Mr McGinley, you are a hero of modern surgery: to have had four joints replaced under local anaesthetic is a triumph. When I qualified, more than 30 years ago, not one of these joints could have been replaced.
Now you have the inguinal hernia. It is a common problem. Around 25 per cent of men will have one at some point in their lives. What happens is that a weakness in the abdominal wall allows a section of the intestine to bulge out into an area of the groin known as the inguinal canal. They can form a visible bulge.
Hernias seem to have a genetic element, and the risk rises with age as the tissues in the abdominal wall weaken. They can also come about as a result of the strain of lifting heavy weights or persistent coughing.
As you say, it can be hazardous to leave a hernia at the groin unrepaired, as there is a chance that it can go onto strangulate.
This happens when the loop of intestine trapped in the hernia tightens and cuts off its own blood supply, hence the term strangulation.
Without a blood supply this tissue can start to die and can potentially prove fatal.
It can be hazardous to leave a hernia unrepaired
Surgery must be carried out at once, within hours, to ease the pressure on the strangulated section of tissue and to hopefully restore the blood supply.
If this is not immediately successful – which the surgeon can judge at the time of the operation – then that imperilled section of intestine must be removed, turning what could have been a relatively minor surgical procedure into a major operation.
However, this rarely happens these days, as once an inguinal hernia has formed surgeons normally repair it with a straightforward operation to close the gap that it pushed through.
This can then avoid the drama and danger of the more major surgery that becomes necessary if a hernia does strangulate.
The implication of what I am saying is that you are quite right: why should you not have your hernia repair surgery?
I accept that having two groin hernias repaired at one session is a bigger procedure than just one; but it is perfectly possible, and it is feasible under local anaesthetic, being commonly carried out in this way on older patients who have the added complexity of other health problems.
I suggest that you discuss the issue along the above lines with your GP. You should be re-referred, and although there may have to be some additional care – if, for example, you are taking warfarin for a heart rhythm irregularity, or low dose aspirin because of the previous heart bypass – but there is no reason why surgery cannot be achieved, for you are only 75, not 95.
Mrs M. Murdin, Wellingborough, Northants.
Tourette’s Syndrome is a neurological disorder brought on by an abnormality in the way some of the regions of the brain work. It causes the child to make odd movements or sounds – we call these ‘tics’.
The affected patient has little control over these sudden moments which can include blinking, facial grimaces, jerking of the head or limbs, grunting, or, even, at times, swearing or obscene gestures.
For some these tics will be quite subtle – so much so others may not even recognise that someone has a problem. But for others the symptoms are intense and obvious.
In most affected children the disorder has become obvious by the age of 11, and boys are more commonly affected than girls, though it is not clear why.
Tourette’s is thought to be a genetically inherited condition, though we do not understand it well; the changes to the brain are complex and there are no consistent findings on brain scanning or other investigations.
There is no cure, although the good news is that the tics resolve by adult life in half of cases.
In the meantime what can help is for the family, teachers, and all those who know or have contact with the child to have better understanding of the condition.
It can be tempting to think the tics are somehow deliberate or within the child’s control. It is important all parties recognise that it is not a psychological disorder – nor is it in anyway ‘put on’ by the child, but stems, as I said, from an issue involving the workings of the brain.
So what can you do? The first thing is to not make too big an issue of the tic – drawing attention to a tic can make it worse. Acupuncture is not known to be of benefit, but the worst symptoms can be helped by drug treatments to try to suppress the tics’ frequency and intensity.
Behaviour training by experienced clinical psychologists has also proved helpful, the success of which can be improved by parents and others also becoming involved, as it helps with consistency and compliance.
No doubt you will have been alarmed at this diagnosis in your young relative: I very much hope that he is under the expert care of a children’s neurology unit where there is experience in helping patients and their families with the condition.
By the way… Treatment by phone is a waste of time
Recent research has shown that the Government’s decision to encourage GPs to have more telephone consultations does not reduce the workload on doctors, and does not save costs. This comes as no surprise to me.
I parted company with the NHS some years ago and I have been working in an independent practice since then.
From the start we permitted telephone consultations in the hope that it would appeal to patients as a way of saving time and money, in a world where both commodities were fast becoming limited. Our experience has been that we made a stick for our own backs.
As a doctor you learn so much more about a person when you see them face to face, just from their appearance and general demeanour. The chance of making the wrong diagnosis is far higher when there is no chance of conducting a physical examination.
Besides, if tests are needed the patient still has to attend to provide a sample or undergo a blood test – doubling the time spent, rather than saving it.
I also have a sense that patients are more likely to request a consultation when it can be done by telephone: take an example from last week when I wrote to a patient to give her the result of a bone density scan.
I explained in the letter that her result was normal for a woman of 53, and no action was needed. Despite this, there came a request for a telephone consultation. The patient wanted to know what she should do to keep her bone health up – a fair question, but one which resulted in a lengthy tutorial over the phone, for someone who does not have a problem.
The only positive thought I can offer is that telephone consulting does at least enable a doctor or nurse to call through the results of tests, rather than sending them in a letter.
This is good for morale and for pastoral support and goodwill, saving the patient some time, and keeping a consultation slot free for someone who is sick.
But telephones for diagnosis and treatment? Generally second best.
Do the politicians ever think about things before they make rash promises?