Toward some principles of school nursing.

An examination of the school nursing role based on four principles covering provision of health care, the nurse as a source of knowledge, the school as a health promoting community, and a team approach which acknowledges parents as partners is presented.

Abnormalities of gastric emptying and pyloric reflux in uncomplicated hiatus hernia.

We have measured the rate of gastric emptying of solid and liquid meals by an external scanning technique and have studied pyloric reflux by a radiological technique. Investigations were performed in patients with uncomplicated hiatal hernia, patients with uncomplicated duodenal ulcer and normal controls. There was a significant delay in the emptying of both solid and liquid meals in the patients with hiatal hernia compared with both the duodenal ulcer patients (solid meals P less than 0.01, liquid meals P less than 0.025) and with normal controls (solid meals P less than 0.05, liquid meals P less than 0.001). Duodenogastric reflux was observed in 35% of hiatal hernia patients compared with 24% of duodenal ulcer patients and no incidence in the controls.

Cardiac arrhythmias on swallowing.

A middle-aged male patient with cardiac arrhythmias on swallowing due to incoordinate peristaltic activity of the esophagus is reported. Medical treatment with propranolol and quinidine sulfate made the symptoms manageable initially but recurrence of symptoms made surgical treatment desirable. Barium sulfate with apple produced the incoordinate peristalsis with resultant arrhthmias as soon as it arrived at the junction between the middle and lower third of the esophagus. This was followed by a normal peristaltic wave which cleared the esophagus and brought the cardiac rhythm back to normal again. Balloon distension of the esophagus located the afferent stimuli as arising from the lower third of the esophagus. A circular esophageal myotomy at the junction of the middle and the lower third, although not completely abolishing the reflex, has made the symptoms less severe. However, this procedure has produced considerable ballooning of the mucosa at the myotomy site, and has resulted in some difficulty in swallowing.

Results of Heller's operation for achalasia of the oesophagus. The importance of hiatal repair.

A survey of 108 patients with achalasia treated by cardiomyotomy is reported. All the operations were done by the abdominal approach and all the patients were followed up for a minimum of 4 years. Fifty-five patients had some form of hiatal reconstruction, 11 of these having a formal plastic repair as practised for oesophageal reflux problems. At 4 years after operation 71 patients (65-5 per cent) had entirely satisfactory results. Twenty-seven patients had recurrent dysphagia and 20 patients had symptoms of reflux oesophagitis. The group who had had a formal repair of the hiatus had no reflux symptoms after operation and also had better swallowing than the other groups. These results suggest that much of the dysphagia following Heller's operation is due to occult gastro-oesophageal reflux and can be avoided by a reflux-preventing procedure. Adequate hiatal repair after myotomy is strongly recommended.

Effect of perfusion of bile salts solutions into the oesophagus of hiatal hernia patients and controls.

Tests of the response to perfusion of the oesophagus were made in 54 patients divided into three groups. Group I consisted of patients with symptomatic hiatal hernia, group II hiatal hernia patients with peptic stricture, and group III normal individuals. Each individual oesophagus was perfused at a rate of 45-65 drops per minute over 25 minutes with six solutions: normal saline, N/10 HCl, taurine conjugates of bile salts in normal saline, taurine conjugates of bile salts in N/10 HCl, glycine conjugates of bile salts in normal saline, and taurine and glycine conjugates in a ratio of 1 to 2 in normal saline. It was found that acidified taurine solutions were more irritating than acid alone. With a 2mM/l solution of taurine in acid, symptoms are produced even in controls. With a 1 mM/l solution of the same conjugates, the majority of normal people feel slight heartburn or nothing, and therefore perfusion into the oesophagus of such a solution could be used as a test for oesophagitis.

Observations on oesophageal length.

The subject of oesophageal length is discussed. The great variations in the length of the oesophagus in individual patients is noted, and the practical use of its recognition in oesophageal surgery is stressed. An apprasial of the various methods available for this measurement is made; this includes the use of external chest measurement, endoscopic measurement, and the measurement of the level of the electrical mucosal potential change. Correlative studies of these various methods are made, and these show a very high degree of significance. These studies involved simultaneous measurement of external and internal oesophageal length in 26 patients without a hiatal hernia or gastro-oesophageal length in 26 patients without a hiatal hernia or gastro-oesophageal reflux symptoms, 42 patients with sliding type hiatal hernia, and 17 patients with a peptic stricture in association with hiatal hernia. The method of measuring oesophageal length by the use of the external chest measurement, that is, the distance between the lower incisor teeth and the xiphisternum, measured with the neck fully extended and the patient lying supine, is described in detail, its practical application in oesophageal surgery is illustrated, and its validity tested by internal measurements. The findings of this study demonstrate that the external chest measurement provides a mean of assessing the true static length of the oesophagus, corrected for the size of the individual.