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Hiatus Hernia
1005
given to patients after mitral valvotomy before attempting conversion, in the hope of preventperiod immediately ing auricular thrombosis during the before sinus rhythm is restored.8 have been
There is no doubt that lone auricular fibrillation is definite clinical entity with a good prognosis ; but every effort must be made to exclude organic heartdisease, and especially thyrotoxicosis, in all patients with auricular fibrillation. They should be kept under observation, since thyrotoxicosis or ischsemic heart-disease may ultimately declare itself. a
Hiatus Hernia ALL is confusion at the cardiac orifice. Is regurgitation from the stomach prevented by the obliquemuscle fibres of the stomach alone,9 or is this a function of the right crus of the diaphragm ? 10 Here opinions differ ; but one thing is agreed-that reflux of stomach contents into the oesophagus is prevented by the acuteness of the angle where those two viscera join. BARRETT9 has demonstrated on isolated specimens of the stomach that with increasing obliquity an angle is reached at which reflux occurs. COLLIS, KELLY, and WILEY 11 have shown that reflux is not related to intragastric tension, and have confirmed that this depends on the angle. In 1907 the diagnosis of hiatus hernia and cesophagitis was not yet born, and Low 12 was concerned only with correcting the erroneous impression that the cesophageal hiatus lay between right and left crura. He showed that it passed through a sling formed by the right crus; and now COLLIS et al. have discovered variations in the form and strength of the right crus, and have related these variations to the findings at operations for hiatus hernia when the right crura were seen to be uniformly weak. This much supports the crural
hypothesis. COLLIS et al. hold that the main symptoms are due to the regurgitation of gastric contents into the oesophagus ; so it is pertinent to inquire why the angle of entry of oesophagus into stomach alters. Œsophagitis and hiatus hernia was first noted by BROWN KELLY 13; his four patients were of tender age, and the condition was subsequently noted in other infants. The oesophagus was short, thus accountfor the alteration of its junction with the stomach. What could be more reasonable than to suppose that this shortening was congenital ? But opinion is now growing that this places cart before horse : that cesophagitis develops owing to the reflux, and that ascending fibrosis 14 shortens the cesopbagus. These changes, it seems, can develop even at an early age. There the matter rests, undecided. These divergent views are reflected in treatment. BARRETT9 postulates that the cardiac region must he freed by dissection and so placed that the obliquemuscle fibres of the stomach wall function effectively ; as a first step the hernia is reduced and fixed so that it will not recur. Reduction of the hernia is required by ALLisoN 10; he maintains reduction by suturing
ing
8. 9.
10. 11. 12. 13. 14.
Wood, P. Brit. med. J. 1954, i, 1113. Barrett, N. R. Proc. R. Soc. Med. 1952, 45, 279. Allison, P. R. Thorax, 1948, 3, 20; Surg. Gynec. Obstet. 1951, 92, 419. Collis, J. L., Kelly, T. D., Wiley, A. M. Thorax, 1954, 9, 175. Low, A. J. Anat. Phys. 1907, 42, 93. Kelly, A. B. Proc. R. Soc. Med. 1930, 23, 1521. Kelly, A. B. J. Laryng, 1939, 54, 621.
diaphragm the cut edge of the peritoneal sac together with the fibro-areolar tissue surrounding the oesophagus, which he calls the phreno-oesophageal ligament. The crural canal is then repaired by sutures placed between its two limbs behind the oesophagus. And now COLLIS et al. suggest that this repair should be done by closing the hiatus in front of the gullet, since this will displace it towards the fundus of the stomach and thus increase the angle at the junction of the two. Moreover, they do not regard reduction of the hernia as essential. With a short oesophagus, they say, it is sufficient by repairing the crural canal to produce an acute angle between the thoracic and abdominal portions of the stomach, and thus prohibit reflux regurgitation from the larger and more active part of the stomach lying below the diaphragm. This suggests that the oblique muscles of the stomach can be dispensed with, but not that they play no part in the prevention of reflux to the lower surface of the
Child Mental Welfare and synthesis are both useful
scientific medicine is said that we It sometimes in techniques. have pursued the first to the point of dismembering but fortunately a reaction has set in, our patients ; and we are learning to think again in terms of the whole man and woman-. even the whole child. Nevertheless (as is pointed out by Dr. J. A. ScoTT, medical officer of health for the County of London) though most of us are now convinced that mental ill health often begins in the nursery, we do very little to prevent it, and the numerous child-welfare clinics which we maintain are almost entirely devoted to physical health. Here, surely, is an ideal situation for applying the method of synthesis. In July, 1953, Dr. ScoTT set up a study group, consisting of professional staff drawn from the public-health department of the L.C.C., and from the Tavistock Clinic, and headed by Dr. JOHN BowLBY, "to investigate the possibility of increasing preventive mental health work in the maternity and child welfare services." The report of this investigation comes as a prompt response to Dr. HEDY SYMONDS’S plea (which we publish on p. 1010) that the emphasis of the publichealth services could now appropriately be shifted from physical to mental health. The Industrial Revolution was almost a century old before our grandparents began to grapple with its physical ill effects. Even at the same leisurely reaction-rate, she suggests, it is now time that we in our turn should begin to cope with the anxiety diseases which have more distantly, but no less surely, followed in its wake. The L.C.C. group, in their report,! remind us that about a third of all ill health in Britain today is mental ill health, and they add that in the opinion of psychiatrists working in L.C.C. child-guidance units the genesis of mental disorders in over 80% of their new cases lies in the pre-school years. The disorders arise in three principal ways. They may be caused by the anxiety of the mother when the child’s development fails to conform to accepted norms (many of which are false) ; or by separation of the young ANALYSIS
1.
Report of Study Group on Preventive Mental Health in the Maternity and Child Welfare Service. To be had from the Public Health Department (A3), London County Council, County Hall, London, S.E.1. Pp. 12.
given to patients after mitral valvotomy before attempting conversion, in the hope of preventperiod immediately ing auricular thrombosis during the before sinus rhythm is restored.8 have been
There is no doubt that lone auricular fibrillation is definite clinical entity with a good prognosis ; but every effort must be made to exclude organic heartdisease, and especially thyrotoxicosis, in all patients with auricular fibrillation. They should be kept under observation, since thyrotoxicosis or ischsemic heart-disease may ultimately declare itself. a
Hiatus Hernia ALL is confusion at the cardiac orifice. Is regurgitation from the stomach prevented by the obliquemuscle fibres of the stomach alone,9 or is this a function of the right crus of the diaphragm ? 10 Here opinions differ ; but one thing is agreed-that reflux of stomach contents into the oesophagus is prevented by the acuteness of the angle where those two viscera join. BARRETT9 has demonstrated on isolated specimens of the stomach that with increasing obliquity an angle is reached at which reflux occurs. COLLIS, KELLY, and WILEY 11 have shown that reflux is not related to intragastric tension, and have confirmed that this depends on the angle. In 1907 the diagnosis of hiatus hernia and cesophagitis was not yet born, and Low 12 was concerned only with correcting the erroneous impression that the cesophageal hiatus lay between right and left crura. He showed that it passed through a sling formed by the right crus; and now COLLIS et al. have discovered variations in the form and strength of the right crus, and have related these variations to the findings at operations for hiatus hernia when the right crura were seen to be uniformly weak. This much supports the crural
hypothesis. COLLIS et al. hold that the main symptoms are due to the regurgitation of gastric contents into the oesophagus ; so it is pertinent to inquire why the angle of entry of oesophagus into stomach alters. Œsophagitis and hiatus hernia was first noted by BROWN KELLY 13; his four patients were of tender age, and the condition was subsequently noted in other infants. The oesophagus was short, thus accountfor the alteration of its junction with the stomach. What could be more reasonable than to suppose that this shortening was congenital ? But opinion is now growing that this places cart before horse : that cesophagitis develops owing to the reflux, and that ascending fibrosis 14 shortens the cesopbagus. These changes, it seems, can develop even at an early age. There the matter rests, undecided. These divergent views are reflected in treatment. BARRETT9 postulates that the cardiac region must he freed by dissection and so placed that the obliquemuscle fibres of the stomach wall function effectively ; as a first step the hernia is reduced and fixed so that it will not recur. Reduction of the hernia is required by ALLisoN 10; he maintains reduction by suturing
ing
8. 9.
10. 11. 12. 13. 14.
Wood, P. Brit. med. J. 1954, i, 1113. Barrett, N. R. Proc. R. Soc. Med. 1952, 45, 279. Allison, P. R. Thorax, 1948, 3, 20; Surg. Gynec. Obstet. 1951, 92, 419. Collis, J. L., Kelly, T. D., Wiley, A. M. Thorax, 1954, 9, 175. Low, A. J. Anat. Phys. 1907, 42, 93. Kelly, A. B. Proc. R. Soc. Med. 1930, 23, 1521. Kelly, A. B. J. Laryng, 1939, 54, 621.
diaphragm the cut edge of the peritoneal sac together with the fibro-areolar tissue surrounding the oesophagus, which he calls the phreno-oesophageal ligament. The crural canal is then repaired by sutures placed between its two limbs behind the oesophagus. And now COLLIS et al. suggest that this repair should be done by closing the hiatus in front of the gullet, since this will displace it towards the fundus of the stomach and thus increase the angle at the junction of the two. Moreover, they do not regard reduction of the hernia as essential. With a short oesophagus, they say, it is sufficient by repairing the crural canal to produce an acute angle between the thoracic and abdominal portions of the stomach, and thus prohibit reflux regurgitation from the larger and more active part of the stomach lying below the diaphragm. This suggests that the oblique muscles of the stomach can be dispensed with, but not that they play no part in the prevention of reflux to the lower surface of the
Child Mental Welfare and synthesis are both useful
scientific medicine is said that we It sometimes in techniques. have pursued the first to the point of dismembering but fortunately a reaction has set in, our patients ; and we are learning to think again in terms of the whole man and woman-. even the whole child. Nevertheless (as is pointed out by Dr. J. A. ScoTT, medical officer of health for the County of London) though most of us are now convinced that mental ill health often begins in the nursery, we do very little to prevent it, and the numerous child-welfare clinics which we maintain are almost entirely devoted to physical health. Here, surely, is an ideal situation for applying the method of synthesis. In July, 1953, Dr. ScoTT set up a study group, consisting of professional staff drawn from the public-health department of the L.C.C., and from the Tavistock Clinic, and headed by Dr. JOHN BowLBY, "to investigate the possibility of increasing preventive mental health work in the maternity and child welfare services." The report of this investigation comes as a prompt response to Dr. HEDY SYMONDS’S plea (which we publish on p. 1010) that the emphasis of the publichealth services could now appropriately be shifted from physical to mental health. The Industrial Revolution was almost a century old before our grandparents began to grapple with its physical ill effects. Even at the same leisurely reaction-rate, she suggests, it is now time that we in our turn should begin to cope with the anxiety diseases which have more distantly, but no less surely, followed in its wake. The L.C.C. group, in their report,! remind us that about a third of all ill health in Britain today is mental ill health, and they add that in the opinion of psychiatrists working in L.C.C. child-guidance units the genesis of mental disorders in over 80% of their new cases lies in the pre-school years. The disorders arise in three principal ways. They may be caused by the anxiety of the mother when the child’s development fails to conform to accepted norms (many of which are false) ; or by separation of the young ANALYSIS
1.
Report of Study Group on Preventive Mental Health in the Maternity and Child Welfare Service. To be had from the Public Health Department (A3), London County Council, County Hall, London, S.E.1. Pp. 12.