SUMMARYThe numerous methods used for treating ingrowing toe-nails are testimony to the lack of a generally acceptable procedure with a low failure rate. A simple procedure with nail preservation is described, and the results of treatment assessed. The procedure consists of making a transposition flap of the nail wall after preliminary curettage of the granulation tissue in the nail groove. A total of 82 patients were treated by this method over a 3-year period, and the results in 63 patients were assessed between 18 months and 3 years after surgery. A total of 120 operations were carried out and 110 (92%) were successful. The treatnent is effective, well tolerated, not technically difficult, and should be considered as an alternative to current methods of treatment.

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Interest in this work developed when it was found that there were patients with persistent abdominal pain, in whom no intra-abdominal cause could be found, who were relieved by peripheral block of the appropriate nerve in the abdominal wall. All these patients complained of pain, which was often severe, burning and intermittent, and was unrelieved by the usual mild analgesic drugs. Discomfort was, curiously, unaffected by rest or exercise. It was not commonly associated with a rise in temperature or nausea and vomiting. A definite onset was infrequently remembered but, once present, the pain continued intermittently for a long time, in some for a number of years. With further experience it was possible to locate a small area of acute tenderness, about the size of a pencil head, deep in the rectus sheath, close to its outer border. Direct injection into this painful zone has proved to be a simpler and more effective method of treatment. M A T E R I A L S A N D M E T H O DOne hundred and three patients were studied over a period of three and a half years. These are presented in table 1 with the clinical presentations and nerves involved. All these patients had been thoroughly examined to exclude an intra-abdominal cause before referral to the Pain Clinic.The trigger area was located by raising the patient's head and shoulders off the pillows, thereby tensing the rectus abdominis, and by pressure along its outer border. In this tender zone, through a skin bleb, the injecting needle was directed towards the posterior wall of the rectus sheath and the solution deposited in the lateral part of this compartment. Early trials with a local anaesthetic, such as lignocaine and a steroid, such as hydrocortisone, showed that pain-relief was only temporary. Repeat injections also failed to provide lasting relief. Eventually, 2-3ml of 5 % aqueous phenol was tried and this is the solution that has been used throughout this series. In this concentration a differential block, with the main impact on nonmyelinated and small myelinated pain fibres occurred'. 293. Many patients felt unwell for a day or two and some reported a dull burning sensation for a further day or two. This has been followed in most cases by complete

The 102 women were a very assorted group in shape, size, age, and occupation, as they were chosen only by their length of sentence. As a toxic reaction was found only in 3 % and was of a mild nature it can be assumed that it is safe and probably advantageous to give metronidazole in twice-daily doses. I thank Dr. Martin Hynes, consultant pathologist to the Royal Northern Hospital, and his laboratory staff for culturing and reading our specimens, and Dr. P. M. Button for her help in taking the tests. I am indebted to the Prison Commissioners for giving me permission to publish this paper. I thank May & Baker Ltd. for generous supplies of " flagyl." BIBLIOGRAPHY

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