 100, 466. McArthur, L. L. (1904) J. Amer. med. Ass. 43, 1039.McVay, C. B., Anson, B. J. (1942) Surg. Gynec. Obstet. 74, 746.

z 2

ANTHISAN IN THE TREATMENT OF

ALLERGIC RHINITIS

A. G. S. CALDERM.B. Edin., F.R.C.S.E.

ASSISTANT SURGEON, EAR, NOSE, AND THROAT DEPARTMENT,SELLY OAK HOSPITAL, BIRMINGHAM

. Fourneau and Bovet (1933) first demonstrated thatcertain phenolic ethers counteracted the action ofhistamine in vivo and in vitro. Since then manycompounds have been synthesised having this action.Those of most promise are ’ Anthisan,’ ’ Antistin,’’Benadryl,’ and Pyribenzamine.’ Of these pyri-benzamine is not generally available in this country.

.

These compounds specifically counteract the physio-logical effects of histamine : (1) they raise a blood-pressure which has been lowered by histamine; (2)they prevent contraction by histamine of intestinal anduterine strips from guineapigs, both when the drug isadded to the fluid in which the strip is suspended andwhen it is administered to the intact animal ; (3) theyhave some analgesic action by counteracting the effectsof histamine on the cutaneous ends of pain nerves ;

(4) they prevent death in experiments on animals fromthe injection of an otherwise lethal dose of histamine ;(5) they diminish capillary permeability resulting fromhistamine and counteract the histamine weal; and (6)they inhibit secretion induced by histamine in lacrimaland salivary glands and in the mucous glands of thebronchial tree. Because undue secretion is a featureof both allergic rhinitis and asthmatic attacks, thislast action is of clinical use. -

.

Anthisan, also called ’ Neoantergan,’ is pyranisaminemaleate (N-dimethylamino-ethyl-N-p-methoxy-benzyl-&agr;-aminopyridine maleate). Dews and Graham (1946)published pharmacological details. Hunter (1947)reported on the treatment of 14 cases of urticaria treatedwith anthisan. Hunter and Hill (1947) found anthisanof value in the control of sensitivity to liver extract andinsulin. In the present series 48 patients have beentreated with anthisan, of whom 44 were followed up andhad a complete course of treatment. Anthisan was ofbenefit to all the 6 hay-fever cases and to 29 (76%)of the 38 cases of vasomotor rhinitis :

Conditions No. of Great Jlodercrte Little or Reactions.

Corzclitions cases beiiejit benefit no benefit Recsetious

Hay-fever.. .. 6 5 1 - -

Vasomotor rhinitis 38 12 17 9 4

VASOMOTOR RHINITIS

The scheme of treatment was to start with one tablet(0.1 g.) three times a day for five days and, if there wereno severe side reactions, to increase this to 0-2 g. threetimes a day. This was continued for ten days. In15 cases benefited by anthisan the effect of dummyanthisan tablets was tried. After this the effect of

benadryl was tried before returning the patients to

regular anthisan dosage. In 10 stabilised cases an attemptwas made to reduce their dosage. Of the 38 cases

4 (10%) showed a side reaction, but in no case did thisinterfere with treatment. The reactions were observedwith the initial dosage and tended to pass off as the treat-ment continued. In 3 cases there was some drowsiness,and in 1 a loss of appetite.

-

Of the 15 patients benefited by anthisan and thengiven dummy anthisan tablets 10 complained that their

864

condition had deteriorated, 3 did not note any difference, -and 2 thought they were better than before.

All the patients were given benadryl for comparisonof effects. In all cases where anthisan was not effectiveno effect was obtained from benadryl. Of the 29

patients who were benefited by anthisan in this smallseries 19 thought anthisan better, 8 thought benadrylbetter, and 2 were not sure. This accords with the

findings of Friedlaender et al. (1947), who in animalsfound neoantergan the most efficacious of the anti-histamine drugs in preventing death from injections ofotherwise lethal doses of histamine.With 2 exceptions in the present series, the improve-

ment in symptoms was accompanied by a correspondingimprovement in the state of the nasal mucosa. The

pale boggy turbinates shrank and became pink, whilethe amount of secretion in the nose returned to normal.Administration of anthisan for weeks or months

apparently did not damage the nasal mucosa.The dosage needed to keep the patient in comfort was

as a rule 0’6 g. a day. The treatment was tolerated wellby children with 0-3 g. a day. In 10 stabilised cases an

attempt was made to reduce the dosage gradually, butfailed. A constant dosage seems to be required whichcannot be reduced without return of part of the

symptoms. The dosage of 0-6 g. a day was preferredin three doses, rather than divided into six doses.

HAY-FEVER ,

Only 6 patients with hay-fever were treated, withcomplete cessation of attacks in 5 and slight symptomsonly in 1. Of the 5 patients successfully treated withanthisan 2 had been treated unsuccessfully with mixedvaccines in the past, and another 1 had not benefitedfrom zinc ionisation. The dosage was 0-2 g. three timesa day till the end of the pollen season, when treatmentwas stopped.

DISCUSSION

Anthisan in allergic rhinitis is an effective anti-histamine drug. Like all these drugs, it does not cure,and must be given for as long as an effect is desired.When the treatment is stopped, there is a quick relapseof the patient’s condition, beginning in 6-8 hours.Desensitisation remains the treatment of choice, and anti-histamine drugs should be used only where the offendingantigen cannot be found, or pending desensitisation.

Clinical evaluation is difficult, since allergic manifesta-tions are often self-limiting. In a chronic condition

spontaneous improvement may take place at any timebecause of the sudden disappearance of certain inhaledor ingested antigens from the patient’s environment,and because of the likelihood of spontaneous desensitisa-tion to certain antigens. Therefore conclusions aboutthe effect of anti-histamine drugs should not be drawnuntil the patient has had a long treatment. Psychologicalinnuences are very important in allergy. The administra-tion of a tablet or a capsule may bring relief, especiallyif the drug has been popularised by the lay press.The incidence of side-effects is generally accepted as

20-25%. Drowsiness is the most common. The lowincidence of mild side-effects with anthisan in this smallseries of cases was noteworthy.

Anthisan deserves a definite place in the manage-ment of nasal allergy. A new series of compounds moreeffective and less toxic in experiments on animals thanany yet used has been described (Halpern 1947).

SUMMARY °

In all of 6 cases of hay-fever, and in 29 of 38 cases ofvasomotor rhinitis, anthisan was effective. Side reactionsdeveloped in 4 of the 44 cases, but they were never severe.

I am indebted to Mr. R. P. S. Kelman, F.R.c.s., medicalsuperintendent of Selly Oak Hospital, for permission to

publish this report, and to Pharmaceutical Specialities(May & Baker) Ltd. for supplies of active and inert anthisan.

REFERENCES

Dews, P. B., Graham, J. D. P. (1946) Brit. J. Pharmacol. 1, 278.Fourneau, E., Bovet, D. (1933) Arch. int. Pharmacodyn. 46, 178.Friedlaender, S., Feinberg, S. M., Feinberg, A. R. (1947) J. Lab.

clin. Med. 32, 47.Halpern, B. N. (1947) J. Allergy, 18, 263.Hunter, R. B. (1947) Lancet, i, 672.

— Hill, A. G. S. (1947) Ibid, ii, 383.

NON-SUPPURATIVE HEPATITISREPORT OF A CASE

W. E. KING* P. J. PARSONS†M.D. Melb. M.R.A.C.P. M.B. Melb.

J. W. PERRY* M. FREEMAN*M.B. Melb. B.Sc. Melb.

From the Clinical Research Unit of the Walter and Eliza HallInstitute of Medical Research and the Royal Melbourne

Hospital, AustraliaTHIS case of non-suppurative hepatitis is reported

because it has been studied in detail during its wholecourse, which ended fatally ten months after the onset.Brief reference to the case has previously been made by Wood et al. (1948) in a review of non-suppurativehepatitis.The patient was a youth of 19 whose illness began with

jaundice, fever, and pain over the liver. The acute

phase passed into mild chronic ill health. He died fromacute liver failure following an apparently mild upperrespiratory infection: The study was made by olinicalobservation, serial biochemical tests for liver function,and aspiration biopsy of the liver in the second andsixth months of the illness. Finally, a full necropsywas made.The cause of the hepatitis in this case was not deter-

mined, but in our opinion it was attributable to thevirus of infective hepatitis. This virus is known tocause an acute hepatitis which is seldom fatal in theearly acute phase, but occasionally the disease does not

______________________

resolve andbecomeschronic.There areno specificserologicalteats for thedisease, andno labora-

tory animalissusceptible.Inoculationof humanvolunteers isthe onlyknown wayof identify-ing the virusin the acuteform, butrecent at-

tempts by.Neefe et al.

(1947) totransmit the

disease from chronic cases gave inconclusive results.Infective hepatitis is endemic in Melbourne, where the

patient lived, but no history of contact with other casesof jaundice could be obtained. His diet had beenadequate, and he had not been exposed to chemicalpoisons. No injection which might cause homologou,serum jaundice had been given.This work was aided by a grant from the National Health and

Medical Research Council of Australia.† Wyeth Fellow in Medicine.

Fig. I-Positive cephalin flocculation and fluctuationsin serum-bilirubin, serum-globulin, and serum-albumin levels in chronic non-suppurative hepatitisprobably due to virus of infective hepatitis.