883

agency might even advertise tobacco, which in the form ofsnuff can be helpful to those who are already addicted to thedrug but have the far worse habit of smoking it. Much moremight be achieved by promoting the use of good things andeven of the lesser evils than by attacking without adequateresources those that are worst or inferior.

London,S.W.10. R. B. D. STOCKER.R. B. D. STOCKER.

1. Bracey, D. W. Ann. R. Coll. Surg. Engl. 1956, 19, 385.2. Bracey, D. W. J. R. Coll. Surg. Edin. 1960, 5, 222.3. Bracey, D. W. 19th Congress of the International Society of Surgery,

Dublin, Sept. 2-9, 1961.

" APPENDICITIS " IN YOUNG WOMEN

JAMES S. HALL.Victoria Hospital,

Deal.

SIR,-Dr. Lee does us all a service by his factual

approach last week to this difficult problem and by dealingwith it on a scientific level. I am less certain that hissincere wish to abolish many appendicectomies is clinic-ally justified.Every surgeon has a number of teenagers, both boys and

girls, referred to his clinic with recurrent pain in the rightiliac fossa. Both the history and physical signs are often vagueby the time the patient gets an appointment. But after fortyyears of general surgery my experience has been that once theappendix bogy has appeared to the parents and the generalpractitioner, there will be little peace of mind for all concernedtill it is laid to rest. To achieve this I think that the use ofa hospital bed for five or six days is more than justified.But all this is against the background of complete frankness

between the surgeon, the parents, the referring doctor, and,in my own practice, the patient. It is very rare indeed for theproffered appendicectomy to be refused.

In the case of young women the question of mittelschmerz,should always be raised, and I think a warning should be giventhat right iliac pain may occasionally recur after operation,but that it may now be lived with without anxiety.

Dr. Lee pays high tribute to our gynxcologists when heinfers that they can exclude a pathological appendix. I wishI had such diagnostic skill. It is quite a salutary experience todescribe the probable state of an "interval" appendix to thetheatre staff before opening the abdomen. More often than notthe estimation of its pathological state and position leave muchto be desired, but it is surprising how many prophylactic casesturn out to be subacute. One must also remember that sub-acute appendicitis and mittelschmerz can occur in the samepatient.

CLEAN AIR

A. FRANKLIN.

SIR,-The National Gallery realises that Clean Air isgood for Old Masters. How many hospitals have air-conditioners in their chest wards ?

London, W.2. A. FRANKLIN.

REPAIR OF FEMORAL HERNIA

D. W. BRACEY.The Memorial Hospital,Peterborough.

SIR,-The perennial discussion about the merits of thevarious approaches to femoral-hernia repair prompts meto record an impression gained over five years.The approach I use is similar to the first stage of an inguinal-

hernia repair, using the mobilised inguinal ligament.1-3 Thisfirst stage consists of a skin incision centred on the middle ofthe inguinal ligament and starting one inch above the pubis.This transverse incision almost invariably follows the lines ofLangham. After exposure of the sac and the lower border of theinguinal ligament, the fascia lata is incised at its junction withthe lower border of the inguinal ligament, both medially andlaterally. The freeing of the fascia lata from its attachment tothe ligament greatly facilitates mobilisation and visualisationof the neck of the femoral hernia from below, whilst the skinincision used makes a superior approach easy if it is required.If the repair of a femoral hernia is being done from below, then

the freeing of the ligament from its attachment to the fascialata makes the suture of the ligament to Cooper’s ligamentpossible without tension. If the repair is being conducted fromabove, then the mobilised ligament in like manner can be

easily approximated to Cooper’s ligament thus closing theupper orifice of the femoral canal.

OSTEOPATHIC MEDICAL ASSOCIATION

BLEDISLOEPresident

A. STODDARDVice-President

J. D. DAVIDSONChairman

M. E. B. CARSONSecretary.

OsteopathicMedical Association,114, Wigmore Street,

London, W.1.

SiR,ņThe Osteopathic Medical Association has beenfounded with the following objects:(i) to contribute towards the promotion and propagation of the

science and art of osteopathy and hold professional and socialmeetings in furtherance of this aim.

(ii) to demonstrate to registered medical practitioners the value ofthe science, art, and practice of osteopathy.

(iii) to encourage research and the publication of results.(iv) to cooperate with other medical associations.

Membership is open to duly qualified medical practi-tioners registered in Great Britain who are interested inosteopathy. All inquiries will be welcomed.

Public Health

Safe Air and Motor-cars ?

IF a list of fundamental human rights were to be drawnup, most people would agree that man is entitled tobreathe air which is safe as well as clean. Perhaps inrecognition of the effects of air pollution on health, theNational Society for Clean Air has now elected a physicianas its president; and Lord Cohen of Birkenhead tookoffice at Brighton on Oct. 4-6. But he began by paying anotable and well-deserved tribute to his predecessor, SirHugh Beaver. When the history of Government actionagainst atmospheric pollution is recorded, he said, noname will stand higher than that of the chairman of theCommittee on Air Pollution. Appearing in 1954, its reportalerted the public to the gross environmental evil ofcontamination of the air we breathe, and in Lord Cohen’swords " removed the idea of clean air from the realm ofeccentricity, fad, and obsession, to become a national

goalConcern is now increasing about the pollution of air by

road vehicles. Most is said, perhaps, about the dark smokefrom diesels-whose number may well double in the nextdecade. But the exhaust fumes from petrol engines-containing carbon monoxide, aldehydes, and lead com-pounds-are probably more harmful and they deservemuch more attention than they have yet had. In Londontraffic jams, carbon-monoxide levels of the order of 200parts per million have been recorded; and, though there isno unchallengeable evidence so far that this is a hazard tohealth, circumstances could arise in which it would be.Danger is also caused by lessened visibility, which maymislead an overtaking driver; and the emission of dark andgreasy dirt on other vehicles and their passengers, and onpavements, pedestrians, and vegetation is a nuisance.