INCISION FOR APPENDICECTOMY

488 the consistence of the feed

so

that it is

rare

for

even a

not to

respond satisfactorily. 0.5—2% (usually 1%) of the powder is added to each feed-i.e., one measure to 100 ml. (3 ounces) of cold breast, ordinary, or modified milk. Any sugar and water required is added to this mixture, and the whole is brought to the boil. When powdered or condensed (evaporated) milk is used, the powder is mixed with the necessary water, and the mixture brought to the boil for a moment before the milk is added with vigorous beating. Carob flour is available on the Continent and is widely used in Switzerland, France, and Belgium. In this country the powder, which is marketed abroad under the trade name of ’Nestargel,’ has received only one mention " The as far as I know; Evans and Mac Keith 3 say : addition of ½—1% of I Poudre Epaississante Nestle’ Nestargel to the feed makes it so adhesive that the child cannot vomit it, but this preparation is as yet not generally obtainable." The import of carob -flour for sale in the United Kingdom is forbidden, and the flour which I have myself I used was kindly supplied by the Nestle Company. have only been able to try it so far in nine cases, but all these have been severe enough to resist all routine measures. All nine babies were cured or remarkably a very short time, all within two weeks and in improved the majority within a week. The mothers were given the powder with instructions on its use, and they had no diiliculty in preparing the feeds. I have no doubt of the efficacy of carob flour in this condition. Its value deserves to be widely known, and the flour should be readily obtainable. I would go so far as to say that if there is no improvement after its use, the diagnosis of the cause of vomiting must be suspect. Before others can share my enthusiasm, the

severe

ban

case

on

the sale of carob flour in Britain must be lifted.

Dr. Helen Morley kindly provided in my small series. Duchess of York Hospital for Babies,

me

with several of the

patients

Manchester.

THEODORE JAMES.

NURSES IN THE MAKING SIR,—Mr. Hodkinson’s letter4 has been followed by a leading article in your issue of Aug. 9. My experience of a cadet scheme in this mentalhospital appears to run parallel to that of Mr. Hodkinson, even to the intention not to publicise it until more experience had been gained. The scheme has now been running for nearly 3 years, and results hitherto have been wholly satisfactory. Two whole days a week are spent in school on " further education " with a teacher provided by the local authority. Three half-days a week are devoted, under the supervision of our nurse-training school, to subjects which will lead up to the preliminary State examination ; and three half-daysare spent in the various departments of the hospital. These young people are at no time in the hospital is regarded as nurses, and that 4)f a student : association with all but the youngest the patients is minimal, and regulations are adhered to, persons employment of young strictly although in view of the student status of the cadets these

deficiency

their status

regarding

regulations rarely apply. Mr. Hodkinson lists five advantages and five essential features. I have just looked up one of my earlier reports on our cadet scheme, and find that I came to the same conclusions, in almost the same order and the same words. If I had to select one outstanding element in the success of any cadet scheme, I would say that this is the " " "

student as opposed to the employee cadet ; and I would add that in this ..

status of the

hospital

3. Evans,

we

accent

P. R., Mac Keith. R. Infant Feeding and Feeding Difficulties. London, 1951. 4. Hodkinson, S. Lancet, 1952, i, 1113.

the " career " element in nursing, as opposed to the " All young people on application anvocation." and educationally and psychologically:examined medically tested ; and we believe that the young men or women who tell us that they wish to take up nursing because the career seems interesting, the money is good, and they wish some day to be a chief male nurse or matron, are better candidates than those who claim they have a call to do nursing. On inquiry this too often is found tit mean that they have a call for nothing and that they an. just drifting into nursing and will thus probably drift out again. The cadet scheme in this hospital is practically our only source of student-nurse recruitment ; it has saved the nurse-training school from extinction and the hospital from the closure of beds. The raising of the minimum age for student nurses to 18 years is a blow to nurse recruitment, but not, I think, too serious a blow ; it will dam but will not choke the stream. Your statement that " there are good arguments for the view that whatever a girl does between leaving school and starting her nursing training, at least she should keep clear of hospitals " is a denial of the fact that some hospitals can lay themselves out to ensure that everything that can be done is done to provide for the proper mental, physical, and emotional maturation of the young male or female nursing cadet. I believe that properly run cadet schemes, run ou " further education " lines, are the answer to the nursing shortage. I also believe that badly run schemes are likely to cause much harm to nursing recruitment. Prudhoe and Monkton Hospital, GEORGE MOCOULL. ,

Prudhoe-on-Tyne, Northumberland.

INCISION FOR APPENDICECTOMY

SIR,—I

was

very interested in Mr. Young’s account of extending Battle’s incision disorders are unexpectedly

(Aug. 9) of his method where pelvic or other

encountered. I have used in about a hundred cases a method which, for want of a better name, I call the " transverse retrorectal approach," and which also may be extended if necessary. An incision is made in the plane between the anterior superior spines of the ilium. Starting in the midline and extending to the right over the right rectus abdominis muscle. it may be made in the natural crease which often lies at this level. The rectus sheath is opened in the same direction as the skin incision ; the rectus muscle is freed from its sheath posteriorly by stripping it with the index fingers, and the muscle is retracted medially. The posterior lamella of the rectus sheath with the closely adherent transversalis fa-icii and peritoneum is picked up above the level of the line/! semicircularis and opened transversely : care must be taken not to include the gut, which is closely applied to the pen toneum here. The inferior epigastric artery, which has just entered the sheath across the linea semicircularis,is medial ; it is usually adherent to the rectus muscle and IS retracted with it. If a pelvic or abdominal condition requiring a more extensiveexposure be encountered the approach may be converted into a Pfannenstiel by extending the skin incision transversely to the left over the left rectus muscle, opening the left rectus sheath in the line of the skin incision, separating and retracting laterally the recti muscles, and extending the previous opening behind the right rectus transversely behind the left rectus. It is, of course, possible to extend the incision to the right by cutting through or separating the oblique and transversus muscles as in W’eir’s approach.

The advantages of the approach are that it is adequate, and the pelvic organs can be easily examined; and the incision can be extended without damage to nerves and. possibly, consequent hernia. Wound healing is earlier: sutures may be removed on the fifth day. The sear is thin, strong, and almost invisible. Keloid formation is rare-possibly because the incision lies in the natural

489

skin-tensionlines of

stretch, and

to

line it is

as

Langer. The scar does not tend it is transverse and often in the crease

cosmetically satisfactory.

River Hospitals,

JOHN MCDONALD.

Joyce Green, Dartford, Kent.

investigation

HYPOGLYCÆMIA IN ROAD USERS SIR,—Motor accidents have very rarely occurred because of hypoglycaemia in diabetics who are taking insulin. This condition may arise from several causes, such as omitting to eat the necessary carbohydrate at the usual time-i.e., at breakfast, in the middle of the morning, at the midday meal, at tea-time, or at the evening meal. If the carbohydrate is either omitted or delayed, a severe reaction may occur owing to overaction of the insulin. A hypoglycaemic attack may also be produced by taking unusual exercise shortly before the car is driven, or as a result of changing

unopposed

wheel. The medical advisory committee of the Diabetic Association therefore asks all doctors looking after diabetics taking insulin and driving motor-cars, or riding motor or pedal cycles, to make certain that their patients understand the possible causes of hypoglycaemic attacks and how they can be prevented by regular intake of carbohydrate at the usual meals, which should be taken Some extra carbohydrate should be eaten both before and after any unusual exercise. A supply of biscuits or 12 lumps of sugar or glucose should always he carried in the car or cycle in case a meal is unavoidably a

punctually.

or unexpected exercise is necessary. committee especially hopes that, if a doctor knows that a patient sometimes does not recognise the symptoms of hypoglyceemia, he will advise his patient not to apply for a driving licence. R. D. LAWRENCE Diabetic Association,

delayed,

The

152, Harley Street, London, W.1.

of fluorine in excess of that known to come from the local drinking-water. In a healthy man a fluorine intake of up to 5 mg. daily can be eliminated, but above this level there is retention of fluorine in the body with cumulative effects in bone.4 A recent 5 has described the effects of chronic fluorosis on kidney structure and function in rats, with a view to demonstrating the existence of a fluorine hazard before such severe intoxication has resulted as to cause obvious skeletal lesions ; the histological examination indicated that in the kidnevs there was

Chairman, Medical Advisory Committee.

FLUORINE INTAKE IN BRITAIN SIR,—The decrease in the incidence and spread of dental caries in certain townships in the United States, resulting from the fluoridation of communal drinkingwaters, has led to the suggestion that fluorine should be added to British public water-supplies at a concentration of one part per million which, together with the ingestion of fluorine in ordinary food, would put the total daily fluorine intake at about 2-20 Mg.1Subsequently a basic ethical objection to such compusory mass medication wa;- made on behalf of the League of British Housewives.3 Considerations of the real differences in nutrition and distribution of population between different countries appear to have been by those responsible for the suggested fluoridation of water-supplies. Small amounts of fluorine occur naturally in many sources of British drinking-waters ; but fluorine-containing ores, tiuxe-. and coals are now used industrially in this country in large quantities. Fluorine compounds are toxic when inspired or ingested ; and, since they may be encountered in various ways in industrial processes, they present a definite hazard to the health of man and animals. Animal fluorosis is being increasingly noted by British farmers and veterinary officers, especially in the neighbourhood of iron and steel works and of coal-consuming electric power "tations. Annuals can be moved from contaminated pasture, f.ut human beings remain in a polluted atmosphere. The etching of window glass by hydrofluoric acid-an easily recognised sign of atmospheric pollution—is now seen in industrial homes ; and in these contaminated regions, examination of the teeth of children and estimation of urinary duorine in adults gives evidence of the absorption

neglected

1. 2.

Mackenzie, E. F. W. Lancet, 1952, i, 961. Ibid, 1951, i, 1356. 3. Sykes, W. M. Ibid, 1952, i, 1112; Ibid, Aug. 2, 1952,

p. 242.

glomerular, and more obviously tubular, degeneration leading to interstitial fibrosis. We do not know how high the actual intake of fluorine is at present in the various industrial regions of this country, and, until further inquiry is undertaken with regard to the fluorine hazards to which different neighbourhoods are now exposed, it seems most undesirable that fluorine should be added to public water-supplies vascular,

in Britain. Laboratory of Human Nutrition, University of Oxford.

DAGMAR WILSON.

BONE REGENERATION

SIR,—Following your survey of this subject (Aug. 23) I should like to refer to recent work on bone grafts carried out in this department by Mr. John Hutchison.6 Bone autografts and homografts were implanted into bone, muscle, and the anterior chamber of the eye of rabbits, and their histological progress followed and compared from 10 to 180 days. Hutchison’s findings are in many respects contrary to those recorded by Barthand Reynolds and Oliver 8 to which you referred. Even at an early stage (10-21 days) there is a striking difference in the histological appearance of autografts and homografts. In the bone autograft, while the more particularly the centrally situated cells, osteocytes, die, the soft-tissue elements of the graft-periosteum, lining of Haversian canals, and endosteum-show active cellular proliferation and are responsible for the subsequent cellular repopulation of the graft which is complete The bony matrix retains its staining after 40 days. affinity, and by 42 days the picture is that of active living bone with no evidence of any dead bone, as implied in your article. The autograft at 42 days therefore represents bone formed by the original cell elements of the graft and may well include much of the original bony matrix of the graft. As these cells constitute the essential living part of bone and are largely responsible for the new bone formation it is evident that the autografts survive. The period required for complete recovery varies according to the type of graft, and is naturally longer in dense cortical grafts. By contrast, sections of the bone homografts from 10 daysonwards show typical dead bone with empty lacunae and faintly stained opaque matrix - the classical sequestrum. There is, with an odd exception, no absorption of the dead homografts, which can be recovered 180 days after implantation. Hutchison’s findings correspond to those recently recorded in an experimental study by Ray et al. Ham lo has also noted the osteogenic of the surviving cells of bone autografts. Both heterotopic bone autografts and homografts induced active osteogenesis by the connective tissue of the host from 10 to 42 days, which then ceased. In the case of homografts this new bone formed by the host tissue died after 42 daysand was added to the graft

activity

McClure, F. J., Mitchell, H. H., Hamilton, T. S., Kinser, C. A. J. industr. Hyg. 1945, 27, 159. Bond, A. M., Murray, M. M. Brit. J. exp. Path. 1952, 33, 168. Brit. J. Surg. 1952, 39, 552. 6. Hutchison, J. 7. Barth, A. Arch. klin. Chir. 1893, 46, 409. 8. Reynolds, F. C., Oliver, D. K. J. Bone Jt Surg. 1950, 32A, 283. 9. Ray, R. D., Degge, J., Gloyd, P., Mooney, G. Ibid, 1952,

4. 5.

34A, 638. 10. Ham, A. W.

Ibid, p. 701.