The Australian and New Zealand Journal of Surgery 1958-08: Vol 28 Iss 1

VOLUME 28

1958-1959

THE
AUSTRALIAN AND NEW ZEALAND

JOURNAL OF SURGERY

Published for the Royal Australasian College of Surgeons

EDITORIAL COMMITTEE:
DOUGLAS MILLER, Chairman
K: F. RUSSELL, Editor
F. D. STEPHENS, Editorial Secretary
J. LOEWENTHAL J. W. F. MACKY R. H. ORTON
A. ©. McEACHERN JULIAN SMITH H. G. WHEELER

CONTENTS

VOLUME 28 — 1958-59

AUGUST, 1958

The Pathogenesis and Treatment of Primary Hydroceles in Infancy and Childhood
Douglas G. McKay, R. Fowler, Jnr., and J. S. Barnett

Thrombosis of the Internal Carotid Artery - John Connell

Carcinoma of the Supra-Aortic Part of the Thoracic Gunde
C. S. Yeoh and Y. Cohen

Anatomical Vagaries of Double Ureters _ F. Douglas Stephens

Cervical Lymph Node Metastases from Epithelioma of the — Lips and Mouth
Howard H. Eddey

The Bowel Sounds in Cases of Haematemesis and Melaena

G. W. Milton and G. J. A. Clunie

Paget’s Disease of the Nipple occurring in a Young Woman

P. R. Joyce and J. S. Lekias
Edward A. Allcock
Thomas H. Ackland

N.C. Tan

A. Distin Morgan

_ Rowan Webb

iia A. "McDonald and G. R. McLeish

Spontaneous Perforation of the Oesophagus
Chronic Inflammatory Mastitis with Duct Ectasia
Traumatic Rupture of the Lung

Anaesthetic Problems in Surgery of the ae we
Hydatid Cyst of the Liver __
Cirsoid Aneurysm of the Pelvis ___
Books Reviewed

Book Received

NOVEMBER, 1958

Brief History of Peptic Ulcer Surgery - W. W. Woodward
Some Recent Studies on the Physiology of Smooth Snel and the Mechanical Aspects
of Gastro-Intestinal Function and some possible implications to Surgical Problems

G. W. Milton
Douglas Cohen
H. D. O’Brien
Stephen Suggit

’ F, Ellis
Kenneth R. Cox

A Simple Method for the Oxygenation of Heparinized Venous Blood

Fluothane -

The Surgery of steno ‘ ,
Closure of Tympanic Membrane Pestecsdinns
Cholecystectomy for Acute Cholecystitis __
Fibrosarcoma of the Scrotum Daniel Lane

Percutaneous Prostatic Biopsy D. G. Macleish

Familial Intestinal Polyposis Associated with Further Sheniendins of Growth
P. J. Kenny and J. O’Neill

Gall-stone Ileus _. J. J. McCarthy

Advanced Carcinoma of the Gente Uteri with este Beyond Five Years after Total
Pelvic Exenteration with Colonic Substitute Bladder __. . Graham Godfrey

Books Reviewed

Page

12

18
27

34

42

A5
50
57
62

71
72
75
80

81

96
108
110
120
126
128
139
141

145
151

155
157

THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

FEBRUARY, 1959

Page
Carcinoma Corporis Uteri __. ies ae A .. Barry Kneale 161
Sporadic Amoebiasis in Victoria _,. oe A. M. Cuthbertson and J. D. Tange 171

Gun for the Attachment of Clips to Small Vessels in Deep Pelvic Surgery
D. Fairbanks, A. S. Manson and Graham Godfrey 180

Intact Extrusion of Hydatid Cysts __ nA 7 in _. W.W. Woodward 186

An Experimental Method for the Production of Mitral Incompetence
Thomas S. Reeve and lan Monk 191

Pilonidal Sinus of the Axilla ‘eh —_ see a ale E. S. J. King 196
Fatal Complications following Colectomy _. sila ides _. E, S.R. Hughes 202
Thrombosis : poe ran idan = _. V.J. McGovern 215

Blood Volume Studies in _ Men
T. S. Reeve, T. H. Oddie, Sheilah Bowman and F. F. Rundle 221

The Administration of Presuren oa ‘ied a oe sibs T. R. Morley 228

Traumatic Intraperitoneal Rupture of the Urinary Bladder = __ ..._ B. Hartley 233

Books Reviewed , - vas a = 238

Proceedings of the Royal Australasian College of Surgeons __. om sont —_ 21
MAY, 1959

Spinal Injuries — A Challenge i one sis oni ._... G. M. Bedbrook 245

The Relationship of Solar Radiation to Melanoblastoma
V.J. McGovern and B. S. Mackie 257

Studies of Renal Transplantation in Sheep _.. _ an ot R. M. Mitchell 263
The Genetic Approach to Hereditary Congenital Ptosis __ ni _. B. K. Rank 274
Biceps Cineplasty for Forearm Amputees __. i = si J. T. Hueston 280

Small Bowel Obstruction following Abdomino-Perineal Excision of the Rectum

E. S. R. Hughes 286

Microdissection Study of Late Renal Disease _ = — . Thelma J. Baxter 290
The Diagnosis of Portal Hypertension -.. GG. Berci, E. A. Allcock and M. R. Ewing 301
Contraction in Wounds Made at Short Time Intervals __ .... A. M. Cuthbertson 309
A Modified Technique of Lower Limb Venography __ sn pe ... R. Paton 312
Traumatic Rupture of the Kidney in Christmas Disease __ .... Robert Shannon 316
Books Reviewed ais a wile — don il _ _— ines ... 319
Book Received — : . vas sii = wie ... 319

Proceedings of the Royal Seanietee College of ia es on i .. SD

The Australian and New Zealand
JOURNAL OF SURGERY

AUGUST,

Vol. 28 —No. 1

1958

THE PATHOGENESIS AND TREATMENT OF PRIMARY
HYDROCELES IN INFANCY AND CHILDHOOD

By Doucias G. McKay

Adelaide

AND

R. Fow.er, JNr., AND J. S. BARNETT

Surgical Research Unit, Royal Children’s Hospital, Melbourne

YDROCELES in infancy and childhood

may be divided into primary hydroceles
and those which are secondary to disease of
the testis or its adnexae. Primary hydroceles
include, firstly, those of congenital origin in
which a macroscopically obvious communica-
tion with the peritoneal cavity allows free
passage of peritoneal fluid into the hydrocele
sac, and secondly, the so-called idiopathic
hydroceles where no such cause for the fluid
accumulation is obvious.

Idiopathic hydrocele is a relatively uncom-
mon finding in adolescent or young adult
males and yet is occurs with considerable
frequency in the younger and older age
groups. This curious incidence, which has
excited little comment, is a reason for doubt-
ing that the idiopathic hydrocele of elderly
males has the same pathogenesis as that of
idiopathic hydroceles in infancy and child-
hood.

Nevertheless the several empiric methods of
surgical treatment of the adult condition have
been variously and indiscriminately applied
to hydroceles in children. These orthodox
methods include total excision, partial ex-
cision and eversion, or eversion only of the
vaginal sac — Jaboulay’s operation. Any of
these procedures may be followed by such
troublesome sequelae as haemorrhage, in-
duration, infection or recurrence, while in

2

children there is the added risk that extensive
procedures in the neighbourhood of the testis
may damage its blood supply or the vas
deferens. For these reasons it was felt that
further attention should be paid to the patho-
genesis and surgical treatment of hydroceles
in children.

This paper reports our experience of a
method of surgical treatment which avoids or
minimises such troublesome complications.
It ignores altogether the hydrocele sac and
strikes directly at the source of the fluid. This
method, we believe, has not previously been
advocated and has a rational basis in our
concept, elaborated in this paper, of the
mechanism of origin of childhood hydroceles.

RATIONALE OF RECOMMENDED TREATMENT

The view is put forward here that all
primary hydroceles of infancy and childhood
have resulted from a persistent patency of the
processus vaginalis — not from some abnor-
mality of the tunica vaginalis as is more often
supposed.

It is logical, therefore, that in preference to
those orthodox manoeuvres directed to the
hydrocele sac itself, we should recommend as
the treatment of choice a simpler procedure
directed to the processus vaginalis alone.
Permanent cure will result merely from the
severance of an obviously patent funicular

2 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY

process or from division of that strand of
tissue running from the peritoneum to the
hydrocele, even though no lumen may be
demonstrable within it at the time of opera-
tion.

The evidence to be presented from this
study attests not only the success in practice
of the method we advocate but also the
validity of the hypothesis on which it is
rationally based.

MATERIAL AND METHODS

The above thesis has been preached and
practised in Adelaide by one of us (D.G.M.)
for the past ten years, and is based upon his
personal experience and observation of more
than 50 cases so treated without any known
recurrence.

For the critical appraisal of these teachings
we have undertaken at the Royal Children’s
Hospital, Melbourne, since 1955, an elective
study of childhood hydrocele and its treat-
ment by this simple technique. This study
has included observations on the nature, for-
mation and reabsorption of hydrocele fluid;
the surgical anatomy of the hydrocele sacs;
the phenomenon of spontaneous cure; recur-
rence after orthodox surgical procedures; and
the results of operation by the Adelaide
method. The observations made on 58
children with 62* hydroceles supported the
foregoing views on the pathogenesis and
correct surgical treatment of this condition.
Accordingly, these views are now based on
the combined Melbourne and Adelaide ex-
perience of more than 100 cases. Hereafter,
unless otherwise stated the figures quoted in
this paper refer to the Melbourne series.

Included in the Melbourne and Adelaide
series were 6 recurrences following orthodox
surgery which were successfully treated by
this simplified method.

The relative infrequency of secondary
hydroceles in children can be gauged by the
fact that we only encountered one such case
during the two years in which this study was
in progress.

*Two hydroceles were no longer present at the
time of operation so that only 60 hydroceles are
represented in the diagrams (Figs. I and II).

EVIDENCE IN SUPPORT OF THE CONGENITAL
HyporuHeEsIs

1. Clinical features
(a) Right-sided preponderance

The right-sided preponderance typical of
childhood hernia and undescended testes
(Gross, 1953), is also a feature of hydrocele.
Out of 62 hydroceles in this present series 38
were on the right, 16 on the left, and 4 were
bilateral; right undescended testes were asso-
ciated with two of the bilateral cases and a
left undescended testis accompanied one of
the left-sided hydroceles. These facts point
to a kindred aetiology and suggest that hydro-
cele has its genesis in some anomaly of
development and closure of the processus
vaginalis testis.
(b) Postural variation in size

The story was often elicited that the swell-
ing, although never completely disappearing,
varied in size and was largest towards the
end of the day. This is just what would be
expected if gravity and any rise in intra-
abdominal pressure were helping to fill the
tunica vaginalis with peritoneal fluid by way
of some communication with the abdominal
cavity.

(c) Recurrence after aspiration

The initial observation leading to the con-
genital concept of hydrocele was that in a
number of boys seen by one of us (D.G.M.)
with the history that an irreducible hydrocele
had been aspirated, the swelling had recurred
within twenty-four hours. It seemed likely
from so rapid a recurrence that these hydro-
celes had some communication with the peri-
toneal cavity.

(d) Recurrence after operation

The next observation was that recurrence
of a hydrocele in childhood could follow
orthodox surgical procedures confined to the
tunica vaginalis testis. Presumably in such
cases a portion of the tunica containing the
lower end of a patent funicular process had
been left behind. In the ensuing months a
new sac formed and likewise became filled
with fluid from the peritoneal cavity. When
sought for, this patent funicular process
could be demonstrated at subsequent opera-
tion and its excision resulted in permanent
cure,

L

Se we

oe aes.

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES a

The 6 recurrent hydroceles in this series
had all reappeared within twelve months or
less from the first operation and were all
found to have a patent funicular process not
dealt with on that occasion.

However, the usual success of the
excision or Jaboulay types of opera-
tion should not be wondered at, since
in a majority of cases the patent
processus will probably have been
obliterated in one way or another;
this may result from the inflam-
matory response to surgical trauma
or the unwitting division of the
processus by some surgeons: other
surgeons intentionally divide the
processus by routinely combining
hernictomy with an orthodox hydro-
cele operation (Gross, 1953), but the
latter procedure is thereby rendered
unnecessary.

2. Surigcal anatomy
(a) Morphological types

The anatomical varieties of hydro-
cele sac and their incidence as re-
corded in this series are shown in
Figs. I and II. It is not suggested
that this display exhausts the pos-
sible permutations or combinations
of sacs and patent funicular pro-
cesses, nor is it intended as a basis
for erecting any new form of clas-
sification. Their variety, however,
does serve to show the futility of
attempting to classify hydrocele sacs
according to the confusing and com-
plex nomenclature that has _be-
wildered generations of students in

the past (Fig. III). FIG.

between these sacs was demonstrable. From
two of tnese macroscopically non-communicat-
ing cases the adjacent sac walls were excised
and _ sectioned serially (at 15, thickness,
mounting and staining every fifth section with

NON-COMMUNICATING HYDROCELES

aye

No. of Cases: 1

ow

Saccular morphology of 12 non-commuricating

hydroceles: (e) represents the “inner sleeve’ arrangement

described in the text and (f) a similar arrangement in which
omentum had become invaginated into the lumen of the inner

We have chosen, solely for con-
venience in presentation, to divide
the cases into non-communicating
and communicating hydroceles, but
we do not believe there is any funda-
mental difference in the pathogenesis
of these two types.

of a

In the first category there were 12 cases in
which an extensive hernial sac was present
(Fig. I), 10 of which shared a common wall
with the hydrocele sac, but no communication

sleeve to form yet another sleeve; (g) was the only example
loculated sac encountered; in (i) there was a small
blind “daughter sac” arising from the common wall of the
hernial and proximal hydrocele sacs; (j) was the only case
of abdomino-scrotal hydrocele encountered. The testis was
undescended and lay in the inguinal canal. The hernial sac
and the upper extent of the hydrocele sac passed upwards in
the pro-peritoneal plane for a distance of approximately 2”

above the internal ring.

haematoxylin and eosin). These sections
likewise failed to show any communication
between the sacs. It must be emphasized,
however, that in all the cases studied, whether

4 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

communicating or non-communicating, a
patency of at least the proximal part of the
processus vaginalis was present.

the peritoneal cavity. In the second group.
a small funnel-like hernial sac was present at
the upper limit of this processus. In the third

COMMUNICATING HYDROCELES

Type I without

Typell

associated hernial sac. with short hernial sac.

No. of Cases: 8 2

bu bei

Type Il

with long hernial sac

Weboes

FIG. Il Saccular morphology of 48 communicating hydroceles
grouped according to the presence and extent of associated hernial
sacs. The distal sac in Type If (d) was obliterated. Type III (a)
is virtually a total funicular hernial sac, but these cases presented
clinically as hydroceles, and the calibre of their lumen was judged
to be too small at the time of operation to admit bowel or
omentum. The calibre of the other patent processes is shown, for
clarity, to be much wider in proportion to the hydroceles than was

the case at operation.

In 48 cases, by careful dissection, a com-
munication between the hydrocele and _peri-
toneal sacs was displayed, although in many
of these the patent processus was so fine
that it would have escaped a mere casual in-
spection of the cord for a hernial sac. The
mechanism of fluid entry into the hydrocele
sacs could therefore be readily accounted for
in these 48 cases.

Broadly speaking, the communicating cases
could be grouped into three representative
types although there were all manner of
variations and gradations between these types
(Fig. 11). Firstly, there were those in which
no hernial sac was present hut a fine patent
processus vaginalis joined the hydrocele with

group, there was a rather extensive hernial
sac extending for most of the length of the
inguinal canal or beyond to communicate by
a short, though very fine, processus with the
hydroceie sac.

(b) Valvular arrangement

One important point in the surgical
anatomy of these hydroceles was that the
patent processus often entered the distal
vaginal sac below its apex, so as to create a
valvular effect (Fig. IV). It is easy to see
how this valve would be shut by the firm
external pressure of attempted reduction but
could permit slow partial emptying of the
sac when a recumbent posture was assumed.
This arrangement would likewise seem to

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES 5

favour a tendency to spontaneous obliteration
at this junction, especially since the valvular
effect was often heightened by a dense fascial
web binding the processus to the side wall of
the sac (Fig. IV).

would often lead to escape of fluid from its
proximal end, indicating its communication
with the peritoneal cavity. Microscopic sec-
tion of these strands anywhere along their
length revealed a lumen. It seems probable

HYDROCELES (after LEE M°GREGOR)

Ss

hagma/ Congenital Infantile Encysted Mya. of cord

HERNIAS (after LEE MSGREGOR)

L8Y

Funicu/ar

/nfant ile Lncysted

HYDROCELES (after BAILEY and LOVE )

Sus

Vaginal Congenital Infantile Encysted

Hourglass

Bilocular Abdommo-scrota/l

FIG. Ill. Diagrams (modified and redrawn from Bailey and

Love and Lee McGregor) illustrating the confusion existing in

conventional schemes of classification of hernial and hydrocele

sacs. The criteria for the selection and application of the

terms used are by no means clear and the types depicted should

be contrasted with those encountered in the present series
(Figs. I and II).

(c) Microscopic communications

In Adelaide, one of us (D.G.M.) has had
experience of cases in which no patent pro-
cessus could be demonstrated at operation but
in which dissection among the cord structures
displayed a tough strand of tissue running
from the upper aspect of the tunica along the
full iength of the cord, and tension on its
upper extremity would pull down a nipple of
peritoneum. Division of this upper portion

that in some other such cases a sufficiently
careful study would likewise reveal a com-
munication between the peritoneal and hydro-
cele sacs.

Nevertheless, it seems likely from our own
study the evidence of which now follows, that
the next phase in the natural history of this
condition is the delayed spontaneous oblitera-
tion at one level or another of the patent

6 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

funicular process. If this delayed spon-
taneous obliteration is accepted as a corol-
lary of the congenital hypothesis then it can
readily be pictured from the observed surgical
anatomy (Figs. I and IL), how the evolution
of the more complex sacs could follow from
the simplest type of communicating sac.

3. Spontaneous abliteration

Obliteration of a patent funi-
cular process has been observed
to occur as a delayed spontaneous
event. It is not very rare to find
that a hydrocele present in the
first few weeks of life has dis-
appeared during the next few
months, and it is believed that this
kind of spontaneous cure is prob-
ably permanent.

Direct evidence of spontaneous
obliteration of a patent processus
vaginalis was obtained in two
patients. Since the findings in
these two cases are important in
regard to the evolutionary changes
which we believe can take place
in hydroceles, their clinical his-
tories are given at some length.

A boy aged two years was admitted
with the history that bilateral scrotal
swelling had been present since birth
and had varied occasionally in size.
The clinical diagnosis of bilateral hydro-
cele was first made at the age of eight
months and had been confirmed on
three subsequent visits. At operation,
however, no hydrocele was found on
either side. Instead, a white fibrous
strand of tissue, clearly demarcated,
was present on both sides in the place
where the processus vaginalis would be
expected, joining the peritoneum to a
normal sized tunica vaginalis testis.
Each fibrous strand was excised but in
histological section only vascular fibrous
tissue without any lumen was seen.

The second child (Fig. Il, Type Ild) was referred
to hospital at the age of four months with an irre-
ducible swelling in the right groin of twenty-four
hours’ duration. The clinical diagnosis of hydrocele
of the right spermatic cord was later substantiated
by several observers and five weeks prior to operation
the lump measured 2” x 14”. One week prior to
operation the hydrocele had disappeared but there
was a palpable thickening of the cord. At operation,
dissection of the cord revealed a very fine patent
processus extending from the peritoneal cavity to a
point about half-way down the inguinal canal, where

it expanded into a small fusiform sac (Fig. Il, Type
IId). Immediately below this little sac, and with no
apparent communication with it, was a small blind
sac containing virtually no fluid and measuring
1” x 3”. This sac had thick vascular walls, adhering
to each other, which could not be readily dissected
from the remaining cord structures. A distance of
half an inch separated it from a normal tunica
vaginalis testis.

FIG. IV. An example of the often encountered valvular arrange-
ment of a patent funicular process. A cough fascial web holds
the terminal processus to the side wall of the hydrocele. The
beaded appearance of this communicating strand, once it has
been distended with fluid, is characteristic.

A — internal inguinal ring; B— fine patent processus;

C — external ring; D fascial web; E — valvular junction

of processus and sac wall; F —hydrocele sac.

Our concept of the sequence of events in
this case is that the fine patent processus
initially supplying a hydrocele of the cord
underwent spontaneous obliteration close to
its junction with that sac. What then followed
was a reabsorption of fluid from the distal
sac and a gradual distension of the now blind
end of the proximal processus to form the
beginnings of a new hydrocele of the cord.

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES rj

It can be readily pictured how this sequence
multiplied several times could lead to the
complex non-communicating sac formations
in Fig. I.

Much of the remaining evidence in support
of the congenital hypothesis will show more
convincingly that the existence of a non-
communicating hydrocele intimately associ-
ated with a hernial sac is still compatible with
the congenital theory of its origin.

1. Other evidence
(a) Hydrocele fluid

Unless those cases without macroscopic
communication are to be explained on the
basis of a sometime persistent patency of the
processus vaginalis, then the origin of the
fluid demands some other explanation. It
could be an inflammatory exudate, but section
of the walls of such sacs revealed no inflam-
matory change, nor did the fluid aspirated
from these hydroceles suggest an inflam-
matory origin. On the contrary, the fluid
obtained from either communicating or non-
communicating hydroceles was indistinguish-
able from the peritoneal fluid which can be
aspirated from a hernial sac. The following
observations were recorded in Adelaide from
a recent case of non-communicating hydrocele
associated with a narrow hernial sac. White
cell counts on the hydrocele and peritoneal
fluid were respectively 223 and 216 cells per
cubic millimetre; in both fluids the cells were
predominantly lymphocytes, together with a
few large endothelial cells but no_poly-
morphs. Similar contents were found in
Melbourne in the fluid from four other child-
hood hydroceles, one with, and three without,
demonstrable peritoneal communications.

The protein content of the fluid from the
non-communicating hydroceles ranged from
3.3 to 4.4 gms per cent. and that of the fluid
from the communicating hydrocele was 3.8
gms per cent. The fluid from either source
had an electrophoretic pattern which was
qualitatively the same as normal serum, again
suggesting a non-inflammatory origin.

(b) Reabsorption of hydrocele fluid

Further evidence for the congenital hy-
pothesis and for the rationale of non-inter-
ference with the hydrocele itself comes from
the reabsorption of hydrocele fluid which
follows the spontaneous or operative ablation
of a patent funicular process.

(i) Reabsorption after spontaneous oblite-
ration.

Direct evidence from 2 patients has already
been presented that reabsorption of hydrocele
fluid follows spontaneous\ obliteration of a
patent funicular process. The reabsorption
of fluid resulting from these experiments of
nature can be mimicked surgically by the
deliberate imprisonment of fluid in a hydro-
cele sac below a ligated funicular process.

(ii) Post-operative reabsorption of hydro-
cele fluid.

If even the finest patency of the processus
vaginalis has been demonstrated and divided,
it is not absolutely necessary to empty the
fluid from the hydrocele sac, because this will
absorb spontaneously. This has been demon-
strated in 12 such cases by deliberate ligation
of the distal cut end of the processus, with
fluid still imprisoned in the vaginal sac.
Follow-up of these cases has shown complete
reabsorption of the fluid within periods vary-
ing from two weeks to six months.

(c) The “non-communicating” hydroceles

(i) History.

Seven out of 12 such cases were distin-
guished by a story that the hydrocele had at
some stage varied intermittently in size. This
suggests that a communication of these hydro-
celes with the peritoneal cavity had been
present at one stage in their life history.

(ii) Reabsorption after herniotomy alone.

Furthermore, in 4 of the 12 apparently
non-communicating hydroceles simple liga-
tion and division of the proximal hernial sac
was performed. This was followed by the
reabsorption of imprisoned fluid from the
hydrocele sac in periods varying from three
weeks to six months. Unless the peritoneal
cavity had been the original source of this
fluid then these hydroceles should have per-
sisted. In support of this contention are the
observations on the remaining eight cases of
apparently non-communicating hydroceles.

(iii) Herniotomy combined with evacua-
tion of the hydrocele.

Seven of these 8 hydroceles were treated by
simple herniotomy, at the same time emptying
the hydrocele of its fluid. In 5 of the 7 cases
this was achieved by needle aspiration or
minimal stab incision. In 2 of the 7 cases
a relatively small portion of the sac wall was

lala)
a)

excised for microscopic study. In the eighth
case a considerable amount of redundant sac
had to be excised to permit of concurrent
orchidopexy.

In all of the above 7 cases, herniotomy
alone sufficed to prevent reaccumulation of
the fluid. The small deficiencies in these sac
walls should have rapidly healed and retained
any fluid formed by purely local disturbances
of fluid exchange across the hydrocele wall,
so that unless the abdominal cavity was the
original source of their fluid these hydroceles
should have recurred.

These observations raise the question of
why the fluid in these non-communicating sacs
had not reabsorbed prior to operation, once
they had lost communication with the peri-
toneal cavity. It may be that in some a micro-
scopic patency had persisted undetected but
this explanation cannot serve for those two
cases from whch serial sections were made.
Alternatively the fluid in the hydrocele might
be a peritoneal transudate from the hernial
sac through their common wall; however, in
spite of the presence of an adjacent proximal
sac this hypothetical mechanism did not pre-
vent the reabsorption of fluid from the case
of hydrocele of the cord described earlier
(Fig. I, Type Id).

The most likely explanation is that spon-
taneous obliteration of their peritoneal com-
munications had occurred too recently for the
fluid to have been absorbed, such absorption
sometimes taking several months as has been
shown in this study. The presence of a large
hernial sac may even impede the reabsorption
of hydrocele fluid along the lymphatic and
venous channels of the cord.

DiscussIOoN

The foregoing evidence leads us to a con-
cept of the congenital origin of all these
hydroceles, their evolution beginning with
simple patency of the processus vaginalis
testis and its gradual distension by peritoneal
fluid. If delayed spontaneous obliteration of
the entire processus should occur then spon-
taneous cure will result and the fluid will be
reabsorbed. If, however, a fine processus

should become obliterated only at its junction
with the hydrocele, the next evolutionary

THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

change would be the dilatation of that portion
of the processus immediately above the distal
sac. In this way, the stage would be set, by
repetition of the earlier changes, for just such
a series of complicated sacs as are seen in
some of the cases illustrated in Fig. 1. When
the communicating processus is wide, and has
a valvular communication with a distal sac,
progressive enlargement of the hydrocele
might take place upwards into the cavity of
the hernial sac above, producing the rather
bizarre “inner sleeve” arrangements pictured
in Fig. 1. These, we believe, have not been
reported before and were certainly confusing
when first encountered.

The congenital aetiology of all primary
childhood hydroceles has not been categoric-
ally stated previously, although suggested by
the writings of Gross (1953) and Keeley
(1954), who both stress the frequent associa-
tion of hydroceles and hernias. At the
Children’s Hospital, Boston, for instance, 15
per cent. of patients operated upon with in-
guinal hernia had associated hydroceles
(Gross, 1953). However, the type of hydro-
cele pictured by Keeley and in most surgical
texts as the commonest variety is a hydrocele
sac with nothing but a solid cord of tissue
between it and the peritoneal cavity. This
anatomical variety was not encountered in this
present study and would require in explana-
tion of its origin some theory of disturbed
fluid exchange through the wall of the hydro-
cele itself.

A disturbance of the normal fluid exchange
across the wall of the tunica could result from
either an increased production of fluid, such
as by inflammation, or from decreased re-
absorption due to deficient venous or lym-
phatic drainage, or to thickening of the sac
wall. These local mechanisms are advanced
in explanation of idiopathic adult hydroceles
(Ozdilek, 1957) but have been excluded as
the prime cause of childhood hydroceles by
the evidence from this study.

Impaired lymphatic or venous drainage
could conceivably play a secondary role in
delaying reabsorption from a non-communi-
cating hydrocele association with a large her-
nial sac, or might sometime be responsible
for a secondary hydrocele developing after
herniotomy or herniorrhaphy in childhood.

ee ———

_

“ F SS oe

we

THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES 9

In regard to our concept of the congenital
aetiology of childhood hydroceles, it may be
wondered in view of the rapid absorption of
fluid which takes place from the pleural or
peritoneal sacs, why the rate of entry of peri-
toneal fluid into a hydrocele sac should not
be balanced by a commensurate absorption
through the wall of the sac. Experimental
evidence indicates that the normal tunica
vaginalis testis is peculiar in this regard and
has the slowest absorption characteristics of
any of the serous sacs in the body, whereas
from the sacs of chronic hydroceles absorp-
tion is even more prolonged (Allen and
Rinker, 1946; Huggins and Entz, 1931). In
line with these experimental findings are our
own observations that fluid imprisoned in a
hydrocele sac may take from weeks to months
to be completely reabsorbed.

Finally, the conventional classifications of
hydrocele to be found in textbooks, founded
as they are on muddled criteria, are unneces-
sarily confusing (Fig. III). They become
almost meaningless when considered in rela-
tion to similar classifications and descriptive
terms applied to hernias (Fig. III). How in-
appropriate such terminology is when applied
to hernias has been admirably discussed
years ago by Hamilton Russell (1923).

Logically, childhood hydroceles may be
classified according to the following criteria,
established by operative in preference to
clinical findings: communicating or non-com-
municating, according to the particular stage
in their life history at which they present;
simple or loculated according to shape;
scrotal, funicular, inguino-scrotal, or ab-
domino-scrotal, according to their extent; and
single or multiple according to the number of
sacs present. Useful as such descriptive terms
may be, they are not indicative of varying
pathogenctic types nor do they possess any
practical significance in regard to the treat-
ment which should be adopted.

SurGicaAL TREATMENT

(a) Principles

Two important principles have emerged
from the present study which influence the
surgical treatment of this condition. Firstly,
the accumulation of hydrocele fluid should
be prevented at its source. We have found
that simple herniotomy with transfixion, liga-
tion and division of any patent derivative or

strand of the processus vaginalis will cure the
condition. Secondly, it is not necessary,
and indeed may be harmful, to remove the
hydrocele sac itself. Ignoring the sac in
this fashion avoids those complications
enumerated earlier, which so often follow the
orthodox surgical procedures.

Furthermore, these orthodox procedures
may fail to prevent recurrence, and our joint
experience of six recurrences of this type has
already been related. These cases should be
explored again, when careful dissection will
reveal a fine strand or patent processus vagi-
nalis bringing the hydrocele into communica-
tion with the peritoneal cavity. Severance of
this processus will cure these hydroceles.

(b) Considerations in technique

Under certain circumstances the surgical
technique required may present two problems
which differ from those encountered in a
simple routine herniotomy—one arising when
the hydrocele sac is very big, and the other
when the communicating processus is very
small.

The problem of finding a very fine proxi-
mal processus will often be solved by the
application of manual pressure either to the
abdomen or to the hydrocele sac. In either
case it may be possible to force a few drops
of fluid along the processus, in which case
it will assume a characteristic distended,
beaded, opalescent appearance (Fig. IV). It
can then be isolated as a separate structure
entirely free from the other cord tissues.
However, pressure on the hydrocele may not
succeed until after the division of fascial
bands at the valvular junction of the pro-
cessus with the hydrocele wall (Fig. IV). It
is often easier to trece the fine processus
downwards from the internal ring where
there is frequently a “tenting” or funnel-like
expansion of the processus at its junction with
the peritoneum. For this reason we have
chosen as a routine to split the external
oblique aponeurosis because of the better ex-
posure and control thereby secured.

In the case of a very large tense sac the
hydrocele may extend right up to the internal
ring, overlapping the communicating sac.
Attempts to dissect around such a_ tense
bulging hydrocele might result in the fine
patent communication being avulsed and
missed completely. If this occurred close to

10 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

the peritoneum, spontaneous cure might
result, but if a processus of any length is left,
the stage could be set for recurrence of a
hydrocele. Preliminary needle aspiration of
the hydrocele through the scrotal coverings,
until it is slack, will enable the dissection to
proceed with greater facility. If aspiration
is attempted through the exposed sac, the
fluid may all be lost through the puncture
hole thus preventing its subsequent use should
it be needed to display the processus.

In the one case of abdomino-scrotal hydro-
cele encountered (Fig. 1) adherence to the
above principles and technique enabled us to
operate successfully by the inguinal route,
without recourse to the more cranially placed
or multiple incisions which have sometimes
been used for this uncommon condition
(Prather, 1942).

(d) Procedures on the hydrocele sac

Once the processus is dealt with, the ques-
tion arises as to what to do with the hydro-
cele itself. The fear that a hydrocele will
result from leaving the distal part of a total
funicular sac should be dispelled by our
observations on the reabsorption of fluid
from such sacs. When a hydrocele occurs
following herniorrhaphy or herniotomy it
is probably due to interference with the
pampiniform plexus or to damage to the lym-
phatic vessels in the spermatic cord (Obney,
1956).

Although we have shown that the fluid will
reabsorb in time, we nevertheless recommend
that the hydrocele should be emptied by
simple aspiration or minimal stab incision.
This is the procedure of choice for all cases
in order to save the child’s parents from an
anxious period of waiting.

(e) Management in infants

In view of the strong tendency towards
spontaneous cure, surgical interference is not
indicated during the first year of life for the
hydrocele itself. Surgery may be required,

however, for the distress or complications of
an associated hernia, the principles of sur-
gical intervention and the management of
infant hernia being admirably discussed by
Sloman and Mylius (1958).

SUMMARY AND CONCLUSIONS

This paper is based on the combined ex-
perience in two children’s surgical centres of
more than one hundred childhood hydroceles.

A wide variety of saccular morphology was
encountered, with all intervening gradations
between the simplest communicating type of
sac and the most complex non-communicating
and multiple saccular formations. It is
emphasized that, whether communicating or
non-communicating, such hydroceles were
always associated with an abnormal patency
of at least the proximal part of the processus
vaginalis testis. From the succession of types
observed it is possible to picture the natural
history of evolution of the various forms and
a congenital aetiology for all of them is en-
visaged. On the concept of their congenital
origin, by distension of a patent processus
with peritoneal fluid, is based the simplified
method of surgical treatment advocated in this
paper.

The following additional evidence from our
study supports this congenital hypothesis :—

1. The right-sided preponderance typical of
hernias and undescended testes was like-
wise found for these hydroceles.

2. A history was usually elicited, even in the
apparently non-communicating cases, of
intermittent variation in the size of the
hydrocele at some stage in its life history.

3. The fluid from both communicating and
non-communicating hydroceles was micro-
scopically and chemically indistinguish-
able from peritoneal fluid.

1. Imprisoned hydrocele fluid was shown to
be reabsorbed from both communicating
and non-communicating cases after simple
operative ablation of a patent funicular
process.

5. If the hydrocele sac was left behind,
emptied of its fluid, with only a needle
puncture or minute incision in its walls,
reaccumulation of such hydrocele fluid did
not occur after severance of the funicular
process or strand.

6. Recurrent childhood hydroceles, in our
experience, were always associated with a
fine patent processus which had been over-
looked at the original operation. Sever-
ance of this fine processus cured the con-
dition.

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THE PATHOGENESIS AND TREATMENT OF PRIMARY HyYDROCELES 11

Difficulties can arise in locating and deal-
ing with a very fine patent procesus or a very
large hydrocele sac, and the appropriate
points in surgical technique are discussed.

In infants, the management of hydroceles
should be expectant because of the tendency
to spontaneous cure.

The conventional terminology and clas-
sifications of hydrocele are critically reviewed
and shown to be confusing. Variations in
saccular morphology are no basis for an
aetiological classification and the treatment of
election is unrelated to whatever descriptive
terms of convenience may be used.

The conclusions drawn from this study
are :—

1. All primary childhood hydroceles are con-
genital in origin and result from the
distension of a patent processus vaginalis
with peritoneal fluid.

2. The ligation and division of a patent
funicular process or strand is all that is
necessary to cure the condition. Simul-
taneous evacuation of the hydrocele by
aspiration or minute incision avoids wait-
ing for the reabsorption of fluid which
has been shown to follow the ablation of

a patent processus.

3. The more extensive interference with the
hydrocele sac inherent in orthodox sur-
gical procedures is therefore unnecessary.
This interference, moreover, is sometimes
followed by recurrence which is demon-
strably due to a patent processus. Liga-
tion and division of this processus will
achieve a permanent cure.

REFERENCES

Auten, L. and Rinker, J. R. (1946), Anat Rec.,
vol. 94, page 446.

Baitey, H. and Love, R. J. McN. (1946), “A Short
Practice of Surgery.” London, H. K. Lewis & Co.,
page 593.

Gross, R. E. (1953), “The Surgery of Infancy and
Childhood.” Philadelphia, W. B. Saunders, pages
461 and 466.

Huccrins, C. B. and Entz, E. H. (1931). J. Urol.,
vol. 25, page 447.

Keetey, J. L. (1954), Jilinois Med. J., vol. 105,
page 1.

McGrecor, A. L. (1957), “Synopsis of Surgical
Anatomy,” 8th Edition. Bristol, John Wright and
Sons.

Opney, N. (1956), Canad. med. Ass. J., vol. 75,
page 733.

Ozpitek, S. (1957), J. Urol., vol. 77, page 282.

Pratuer, G. C. (1942), New Engl. J. Med., vol. 226,
page 255.

Russet, R. H. (1923), “Papers and Addresses in
Surgery.” Melbourne, Grant, page 104.

Stoman, J. G. and Mytius, R. E. (1958), Med. J.
Aust., vol. 1, page 242.

THROMBOSIS OF THE INTERNAL CAROTID ARTERY

By JoHNn CONNELL

St. Vincent’s Hospital, Melbourne

HROMBOTIC occlusion of the internal

carotid artery has emerged as a de‘initely
recognized clinical entity only in the last
decade. The condition is apparently quite
common and is being diagnosed with increas-
ing frequency as the cause of shortlived cere-
bral attacks which were previously often
attributed to cerebral spasm (Denny-Brown,
1951). Because the treatment of this malady
by direct arterial surgery has not been pre-
viously reported in this country, so far as I
am aware, | thought that the following com-
munication and case reports might be of
interest.

The pathology and clinical features of in-
ternal carotid artery occlusion have been fre-
quently described in the medical literature.
The importance of the clinical recognition
of the condition lies in the fact that the
occlusion is often partial for a start, and
gives rise to intermittent premonitory events,
which may warn of the possibility of complete
thrombosis. It is at the stage of incomplete
occlusion that direct arterial surgery has its
greatest use and seme brilliantly successful
results have been published.

It seems that the primary lesion is the for-
mation of an atheromatous plaque in the wall
of the internal carotid artery, most commonly
in its first two centimetres. This is recog-
nized as the same localized degenerative pro-
cess which is likely to affect any of the large
arteries after middle age. In fact it is often
accompanied by arteriosclerotic occlusions
elsewhere. In the natural course of events
the partial occlusion tends to become complete
(Millikan and Siekert, 1955; Rob and
Wheeler, 1957) either by the formation of
an intramural thrombosis or a haemorrhage
beneath an atheromatous plaque. Once this
occurs the chances of surgical help to the
patient are very much reduced. Hence the
importance of recognizing the lesion when
the block is partial only.

Intermittent insufficiency of the internal
carotid artery system, producing a succession
of “little strokes” (Alvarez, 1955) is the most

common manifestation of partial occlusion.
The pattern of these attacks and their im-
portance as the usual precursors of permanent
cerebral infarction, from complete occlusion,
have been fully described by Rob, Alvarez,
Denny-Brown and others (Eastcott, Rob and
Pickering, 1954; Alvarez, 1955; Millikan and
Siekert, 1955; Denny-Brown, 1951; Rob and
Wheeler, 1957; Lyons and Galbraith, 1957).
Temporary paresis of whole or part of the
contralateral side of the body, with or without
disturbances in sensation, loss of speech and
transient homolateral blindness are the most
often reported features of the condition. The
patient, usually a male past middle age, will
suddenly lose the power in a limb or suffer
a complete hemiparesis and then recover
quickly. Attacks of numbness on the contra-
lateral side may be the only feature. Cases
of homolateral sudden blindness, from which
recovery occurs in a short time, have been
reported (Millikan and Siekert, 1955).

The duration of these “little strokes” varies
from a few minutes to several hours as a rule.
The attacks may be very frequent, often daily
or even several in the one day. FEastcott,
Pickering and Rob (1954) report the case
of a 66-year-old housewife who had 33 attacks
of left hemiparesis and blindness in the right
eye, lasting ten to thirty minutes and occurr-
ing almost daily until she was operated upon.
The clinical features of the syndrome may
vary from these common presentations and
for more detailed analysis the reader is re-
ferred to the authorities mentioned above.
Millikan and Siekert (1955) have pointed out
that convulsions and disturbances of cons-
ciousness are not features of this disease.

The essential cause of this intermittent
unilateral impairment of cerebral function is
a temporary state of internal carotid artery
insuficiency. The symptoms result from
ischaemia due to inadequacy of collateral
blood flow into the anterior and middle cere-
bral arteries (Denny-Brown, 1951). The at-
tacks are most often precipitated by a drop
in blood pressure. Many of the reported cases
have occurred during sleep (Millikan and

et a

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it

_— a

THROMBOSIS OF THE INTERNAL CAROTID ARTERY 13

Siekert, 1955; Eastcott, Pickering and Rob,
1954). Sudden changes in posture may pro-
duce symptoms. In any event the ischaemia
is usually temporary only; no cerebral infarec-
tion occurs, and the patient either completely
recovers, or is left with minimum permanent
damage. Sooner or later, in probably a ma-
jority of cases (Millikan, 1955), complete
occlusion of the artery occurs, and then a
cerebral infarct is much more likely.

FIG. I. “There is a filling defect consistent with

the diagnosis of an atheromatous plaque on the

right internal carotid artery, just distal to its
origin.’’ Radiologist’s report.

There are no pathognomonic physical signs
to certify the diagnosis. Diminution in carotid
artery pulsation high in the neck is an un-
reliable guide. A drop in retinal artery pres-
sure on the side of the lesion is confirmatory,
but the methods of measuring such pressures
are most inaccurate (Rob, 1957). Carotid
angiography is by far the most reliable diag-
nostic weapon, and is seemingly free of real
risk. It is now universally used where the
diagnosis is suspected.

Eastcott, Pickering and Rob were the first
to practise reconstructive surgery in occlusion

of the internal carotid artery. In 1954 they
reported a case of resection of the partially
occluded segment of the artery with re-anas-
tomosis to the common carotid. The result
was the complete relief of a most distressing
series of daily hemipareses. Since then Rob
(1957) has published the results of 27 ex-
plorations of the internal carotid artery, for
complete and incomplete occlusions. His ex-
perience has been that in incomplete occlusion
it is always possible to remove the obstruction
and to re-establish the arterial flow. In cases
of complete occlusion his results have been
disappointing. If surgery is to be of benefit
in complete occlusion, it seems as though it
will have to be performed very soon after the
catastrophe occurs.

FIG. Il. “The filling defect at the base of the
internal carotid artery is no longer present.”
Radiologist’s report.

Case 1

Mr. P.O’H. (UR 38880) was admitted to hospital
on 10 Dec., 1957, under the care of Dr. John Billings.
He was aged 54, and until this admission had no
illnesses except appendicitis years ago. Nine days
before admission, while engaged in conversation
with a friend, he noticed the sudden onset of numb-
ness down the whole left side of his body. Associated

14 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

with this was a slurring of speech and a blurring
of vision in the right eye. After three minutes these
symptoms disappeared and he felt quite well again.
Four days later an exactly similar attack occurred,
which was again short-lived. The following day the
same sequence of events were repeated. Mr. O’H.
had never suffered from angina of effort or intermit-
tent claudication.

Examination revealed a fit looking man whose only
abnormality was a slight drooping of the left corner
of his mouth, Blood pressure was 150/100 mm. of
mercury, and his radial vessels were thickened. The
E. C, G. was normal.

Dr. Billings diagnosed partial occlusion of the
right internal carotid artery, and this was confirmed
by a carotid arteriogram (Fig. I). He was then
referred for surgery.

FIG. Ill. The patient from Case 1, showing mild
facial paresis indicating minimal pre-operative
cerebral damage.

Operation was performed on 13 Dec. Anaesthesia
was gas, oxygen and relaxant, and the patient’s
oesophageal temperature was lowered to 28.6 C.
The carotid bifurcation was exposed, and_ the
atheromatous plaque almost completely occluding
the right internal carotid artery identified with ease.
After clamps were applied, intra-arterial heparin was
injected, and then the artery was opened and the
occluding plaque removed. Good back flow was
obtained when the distal clamp was removed. The
longitudinal slit in the artery was re-sutured, and
complete haemostasis procured. The period of com-
plete occlusion of the carotid system was fourteen
minutes,

Post-operative convalescence was completely un-
eventful with the exception of a haematoma in the
right groin from an incision made to secure the
long saphenous vein, should it prove necessary.

Mr. O'H. has remained very well since the opera-
tion, The post-operative arteriogram (Fig. II) shows
that the obstruction has been completely removed.
The drooping of the left angle of the mouth remains,
indicating that mild permanent cerebral damage
occurred before operation (Fig. III).

Case 2

Mrs. J.0. (UR 09361), a diabetic aged 50 years,
was admitted to hospital on 15 March, 1958. She
had been on insulin for years, and had been subject
to sporadic hypoglycaemic attacks.

“There is a smooth filling defect at the
internal carotid artery.”

FIG. IV.
origin of the left

She had been fairly well until four days before
admission when she awoke in the morning to find
herself at the wrong end of the bed and covered in
vomitus, She had a severe headache, and vomited
practically everything she ate that day.

Two days before admission, she awoke to find that
her right arm was “dead and limp”. On attempting
to get up she fell to the floor because of weakness
and clumsiness in the right leg. Later that day she
recovered her power of walking, but she was still
aware of some weakness on the right side.

un-
the

he

ra-
ws
od.
ns

rs,
he
ct

THROMBOSIS OF THE INTERNAL CAROTID ARTERY 15

The following morning she arose, and was per-
fectly well until she vomited her morning tea. She
then had another attack of weakness in the right leg
which lasted about an hour.

She was admitted under Dr. W. Hamilton-Smith.
Examination revealed a mentally alert middle-aged
lady with a blood pressure of 150/90 mm. of mer-
cury. Her fundi were clear and cranial nerves were
normal. There was at this stage mild loss of power
in the right lower limb and a general depression of
sensation over the whole of the right side of the
body. The next day sensation was normal.

FIG. V. Post-operative arteriogram from Case 2.

A left carotid arteriogram revealed a smooth
localized filling defect at the origin of the internal
carotid artery (Fig. IV). She was referred for
surgery.

Operation was performed under hypothermia on
11 April, 1958. As soon as the carotid bifurcation
was exposed a large atheromatous plaque in the
position of the filling defect shown in the X-ray
could be seen and felt. With the oesophageal tem-
perature at 28.6° C., the carotid system was clamped
off and endarterectomy performed without difficulty.
The time of carotid occlusion was twelve minutes.
Intra-arterial heparin was injected and the wound
closed.

Apart from some post-operative oozing from the

wound, due probably to the use of too much heparin,
convalescence was uneventful, She is now very well.

The post-operative arteriogram is shown in Fig. V.

It is likely that the “attacks” in this patient were
produced by the hypotension of sleep and possibly
hypoglycaemia.

Case 3

Mr. M.Z., aged 54 (UR 12015), was admitted to
St. Vincent’s Hospital under the care of Dr. John
Billings on 3 Dec., 1957, The patient’s history com-
menced six years previously when he noticed the
onset of numbness in the first three digits of the
right hand; this persisted. Four years before admis-
sion he experienced the sudden onset of weakness
in the right upper limb. He recovered quickly from
this. Two years later he suffered from a sudden
right hemiparesis and aphasia, from which he re-
covered, At this time it was discovered that he had
diabetes. A month prior to admission he experienced
a giddy turn, followed by a violent headache and loss
of vision. He recovered from this attack in thirty
minutes, Three or four days later his vision became
blurred, and this disability persisted,

FIG. VI. “Angiogram revealing complete block of
the left internal carotid artery, one centimetre
from its origin.”’

Examination revealed some weakness and increased
reflexes in the right upper limb and some diminu-
tion of sensation over the radial side of the right
hand, Carotid angiography revealed a complete block
of his left internal carotid artery (Fig. VI), and he
was referred for surgery.

16 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

Although it was felt that the chances of success
were dim, exploration of the carotid system was
decided upon, in the hope of re-establishing arterial
flow. It was felt that grafting would probably be
necessary. Operation revealed complete occlusion of
the commencement of the internal carotid artery, and
beyond the block the vessel was shrunken to a blood-
less fibrous cord (Fig. VII). It had apparently
undergone complete atrophy. The operation was
therefore abandoned.

This case probably illustrates the natural progres-
sion of this disease. It is likely that the attacks of
short-lived hemiparesis which the patient suffered
from four years and two years before admission were
due to a partial occlusion of the artery. Surgery
would probably have been successful at that time.

FIG. VII. The operative finding in Case 3 illus-
trating the complete atrophy of the _ internal
earotid artery beyond the occlusion.

Thrombo-endarterectomy is the method of
choice in relieving the arterial occlusion, al-
though in North America the by-pass opera-
tion has its advocates (Lyons and Galbraith,
1957). Resection of the occluded segment
followed by end-to-end anastomosis or arterial
grafting may be necessary in some cases.

The operation is done under hypothermia
when the obstruction is partial. Freezing is

not necessary, of course, in complete occlu-
sions. One aims for a temperature between
28° and 30° C. during the time the carotid
arterial flow is clamped off. One must be
prepared to open the chest rapidly for cardiac
massage or defibrillation when hypothermia is
used. The operation is preferably done with
a cardiac monitor in continuous use. The
incision is a longitudinal one following the
anterior border of the sternomastoid. It gives
very adequate exposure of the operative field

(Fig. VIE).

FIG. VIII. The incision used to approach the
carotid bifurcation.

Dissection of the carotid arteries must be
gentle or one might easily detach portion of
a mural thrombus. The hypoglossal nerve is
easily avoided, and the glossopharyngeal nerve
barely enters the field. Before the arterial
clamps are placed on one must have all instru-
ments ready for immediate use. This ensures
that the period of complete carotid occlusion
is as brief as possible. Heparin solution is
injected above and below the clamps after
their application.

The technique of endarterectomy is quite
simple. It is easy to find the line of cleavage
and extract the atheromatous plaque. The
vessel wall always looks remarkably smooth
after this procedure. In resuturing one must
be careful not to narrow the lumen of the
vessel.

During the operation, and for the first

forty-eight post-operative hours, one must be
careful not to allow hypotension to occur for

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on

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THROMBOSIS OF THE INTERNAL CAROTID ARTERY 17

fear of causing clotting at the suture line. The
vound in the neck is drained with a soft
ubber tube. Following the operation the
yatient’s temperature can be quickly restored
o normal with an electric blanket.

Heparinization is continued for ten days

ollowing the operation. Rob (Rob and
Vheeler, 1957) recommends permanent anti-
oagulent therapy, but I believe that the
langer of cerebral haemorrhage with this
egime outweighs its advantages.

SUMMARY

Attention is drawn to the “little stroke”
-yndrome produced by atheromatous occlu-
sion of the internal carotid artery. The clinical
features and diagnosis of the condition are
liscussed. Three cases are presented and the
important technical details in the operative
procedures are stressed.

ACKNOWLEDGEMENTS

I would like to acknowledge with gratitude
the opportunity given me to operate on these

cases. Both the Radiological and Anaesthetic
Departments were of tremendous help.

ADDENDUM

Since this report has been submitted two
more cases of partial occlusion of the internal
carotid artery have been operated upon.

REFERENCES

Atvarez, W. C. (1955), J. Amer. med. Ass., vol.
157, page 1199.

Denny-Brown, D. (1951), Med. Clin. N. Amer., vol.
10, page 1457,

Eastcott, H., Pickerinc, G., and Ros, C. (1954),
Lancet, page 994,

Epwarps, C., and Ros, C. (1956), Brit. med. J. vol.
11, page 1265.

Lyons, C., and Gatsraitu, G. (1957), Ann. Surg.,
vol. 146, page 487.

MILLIKAN, C. H., and Srexert, R. G. (1955), Proc.
Mayo Clin., vol. 30, page 186.

Ros, C., and Wueeter, E. B. (1957), Brit. med. J.,
vol. 11, page 264.

CARCINOMA OF THE SUPRA-AORTIC PART OF THE THORACIC
OESOPHAGUS

By G. S. YeEou anp Y. COHEN

Department of Surgery, University of Malaya

i brs problem of the treatment of carcinoma
of the oesophagus devolves very much
upon the site of the growth. The surgical
attack upon the lower third has been suffi-
ciently well established by the methods of
Churchill and Sweet and of Allison as to
make it a highly practicable and now almost
routine procedure. The method of block
dissection as described by Allison makes it
possible to follow the principles of cancer
surgery in as much as the growth is excised
with its lymph field and intervening tissues.

Growths of the middle third of the oeso-
phagus offered a considerable challenge for
many years. It was clear that the best means
of approaching this area of the oesophagus
was through the right chest. The difficulty,
however, of bringing up the stomach by this
approach disheartened many workers from
using it until Ivor Lewis devised his two-
stage procedure whereby the stomach was
mobilized through an abdominal approach and
the oesophageal growth resected by the
thoracic approach. A primary anastomosis
could then be accomplished by pulling up the
mobilized stomach through the oesophageal
hiatus into the right chest.

Excision of the cervical oesophagus has
been a problem which has occupied the enter-
prise of surgeons over many years. The work
begun by Czerny culminating in the operation
of tracheo-oesophagectomy of Wookey has
given us a sufficiently well established method
by which growths at this site can be radically
excised,

The problem, however, of a growth that
occurs in the supra-aortic part of the thoracic
oesophagus is yet to be solved. Removal of
growths between the arch of the aorta and the
dome of the cervical pleura by the Ivor Lewis
approach makes the performance of an anas-
tomosis in the chest extremely difficult because
of an insufficiency of oesophagus for a com-
fortable and, therefore, safe anastomosis.
There is, in addition to this, the danger that

the stomach, having perforce to be stretched
to its utmost limit, may undergo necrosis at
its upper end. This risk is all the greater
in subjects who have suffered from dysphagia
over a greater or lesser period of time and
whose stomachs are often contracted and thus
smaller than normal. Although in a large
number of cases of growths of the middle
third an Ivor Lewis type of operation entails
an anastomosis at a high level, the adequacy
of the oesophageal stump in blood supply
and length makes such an anastomosis safe.
In higher growths the shortness of the oeso-
phagus makes it unsafe for anastomosis be-
cause of the danger of a leak. This leak may
take place either because the stomach under-
goes gangrene at its upper end from the
overtaxing of its already limited blood supply
or by a break-down of the anastomosis itself
because of tension. This has also been the
experience in operations when such an anas-
tomosis is made using the left thoracic and
cervical approach (Garlock, 1948 and Sweet.
1948) and it has led Robertson and Sarjeant
(1950) to use an isoperistaltic retrosternal
jejunal loop for a_ cervical oesophago-
Jejunostomy.

Fortunately, growths in this part of the
oesophagus are relatively uncommon and pro-
vide only about 5 per cent. of the total.
When, from time to time, they do present
they offer a problem in surgical operative
management which would appear to be insur-
mountable. These growths are further com-
plicated by the fact that there may be lym-
phatic spread upwards towards the neck. Such
lymph-node involvement is not always clear
on clinical examination and may only become
apparent at operation.

It is clear that the oesophagus has to be
transected well up in the cervical oesophagus
in order to excise the growth adequately
above its upper limit. It is also clear that
such a growth is best approached from the
right side in order to obtain a reasonable

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CARCINOMA OF THE SuPRA-AORTIC PART OF THE THORACIC OESOPHAGUS 19

‘stimate of its resectability. The actual pro-
ess of resection is also rendered easier and
afer since the azygos vein is very often in-
olved in such a growth and can be divided
inder vision. Such a procedure, of course, is
endered hazardous because of the danger of
‘ringing the mobilized stomach to such a high
evel.

Showing the spread of dye into the lower

FIG. I.
6 cm. of the oesophagus after injection of the
right gastric artery.

It occurred to one of us (G.S.Y.) that a
possible method would be to preserve the
lower third of the oesophagus and anastomose
it to the cervical oesophagus above the
clavicle in the neck. Doubt, however, whether
the blood from the right gastric and the
gastro-epiploic arteries would reach this
lower third of the oesophagus discouraged
us from attempting such a procedure on em-
pirical grounds only. It was decided to carry
out investigations on the cadaver to see if
blood from the right gastric artery would
supply the lower third of the oesophagus. The
left gastric artery was tied at its origin and
the right gastric artery injected with dye just
above the pyloro-duodenal junction. The dye
was shown to go up the oesophageal branch
of the left gastric artery and stain 6 cms. to
7.5 cms. of the lower end of the oesophagus
in every case and on closer examination the
whole network of blood vessels in the oeso-
phageal mucosa and sub-mucosa in this area
was found to have taken up the stain (Fig. I).
Similar injections into the right gastro-

epiploic artery showed no such staining of the
lower oesophagus, but the fundus of the
stomach, however, was adequately stained by
anastomotic channels through the arcade along
the greater curvature and the vasae breviae
(Fig. II). It seemed obvious, therefore, that
all the blood supply of the lower third of

the oesophagus after mobilization of the
stomach must go through the oesophageal
branch of the left gastric artery.

On the strength of these observations it was
decided to attempt to bring up the lower
third of the oesophagus to the neck and effect
an anastomosis above the level of the clavicle.

FIG. II. Showing the spread of dye into the
fundus of the stomach after injection of the right
gastro-epiploic artery.

PROCEDURE FOR LESIONS IN THE
SUPRA-AORTIC OESOPHAGUS

(SYNCHRONOUS COMBINED OESOPHAGO-
OESOPHAGOSTOMY )

Summary

The operation is carried out in two main
stages. The first is though an abdominal
approach whereby the stomach and the lower
oesophagus are mobilized. The abdominal in-
cision is then closed. The second stage is a
synchronous-combined procedure, one surgeon
working in the chest and the other in the
neck in order to effect a complete mobiliza-
tion of the oesophagus and a cervical oeso-
phago-oesophagostomy after resection of the
growth.

Position of the patient
The First Stage. The abdominal approach
is done with the patient in the supine position.

The Second Stage. The patient is turned
on to his left side and is positioned to effec-
tively expose the posterior triangle of the
neck and the right chest for an approach
through the bed of the fifth rib. The placing
of the right arm is important and is effected
by means of an arm rest (Fig. III) so as not

20 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

to get in the way of either of the surgeons.
The position for this stage is shown. Towels
are then arranged into place.

FIG. Ill. The posture of the patient during opera-
tion showing the position of the right arm.

DETAILS OF THE OPERATION

Stage One

The abdomen is opened through a left
paramedian muscle-splitting incision extend-
ing from the costo-xiphisternal angle to an
inch or so below the umbilicus. Adequate
exposure is important in order to mobilize
the cardia of the stomach and the lower oeso-

phagus.

Mobilization of the stomach begins by
dividing the gastro-colic omentum one inch
or so away from the arcade of the greater
curvature. This is done with great care and
only small sections of omentum are tied at
any one time in order that no kinking what-
ever takes place in the gastro-epiploic arcade.
This dissection continues toward the right to
just below the first part of the duodenum and
upwards to the left as far as the oesophago-
gastric junction. The vasae breviae are tied
singly as far away from the stomach margin
as possible. It has been found useful to put
two abdominal packs behind the spleen so as
to bring it forwards to facilitate this portion
of the dissection.

The gastro-hepatic ligament is then divided
above the centre of the stomach well away
from the arcade of the lesser curvature. Divi-
sion is continued on the right to the first
part of the duodenum and on the left and
upwards towards the oesophagus. The stomach
is then turned upwards and the left gastric
artery is then isolated and tied as near to its

origin as possible. The stomach is then gently
retracted downwards so that the reflection of
the peritoneum on to the oesophagus is
stretched and this with the liver is retracted
upwards. The reflection of the peritoneum is
incised, keeping well away from the oeso-
phagus so that none of the blood vessels are
cut. Branches from the inferior phrenic artery
may be encountered and have to be dealt with.
The index finger is then insinuated into the
oesophageal hiatus and the oesophagus gently
mobilized by rotatory movements all round
but well away from it. The dissection is con-
tinued upwards as far as the finger will reach
and very often the whole of the lower third
of the oesophagus can be mobilized by this
procedure.

During the separation of the anterior aspect
of the oesophagus from the pericardium, the
patient usually develops extra-systoles which
stop as soon as the manipulation is discon-
tinued. Some oozing occurs during this pro-
cedure but this has never been found to be
of a serious nature. The oesophageal hiatus
is then widely stretched digitally in order to
accommodate the stomach comfortably. The
pyloric sphincter is then paralysed by in-
vaginating a finger through the anterior gas-
tric wall to stretch it. The abdomen is then
closed in layers.

It is important to stress that the handling
of the stomach throughout this procedure
must be done with the utmost care and every
effort is made to prevent unnecessary trauma.

Stage Two
The thoracic part

The right thoracic cavity is opened by
resection of the fifth rib. The lung is re-
tracted forwards and the tumour palpated
to assess its resectability. If resectable, the
azygos vein is tied and divided between liga-
tures and the mediastinal pleura is incised
along the oesophagus as far up as the dome
of the pleural cavity. Dissection continues
upwards from the part that has been mobilized
through the abdominal approach in the first
stage. Oesophageal branches of the aorta are
clamped and tied. Mobilization of the oeso-
phagus by blunt dissection is continued up-
wards towards the neck to join up with the
dissection of the cervical oesophagus, so that
the mobilization of the oesophagus is effected
by the two surgeons working synchronously.

sae lane

When the oesophagus has been completely
‘reed, the stomach is gently drawn up into the
thoracic cavity. The whole oesophagus is
then pulled through the incision made in the
reck. It is important at this stage, to make
sure that the stomach undergoes no rotation
ind the greater curvature is, as much as pos-
sible, placed towards the left side. The lung
s re-expanded and the thoracic wound
‘losed in layers with a single tube drainage.
ligh air drainage is also instituted, should
he lung have developed a leak during this
yhase.

lhe cervical part

The cervical approach is by a transverse
incision two fingers breadth above the upper
border of the right clavicle. The superficial
fascia, platysma and the deep cervical fascia
are incised. The medial half of the right
sternomastoid muscle is divided in order to
provide more adequate exposure. The inferior
belly of the omohyoid is retracted laterally
(this has on one occasion been divided when
it was felt that it would limit exposure).
Branches of the transverse cervical vessels
when encountered are tied and cut. There
has been no need to divide the external
jugular vein. The great vessels of the neck
are retracted laterally. The inferior thyroid
artery is ligated and divided. Hemi-thyroidec-
tomy has not been found necessary. The oeso-
phagus is mobilized by dissection with the
index finger. So far, the recurrent laryngeal
nerves have not been injured although no
special effort has been made to visualize them.

When mobilization is complete, gentle trac-
tion on the lower part of the cervical oeso-
phagus is effected to deliver nearly its whole
length into the neck. Some difficulty may be
found in delivering the growth through the
thoracic inlet, but this can usually be over-
come by manipulation. The oesophagus is
then divided well above the growth. The
lower end is divided at a level that would
afford a comfortable end-to-end anastomosis.
This level is about 6 cm. above the cardia.

In all cases of this series the oesophagus
has been found to bleed when transected at
this level. A two layer anastomosis is then
carried out in the neck by means of inter-
rupted fine linen sutures. The oesophagus
falls back into its original bed in the neck.
No tension is found to occur at the suture
line. The neck wound is then closed in

CARCINOMA OF THE SupRA-AorRTIC PART OF THE THORACIC OESOPHAGUS

21

layers without drainage. A Ryle’s tube, placed
in the upper oesophagus before operation, is
guided down into the stomach during the
anastomosis, and care is always taken that a
considerable length of it lies in the stomach
so that the sump created at the lower end of
the stomach can be kept empty during the
post-operative phase.

The whole operation averages three hours.

PRE-OPERATIVE TREATMENT

Correction of Dehydration and Anaemia
The average period of dysphagia in this
series was three months and these patients
showed a marked degree of dehydration which
had to be corrected. On the whole, our patients
were not as anaemic as we would have ex-
pected, but if any, anaemia was corrected by
blood transfusions and parenteral iron given
pre-operatively. Serum electrolyte and pro-
tein estimations were carried out routinely.

Vitamin Therapy

Owing to the period of dysphagia the
nutritional state of these patients was poor
and vitamin deficiencies were inevitably
present. These were corrected as a routine
by vigorous parenteral vitamin therapy.

Oral Hygiene
Oral sepsis, which was invariably present,
was treated during this pre-operative period.

Oesophagoscopy

This was carried out as a routine. By this
the growth was visualized, its level deter-
mined and a biopsy taken to confirm the
diagnosis.

POST-OPERATIVE MANAGEMENT

Oxygen Therapy

The patient was nursed in an oxygen tent
during the first twenty-four hours as a matter
of routine.

Intravenous Therapy

Blood transfusions were given during and
after operation. After the replacement of the
estimated blood loss a dextrose infusion fol-
lowed, with saline if necessary. Intravenous
dextrose infusion is carried on until the fifth
day when glucose water and later citrated
milk were given by the indwelling Ryle’s tube
instead.

24 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

Oesophagoscopy: Showed a growth at the lower
end of the superior one quarter of the thoracic
oesophagus. This was haemorrhagic. Section showed
a squamous cell carcinoma,

Radiology: Narrowing of the oesophagus at the
level of the arch of the aorta.

Operation: Was performed on 11 July, 1957,
(anaesthetist — Dr. E, Goonetilleke). Growth 5 cms.
long with its upper end at the level of the azygos
vein and involving it. An enlarged affected lymph
node found at the dome of the cervical pleura
to the right of the oesophagus.

There was an old healed tuberculous lesion in the
right apex with adhesions to the parietal pleura
requiring division.

Post-operative Progress: Smooth. Feeding through
Ryle’s tube was begun four days later and by
mouth on the ninth day.

He was readmitted on 2 Sept. with dysphagia.
Oesophagoscopy and biopsy did not reveal any local
recurrence at the site of the anastomosis. He soon
developed bilateral enlarged cervical and _ supra-
clavicular lymph nodes and it was felt at this
stage that radiotherapy would be of no avail.

A palliative jejunostomy was done and the patient
died three months after operation.

Comment:

The finding of an enlarged lymph node
near the dome of the cervical pleura was
significant and indicated an advanced lym-
phatic spread upwards. A barium swallow on
the return of dysphagia showed a narrowing
at the junction of the oesophagus and stomach
probably due to a recurrence of the growth
at the original site.

Post-mortem was not done as the patient
died at home.

Case 5

L.L.H., male aged 58, a labourer from Sarawak
(Borneo). This subject complained of five months
difficulty in swallowing solids, semi-solids, liquids
and saliva, and the food obstructed at the level
of the cricoid. He had lost twenty pounds in
weight but was well covered and hydrated in spite

of this.

Oesophagoscopy: Revealed an annular growth in
the cervical and upper thoracic oesophagus. The
lumen was patent up to the level of the sternal
notch, Section showed a squamous cell carcinoma.

Radiology: Showed an obstruction to barium be-
ginning at the level of the sixth cervical vertebra.

Operation was performed on 25 July, 1957 (anaes-
thetist — Dr Goonetilleke). The growth ex-

tended from the level of the dome of the cervical
pleura up to just below the cricoid process, It
was adherent anteriorly to the trachea and was

extremely difficult to be mobilized by both opera-
tors. Growth had perforce to be left behind on
the posterior surface of the trachea. The oeso-
phagus was torn through during the dissection.

Only a one layer anastomosis could be accom-
plished and this with difficulty.

Post-operative Progress: Smooth, much to our
surprise. Ryle’s tube feeding was begun only on
the tenth day and oral feeding on the thirteenth
day, semi-solid feeding was begun on the twenty-
fourth day.

The patient was discharged from hospital one
month after operation and returned to Sarawak. In-
formation received stated that he was soon begin-
ning to have difficulty in swallowing solids although
the patient was alive for eight months, in March,

Comments:

In many ways the removal of this growth
was hardly worth embarking on. The growth
left behind on the trachea would early invest
the oesophagus. This clearly shows one short-
coming of this operation which is that no real
assessment of resectability can be made until
the dissection has actually begun, by which
time one has already arrived at the “point
of no return”.

Case 6

C.K.C., a female aged 68, housewife, was extra-
ordinarily well covered and obese. She had had
dysphagia for four to five months for solids, semi-
solids and liquid food. The dysphagia was inter-
mittent in nature and the food obstructed at the
root of the neck,

Oesophagoscopy: Showed a growth high in the
oesophagus at about the level of the inlet of the
thorax. Section showed a squamous cell carcinoma.

Radiology: Obstruction of oesophagus at the level
of the first thoracic vertebra.

Operation: Performed on 26 July, 1957 (anaes-
thetist — Dr. A. Ganendran). The neoplasm ex-
tended from T1-T4, and was 10 cms long. It in-
volved the azygos vein and was slightly adherent to
the trachea anteriorly. Mobilization was not diffi-
cult. Minimal growth left behind attached to the
posterior surface of the trachea.

Post-operative Progress: Stormy, although the
patient’s condition immediately after operation was
satisfactory, she became dyspnoeic and collapsed
on the second night following the operation. Resus-
citative measures failed to relieve her and she died
forty hours after the operation.

Post-mortem: There was massive collapse of the
right lower lobe and the left lung showed small areas
of collapse. There was viscid greenish mucopus in
both bronchi.

The anastomosis was sound and the reconstituted
oesophagus showed no evidence of gangrene.

——

Toa Leena a tte

os PRT

CARCINOMA OF THE SuprA-AorTIC PART OF THE THORACIC OESOPHAGUS 25

Comments:

There is little doubt that immediate bron-
choscopy and aspiration would have helped
this patient considerably and may have
averted her untimely end.

DISCUSSION

Although the aim of surgery in malignant
disease is complete eradication of the growth,
the prospect of doing this with the oesophagus
is not by any means good because of its
anatomical relation, which in actual practice
prevent the total removal of the growth in
most cases. Infiltration of surrounding vital
structures often made it necessary to leave
behind some growth. The majority of opera-
tions, therefore, for resection of carcinoma
of the oesophagus must be considered to be
palliative. The palliation consists of relieving
the patient from distressing dysphagia by the
re-establishment of the natural channels and
so enables him to feed in relative comfort
till the inevitable end comes. There is always
hope that growth may occasionally be found
at such an early stage as to make a complete
removal feasible. We feel that this can be
accomplished by the operation described
above. Recurrence may be controlled by
means of radiotherapy, although we have not
tried it on any case in this series.

Of the six cases which were operated upon,
there was one immediate post-operative death
from broncho-pneumonia and atelectasis of
the lung. This patient was emphysematous
and she was unco-operative with regard to her
breathing exercises. Another patient died on
the twenty-fifth day. It is felt that the break-
down of the anastomosis was due to a
mechanical cause, i.e. too early feeding. The
oesophagus which had been brought up to
the neck showed no evidence of gangrene at
the site of the anastomosis. Two patients sur-
vived three months and one of these had a
very rapid extension of the growth which had
been left behind and developed a tracheal
obstruction which required tracheostomy. One
patient survived eight months and although
he returned to his country soon after opera-
tion, is known to be still alive at the time of
writing. The sixth and youngest patient is
still alive, ten months after operation. He is
able to take a fairly solid diet and has re-
turned to his work as a labourer, eight months
after operation.

3A

It would appear that symptoms of recur-
rence from growths in this part of the oeso-
phagus develop rapidly and sometimes much
earlier than those of the middle third. It
may well be that the reason for this is the
proximity of the structures of the neck and
the lack of space for expansion in a recur-
ring growth. The relief of dysphagia, how-
ever, appears to be well worth obtaining even
for the short period of survival that follows.

The operation itself, we feel, can become
a standard procedure for growths which affect
that high segment of the thoracic oesophagus
and may be also utilized for growths affecting
the hypopharynx and upper cervical oeso-
phagus. In 1955, Jack reported a case in
which he used the lower oesophagus for a
pharyngo-oesophagostomy after excising an
extensive carcinoma of the upper oesophagus
with involvement of the larynx; he used a
left sided approach.

The importance of a very careful mobiliza-
tion of the stomach cannot be too highly
stressed, and effort must be made during: this
phase of the procedure to preserve every
vessel that may help in maintaining the blood
supply. We feel that this method of joining
the two ends of the oesophagus together is
superior to the attempts made to bring the
stomach up to the root of the neck for anas-
tomosis with the cervical oesophagus. The
fundus of the stomach is clearly the part of
the displaced alimentary system that is most
likely to undergo gangrenous change. Anoma-
lous as it may sound, we feel that preservation
of the lower oesophagus with the rich anas-
tomosis that takes place at its junction with
the stomach goes a long way in maintaining
a more adequate blood supply to the fundus.
The removal of this part of the oesophagus
along with the oesophageal branch of the left
gastric artery which would also be removed
would endanger the blood supply to the dome
of the fundus of the stomach. Further, the
need to anastomose the cervical oesophagus
to the fundus would inevitably produce more
tension than this poorly supplied part of the
organ can stand. We feel that the comfortable
position which the fundus takes in the upper
mediastinum enables it to survive better on
its minimal blood supply.

It is clear from the cases which have been
done that the lower oesophagus will survive

26 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

on the blood supply that comes to it from
the right gastric artery through its anasto-
mosis with the left gastric.

SUMMARY AND CONCLUSIONS

1. Carcinoma of the supra-aortic part of
the thoracic oesophagus offered a_ serious
problem in oesophageal surgery. Difficulty
in anastomosing the stomach as high up as
the neck has been the reason.

2. It has been shown that the lower 6 cms.
to 7.5 ems. of the oesophagus receive an
adequate blood supply through the oesopha-
geal branch of the left gastric artery via its
anastomosis with the right gastric artery.

3. It is considered that this adequacy of
blood supply permits the lower third of the
oesophagus to be transferred to the neck for
anastomosis with the cervical oesophagus.

4. This method of anastomosis enables a
resection to be carried out on these high
growths of the thoracic oesophagus in the
same fashion as growths of the middle third
of the cesophagus.

5. A method of carrying out this pro-
cedure is presented with the management
thereof.

6. Six cases are reported and comments
made on each case.

7. It is advocated that the lower third of
the oesophagus should be preserved for anas-
tomosis with the upper oesophagus in the
treatment of growths of the supra-aortic oeso-
phagus.

REFERENCES
Auutson, P. R. (1946), Proc. roy. Soc. Med., vol.

39, page 415.

Cuurcuiut, E. D. and Sweet, R. H. (1942), Ann.

Surg., vol. 115, page 908.

Gartock, J. H. (1948), Surgery, vol. 24, page 1.
Jack, G. D. (1955), Brit. J. Surg., vol. 42, page 530.
Lewis, I. (1946), Brit. J. Surg., vol. 34, page 18.

Ropertson, R. and Saryeant, T. R. (1950), J.

thorac, Surg., vol. 20, page 689.
Sweet, R. H. (1948), Surgery, vol. 24, page 929.
Wookey, H. (1948), Brit. J. Surg., vol. 35, page 249.

ant Sete

ANATOMICAL VAGARIES OF DOUBLE URETERS

By F. DoucLas STEPHENS

Department of Surgical Research, Royal Children’s Hospital, Melbourne

fibers position of emergence in the genito-
urinary tract of each component of a
double ureter has for long held anatomical
and embryological interest.

Generally an ectopic orifice will lie caudal
to the orthotopic orifice (Weigert, 1877).
Meyer (1946), however, claimed that the posi-
tion of the two orifices was so constant that
he formulated a law — the Weigert-R. Meyer
“law”. This “law”, that the ectopic orifice
lies caudal and medial to the orthotopic
orifice, incorporates the observations of both
Weigert and Meyer.

Four exceptions to this “law” have been
reported respectively by Kerr (1911), Mills
(1939), Lund (1949), and Dougherty (1954),
all of whom place the ectopic orifice medial
to the orthotopic orifice but cranial. Their
observations are thus at variance with the
Weigert-R. Meyer “law.”

To this law there are seven more excep-
tions. These have occurred in my own cases
and were found both by clinical investigation
and by post-mortem studies.

Because of the reports of anomalous loca-
tions of the ectopic orifice, and because of
my own clinical findings in double ureters, I
have made an investigation of post-mortem
specimens in order to record accurately loca-
tions and courses of double ureters.

It was found that the positions of the ectopic
orifices, which violate the Weigert-R. Meyer
“law”, lay on an embryological “ectopic path-
way. Hitherto the pathway has not been
recognized in its whole extent. Further, there
were points of embryological interest and of
practical surgical importance in regard to
these orifices.

MATERIAL

There were thirteen post-mortem specimens,
the subjects providing them ranging in age
from prematurity to senility. In the speci-
mens dissected there were sixteen double
ureters. The ectopic ureters possessed inde-

pendent orifices in 12 but joined the ortho-
topic ureter, proximal to the bladder to form
a conjoined ureter in four.

The study of these specimens provided an
accurate basis for a determination of the
situations of the ectopic orifices, and the
ureteric crossings along their courses.

Thirty-five independent ectopic orifices were
accurately plotted in 27 children. Operative
and radiological observations of the complex
crossings of the double ureters were suspect
and excluded, but the positions of the 35
recorded ectopic orifices were clearly estab-
lished, allowing for minor inaccuracies which
were always contingent on cystoscopic exami-
nation.

The total number of double ureters studied
was 51. The combined number of patients
and post-mortem specimens was 40. The
anomaly was bilateral in 11.

There was a majority of females affected
by double ureter anomalies. In this overall
study the ratio was F : M :: 30 : 10.

TERMINOLOGY

The lower portion of the double kidney, its
ureter, and its orifice which was invariably
located in the lateral cornu of the trigone,
all come under the term orthotopic.

The upper portion of the double kidney,
the ureter, and its orifice, which varied in
position, all come under the term ectopic.

A conjoined ureter is one which is formed
by the junction of the orthotopic and ectopic
ureters to make a single stem.

The ureter may have a long course and for
descriptive purposes it is divided into three
parts (Fig. I) :—

(i) intramural when it lies in the intra-
mural tunnel of the bladder,

(ii) extravesical when it lies cranial to

the tunnel,

28 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY

(iii) submucosal when it lies caudal to
the tunnel in the submucous plane of
the bladder or urethra.

Letoic U
Extravesical course % Orthotgoie U

Intramural course

SU ec al

a

Submucosal
course

Muscle coat

Mucosa

FIG. I. Diagram to show the descriptive sub-
divisions in the course of double ureters (on the
left side)—extravesical, intramural and submucosal.

The ectopic ureter, regardless of the loca-
tion of its orifice whether in bladder, urethra,
vestibule or vagina, invariably entered the
intramural tunnel and submucous space of the
bladder in company with the orthotopic
ureter (Fig. 1).

THE SITUATION OF THE ORIFICES

Post-mortem examination of orifices

Thirteen specimens were available for this
study. The double ureter anomaly was bi-
lateral in 3 and conjoined in four. The posi-
tions of the 12 ectopic orifices and their
subsequent description are clarified by refer-
ence to Fig. II.

(a) Orthotopic orifice.

In 12 this was normally situated in the
lateral extremes of the cornua of the trigone.
In one the orifice lay in a diverticulum, which
corresponded in position with the orthotopic
orifice of the opposite side. In all the double
ureter anomalies in this post-mortem series

the orthotopic orifice was found to lie in the
normal situation relative to the trigonal plat-
form and to the opposite orthotopic orifice.
It was the ectopic ureter that lay in abnormal
positions.

(b) Combined orthotopic and ectopic ori-
fice.

In one specimen the orthotopic orifice was
shared by the ectopic ureter. Here the cranial
portion of the lumen of the common orifice
was that of the ectopic ureter. From within
the bladder the dividing septum was not
visible but when traced from above the ureters
were found to join within 0.2 cm. of the
orifice.

(c) Ectopic orifice.

The ectopic orifices, usually appearing as
dimples or fine elongated grooves, were
smaller than their corresponding orthotopic
orifices.

Seven lay medial to the orthotopic orifice.
They were close to the medial half of the
circumference of the orthotopic orifice -- a
distance of 0.2 cm. from it in the new-born
and 0.6 cm. in the adult specimen.

Three orifices were seen in the cranial
and medial quadrant.

In one instance the ectopic orifice was
found in the caudal and medial quadrant;
three were situated medial to the orthotopic
orifice, and in the same plane.

In four other double ureter specimens the
ectopic orifices lay beyond the orthotopic
orifice — one lay exactly caudal to its lower
lip, another lay on the inferior margin of the
trigone and the other two, after a long sub-
mucosal course, opened in the vagina on the
cranial surface of the hymen (Fig. II).

Cystoscopic examination of orifices
The pathway, along which 35 ectopic ori-
fices were found to lie, was plotted from the

study of 27 children (Fig. II).

In 8 instances the ectopic orifice lay in
very close proximity to the medial margin of
the orthotopic orifice. One, slit-like in appear-
ance, lay in the rolled out upper lip of the
orthotopic orifice and the other three were
situated cranio-medially. Two were situated
in the caudo-medial arc and two were directly
caudal.

St an AS cso cet i

Aor a aie asm af

Thirteen orifices were distributed along the
lower border of the trigone as far distally
is the internal meatus.

In the urethra, the orifice of the ectopic
ireter opened most frequently into the in-
ernal sphincter zone; at this site in the female
hildren the orifice was _ characteristically
arger than normal. There were 10 ectopic
wifices in this zone. Only two lay in the
xternal sphincter zone of the female urethra.

positions of the
pathway” in

FIG. Il. Diagram to show the

ectopic orifices on the “ectopic

the post mortem specimens (black dots) and the

clinical cases (circles). The two horizontal lines

demarcated the extent of the internal sphincter

zone. E.U.O.—external urethral orifice. V.
vagina.

Inset shows a composite view of the positions of

all the orifices both right and left lying in close
proximity to the orthotopic orifice.
One child exhibited an ectopic orifice

postero-lateral to the external urethral orifice
in the vestibule.

In one male child, the ectopic orifice, small
in size, could be recognized on the cranial
side of the verumontanum but close to it.

In another patient who is not included in
this series the ectopic orifice was not recog-
nized in the bladder or the urethra. Pre-
sumably it joined the ejaculatory duct system.

Wetting is not a symptom of the condition
in which the orifice of the ureter lies in the

ANATOMICAL VAGARIES OF DouBLE URETERS

29

internal sphincter zone; by contrast, uncon-
trolled leakage occurs when the orifice in the
female lies in or more distal to the external
sphincter zone.

The course of the “ectopic pathway” (Fig. I1)

The line connecting all these ectopic
orifices, which were visualized not only at
operation but also in the series of post-mortem
specimens, had a devious course which could
appropriately be called the “ectopic pathway”.
It arose tangentially from the upper margin of
the circumference of the orthotopic orifice.
It was directed cranio-medially and then fol-
lowed closely the medial hemi-circumference
of this orifice until it reached the most
caudal point. The pathway then deviated
from the are of the circle to follow the
infero-lateral border of the trigone into the
urethra.

In the female, it coursed along the posterior
wall of the urethra to the side of and ad-
jacent to or overlapping the midline, as far
as the external orifice. The pathway in the
vulva lay on the postero-lateral aspect of the
urethral orifice (as observed in one patient),
continued posteriorly to the side of the midline
through the vaginal orifice to the antero-
cranial aspect of the hymen (as in the bi-
lateral specimen in this post-mortem series)
(Fig. Il). The path could have extended
higher in the anterior wall of the vagina
(Abeshouse, 1943; Honke, 1946; Hepler,
1947), but in this series there was no material
available to determine its upper limit.

In the male, the ectopic pathway was traced
on the posterior wall of the urethra to the
side of the midline, cranial to the verumon-
tanum. No proven extension beyond the veru-
montanum occurred in this series. Cases have
been recorded in which the ectopic ureter
joined the ejaculatory duct system or Wolffian
derivatives (Eisendrath, 1938; Way and Pop-
per, 1946; Campbell, 1951).

Weigert (1877) described 7 specimens with
complete duplication of the ureter. He made
the pronouncement that in all cases the lower
lying orifice in the bladder corresponded to
the ureter coming from the upper renal pelvis.
Weigert (1878) reported 6 more cases of
completely duplicated ureters which con-
formed to this pattern. He observed also an
exceptional case of a double monster in which

30 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

the ureter from the upper pelvis of a double
kidney opened into the bladder in a higher
place than the ureter from the lower pelvis.

ORTHOTOPIC
ORIFICE

The Ectopic Pathway

WE/GERT PATHWAY

R.MEYER EXTENSION
Pr WEIGERT, KERR, MILLS,

LUND, DOUGHERTY
& AVTHORS EXTENSION

AUTHORS EXTENSION

FIG. III. Diagram to indicate contributors and
their contributions to the ectopic pathway.

Meyer (1946) elaborated Weigert’s observa-
tions, and formulated the Weigert-R. Meyer

“law,” viz., that the ureter from the

upper kidney characteristically ends

more caudally and medially than the C)
ureter from the lower kidney. At the KC.

{]

same time Meyer was prepared to ~ \
allow that his generalization would \

be better regarded as a rule than a \
law because a few exceptions had

been recorded. ’

|
| 2
\
Since Weigert’s first passing refer- <? ee Ce)
<7 NM

ence to a case which violated this
rule, there have been reports of two
post-mortems (Kerr, 1911; Mills,
1929) and two cystoscopic (Lund,
1949; Dougherty, 1954) studies of
double ureters exhibiting ectopic orifices
lying higher in the bladder than the cor-
responding orthotopic orifice.

Seven cases in this investigation, including
3 in a post-mortem series and 4 in patients
being examined cystoscopically, also revealed
a more common incidence of this so-called
anomalous positioning of the ectopic orifice
(Fig. Ill). There was an incidence of 7 in
36 patients with complete duplication of the
double ureters. When both complete double

\

FIG. IV.
Nos. 1. 2 and 3, eonioined ureters: No. 4, double ureters
with common orifice; 5-6 and 7 and 8 complete duplica-

ureters in bilateral cases were included in
the total, the incidence was 7 non-conforming
in 47 complete double ureters.

It would seem fair on the evidence to extend
the pathway beyond the limits described by
Weigert and R. Meyer in order to include all
the deviations from the recognised ectopic
pathway (Fig. III) described in this com-
munication, and in those of Kerr (1911),
Mills (1929), Lund (1949) and Dougherty
(1954).

Course oF DousLe URETERS

The ectopic pathway in the bladder, and
beyond the bladder, has now been estab-
lished; but it should be of interest in relation
to this study, to observe the course of the
ectopic ureters both in the conjoined forms
and in complete duplications.

In six examples of conjoined double
ureters, the ectopic ureter was found to lie
in a plane anterior to its accompanying ortho-
topic ureter. Frontal crossings of this ectopic
ureter varied; but all the ectopic ureters
down to and including the double ureters
which became conjoined at the common

if fA

—~
dy +
(>

'

\W—

\

ho

|

‘\

Js

Diagrams to show the course of double ureters:

tions with separate orifices.

orifice in the bladder, joined the anterior
aspect of the orthotopic ureter in forming the
common stem (Fig. IV).

Though the frontal crossings of conjoined
ureters varied, a definite pattern of rotation
of the lower end of the ectopic ureter around
the orifice of the orthotopic ureter was noted
when the ureters were completely duplicated.

The distribution of the ectopic orifices has
already been plotted along the ectopic path-
way. For ease of description three points

annals ns

Se a

a eat

Paci

.
.

a

ANATOMICAL VAGARIES OF DouBLE URETERS 31

on this pathway are selected, namely, the
cranial, the medial and the caudal points in
close proximity to the medial border of ortho-
topic orifice.

When the ectopic orifice was cranial the
ectopic ureter was anterior and when the
orifice was medial the ectopic ureter lay
medial; a caudal orifice was associated with
an ectopic ureter which lay posterior to the
orthotopic ureter (Fig. IV). Intermediate
positions of the orifice were indicative of
graduated degrees of rotation of the ectopic
ureter about the orthotopic ureter (Fig. V).

FIG. V. Diagram to show the submucosal courses

of the ectopic and orthotopic ureters. The ortho-

topic ureter is shaded. Note the posterior course
of the ectopic ureter in (e) and (f).

Even when the ectopic orifice lay still more
caudally at any point along the ectopic path-
way, the ectopic ureter crossed the ortho-
topic orifice posteriorly and appeared caudal
to the orifice in the submucosal plane (Figs.
I and IV (8)). When the ectopic orifice lies
level with and medial to the orthotopic orifice,
the two ureters may be totally uncrossed.

There were no crossings in one specimen
examined by me. Lund (1949) reported a
case of uncrossed double ureters. After care-
ful analysis of the literature on this unusual
arrangement he considered that uncrossed
double ureters could occur in approximately
8 per cent. of complete duplications.

This intricate pathological anatomy of the
ectopic pathway, and the terminal rotation of
the ectopic ureter have both embryological
and surgical interest.

EMBRYOLOGY

In this study the plotting of ectopic orifices
indicates that in addition to the well recog-
nized caudo-medial positions of the ectopic
orifices, there is a definite grouping cranial
and cranio-medial to the orthotopic orifice.

Furthermore, the orthotopic orifice in all
instances was normally placed in the lateral
cornu of the trigone and it was invariably
the ectopic orifice which was disposed about
it.

The ectopic ureter, lying anterior to the
orthotopic ureter when conjoined, and pos-
terior when its orifice is caudal, may be said
to have undergone a developmental somer-
sault about the orthotopic orifice. It is not
unlikely :

(i) that conjoined ureters arise from the

Wolffian duct as a single bud;

(ii) that ectopic ureters, whose orifices lie
along the pathway caudal to the ortho-
topic orifice arise as two independent
ureteric buds from the Wolffian duct;

(iii) that the ectopic ureters issuing on to
the medial arcway in close proximity
to the orthotopic orifice originate as
junctional buds;

(iv) that the ectopic ureter which shares
a septate orifice with the orthotopic
ureter represents the true bifurcated
ureteric bud arising from the Wolffian
duct.

The ectopic pathway represents all levels
of origin of the second ureteric bud to the
point where it is no longer an independent
but a conjoined bud.

SuRGICAL IMPORT

There is a surgical import in all this
intricate anatomical relationship of double
ureters.

In the first place the lowermost crossing
of complete double ureters in their submucosal
course, unlike the more proximal crossings
in the extravesical parts of the ureters may be
obstructive to the orthotopic ureter. Obstruc-
tion ensues only if the ectopic ureter itself
is obstructed, when the distended turgid ec-
topic ureter compresses the orthotopic orifice

32 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

at the point of crossing. Release of the ob-
struction of the ectopic ureter creates a spon-
taneous decompression of the orthotopic
ureter.

Secondly, ureteric crossings are non-
obstructive when both ureters are normal
in calibre. This is important in the assess-
ment of the common complaint of periodic,
short-lived peri-umbilical colic in children in
whom normal calibre double ureters co-exist.
In one child in this study, the colic was in-
deed severe, but the ureters did not cross
from their origins to their terminations in

the bladder.

Thirdly, pain of double ureters is most
often attributable to infective crises. It is the
pain of acute pyelonephritis; it is situated
in the loin; it may persist for hours or days
sometimes with exaccerbations. It subsides
when the infection subsides.

The principal factor promoting infection
is urinary stasis; for example, ureter-to-
ureter reflux in conjoined ureters, vesico-
ureteral or urethro-ureteral reflux in complete
duplications, or ureteral obstruction (Ste-
phens, 1956 and 1957). These children were
remarkably free from pain in the absence of
infection.

Finally, when undertaking total excision of
the ectopic ureter or its ureterocele, the sur-
geon, armed with this exact anatomical know-
ledge can dissect with precision in the intra-
mural and submucosal planes in order to pre-
serve unharmed the accompanying orthotopic
ureter and its orifice.

CONCLUSIONS
(1) The position of the ectopic orifice rela-
tive to the orthotopic orifice in double
ureter anomalies was studied in 5]
double ureters.

When their positions were accurately
plotted, the ectopic orifices were found
to lie along a clear cut pathway (Fig.
Il). This is called the “ectopic path-

way

(2

This pathway in its greater part con-
forms with the terms of the Weigert-R.
Meyer “law”. A small important cranial
extension composed of ectopic orifices,
which violate this rule is described. An

incidence of 7 non-conformers in 47 com-
pletely duplicated ureters studied in this
series indicates that a higher proportion
of ectopic orifices is located on this
cranial extension than has been hitherto

described.

(3) The course of the ectopic ureter, when
its orifice lies on the cranial are of the
ectopic pathway, is anterior or medial to
the orthotopic ureter. When its orifice
lies on the caudal are or more distally
along the ectopic pathway, the ectopic
ureter comes to lie postero-medial and
posterior, respectively, to the orthotopic
orifice.

(4) The “ectopic pathway” indicates a con-
tinuous embryological sequence brought
about by the incorporation of two
separate ureteric buds into the genito-
urinary tract. The common orifice in the
orthotopic site, shared by both the ectopic
and orthotopic ureters represents the dis-
tinguishing point between double ureters
arising as two separate buds from the
Wolffian duct and conjoined ureters
which arise as a single bud and divides
cranially to its point of origin.

(5) There are surgical implications of this
anatomical study; double ureters of nor-
mal calibre are non-obstructive to one
another and do not cause pain in the
absence of infection but an_ ectopic
ureter, distended and enlarged by ob-
struction of its orifice, can partially ob-
struct the orthotopic ureter at the point
of crossing in its submucosal course.

ACKNOWLEDGEMENTS

I wish to thank the Medical Staff of the
Royal Children’s Hospital for their help and
co-operation in the investigation and manage-
ment of these patients. It is a pleasure to
acknowledge the help of Dr. Alan Williams
who has given much advice and _ technical
assistance in the study of the post-mortem
material.

Many of the specimens are obtained from
the Department of Pathology of the Royal
Women’s Hospital by courtesy of the Director,
Dr. Hans Bettinger and Dr. Robert Barter
and Dr. C. Stanton. For one specimen I am
indebted to Associate Professor L. Ray of the
Anatomy School of the Melbourne University.

a

caution

ee Sere

ANATOMICAL VAGARIES OF DouBLE URETERS

Sir Hugh Devine and Dr. Reginald Web-
ter have again given freely of their advice
nd time in the preparation of the manu-
‘ript.

REFERENCES

sesHousE, B. S. (1943), Urol. cutan. Rev., vol. 47,
page 447.

\MPBELL, M. (1951), “Clinical Pediatric Urology”.
Philadelphia and London, W. B. Saunders, page

219.
)UGHERTY, J.
page 160.
sENDRATH, D. N.
42, page 404.

(1954), J. int. Coll. Surg., vol. 21.

(1938), Urol. cutan. Rev., vol.

Hepcer, A. B. (1947), J. Urol., vol. 57, page 94.
HonkeE, E. M. (1946), J. Urol., vol. 55, page 460.
Kerr, A, T. (1911), Anat. Rec., vol. 5, page 55.
Lunp, A. J. (1949), J. Urol., vol. 62, page 22.
Meyer, R. (1946), Anat. Rec., vol. 96, page 355.
Mitts, J. C. (1939), Urol. cutan. Rev., vol. 43, page
444.
STEPHENS, F, D. (1956), Aust. N.Z. J. Surg., vol. 26,
page 81.
(1957), Med. J. Aust., vol. 2, page 679.
Way, R. A., and Popper, H. (1946), J. Urol., vol.
55, page 454.
Weicert, C. (1877), Virchows Arch., vol.
490.
—, (1878), Virchows Arch., vol. 72, page 130.

70, page

CERVICAL LYMPH NODE METASTASES FROM EPITHELIOMA
OF THE FACE, LIPS AND MOUTH

By Howarp H. Eppey

Royal Melbourne Hospital

PITHELIOMA of the face, lips and

mouth is a relatively common disease.
The statement of hospital admissions in Mel-
bourne for the year 1957 compiled by the
Anti-Cancer Council of Victoria lists 128
patients with epithelioma of the lip, 24 with
epithelioma of the tongue and 25 with epi-
thelioma of other parts of the oral cavity.
The vast majority of such patients are treated
in this State by radiotherapy, surgery being
limited to neck dissections for cervical node
metastases and to combined neck and mouth
dissections for mandibular involvement or
mouth recurrence. That such surgery is
necessitated uncommonly indicates the sound
foundation on which radiotherapy is based
and the relative infrequency of cervical node
metastases, mandibular involvement or local
recurrence. It is with the problem of cervical
node metastases that this paper is concerned
and any conclusions are based on the writer’s
personal experience between 1947 and 1957
inclusive.

CLInIcAL MATERIAL

Although having an interest in this subject
for some years, only 48 patients have come
under the writer’s personal care. Almost all
of these have been kindly referred by various
radiotherapeutists either privately or at the
Royal Melbourne Hospital and the records of
treatment and follow-up to date are complete
in all of these patients. This series reflects
the small amount of such material available
to one surgeon and the difficulty of reaching
any firm conclusions on management.

Males far outnumbered females (41 to 7)
and the average age was 57 years (29 years
to 79 years). Eight patients were 70 years
or more; 15 were in the seventh decade, 14 in
the sixth decade, 5 in the fifth decade and 6
were below 40 years. Three patients were
operated upon in 1947, 3 in 1948, 2 in 1949,
2 in 1950, 6 in 1951, 4 in 1952, 4 in 1953,
12 in 1954, 4 in 1955, 3 in 1956 and 5 in
1957.

The site of the primary tumour is indicated
in Table 1.

TABLE |

SITE OF THE PRIMARY EPITHELIOMA

Skin of the face _. 7
Upper lip 2
Lower lip 13
Mucosa of the cheek _. 8
Floor of the mouth _. 7
-Tongue 6
Palate 3
Tonsil 2

Fifty-eight operations have been carried out
on these 48 patients. Forty-nine operations
were radical neck dissections, 8 were com-
bined neck and mouth dissections involving
resection of portion of the mandible and one
was a combined neck and mouth dissection
involving division of the mandible for access.
The technique of these procedures has been
described previously (Carroll, 1952; Morfit,
1952; Eddey, 1954, 1957). In some cases of
bilateral dissections, both internal jugular
veins have been removed and this problem
has also been discussed previously (Guis and
Grier, 1950; Eddey, 1954). There have been
two post-operative deaths (mortality 3.5 per
cent.), one being due to reactionary haemor-
rhage associated with oedema of the glottis
(and avoidable) and the other due to a
cerebral haemorrhage on the fifteenth post-
operative day.

TREATMENT OF THE PRIMARY TUMOUR

Whilst treatment of the primary tumour is
probably equally efficacious by surgery as by
radiotherapy, it is standard practice in this

a

State to treat the majority of these tumours
yy radiotherapy. This was so in this series
‘xcept for the following cases :—

1. Four tumours of the lower lip and three
of the face, which were excised.

2. Two tumours of the floor of the mouth
involving the mandible which were
treated by a combined neck and mouth
dissection with excision of portion of
the mandible.

3. Three tumours of the floor of the mouth
impinging on or invading the mandible
which were treated by combined neck
and mouth dissection with excision of
portion of the mandible after prelimi-
nary radiotherapy.

4. One case of epithelioma of the tongue
treated by combined neck and mouth

dissection after preliminary radio-
therapy by dividing the mandible for
access.

It is not the purpose of this paper to dis-
cuss the various merits of treatment of the
primary tumour by radiotherapy or by sur-
gery.

Time interval between the onset of the tumour

and the institution of its treatment

This interval was unknown in 12 patients,
but in 36 patients, it varied from one month
to two years with an average delay of 4.6
months. Delay was due to either the diagnosis
not being suspected or to a wrong diagnosis
being made. The latter occurred only once
in the presence of a strongly positive Wasser-
mann reaction and several months delay
occurred whilst antisyphilitic treatment was
given. By the time a diagnosis by histo-
logical examination was made, bilateral neck
metastases were present and the patient died
six months after completion of surgery from
widespread metastases.

The usual reason for delay in diagnosis is
to regard the lesion as inflammatory or trau-
matic and to treat it with various ointments,
penicillin injections, a ban on smoking and
teeth extraction. In those cases where some
measure of blame may have occurred, re-
sponsibility rested with the general prac-
titioner on five occasions, with the dentist on
two occasions and with a skin specialist on
two occasions. It cannot be too strongly
stated that an ulcer on the face, lips or in

CERVICAL LympH Nope METASTASES FROM EPITHELIOMA OF THE FACE

35

the mouth cavity in any age group that does
not heal rapidly must be subjected to histo-
logical examination. A positive Wassermann
reaction is no guide to diagnosis in modern
society. It is interesting that in only two
cases was there a previous history of marked
leukoplakia.

TREATMENT OF CERVICAL LympH NODE
METASTASES

It is universally accepted that excision of
the cervical lymph field is the correct treat-
ment when metastases develop, radiotherapy
being reserved as a palliative treatment in
bad risk patients. Since the operation of
radical neck dissection carries a low mor-
tality even in the elderly, surgery is rarely
contra-indicated. That this is so is largely
due to the help of the anaesthetist and the
resuscitation officer.

Operation is normally indicated when
metastases become clinically apparent. Such
metastases are diagnosed during the follow-
up when unilateral lymph node enlargement
in the lymph field draining the site of the
primary tumour is detected. It is usual to
regard a node of greater than 1 cm. in
diameter as significant provided that there is
no uncontrolled inflammatory element present
in the primary growth area or in adjacent
tissues. If present, subsidence must be awaited
before the diagnosis is confirmed. Usually an
involved node is hard, but since metastases
of squamous epithelioma readily undergo
necrosis upon increase in size, an involved
node may be soft and has even been mistaken
for an abscess.

Spread of the tumour through the lymph
node capsule renders neck recurrence likely
after neck dissection and such spread is indi-
cated by fixity of the involved node. This
has been seen on three occasions where a
submandibular node appeared fixed to the
mandible. On each occasion, a combined
neck and mouth dissection including resection
of portion of the mandible at the site of
attachment of the node has been carried out,
but in all three cases bony involvement had
not occurred. It seems as if removal of
periosteum af the site of attachment may be
all that is necessary in these circumstances,
thus avoiding dissolution of continuity of the
mandible. Whilst neck dissection has usually

36 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

been carried out as a therapeutic measure,
some prophylactic dissections have been per-
formed and these for tumours in the posterior
part of the oral cavity where a high percent-
age of undifferentiated cells has been present.

Accuracy of clinical diagnosis of node metas-

tases

This may be considered by patient or by
operation analysis. Forty-one of 48 patients
had clinically involved nodes on one or both
sides and of these 36 were confirmed on
pathological examination, giving an accuracy
of clinical diagnosis of 88 per cent. Of the
7 patients who had a prophylactic neck dis-
section for an active growth in the oral cavity,
one (tonsil primary) revealed metastatic
deposits of epithelioma on microscopical
examination.

Forty-nine of 58 neck dissections were per-
formed for clinically significant nodes and of
these, pathological examination confirmed the
diagnosis in 42 dissections, an accuracy of
clinical observation of 86 per cent. The two
further dissections on clinically negative
nodes were performed because the first dis-
section confirmed metastatic involvement of
nodes and the primary tumour transgressed
the midline.

Time between the treatment of the primary
tumour and the first operation of neck dis-
seclion
This period gives an indication of the time

metastatic involvement was detected clinically
after the primary diagnosis of epithelioma
was made. In one case a period of ten years
and in another, three years elapsed between
ihe treatment of the primary and the appear-
ance of a cervical metastasis. The average
time interval in the remaining 46 cases was
3.6 months with the longest interval being
sixteen months. It is probable therefore that
if a patient continues for two years following
treatment of the primary growth without the
appearance of lymph node metastases, he will
remain well provided the primary tumour
does not recur or distant metastases do not
develop.

INDICATIONS FOR CoMBINED NECK AND
MoutH Dissection
Excision of the primary tumour and the
lymphatic field in continuity is the ideal of
cancer surgery and its implementation in

the mouth and neck presents no difficulty
with modern anaesthesia and resuscitative
measures. A portion of the mandible is ex-
cised or the mandible is divided for access
to the oral cavity, continuity being re-estab-
lished in the latter case by wire sutures passed
through the divided mandible. Radiotherapy
may or may not precede such an excision and
when used is designed merely to localize and
reduce the soft tissue spread of tumour in the
oral cavity.

FIG. 1. Photograph of the Indian patient operated
upon in Singapore showing an epithelioma of the
mucosa of the cheek involving the skin of the
cheek and the mandible and the endotracheal
nasal catheter used to administer the anaesthetic.

The indications for such a dissection are
as follows:—

1. When the tumour in the oral cavity in-
volves the mandible (three cases).

2. When the tumour in the oral cavity
spreads through the floor of the mouth
and involves the cervical lymph nodes
(one case).

3. Where an infiltrating tumour in the oral
cavity is adjacent to the mandible with
possible involvement of bone by growth
and probable bone necrosis after radio-
therapy (two cases).

i atte 5 KOSS. atl alia a

se Nh hime

edna nteitas

Where a metastasis in a submandibular
lymph node has spread through the
capsule of the node to become fixed to
the mandible (two cases).

5. Where the primary tumour in the mouth
has recurred after radiotherapy (one
case). Such recurrences may develop
after a radical neck dissection has been
performed in which case diathermy ex-
cision of the recurrence is indicated.
If recurrence occurs before any surgery
has been undertaken, a combined mouth
and neck dissection must be performed
whether cervical metastases are present
or not. Such recurrences with modern
radiotherapy indicate growth activity
and the likelihood of spread.

J.C.
external

showing an
ear to
lymph node.

FIG. Il. Photograph of Mr.
epithelioma spreading from the
involve the pre-auricular

Preliminary radiotherapy was given in two
of the cases in group one, in the case in group
two and in both cases in group three. In one
case in group one, an Indian (Fig. I) whose
‘betel-nut’ epithelioma of the cheek mucosa
involving the mandible was operated upon
during a visit to Singapore, a plastic pro-
cedure (King, 1956) was necessary to obtain

CervicAL Lympu Nope METASTASES FROM EPITHELIOMA OF THE FACE

37

closure. There was one death in the 9 cases
in which a combined neck and mouth dis-
section had been carried out and this occurred
from cerebral haemorrhage on the fifteenth
post-operative day, in the patient (a woman
aged 72 years) in group two. Bone replace-
ment of the defect after excision of portion
of the mandible was carried out (Mr. A. R.
Wakefield) in one of the cases in group four,
who had remained free from tumour for three
years. This patient died from tuberculosis
seven years after his primary treatment and
at the time of his death was still free from
epithelioma.

TREATMENT OF RECURRENCE

A careful follow-up of all cases is carried
out, so that recurrence may be detected at an
early date and definitive treatment instituted.

Local recurrence

Local recurrence is usually obvious and the
diagnosis is readily confirmed by histological
examination. There have been seven local
recurrences in this series, four in the mouth,
two in the lip and one on the face and in all
of these the primary tumour had been treated
by radiotherapy. In four cases the primary
tumour has been uncontrollable and has led
to the patieni’s death (Table 2) but in an
additional three mouth recurrences surgical
excision has resulted in control to date.
Radiotherapy has little place in the treatment
of local recurrence as, if the primary radio-
therapy has been adequate, extensive and
painful radionecrosis will result. Mouth re-
currence after primary radiotherapy must be
treated by wide diathermy excision leaving
the resulting raw area open to granulate
over, a process which occurs quite rapidly.
Excision of lip or face recurrence after radio-
therapy must also be radical and must be
accompanied by plastic procedures either im-
mediately or later to close the defect. A close
follow-up is necessary to diagnose local recur-
rence early so that radical surgery may be
effective. The difficulty of control is illus-
trated in the following case report:—

Mr. J.C., aged 54, presented to a radiotherapeutist
in February, 1955, with a small epithelioma of the
right external car. Radiotherapy was followed by
early recurrence and further radiotherapy in May,
1955, failed to control the tumour. The patient de-

layed reporting for follow-up and six months later
he was referred to the Royal Melbourne Hospital
because of extensive involvement of the external ear

38 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

and metastases to the parotid and upper deep cervical
lymph nodes (Fig. Il). Radical surgery seemed
indicated although it was realized that local control
of the tumour would prove difficult. Excision of the
external ear, surrounding skin, parotid salivary gland
and the lymph nodes of the neck in continuity was
carried out in December, 1955, and although the neck
wound was closed easily, skin grafting only partially
covered the defect left by removal of the external
ear. By March, 1956, it was obvious that despite
a radical local excision, recurrence in the external
auditory meatus and surrounding tissues had occurred
(Fig. Ill) and this was treated by diathermy excision
to include the mastoid process and the contents of
the middle ear. Control was not achieved as spread
continued into the petrous temporal bone and the
patient died in June, 1957, from local recurrence
remaining free from neck recurrence or distant
metastases.

FIGS. III. Photograph of Mr. J.C. after excision of

the primary tumour, the parotid salivary gland

(with the facial nerve) and the lymph nodes of the

neck in continuity showing a local recurrence in
the external auditory meatus.

It is clear therefore that if radiotherapy is
chosen as the primary treatment and control
is not achieved, radical surgery must be
undertaken at an early stage to effect a cure.
However, much may be said for surgical
treatment of the primary tumour, certainly in
some situations and circumstances, and it is
certain that the patient receives the best treat-
ment when this is planned by surgeon and
radiotherapeutist together.

Neck recurrence

The development of residual lumps in
the neck after neck dissection presents some
problems. It is difficult to be sure of the
significance of such a lump and therefore it
is of value to consider the time at which
definite neck recurrence occurred in_ this
series. There have been six neck recurrences,
all of which occurred within a few months
after completion of the neck surgery, the
longest period being ten months. Five of
these patients are dead and one has been kept
alive to date with repeated limited radio-
therapy treatment. However, not all lumps
developing in the neck are recurrences. In
two cases the lump excised proved to be a
granuloma around a suture, in two cases a
neuroma and in one a localized calcification
of the bifurcation of the common carotid
artery and in all five cases excision of the
lump was carried out three or more years
after the neck dissection. It is felt therefore
that if a lump is detected in the neck two
years or more after a neck dissection, it is
probably not a recurrence. The sooner the
lump is detected the greater the likelihood of
it being a recurrence and when this does
occur, diathermy excision is the method of
choice although control is difficult and cure
unlikely.

Recurrence in the neck after adequate neck
dissection results from division of involved
lymphatics. Such involvement may result
from spread to one or more lymph nodes
from the primary tumour by permeation
rather than by embolism or by spread through
the capsule of an involved node into the sur-
rounding tissues and lymphatics. That neck
recurrences do not occur more frequently is
due to early operation when a cervical node
metastasis is detected and to the common
method of spread from the primary tumour
to the nodes being by embolism since in most
cases the tissues between the primary tumour
and the lymph field in the neck are not ade-
quately attacked either by radiotherapeutist
or by surgeon. Recurrence after neck dis-
section occurs early, spreads rapidly and is
extremely difficult to control.

Treatment of such recurrence by radio-
therapy may lead to radionecrosis with the
production of a painful indolent ulcer which.
if in the region of the carotid artery, may

eS tease

ns ratscneh aan

ee eee een

lead to fatal secondary haemorrhage (Fig.
V). Diathermy excision may necessitate the
acrifice of much tissue and if the recurrence
nvolves the carotid arteries (Fig. V) hemi-
legia will result as there is no place for
econstructive surgery in the neck in the
wesence of recurrence of epithelioma after
eck dissection. Despite wide excision,
‘urther recurrence is likely and this soon
ecomes uncontrollable.

FIG. IV. Photograph of a patient in whom radio-

therapeutic treatment of a neck recurrence pro-

duced a_radicnecrotic ulcer which eroded the

common carotid artery. Ligation of the artery

led te hemiplegia and death occurred shortly
afterwards,

It is apparent that to avoid neck recurrence,
neck dissection must be performed before in-
volved lymph nodes became fixed and that
consideration must be given to the perform-
ance of more combined neck and mouth
dissections, either with or without preliminary
radiotherapy, to remove the primary tumour
and the related lymph field in continuity.
This avoids the division of possibly involved
lymphatics which may occur when neck dis-
section and treatment of the primary tumour
are separate phases in the management of the
patient.

CERVICAL LympH Nope METASTASES FROM EPITHELIOMA OF THE FACE

39

There is also a definite place for prophy-
lactic neck dissections either after control of
the primary tumour or as a dissection in con-
tinuity with excision of the primary tumour
with or without preliminary radiotherapy.
Such prophylactic dissections are indicated
for active infiltrating tumours of the posterior
part of the tongue and oral cavity, par-
ticularly if the tumour encroaches on or
involves the mandible, and for local recur-
rences.

FIG V. Photograph cf a neck recurrence showing

the internal and external carotid arteries involved

by tumour. This excision resulted in hemiplegia
and death.

Treatment of radionecrosis of the mandible

Radionecrosis of the mandible has not
been a great problem in this series and with
modern methods such a complication will be
rare. When it does occur, excision of portion
of the mandible must be carried out and this
may need to be repeated over the years as
necrosis slowly spreads. Excision is necessary
to rid the patient of necrotic bone which pro-
duces a foul discharge into the mouth and
such treatment has been necessary in two
patients. However, two more patients whose
primary tumour has remained controlled for
six and nine years respectively, but who were
not referred for neck dissection, have had
operations for excision of portions of necrotic
bone and loss of portion of the body of the
mandible is a small price to pay for freedom
from a foul tasting and smelling oral and
sometimes cervical discharge.

RESULTS OF TREATMENT

Of 48 patients treated, 18 have died and
of these 10 had an epithelioma of the oral
cavity, 6 an epithelioma of the lip and 2 an
epithelioma of the skin of the face. The cause
of death is indicated in Table 2.

10 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

TABLE 2
CAUSE OF DEATH — 18 PATIENTS

Cause of Death

Site of the Primary
Tumour

Period Between Completion
of Surgery and Death

Post-operative (reactionery haemor-
rhage and oedema of the glottis)

Post-operative (cerebral haemor-

rhage
Uncontrolled primary tumour
Uncontrolled primary tumour
Uncontrolled primary tumour
Uncontrolled primary tumour

Neck recurrence

Side of the tongue
Floor of the mouth

Palate
External ear
Upper lip
Lower lip

Tip of the tongue

Two hours
Fifteen days

Sixteen months
Eighteen months
Twenty months
Seventeen months

Four months

Neck recurrence

Neck recurrence

Lower lip
Lower lip

Mucosa of the cheek

Eight months
Eight months

Seven months

Neck recurrence

Distant metastases (lumbar spine)
Pulmonary abscesses
Tuberculosis |

Cardiovascular disease

Cardiovascular disease Palate

Mouth and neck recurrence Tonsil
Distant metastases (pulmonary) | Nose
Distant metastases (pulmonary) Mouth

Upper lip
Side of the tongue
Floor of the mouth

Lower lip

Sixteen months

Four months
Four months
Seventeen months
Seven months
Seven years
Twelve months

Three years

In the last three cases, the patient remained
free from epithelioma up to the time of death.

Excluding death from unrelated causes it
can be seen that the longest period between
the completion of the surgical phase of
treatment and the patient’s death was twenty
months. In this small series it might there-
fore be useful to consider the results to date
of those patients treated between 1947 and
1955 inclusive. Of the 40 patients included
in this period who have been subjected to one
or other form of surgical treatment, 24 are
alive and 16 dead. Fifteen of the 24 survivors
had metastases to cervical nodes confirmed on
pathological examination which gives a sal-
vage rate in this group of 37.5 per cent. Of
the 16 who died since completion of their
treatment, 14 had metastases to cervical nodes
confirmed on pathological examination and
of the two whose nodes were clear, one died

from tuberculosis seven years later and one
died of an uncontrolled primary tumour
eighteen months later.

From 1947 to 1952 inclusive, 20 patients
were subjected to operation and of these, 11
are still alive, 8 having metastases confirmed
on pathological examination (survival rate
10 per cent.) and 3 being free from metas-
tases at operation. In 1956 and 1957 eight
more patients have been subjected to surgical
treatment of whom 6 are still alive (5 having
metastases in the cervical nodes) and 2 are
dead (1 post-operatively on the fifteenth day
and one from pulmonary metastases).

A combined neck and mouth dissection
with excision of portion of the mandible has
been performed on 8 patients of whom 5 are
already dead. A combined neck and mouth
dissection with division of the mandible for

Dower wee Sia

Bacte>

access has been performed on one patient who
lied on the fifteenth post-operative day from
‘erebral haemorrhage.

The time between completion of the surgical
hase of treatment to death has varied be-
ween two hours and twenty months with an
iverage time interval of ten months. It is
herefore probable that if a patient survives
‘or two years without recurrence or metas-
ases, he has a good chance of cure from his
reatment. In view of the few survivors from
1 combined neck and mouth dissection, it is
vident that a patient who has metastases to
ervical lymph nodes from an epithelioma of
he face, lips or mouth has the best chance of
ure if his primary tumour is confined to soft
issue, is easily and permanently controlled
yy surgery or by radiotherapy and whose
cervical metastases are discovered early so
that an adequate neck dissection can be car-
ried out before tumour spread through the
capsule of the involved node occurs. Age is
no bar to a definitive plan of treatment for
cervical metastases from face, lips or mouth
epithelioma.

SUMMARY

1. The results of treatment of 48 patients
with epithelioma of the face, lips or mouth

CervicAL LympH Nope METASTASES FROM EPITHELIOMA OF THE FACE

41

who were referred for surgical treatment
of cervical lymph node metastases have
been considered.

2. Some of the problems of management
have been discussed with particular refer-
ence to the indications for combined neck
and mouth dissection and to the treatment
of recurrence.

3. Some indication has been given of the
prognosis in this condition.

ACKNOWLEDGEMENTS

I am most grateful to Dr. R. Kaye Scott
and to Dr. W. P. Holman who have referred
the great majority of these patients for the
surgical phase of their treatment.

REFERENCES

Carrot, W. W. (1952), Arch. Surg. (Chicago),
vol. 64, page 647.

Eppey, Howard H. (1954), Aust. N.Z.J. Surg., vol.
23, page 175.

—— (1957), Aust. N.Z.J. Surg., vol. 25, page 161.

Guts, J. A. and Grier, D. H. (1950), Surgery, vol.
28, page 305.

Kinc, G. D. (1956), Surg. Clin. N. Amer., June,
page 595.

Morrit, H. M. (1952), Arch. Surg. (Chicago), vol.
64, page 631.

THE BOWEL SOUNDS IN CASES OF HAEMATEMESIS AND MELAENA

By G. W. Mitton* and G. J. A. CLUNIE

Department of Surgical Science, University and Royal Infirmary, Edinburgh.

HE object of this short paper is not to

present any new or original observation
but to emphasize the value and limitations
of a physical sign in the management of
patients suffering from gastro-intestinal
haemorrhage. Vaughan and Torek (1939)
and Torek (1947) mention the importance
of a study of the bowel sounds in the differ-
ential diagnosis of bleeding into the gut as
opposed to bleeding into the peritoneal
cavity. These authors point out that if bleed-
ing occurs into the gut the bowel sounds are
increased. However, in cases of intraperi-
toneal haemorrhage the bowel sounds are
diminished or absent. Torek also stressed
the value of abdominal auscultation as a
means of assessing the recurrence of gastro-
intestinal bleeding in a patient under observa-
tion. It is primarily with this aspect of the
auscultation of the bowel sounds that the
present paper is concerned.

In a previous paper (Milton, 1958) a
method for obtaining a rough quantitative
assessment of the bowel sounds at the bed-
side was described. It was concluded that
with practice in counting the bowel sounds
for one minute in each of the four quadrants
of the abdomen an observer may make a
reasonably good quantitative assessment of
the bowel sounds. If the sounds are very in-
frequent i.e., an average of less than 5-10
sounds per minute then the results obtained
by different observers were comparable. If
the sounds are more frequent then the results
obtained on different occasions are only com-
parable if obtained by the same person. An
increase in the bowel sounds above the nor-
mal was defined as an average count of more
than 20 sounds per minute in a patient who
had been fasted for more than 12 hours. (This
represents more or less continuous bor-
borygmi for four minutes in a fasted patient. )
A considerable volume of sound and _ the
presence of a palpable fremitus on the anterior
abdominal wall does not necessarily indicate

* Present address, Department of Surgery, University
of Sydney.

any increase above the normal. The same
method has been used by us to investigate the
abdominal sounds heard in patients suffering
from gastro-intestinal haemorrhage.

MATERIAL AND METHODS

Twenty cases of gastro-intestinal hzemor-
rhage were studied from the time of their
admission into hospital until they were ready
for discharge or considered suitable for
operation. The cases were admitted to the
Royal Infirmary, Edinburgh, or to the Royal
Prince Alfred Hospital, Sydney. The ab-
domen was examined two or three times a
day. The bowel sounds were examined be-
fore the patient’s progress was assessed by
other means. At the beginning of the investi-
gation no significance was consciously at-
tached to any change in character of the
bowel sounds when planning further treat-
ment, but with greater experience the value
of the bowel sounds in assessing the progress
of the haemorrhage became more apparent.
In addition to abdominal auscultation a
record was kept of the pulse rate, blood
pressure and the details of any haematemesis.
melaena, and gastric aspirate. The quantity
and time at which any fluid had been taken
by mouth was noted and also the volume and
content of any intravenous infusions or any
administered drugs.

RESULTS

(1) There are usually no bowel sounds to
be heard in a patient who has recently
had a severe bleed and who is grossly
shocked (systolic B.P. less than 100 mm.
of mercury). The average count of the
bowel sounds was 0-5 sounds per minute.

(2) As the systolic blood pressure rose above
100 mm. of mercury either as a result
of transfusion or of vasoconstriction the
bowel sounds began to be audible again.
At first the counts were between 5-10
min., but within a few hours the sounds
became almost continuous (20-30+
min.) in each of the four quadrants. The
sounds were loud and could be heard
all over the abdomen, but the fremitus

lasek sia Sea

oer es

Whe

A ih Wella Shs Daslta

co alia don es sancti Diet t

irra a

which was often marked was
felt most in the central and
lower parts of the abdomen.
The sounds had a charac-
teristic watery or sloshy
character which was very
similar to the sound pro-
duced by the exteriorized
dog intestine when it was
filled with water and con-
tracting vigorously under
the influence of eserine or
prostigmine (Milton, 1958).
None of the patients
examined at this stage, that
is, after a severe haemor-
rhage and recovery from the

} initial shock, had had any-
¢ thing by mouth except a
‘ few sips of water for twelve

hours or more prior to the
examination.

(3) As the patient improved
and if there was no evidence
from the blood pressure,
pulse rate or gastric aspirate
of further haemorrhage, the
frequency of the bowel

sounds gradually decreased

. during the next twenty-four

hours. Sometime during

this period a melaena stool
was usually passed.

1S IRENE a5

(4) If during this period of

relative quiescence, i.e., with
» the average sound counts of
less than 20/min. over four
minutes, the sounds began
to increase and also became
watery or sloshy in charac-
ter, it was found that the
pulse rae usually began to
creep up within two to three
hours. Within a few hours
or less the blood pressure
began to fall. In _ those

wore.

stage the upper small

a1

THE Bowe Sounps 1n Cases OF HAEMATEMESIS AND MELAENA

patients who came to operation at this

intestine was

found to contain quite large amounts of (5)
blood. An important exception to the
rising bowel sound count occurred in
those patients who had been given food
or fluids within half an hour of the
examination. As a result of this finding

43

| orm | ram. | 2am |rosoan| 1sopm| 50 em 1 zomfoesondi2 sory

A 8
Decision
130 4 ° ° ° to
Operate
= 120 ee ©
E
E £& 0 4 * °o
g *
>
t 5 100 4 °
«
J
8 8
oe? 0 7 e ° e eS
2 a
£
a 80 +4 a e
wv
70 4 = e
30 4 x x
30 -
x
€
= 26 4 x
2
= 20
8
=
8 ts 4
FS x
¢@
10 4
x L |
5 4 nm La
o | © Systolic BP | r
| | Bowel Sound Count
@ Pulse Rote } Average Sounas /Min
FIG. I. A record of the systolic blood pressure, pulse rate, and

average bowel sound count from a typical patient. On the day
prior to admission he had vomited about 1 pint of bright blood.
At the time he was first examined his condition was satisfactory,
the bowel sounds were loud and sloshy in type. During the
night of 9th May, 1957, he apparently had a further bleed but
this was not followed by the usual increase in bowel sounds
at the time the blood pressure returned to normal. On the
following morning, in spite of the absence of food for more
than twelve hours the sounds had increased in number and
had become sloshy. At this point, it was decided that an opera-
tion should be done, but by the time the theatre was available
two hours later there was considerable increase in the bowel
sounds, the pulse rate had begun to rise, and the B.P. to fall.
At operation an actively bleeding duodenal ulcer was found.

it became our practice to listen to the
abdomen immediately before feeding.

In no case was it found possible to dis-
tinguish rhythmic sounds heard from the
pyloric region or to distinguish the six
second rhythm of the small bowel.

Fig. I shows the record of a typical case.

44, ‘THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

DISCUSSION

Auscultation of the abdomen is an exami-
nation, which, to be of full value, requires
more practice than the auscultation of the
chest. The reason for this is that the varia-
tion in the normal quantity and quality of
abdominal sounds is much greater than the
normal variation in the sounds produced in
the chest.

Abdominal sounds are largely produced in
the small intestine and much less often in the
stomach by the forcing of mixtures of fluid
and gas through tonically contracted seg-
ments of bowel; but there are many variable
factors in the production of bowel sounds
(Milton, 1958).

Blood outside the lumen of the blood
vessels is usually an irritating substance, wit-
ness the pain and rigidity produced by haemo-
peritoneum. A large amount of blood in the
lumen of the gut apparently is also an irri-
tant because it is so frequently followed by
diarrhoea. This diarrhoea is not simply due
to a large fluid volume in the gut because
several pints of beer or water may be drunk
without either vomiting or diarrhoea but a
pint or two of blood in the stomach usually
results in both vomit and diarrhoea.

The submission of this paper is that in-
creased intestinal motility is produced by
blood in the bowel lumen, and that this in-
creased motility may first be detected by the
increasing bowel sounds as Torek described.
The increase in the bowel sounds can occur
before there is evidence of continued bleed-
ing in a rising pulse or falling blood pressure.
Later, provided there is no severe shock, the
sounds become very loud and associated with
a palpable fremitus on the anterior abdominal
wall, but unless the patient has been without

food for twelve hours or more, the frequency,
and volume of the sound are not above the
upper limit of normal (Milton, 1958). In-
creasing bowel sounds in a fasted patient is
therefore the first sign of a recurrent bleed,
but if the patient is shocked the sounds may
be absent.

Although the bowel sounds may be a useful
guide in distinguishing between intra-intestinal
and intraperitoneal haemorrhage there are
often other features in the history or in the
physical examination which are more reliable.

Frequent and loud bowel sounds also ac-
company diarrhoea due to other causes, e.g.,
gastro-enteritis, but these are rarely confused
with gastro-intestinal haemorrhage.

SUMMARY

1. A careful assessment of the frequency
of the bowel sounds was made in twenty cases
of haematemesis and melaena.

2. It was found that:—

The bowel sounds are increased above what
has been defined as the upper limit of normal,
when there is much blood in the small intes-
tine.

The frequency of the bowel sounds in-
creases before there is other evidence of a
restart in gastro-intestinal haemorrhage.

The bowel sounds are absent if the patient
is severely shocked.

REFERENCES
Mitton, G. W. (1958), Med. J. Aust. (in the press).
Torek, P. (1947), Amer. Pract., vol. 1, page 378.

VaucHAN, R. T., and Torex, P. (1939), Amer. J.
Surg., vol. 45, page 230.

_—

= a = a Beest«cs

t
‘
|

ee

PAGET’S DISEASE OF THE NIPPLE OCCURRING IN A YOUNG
WOMAN

WITH REVIEW OF THE LITERATURE

By P. R. Joyce anp J. S. Lextas
Perth

T is customary to think of Paget’s disease

of the nipple as occurring in women in
the fourth to the sixth decades of life. In his
original description of the clinical condition
in fifteen cases Paget (1874) stated “the
patients were all women various in age from
40 to 60 or more years.” In their classical
monograph on diseases of the breast Cheatle
and Cutler (1931) described 17 cases the
youngest of which was 47 years of age. The
youngest in Inglis’ series of 24 cases was aged
39 years (Inglis, 1936). Current textbooks
of pathology identify the lesion as occurring
in approximately 5 per cent. of all mammary
carcinemata and in an older age group of
women than the usual carcinoma (Anderson,
1957).

In textbooks of surgery and dermatology
the same emphasis on the later age groups is
noted. Aird (1957) describes Paget’s disease
as “a unilateral eczema of the nipple occur-
ring in elderly women” and Illingworth
(1955) mentions that the condition has to be
diagnosed from the dermatitis occurring in
young women.

Paget’s disease of the nipple has been re-
ported also in the male. Sandison (1956) in
briefly reviewing the small number of accept-
able cases, records ages varying from 47-80
years. Reports of cases before the age of 30
years are few. Alcock (1901) reported a
case in a young woman of 28 years which
clinically was Paget’s disease. Of the patho-
logical examination he stated that the morbid
conditions were “limited to the cutaneous
tissues” and he illustrated the histological
appearances in the epidermis. Unfortunately
the poor quality of the diagram and the lack
of the characteristic cells in it prevent histo-
logical confirmation. No carcinoma of the
breast was found in this case.

One of Muir’s cases was aged 26 years —
a patient with localized intraduct carcinoma
and infiltrating carcinoma with metastases to
the lymph glands. Of the microscopic Paget’s
disease found in a section through the nipple
Muir himself wrote “some might question
whether they are really Paget cells” (Muir,
1939).

It is the purpose of this communication to
briefly review the literature and to report a
case of Paget’s disease in a woman, clinically
evident at the age of 28 years but not diag-
nosed until two years later when it was con-

firmed by biopsy.

Mrs. Y., a 30-year-old housewife from the country
with four children ranging from 11 years to two
years of age, stated that at the age of 19, during
her first pregnancy, she noticed cracking of the
right nipple. There was apparently no discharge
at this stage, nor was there any difficulty in healing
after weaning. She had no further trouble for ten
years when, during her final pregnancy, the nipple
cracked again at the same place during the sixth
month of pregnancy. This was treated and began
to clear up to the degree that it was possible to feed
the child for four months, although the nipple was
painful.

Two weeks after weaning the crack reappeared at
the same place and began to discharge smelly
material which stained her clothes for the first time.
Over this ensuing period of eighteen months a rash
appeared and the nipple began to be gradually
eroded despite a large variety of treatments includ-
ing Coal Tar ointment, Savion and X-ray treatment.
No sign of improvement occurred at any stage.

She was referred because of lack of improvement.
On examination, she was a fit looking young woman
with medium-sized breasts. The left breast was
normal, the right breast showed a scaly crusted rash
involving the nipple area and areola. The nipple
was eroded and partially destroyed. Careful palpa-
tion of the breast indicated a very small tumour
under the nipple but its existence was not certain.
No deep breast mass could be felt, nor were there
any glands palpable in either axilla.

46 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

A biopsy was taken and forwarded for histological
examination. The specimen consisted of two frag-
ments of skin and subcutaneous tissue which were
resected from the remaining portion of the nipple.
The histological report was as follows:—

The epithelium of the nipple shows acanthosis
and some parakeratosis. There are marked changes
in the Malpighian layer including clear cells, round
bodies, nuclear irregularity and mitoses. There is
much chronic inflammatory reaction in the sub-
epidermal zones.

duration of the lesion. It is difficult to be certain of
the integrity of the basement membrane in all these
sections but there is certainly no gross infiltration
of the connective tissue. However, a single small
deposit of intraduct carcinoma was found attached
to the capsule of one of the axillary nodes. No
evidence of metastases was seen in any of the re-
maining nodes. As noted in the macroscopic descrip-
tien the intraduct carcinoma extended well into the
axillary tail and this is thought to account for the
extension to the lymph node capsule. Extension into
the mammary fat was also apparent in the sections.

FIG. I. Intraduct carcinoma. Comedo pattern.

Conclusion: These are the changes of classical
Paget’s disease of the nipple. There may or may not
be an underlying carcinoma of the breast.

At this stage the breast was re-examined by both
authors and the absence of a definite lump in this
medium-sized mammary gland was again noted.

The breast was amputated five days after biopsy.
Radical mastectomy was performed and the axilla
was cleared. The pathological report on the breast
was as follows:—

A medium-sized breast was received. There was a
recent surgical incision at the nipple. The remaining
portion of the nipple was retracted hard and
excoriated. The ducts immediately beneath the
nipple were slightly dilated but no evidence of a
tumour was found in this region. A well-defined
oval mass 2 cm. in diameter was found in the fat
close to the origin of the axillary tail. Its cut sur-
face showed many dilated ducts. Seven lymph nodes,
the largest 2 cm. in diameter, were found in the
axillary tail.

Numerous blocks were sectioned from the breast
parenchyma, the nipple and areola and the axillary
nodes. Sections from several different areas of the
breast parenchyma including the well-defined nodule
close to the axillary tail show intraduct carcinoma
and also early lobular carcinoma (Figs. I, II, III).
Normal and near normal breast lobules can be seen
adjacent to malignant lobules. A comedo pattern is
seen in the larger ducts suggesting relatively long

FIG. II. Lobular carcinoma. High power view.
Carcinoma cells within a duct are seen at the top
of the photomicrograph.

FIG. III. Comedo carcinoma. High power view.

Pacet’s DISEASE OF THE NIPPLE

In the epidermis of the nipple and areola and at
the duct orifices the Paget’s disease is extensive.
The Paget cells are well preserved. They are the
typical round clear cells and many of them show
mitoses. Some are degenerated and show the
pyknotic nucleus lying in a clear space (Fig. IV).
In many areas contiguous Paget cells have resulted
in a coalescence of the clear spaces to form clefts
resembling duct structures (Fig. V).

FIG. IV. Paget cells in epidermis. Selected area
to show cells escaping from the _ restraining
germinal layer at right of downward epithelial

prolongation. Note two mitotic figures.

resulting in
appearance resembling ducts.

FIG. V. Contiguous Paget cells

OccuRRING IN A YOUNG WOMAN 47

Intraduct carcinoma is present in the lactiferous
ducts at their orifices. In those sections which show
lactiferous ducts communicating with the surface, the
epidermal changes and intraduct carcinoma are in
continuity but the whole process appears to stop
abruptly at the upper end of the duct and the
deeper portion of the duct appears normal in the
rest of its length. In other words there is dis-
continuity between the intraduct carcinoma of the
breast and the intraduct carcinoma in the nipple.

While most of the Paget cells in the epidermis are
limited in their proliferation by the cells of the basal
layer there are areas where the basal layer seems to
have vanished and the pigment of the melanocytes
in that layer can be seen to be superficial to the
Paget cells; constituting incipient invasion of the
dermis — an unusual feature (Fig. IV).

DISCUSSION

The histogenesis of Paget’s disease of the
nipple has been a controversial subject since
the histology of the condition was first
studied. This is not due to any marked varia-
tion in the microscopic picture in different
cases clinically alike. The microscopic ap-
pearances are in fact characteristic, and form
confirmation of the nature of the nipple
affection. The earlier theories of parasitism
of the epidermis (Darier); degenerative
changes — alone, or in combination with non-
neoplastic proliferation (Thin); and inflam-
matory change, have been discarded. At the
present time when carcinoma in situ is being
intensively studied, all are agreed that the
epidermal changes in the nipple constitute
intra-epithelial carcinoma.

The difficulty is that the appearances of
this malignant change are regarded by some
as being of epidermal origin, while others
maintain that the carcinomatous cells are
ductal in origin. The former view has fewer
adherents at the present time because it does
not explain the association of the epidermal
lesion with the intraduct carcinoma of the
nipple or the underlying breast, which in-
variably accompanies it. Further, Paget’s
disease of the nipple does not behave like the
usual epidermal carcinoma in situ in that it
never progresses to epidermoid carcinoma.

The latter view appears to fit the observed
facts better, but again there is controversy as
to how the Paget cells get to the epidermis.
Muir (1927) considers that they are produced
by a neoplastic proliferation of the epithelium
of the upper parts of the ducts of the nipple

18 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY

and thence they pass into the epidermis within
which they extend — the mode of extension
is thus intra-epithelial.

Inglis (1936), while agreeing that the pri-
mary lesion is in one or more ducts near their
outlet, and that the spread to the epidermis
occurs from this region, maintains that when
infiltrating carcinoma is found in association
with Paget’s disease of the nipple it is due to
secondary spread downwards from the intra-
dermal lesion in the nipple. He considers
the intraduct carcinoma occurring with
Paget’s disease to be a special type of carci-
noma due to intra-epithelial spread within the
ducts and in his 24 published cases stresses
the occurrence of infiltrating carcinoma sub-
sequent to the Paget’s disease. However it
must be noted that the absence of infiltrating
carcinoma at the time the nipple lesion is
detected rests on clinical grounds alone.
Clinical criteria in the examination of the
breast are open to question. Illingworth
(1957) states, “We now recognize that most
of the signs of breast cancer as formerly

taught . . . are signs of late cancer.”

Mammary carcinoma was not diagnosed
pre-operatively in the case presented though
histologically it was an advanced type of
comedo carcinoma which had extended well
into the axilla and was very likely present
from the start.

Whatever the sequence of events, it seems
likely that invasive carcinoma of the breast
occurring in Paget’s disease of the nipple is
a late, it may be very late, stage whether it
originates from extension of the nipple
changes down the ducts or more likely results
from extension through the basement mem-
brane of ducts in the breast, which are al-
ready the seat of intraduct carcinoma.

It is strange that the theory of persistence
of embryonic nests does not appear to have
been evoked to explain Paget’s disease. When
it is remembered that the nipple, areola, and
mammary duct system arise from the one
primitive ectodermal anlage, and that the duct
systems develop by canalization of downward
proliferating epithelial pegs of the rete muco-
sum; a resemblarice can be seen in the auto-
lytic activity of the Paget cells which tend to
form channels when they are contiguous

(Fig. V). If this were the case then as
Geschickter (1945) says, Paget cells arise
in situ in the epidermis but are related to
the cells of the nipple bud and therefore
differentiate into duct epithelium rather than
squamous epithelium. The concept then
would be that of mammary carcinoma of
multicentric origin in which any sequence of
histological changes is possible, with invasion
of the connective tissue stroma as a late
occurrence.

SUMMARY AND CONCLUSION

1. A case of Paget’s disease of the nipple is
described, and a brief review of theories
of histogenesis is presented.

2. Attention is drawn to the fact that the
disease can occur, though rarely, in a
younger age group than is usually de-
scribed.

3. Although the histogenesis is controversial,
the clinical appearance is usually accepted
as an eczematous condition.

1. Accordingly, every chronic eczematous
lesion of the nipple and areola should
excite the suspicion of Paget’s disease.
True eczema of the nipple is stated to re-
spond readily to simple local measures.
If an eczematous condition of the nipple
persists beyond a month or two despite
continued treatment a biopsy should be
taken.

5. It is claimed that Paget’s disease of the
nipple is a manifestation of mammary
carcinoma which is of a diffuse type, and
in cases seen at an early stage, is intra-
ductal and intra-dermal; later to become
invasive.

ACKNOWLEDGEMENTS

The photomicrographs are the work of Mr.
R. Plummer of the Public Health Department
of Western Australia whose assistance we
gratefully acknowledge. Miss M. A. Gillett
of the Medical Library of the University of
Western Australia greatly assisted in obtain-
ing the earlier literature.

REFERENCES

Airp, I. (1957), “Companion in Surgical Studies.”
Second Edition. Edinburgh, E. & S. Livingstone,
page 623.

Atcock, R. (1901), Lancet, vol. 2, page 847.

PaceTt’s DISEASE OF THE NIPPLE OCCURRING IN A YOUNG WOMAN 49

Anperson, W. A. D. (1957), “Pathology.” Third
Editicn. St. Louis, C. V. Mosby, page 1123.
Cueatie, G. L. and Cutter, M. (1931), “Tumours
of the Breast; Their Pathology, Symptoms, Diag-
nosis and Treatment.” London, Arneld.

Deaver, J. B. and McFartanp, J. (1918), “The
Breast: Its Anomalies, its Diseases and Their
Treatment.” London, William Heinemann.

GescuickTer, C. F. (1945), “Disease of the Breast.”
Second Edition. Philadelphia, J. B. Lippincott
Co.

IntincwortH, C. F. W. (1955), “Short Textbook of
Surgery.” Sixth Edition. London, Churchill,
page 405.

—— (1957), Brit J. clin. Pract., vol. 11, page 21.

Incuis, K. (1936), “Paget’s Disease of the Nipple,
and Its Relation to Surface Cancers, and Pre-
cancerous States in General.” London, Oxford
University Press.

Lever, W. F. (1954), “Histopathology of the Skin.”
Second Edition. Philadelphia, Lippincott, page
339.

Muir, R. (1927), J. Path. Bact., vol. 30, page 451.

— (1939), J. Path. Bact., vol. 49, page 299.

Pacet, J. (1874), St. Bart’s Hosp. Rep., vol. 10, page
87.

Sanpison, A. T. (1956), Brit. J. Surg., vol. 44,

page 330.

SPONTANEOUS PERFORATION OF THE OESOPHAGUS

By Epwarp A. ALLcock

Department of Surgery, University of Melbourne

‘prs relative rarity of spontaneous rupture
of the oesophagus and even more occa-
sional survival following treatment is the
reason for recording a recent successful case.
It is evident, too, that the condition must
always be borne in mind, for failure in diag-
nosis will inevitably cost the patient his life.

FIG. I. Pre-operative chest X-ray showing the

presence of gas in the mediastinum, especially

between the hilum of the left lung and the

pericardium. There is also gas in the soft tissues

in the right supraclavicular area above the right
clavicle.

History

G.E., a 49-year-old man, came to hospital com-
plaining of severe epigastric pain. Earlier he had
been found to have a rigid abdomen with absent
bowel sounds, grunting respiration and considerable
collapse. A provisional diagnosis of perforated peptic
ulcer had been made.

No previous history of indigestion could be
elicited, though he had vomited occasionally for no
apparent reason. There had been one previous attack
of severe upper abdominal pain two years previ-
ously which had passed off very quickly. The patient
asserted that he was of abstemious habit and always
ate slowly.

On the afternoon before his admission he had
attended a football match, though feeling a little
“off colour and cold inside”. On his way home he
had had two glasses of beer (16 fluid ozs.) and
collected some bags of cement. While eating his
evening meai of roast lamb and vegetables he be-
came nauseated and had to vomit. Feeling a little
exhausted he had rested for fifteen minutes and then
had vomiied again. On this occasion there was a
great deal of retching, with very little vomitus, for
he had emptied the bulk of his meal from the
stomach previously. Suddenly, he was seized by a
most violent pain, which extended along the right
border of the sternum and radiated to the abdomen,
where it settled mainly in the epigastrium. There
was also pain in the back. Though of a stoic
nature, he was so overwhelmed by this pain that
he could neither move nor summon assistance.

FIG. Il. Pre-operative X-ray showing a_ small
right pleural effusion.

He was admitted to hospital eight hours after
the incident following a long ambulance drive. He
was in very obvious pain. There was mild cyanosis
and the respiration was grunting in character. The
pulse was 98 per min. and the blood pressure was
120/90 mm. of mercury. The apex beat was regular,
10 cm. from the midline and in the fifth left inter-
costal space. The chest expansion was poor though
fremitus, resonance and air entry appeared normal.

The abdomen was rigid in all quadrants. There
was no local tenderness or rebound tenderness.
Bowel sounds were absent and the liver dullness
normal. No abnormality was detected rectally.
While trying to determine whether the patient had
pain referred from the under side of the diaphragm
to the shoulder the presence of subcutaneous emphy-
sema was noted, This immediately suggested the

m
by

re

SPONTANEOUS PERFORATION OF THE OESOPHAGUS Si

diagnosis of perforation of the oesophagus. This was
confirmed by an X-ray which demonstrated the
presence of gas in the superior mediastinum and
behind the heart. Gas was also shown to be present
in the tissues of the neck (Fig. I). A right pleural
effusion was also found, though no pneumothorax
was demonstrated (Fig. II).

bene

twelve days post-
leak of barium

swallow

Barium
There has been a
into an irregular cavity behind and to the right

FIG. III.
operatively.
of the rupture.

of the oesophagus at the level

An intravenous transfusion was immediately com-
menced with 1 bottle (450 ml.) of plasma, followed
by blood. A general anaesthetic using thiopentone,
curare, nitrous oxide and oxygen with controlled
respiration was administered (Dr, Brenda Paine).

The right pleural cavity was entered through the
bed of the sixth rib and found to contain 900 ml.
of turbid fluid and a little gas. The pleura was
intensely inflamed. The posterior mediastinal pleura
was dull, black and gangrenous. On closer in-
spection a perforation of 1 mm. in diameter was
found in the mediastinal pleura 9 cm. above the
hiatal reflection. The mediastinum was then opened
widely, revealing the solid contents of his last
meal. The undermined pleura was then excised
and the food debris sucked and sponged away. This
revealed a longitudinal tear in the oesophageal
muscle 7.5 cm. in length with a mucosal rupture
2.5 cm. in length also in the long axis of the viscus.
The mucosal tear was closed, using interrupted 0000
silk stitches. The muscle was then approximated
with a second layer,

One gm. of streptomycin and 1 mega unit of
penicillin were instilled into the pleura. The chest
was then closed with an intercostal drain and under-
water seal brought out through a stab wound in the
9th intercostal space.

Post-operative penicillin and streptomycin were
given parenterally for eight days. Under water drain-
age was continued for five days. Nothing was given
by mouth for four days, when a fluid diet was com-
menced, Physiotherapy was begun immediately post-
operatively and was continued throughout his con-
valescence. Twelve days post-operatively a barium
swallow was done as a routine investigation and
demonstrated the escape of a small quantity of con-
trast into the mediastinal tissues (Fig. III). This
was believed to have outlined the wall of a small
abscess, which had drained into the lumen of the
oesophagus. No upset in the patient’s general con-
dition was noted. His treatment was continued ex-
pectantly and it was felt that he was well enough
to go home three weeks after the rupture, When
last seen seven months later he was very well. A
recent barium swallow is normal.

DISCUSSION

The literature recording the autopsy find-
ings and attempts at diagnosis of this rare
and overwhelming condition of spontaneous
rupture of the oesophagus has been spread
widely over two centuries. Boerhaave, the
great Dutch physician, gave the first descrip-
tion in. 1724. There were other fascinating
features about this case, apart from its unique
place in the literature, for a total disruption
was recorded in a Grand Admiral of the Dutch
Fleet. In the historic year of 1848, Williams
presented a brief paper to the Pathological
Society of London, in which he recorded the
association of rupture of the diaphragm and
oesophagus. “In this case the vomiting came
on after dinner and in the act the patient
fainted. He rallied and was again attacked by
fainting accompanied by a great desire to
vomit, which, however, could not be accom-
plished. The ordinary symptoms of perfora-
tion now occurred, but with great intensity

52 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

and in 13 hours after the first attack the
patient sank. On examination, the oesophagus
and diaphragm were found to have sustained
rupture and the contents of the stomach had
poured into the left pleural sac. The cavity
was the seat of unequivocal signs of acute
inflammation.”

Fitz (1877) gave a further account of the
condition but MacKenzie (1884), in the first
edition of his work on ear, nose and throat
surgery, gives one of the best descriptions yet
published. Apart from a clinical description
of great merit he described experiments upon
cadavers in which he was able to reproduce
the type of tear observed clinically with a
mean hydrostatic pressure of 11 lbs. 4 per
sq. in. Under these circumstances, the rupture
occurred in the lower third of the oesophagus
in the longitudinal axis.

With the turn of the century it would seem
clear that the clinical features of ruptured
oesophagus were being recognized and
thought was turning to management and
treatment. Walker (1914) first observed that
“there might be some chance of saving the
patient by approaching the lesion through the
posterior mediastinum, repairing the rent and
draining the mediastinum and pleural cavity.”
Clearly, however, the time for this to be pos-
sible had to await the appreciation of how to
treat the shock and the development of con-
trolled respiration. It was, therefore, not until
thirty-three years later that the first case of
recovery following operative closure was re-
corded (Barrett, 1947) though Collis et alii
(1944) reported an unsuccessful thoracotomy
and attempted suture. Occasional cases of
recovery following drainage of the empyema
and healing of the fistula were reported
(Ballin et alii, 1922; Benson et alii, 1938;
Evarts Graham, 1944). Spontaneous rupture
of the oesophagus is, however, a comparative
rarity; Grey Turner (1946) in his Hunterian
Oration on “The Surgery of the Oesophagus”,
remarked that, in forty-six years of active
surgery he was unaware of seeing a single
case.

AETIOLOGY

Though spontaneous rupture has been re-
corded in the cervical oesophagus (Russell,
1953), the great majority occur in the lower
third. Almost all of them are caused by
vomiting and Samson (1951) prefers to use
the term “post-emetic rupture” in describing
the lesion. The possibility of pre-existing

lesions must always be considered, but if
they are known to be present the term “spon-
taneous” cannot be applied.

The precipitating cause of the rupture is
usually vomiting. The site of rupture is almost
invariably in the lower third. This has re-
ceived experimental confirmation (MacKen-
zie, 1884; Kinsella, 1948). Straining, apart
from vomiting, has been shown to cause rup-
ture in some cases. Murdoch (1928) and
Aldrich (1941) noted the association with
crush injuries of the abdomen; Eggars
(1942) with defaecation; Grossman (1943)
with convulsions; Gardner (1949) with
sporting injury at hockey; Kennard (1950)
in women in labour; Kraft (1952) with
coughing; Starkey (1955) recorded the case
of a man who, after a heavy meal, lay supine
on the floor for a rest, yawned and perforated
his oesophagus; Windsor et alii (1957) in a
fatal motor cycle accident. Post-operative
vomiting has been widely recognized and
Flipse (1951) in an exhaustive paper has
drawn attention to the association with
disease of the central nervous system; cere-
bral tumour, brain-stem and mid-brain lesions
and also with neurosurgical operations. Petrov
(1908) records the case of a man who acci-
dentally blew up and ruptured his oesophagus
with a compressed airpump held in his teeth.
The rupture was in the classical situation in
the lower third and was on the left side.

MECHANISM AND SITE OF RUPTURE

MacKenzie (1884), Kinsella (1948) and
Mackler (1952) have all shown that distension
of an oesophagus leads to rupture in the lower
third. The rupture usually is longitudinal and
conforms to the pattern seen clinically. Duval
(1921) showed that rapid distension of a
viscus produced rupture more easily than
slower air distension. The two factors in-
volved are rate of rise in pressure and the
final pressure achieved. It would seem that
vomiting is occasionally capable of producing
these conditions.

Radiologically, the first sign that vomiting
is imminent is a very firm contraction of the
pylorus, followed by vigorous swallowing.
Deep furrows of reversed peristalsis may be
seen sweeping across the stomach until the
cardiac orifice opens and the sudden violent
spasm of the abdominal wall and diaphragm
propels the gastric contents into the oeso-
phagus. The food bolus dilates the oeso-
phagus very rapidly and this, associated with

SPONTANEOUS PERFORATION OF THE OESOPHAGUS 53

a small area of spasm, frequently seen at the
junction of the middle and lower thirds of
the oesophagus, is sufficient to cause the rup-

ture (Fig. IV).

The side on which the rupture occurs is of
far greater significance therapeutically than
the level. Aird (1946) states that “the tear
is usually longitudinal on the right posterior
aspect of the oesophagus and just above the
cardia”. Ridgway and Duncan (1937), in a
review of 35 cases recorded 25 to 1 in favour
of the left side where sufficient information
was available in the records. A_ personal
review of 65 cases from the literature where
the facts are recorded precisely has demon-

strated a similar preponderance of left-sided
perforations; a proportion of 53 to 12 is
found. This preponderance of the left side is
so great that Mackler (1952) did a left thora-
cotomy in the presence of a right pleural
effusion, to find the rupture as anticipated on
the left of the oesophagus, but obscured
by an adherent pleura on the side of operation
(Table 1; Fig. V). The sex incidence is
heavily in favour of the male (56 to 9 in the
series reviewed).

DIAGNOSIS

The tetrad of symptoms described by Gott
(1933) which consists of pain in the lower
chest associated with vomiting, subcutaneous

TABLE 1]
Successful Cases Unsuccessful Cases

Author Age | Sex | Side Author | Age | Sex Side
Frink (1947) | 42 | M R Williams (1848) | | M L
Barrett (1947) 46 | F R Fitz (1876) |; 31 | M R
Moore et alii (1948) | 73 | M L MacKenzie (1884) 24 M L
Lynch (1949) | 45 | M L | West et alii (1897) 55 | M L
| 56 | M L Walker (1914) 39 | M L
62 | M L 52 F L
Scholefield (1949) | 63 | ii R Gott (1933) 7 F ke
Gardner (1949) | 30 | M | R 74 M L
Beal (1949) 52 | M | L Ridgway et alii (1937) 34 M L
Samson (1951) 455 | M i Mallam et alii (1939) 44 M :
| 55 | M L_ | Scholefield (1949) 41 | M L
Kraeft et alii (1952) 55 | M L Collis et alii (1944) | 41 | M L
Susman (1952) =: R | 32 M R
Alt (1955) | 69 M L Eliason et alii (1946) 7 M R
| 6 | F | L 73 M L
| 53 | M L Kinsella et alii (1948) 16 M L
Borrie (1955) 52 M R 70 M L
| 4% oe A 74 M L
Starkey (1955) 53 M | L 67 M L
Clain et alii (1956) | 74 ~ | + Ware et alii (1949) 53 M L
Anderson (1952) 51 M | R 76 M i,
48 M | a Loewenthal et alii (1951) 76 M #
59 M L Carter (1951) 66 F L
Mackler (1952) | 47 M L Flipse (1951) 43 M R
| 32 M L Rigdon et alii (1951) 38 M L
| 51 M L Susman (1953) 64 F R
Bunch (1957) | 55 M L 51 M L
Windsor et alii (1957) | 54 M L Moynihan (1954) 42 M L
30 | M L 32 M R
Alt (1955) 69 M L
| Boule (1955) 73 F L
| 69 | M L
Starkey (1955) 75 M L
55 M L
Bunch (1957) 66 M L
Windsor et alii (1957) 53 F F
| | | 54 | M L

| |

55 out of 65 were male,
53 out of 65 were on the left side.

54 THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY

emphysema of the neck, respiratory distress
and prostration is said to be characteristic.
It would seem, however, that pain is the only
universal finding. The degree of shock and,
in fact, the cause of death within a few
hours is probably connected with the irritant
nature of the fluid regurgitated from the
stomach into the pleural cavity. The severe
nature of the pleuritic reaction is quite re-
markable and the need for rapid dilution and
buffering of the relatively large quantities of
irritant gastric secretion explains the presence
of the serous fluid in the pleura.

FIG. IV. The mechanism of vomiting:

A. Ocsophagus, stomach and pylorus at
rest.

B. Swallowing with oesophageal peri-
stalsis and pyloric spasm.

C. Spasm as in B maintained with
addition of reversed peristalsis.

D. Contraction of diaphragm and ab-
dominal wall with relaxation of
eardia and regurgitation of gastric
contents,

The time of appearance of subcutaneous
emphysema is very variable. It is to be
found, if present at all, in the posterior tri-
angle of the neck. In some cases it may be
very extensive. Whether gas is present in the
neck or not, it is usually possible to detect
it radiologically in the mediastinum. At the
same time the demonstration of a_hydro-
pneumothorax may be very valuable in
lateralising the rupture. It is of interest,
however, to recall that McCorkle et alii

(1937) and Welty (1947) recorded sub-
cutaneous emphysema after a perforated gas-
tric ulcer; O'Donoghue (1956) following a
perforated duodenal ulcer and Ryssing (1948)
following a rupture of the uterus.

The presence of referred abdominal symp-
toms and signs is a very confusing feature.
The patient usually complains of epigastric
pain and on examination rigidity and a
silent abdomen are found. The rigidity, how-
ever, is unassociated with tenderness, a com-
bination which must cast doubt upon the
possibility of an intra-abdominal catastrophe.

ia] 53.

FIG. V. 81 per cent. of cases of spontaneous
rupture of the oesophagus occur on the left side.

INVESTIGATION

Prolonged investigation of the patient is
precluded by the urgency of the situation.
Every effort must be made to confirm the
diagnosis, however, and from a therapeutic
point of view the side of the perforation must
be established with complete assurance. Plain
films of the chest will show mediastinal gas
and if they show fluid on the one side only
or a hydropneumothcrax, evidence of the
side of the rupture is more certain. A radio-
opaque swallow with water soluble medium
is also very valuable for the leak may then
be shown radiologically. Barium, because of
its particulate nature, cannot be advocated in
the face of the water soluble media which
are easily absorbed from the tissues and ex-
creted by the kidney. Finally, oesophagoscopy
may still be necessary so that these instru-
ments should be available in the theatre for
final proof of the side of the lesion.

~ | met 2 Oe

SPONTANEOUS PERFORATION OF THE OESOPHAGUS 55

TREATMENT

Abdominal approaches to the rupture have
been tried and have failed universally. The
only logical method of treatment is to open
the pleura widely, close the perforation and
allow drainage of the mediastinum to occur
if it should be necessary. Very occasional
cases have survived with nothing more than
drainage of the empyema. Ballim and Saltz-
stein (1922) record the recovery of a 15-year
old boy, where drainage of the post-rupture
empyema was followed by an oesophageal
fistula which closed in one year. It may be
that still others have survived with no active
treatment at all. There are, apart from
closure of the perforation, two other factors
which direct operation will resolve concur-
rently, the pleural soiling and mediastinal
foreign material. The pleural soiling with acid
gastric juice produces profound shock very
rapidly by calling forth a large effusion.
Pneumothorax, especially of the tension
variety, and interstitial air will also con-
tribute to the shock syndrome. Mediastinal
foreign material needs little comment, for if
the patient does not succumb to the initial
shock he will certainly develop a severe infec-
tion in the presence of organic debris in the
para-oesophageal tissues. Removal must,
therefore, be advocated in order to anticipate
this infection. The operation should be car-
ried out at the earliest opportunity. If the
patient survives a period of observation as-
sociated with a delayed diagnosis and sup-
portive therapy, it is still worth while closing
the perforation, because good results may
ensue. Bosher (1957) reports the survival of
a 78-year old man treated by initial drainage
of a tension pneumothorax and subsequent
closure of the perforation twenty-four hours
after it had occurred.

In the event of an empyema becoming
established, drainage must be instituted when
an oesophageal fistula may ensue. The fistula
may then be expected to close slowly but
spontaneously. The treatment of choice, how-
ever, is early direct suture of the rupture.
The late cases are far more difficult to manage
for the mediastinal food material will still be
present and will, despite the poor condition
of the patient, demand drainage at the earliest
possible moment.

SUMMARY

1. A successful case of spontaneous rupture
of the oesophagus pointing to the right
side 9 cm. from the hiatus is recorded.

2. The clinical picture and management are
discussed.

3. Immediate exploration and suture of the
oesophageal rupture is advocated.

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page 369,

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Benson, C. D. and Pemspertuy, G. C., (1938),
Surgery, vol. 4, page 777.

BEALE, J. M. (1949), Ann. Surg., vol. 129, page 572.

Bosuer, L. H. (1957), Ann. Surg., vol. 145, page
1010.

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Crain, A., and HeFFernan, S. T. (1956), Lancet,
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Gynec. Obstet., vol. 83, page 234.

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Surg., vol. 129, page 619.

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page 17.

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page 133.

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59, page 710.

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400.

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calli sn

CHRONIC INFLAMMATORY MASTITIS WITH DUCT ECTASIA

By Tuomas H. ACKLAND
Melbourne

AMES EWING in 1933 applied the term

“plasma cell mastitis” to a series of cases
of unusual inflammation of the breast which
had been collected at the Cancer Memorial
Hospital, New York. Although there is no
doubt that a separate clinical entity exists, this
subject has received very little attention in
surgical literature. Furthermore, much con-
fusion has been caused by the fact that when
reference has been made to it by writers,
many names other than “plasma cell mastitis”
have been applied. Bloodgood was the first
to mention the condition of dilated mammary
ducts which is frequently the earliest change.
He wrote of “the clinical picture of dilated
ducts beneath the nipple frequently to be
palpated as a doughy worm-like mass — the
varicocele tumour of the breast”’—a rather
wordy title for an important paper which
contains a vivid original description.

Cheatle and Cutler in 1931 reported 10
cases of “plasma cell mastitis” which had
been observed at the Memorial Hospital for
Cancer and Allied Diseases, New York, and
Adair in 1933 made a further detailed study
of the same series of patients. The specimens
from these patients were those which formed
the basis for Ewing’s observations. Although
none of these reports emphasize duct dilata-
tion, it now seems certain that they were
describing a later stage of the same condition
to which Bloodgood had referred.

Occasional case reports have since appeared
in the American literature. Rodman and
Ingleby (1939), Miller (1939), Parsons, Hen-
thorne and Clarke (1944) and Gaston (1947)
have all referred to “plasma cell mastitis”,
while Dockerty (1941) calls the disease
“comedomastitis”, and Payne and his col-
leagues (1943) used the term “mastitis
obliterans”. The only report on the condition
in Australian literature is that of Newton
(1949). It is however likely that the disease
is not as rare as the small number of reported
cases would lead one to believe and there is
little doubt that a considerable number of

4A

unrecognized examples have been hidden in
hospital and private records under the em-
bracing term of “chronic mastitis”.

GENERAL DESCRIPTION AND TERMINOLOGY

The essential features are now clear. In
most cases there first occurs a dilatation of
the collecting ducts beneath the nipple and in
these, fatty material stagnates. Later on irri-
tating products from this material pass
through the duct wall into the breast tissue
where an inflammatory reaction occurs. This
reaction is remarkable by the fact that in it
plasma cells frequently predominate; but they
do not always do so and are by no means as
constantly found as has been suggested. In
actual fact a wide variety of inflammatory
cells may occur as well, or in their place.
It would therefore seem that the term “plasma
cell mastitis” is too narrow and that the
disease is better described by the more em-
bracing title of “chronic inflammatory mas-
titis” or as suggested recently by Haagensen,
by the term which describes the usual initial
lesion “mammary duct ectasia”. However,
the objection to using this latter term without
qualification is that on the one hand it gives
no hint of the gross, even alarming, clinical
signs with which the patient may present,
nor on the other hand does it seem to make
due allowance for the fact that advanced duct
ectasia may be present without the patient
complaining of any symptoms whatever. It
is therefore suggested by the writer that either
“chronic inflammatory mastitis” or “chronic
inflammatory mastitis with duct ectasia” are
the most suitable names for this disease.

The importance of the condition lies in the
fact that carcinoma of the breast is likely to
be precisely simulated and the patient sub-
mitted to an unnecessary radical mastectomy.
This has been the most striking feature of
almost every reported case.

AETIOLOGY AND PATHOLOGY

Chief credit for giving a correct descrip-
tion of the pathogenesis of the lesion must be
given to James Ewing who commented upon

58 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

Adair’s cases in 1933. He stated that this
process was a true inflammation but differed
from ordinary suppurative mastitis in several
ways, viz.—the absence of definite abscesses,
its wide extent, its peculiar persistence with
little tendency towards spontaneous resolution
and in the fact that the “productive” element
was more pronounced. He further stated,
after finding that cultures were often sterile,
that bacterial infection was much less im-
portant aetiologically than the chemical effect
of decomposing fatty material within dilated
ducts.

A full and convincing account of the
natural history of the disease has recently
been given by Haagensen in elaboration of
the above ideas expressed by Ewing. Haagen-
sen insists that the starting point is the dila-
tation of the terminal collecting ducts under-
neath the nipple, which he appropriately terms
“mammary duct ectasia”. It has long been
recognized that such a condition sometimes
occurs —the cause probably being an ab-
normal hormonal stimulus. These dilated
ducts may be present for a considerable time,
even permanently, without the patient having
any symptoms whatever. A recent autopsy
survey of apparently normal female breasts
has been carried out by Frantz and her associ-
ates, who found that an appreciable degree
of duct ectasia was present in a quarter of
the subjects examined. The average age in
this series with symptomless ectasia was 61.7
years, which would suggest that the condition
is an involutionary manifestation; but there
is no doubt that it may also occur in much
younger women. The change tends to be con-
fined to one sector. This finding is in contrast

to the dilatation of a single duct found in
association with an intraduct papilloma — a
lesion not found in combination with mam-
mary duct ectasia.

Symptoms and signs of chronic inflam-
matory mastitis occur only in a small propor-
tion of individuals who have mammary duct
ectasia, the inflammatory changes in the duct
walls and breast tissue resulting from the
irritating nature of the material contained
within the ducts.

FIG. II. A _ similar duct containing amorphous
fatty debris. It shows atrophy and actual breaking
of the lining epithelium.

Lepper and Weaver have shown that this
is for the most part an amorphous substance
consisting almost entirely of neutral fat which
stains intensely with Scharlach R. Scattered
throughout it, but taking no stain, are often
found rounded crystalline bodies with a
radial structure.

Before any inflammatory changes have oc-
curred in the breast stroma, the duct dilata-
tion may extend peripherally for a consider-
able distance in one sector. The ducts at this
stage are likely to be greatly thickened by
fibrosis and accumulations of inflammatory
cells in their walls, but the epithelial lining
of the duct does not proliferate. Such chronic
inflammation causes shortening of the ducts
with the result that retraction or deviation
of the nipple may be the first clinical sign
of this disease.

At a later stage there occurs atrophy of the
lining cells of the duct walls, and here and
there actual breaks in their continuity, allow-
ing the contained lipid material to pass into

oon aes

the breast stroma. Here an inflammatory reac-
tion of variable intensity is set up, and histio-
cytes, polymorphs, lymphocytes and plasma
cells gather in variable quantities as well as
phagocytic giant cells. In some instances the
density of polymorphs may even reach the
proportions of an abscess. This accumulation
of cells results in the formation of a discrete,
partly fixed tumour, which is firm or even
hard in consistency. The sequence of dilata-
tion of ducts, inflammatory reaction and
fibrosis of duct walls may extend throughout
a number of sectors so as to involve the
greater part of the breast with the production
of a very large and visible tumour. If the
lump is cut across it will be seen to be a good
deal firmer than an area of lobular hyper-
plasia, although not possessing the “unripe
pear” character of carcinoma. There will
usually be seen the thick walled ducts oozing
paste-like yellowish material, but at times the
central portion will have broken down to pro-
duce a cavity filled with semi-liquid debris
resembling thick pus. Figs. I, I], III illus-
trate some of these changes.

FIG. III. Typical heavy cellular infiltration in a

case of chronic inflammatory mastitis. Polymorphs,

mononuclears, plasma cells and foreign-body type
giant cells are present.

THE CLINICAL PICTURE

Although chronic inflammation associated
with mammary duct ectasia usually occurs
in an active ageing breast, this is not neces-
sarily so. The average age of a group of 40
patients with symptoms or clinical signs was
found by Haagensen to be 52 years, the
youngest subject being 26. The condition
appears unrelated to recent lactation, although
it most frequently occurs in multiparous
women. Thirty-three of Haagensen’s series
of 40 cases had borne children.

Curonic INFLAMMATORY MAsTITIS WITH Duct EcTASIA

59

When symptoms occur, this disease is
likely in most cases to show features which
suggest in the strongest possible manner the
presence of an active and perhaps widespread
carcinoma of the breast. At this stage one
breast only is likely to be affected, although
in the course of time, as well as repeated
episodes occurring in the same breast, the
other side is likely to be affected also. The
patient illustrated in Fig. IV was 28 years of
age and had retracted nipples on each side.
She developed a hard mass in the right breast
which was clinically considered to be a carci-
noma. Biopsy revealed chronic inflammatory
mastitis and a similar lesion subsequently
developed on the opposite side.

FIG. IV.

Chronic inflammatory mastitis in a
patient with bilateral retracted nipples.

It has already been mentioned that the
first sign of the disease may be retraction or
deviation of the nipple. At this stage there
may also be a nipple discharge of brownish
or even blood-stained material. These two
features can be present for some years with-
out any further symptoms developing. The
next event is likely to be the gradual forma-
tion of a rather massive non-tender lump, the
patient seeking advice then perhaps for the
first time. If a policy of further observation
is adopted, the lump shows itself to be
peculiarly persistent, tending to increase in
size. Not only is it likely to become fixed
within the breast tissues but there may also be
some degree of attachment of the mass to the
chest wall as well as adherence or peau

d orange of the overlying skin. When these
observations are combined with the presence
of large firm or hard glands in the axilla the
diagnosis of carcinoma will never seem more
certain.

60 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

Early or late in the course of the disease
process, perhaps even as the first indication,
clinical signs of inflammation usually appear.
There will be redness and oedema of the over-
lying skin with pain or discomfort and ten-
derness. These symptoms are usually of a
mild degree and after a week or so the acute
process is likely to subside. But in other
cases it may appear that an acute breast
abscess is about to develop, so that the mass
may be incised and some thick pus-like ma-
terial evacuated, or the central part may itself
soften and discharge.

In the latter instance a residual sinus will
form, which will show little tendency to heal
spontaneously, and local excision of the
diseased breast area will be required. The
patient illustrated in Fig. IV developed a
chronic sinus on the side first affected, and
was treated in this way.

The natural course of the disease, when un-
interrupted by surgical treatment, is likely
to be extremely protracted. Nipple discharge,
tumour, recurrent inflammatory attacks or a
sinus may certainly be present for many years,
perhaps indefinitely. Few cases will remain
untreated. By far the majority, in past years
at any rate, have been subjected to unneces-
sary radical mastectomy.

DIFFERENTIAL DIAGNOSIS

There is no way in which by clinical
examination alone, this form of mastitis may
be distinguished from carcinoma of the
breast. A hard poorly defined tumour, fixa-
tion in the breast tissue, retraction of the
nipple, attachment and dimpling of the over-
lying skin and enlargement of the axillary
glands are the usual features. Moreover pain
and tenderness cannot be taken as evidence
against carcinoma.

Thus the consideration of differentiating
details, whereby the actual diagnosis may be
made clinically, is in the writer’s opinion
completely futile. Radical mastectomy should
never be performed without a _pathologist’s
report that carcinoma is present. Biopsy and
frozen section will enable the two diseases
to be distinguished. Most surgeons, at least
in their earlier. years, have felt that the use
of such a precaution for every case of prob-
able breast cancer casts an unnecessary slur
on clinical judgment, but the accumulated

experience of errors which have been made,
forcibly dictates the wisdom of this rule. The
fallibility of clinical diagnosis must be recog-
nized.

TREATMENT

Some patients with nipple retraction and
discharge as the only symptoms will require
no surgical treatment at all. But if the dis-
charge is persistent and troublesome, excision
of the collecting ducts together with a pyrami-
dal shaped portion of the underlying breast
tissue is to be recommended, especially in
patients who are unlikely to become pregnant
again.

When inflammatory mastitis has produced
a tumour or abscess, or if a sinus is present.
local excision of the diseased segment should
be carried out since it is probable that con-
servative treatment will prove unsatisfactory.
On the other hand it must be admitted that
the natural history of this disease without
surgical treatment cannot be stated with any
certainty, since in practically all reported
cases mastectomy has been performed. But it
would appear that, at the best, the residual
phases are likely to be extremely protracted.
if not indefinite.

Geschickter states that moderate doses of
deep therapy (1000" in divided doses) will
often bring about regression of an inflam-
matory tumour in ten to twenty days, and
when no sinus is present this method may be
worth a trial.

SUMMARY AND CONCLUSION

1. Attention is drawn to the occasional oc-
currence of true chronic inflammation in
the breast.

2. The term “plasma cell mastitis” does not
necessarily describe the changes which
occur, so that a more embracing descrip-
tive term is required.

3. The inflammation probably results from
the escape of retained fatty material
through the atrophied walls of dilated
ducts into the surrounding breast tissue.

4. The diagnosis of carcinoma of the breast
is very likely to be made in these cases.

5. The desirability of biopsy and frozen sec-
tion being performed on all breast lumps
is, therefore, stressed.

Curonic INFLAMMATORY MastTITIS wiTH Duct EcTAsIA 61

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Cromar, C. D. L., and Docxerty, M. B. (1941),
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Frantz, V. K., Picken, J. W., Metcuer, G. W., and
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Gaston, E. A. (1947), Surgery, vol. 21, page 208.

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Haacensen, C. D. (1956), “Diseases of the Breast”.
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(1943), Surgery, vol. 14, page 719.

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vol. 109, page 921.

TRAUMATIC RUPTURE OF THE LUNG

By N. C. Tan

Singapore

PEN pneumothorax associated —_ with

laceration of the lung is a common occur-
rence but open pneumothorax with rupture of
the lung is uncommon. This case reported
here is the first of its kind seen in Singapore
and, as far as | am aware, no other case has
been reported in the available literature. This
case is interesting because clinically the
patient appeared to have a laceration of the
lung but at operation several unusual features
were noticed. That the patient made a smooth
uneventful recovery following such an exten-
sive injury is noteworthy.

FIG. I. A photograph of the radiograph taken
immediately on admission. It shows fractures of
the left 5th-9th ribs, with much emphysema of the
left chest wall, and the probability of some fluid
in the left thorax. Although no well defined
collapse can be seen, the findings are such as to
suggest that there is tension pneumothorax on the
left side.

Case Report

On 20 Sept., 1957, at 4.30 p.m., a Chinese boy,
16 years of age, was admitted in a critical condition

following an injury sustained in a granite quarry.
At 3.30 p.m., following a blast of gun-powder, the
boy moved out of his shelter to collect the pieces
of granite loosened by the blast. Whilst stooping
down, he was hit from behind by a large piece of
stone which sent him sprawling. He became un-
conscious and regained consciousness in the ambu-
lance on the way to the hospital. The severe haemor-
rhage from a large wound on the back of his left
chest was controlled at the site of the accident by
packing with gauze and strapping the wound.

MADE WS

FIG. II. A photograph of the specimen taken from
the side showing the torn surfaces.

On admission to hospital, the patient was shocked,
his systolic blood pressure was 80 mm. of mercury,
and his diastolic pressure was not recordable. His
pulse rate was 120/min., he was deeply cyanosed,
he showed signs of air hunger and his temperature
was subnormal. His trachea was shifted markedly
to the right and surgical emphysema was present
over his left chest extending from the neck to the
lumbar region. The left chest was hyperresonant
anteriorly and dull posteriorly and no air entry was
detected. The apex beat could not be felt. There
was some diminution in the air entry into the right

ee

lung. A large wound was present posteriorly in the
left chest. Incidental findings were severe lacerations
of the left thumb and of the ring and little fingers.

A needle was introduced into the left pleural
cavity through the 3rd intercostal space in the
anterior axillary line and connected to an under-
water seal. After the initial outflow of air, a few
bubbles were noticed to enter the bottle during each
expiration. The patient was put into an oxygen
tent and an intravenous drip was set up, dextran
being given until blood was available. A portable

7 wr ,

FIG. III. A photograph of the radiograph taken
on the first post-operative day.

radiograph showed that there were fractures of the
left 5th, 6th, 7th, 8th and 9th ribs, with much
emphysema of the left chest wall and with also the
probability of some fluid in the left thorax and
although no well defined collapse could be seen,
the findings were such as to suggest that there was
tension pneumothorax on the left side (Fig. I).

After the patient’s condition had improved, opera-
tion was performed by Pro. G. S. Yeoh with the
patient under endotracheal positive anaesthesia ad-
ministered by Dr. W. Rasanayagam. The patient
was placed in a right lateral position, a wound toilet
was done and the needle was removed. The wound,
which was 5 inches long, extended along the length
of the 7th rib and was directed upwards into the
pleural cavity. Air escaped through the wound as
the anaesthetist compressed the bag and difficulty
was experienced in keeping the bag inflated. The
pulse gradually weakened and at one stage could not
be felt.

TRAUMATIC RUPTURE OF THE LUNG

63

After wound excision, the thorax was opened by
extending the wound anteriorly and posteriorly along
the 7th rib. As the pleural cavity was approached,
more and more air came through the chest wall until
pressure could no longer be built up. The patient’s
pulse became imperceptible at this stage. The pos-
terior end of the 7th rib was found projecting into
the pleural cavity and was resected. Large clots

were removed from the pleural cavity and the lung
gripped firmly with both hands. The anaesthetist was
then able to build up pressure in the circuit and the
patient’s pulse returned.

FIG. IV. A photograph of radiograph taken on
the thirteenth post-operative day. The mediastinum
is central at this stage.

On examining the lung, the lower lobe was found
to be torn open, the tear extending from the apex
to the base on the lateral aspect. The bronchus to
the medial basal segment was seen in the depths
of the laceration and the apical bronchus of the
lower lobe was torn across (Fig. II). There was no
bleeding from the lung. The heart and the peri-
cardium were intact, The lung was clamped with
large Duval’s lung forceps, bringing the torn surfaces
together, and a left lower lobectomy was done by
the dissection technique. The fractured ribs were not
wired. A tube was inserted into the pleural cavity
in the 9th intercostal space in the mid-axillary line
and connected to a motor suction apparatus, A
solution of penicillin (1 mega unit) and streptomycin
(2 gm.) was sprayed over the mediastinal struc-
tures and over the edge of the incision. The wound
was closed in layers. At the same time, the thumb
and the ring and little fingers were amputated by an
orthopaedic surgeon.

64 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

On the first post-operative day, the patient lost
22 ounces of blood through the chest tube, this loss
being replaced by a blood transfusion. The trachea
remained shifted to the right. Over the next few
days, the remaining portion of the left lung began
to expand and convalescence was smooth. Penicillin
and streptomycin injections were given for ten days
and the chest tube was removed on the third day.
The chest wound healed by first intention and on
the tenth day the stitches were removed (Figs. III
and IV). The patient was discharged twenty-one
days after the operation and is being followed up in
the out-patients’ department. He was last seen on
llth Dec., when he looked fit and felt well (Fig. V).
A radiograph at that time showed that the remaining
lung filled up the whole pleural cavity but there was
still an incomplete union of the rib fractures with
persisting displacement (Fig. VI).

FIG. V. A photograph of the patient taken from

the back showing the approach to the pleural

eavity. The raised keloid is the situation of the
original chest wound.

COMMENT

That the patient was unconscious follow-
ing the injury probably contributed to his
survival in so far as he was unable to help
himself by getting up or fighting for his
breath. Such efforts (Tudor Edwards, 1938)
set up a vicious circle and are responsible for
embarrassment of both the circulation and
the respiration by causing mediastinal flutter
and paradoxical respiration. This fact was

also observed by Bohrer (1941). Any attempt
at struggling or calling for help, which causes
a rise in pressure within the bronchial tree,
would expel large quantities of air through
the ruptured lower lobe and, besides keeping
it patent and preventing it from being sealed
off, would leave insuflicient air within the
bronchial tree to sustain life. The initial
blood loss caused a fall in blood pressure and
this resulted in a reduction of the rate and
force of the blood flow through the injured
tissues. Hence the blood clotted readily and
sealed off the laceration. The psychic factor
maintaining an artificially raised blood pres-
sure was also in abeyance.

FIG. VI. A photograph of the radiograph taken

eighty-two days after the accident. It shows the

complete filling of the left pleural cavity with the
remaining portion of the lung.

The first-aid measures rendered at the site
of the accident helped improve the mechanics
of respiration and also promoted clotting in
the chest wall. Tudor Edwards (1938) stated
that, when one lung is collapsed and the
mediastinum is shifted to the opposite side,
there is sufficient lung tissue to maintain an
adequate oxygenation of the blood provided
that the remaining lung is healthy. He em-
phasized, however, that the subject must be
breathing at a calm and even rate.

= ik enn:

Clinically, the patient presented with an
open pneumothorax complicated by some
damage to lung tissues. The passage of a few
bubbles into the underwater seal associated
with the obvious improvement of the patient
following the introduction of the needle into
the pleural cavity suggested a small lacerated
wound of the lung. Only when the patient
was under positive pressure controlled respira-
tion did it become clear that the injury was
more severe than a mere laceration of the
lung. The positive pressure must have caused
dislodgement of blood clots from a ruptured
bronchus.

When the chest wall was opened, a large
tear was seen in the left lower lobe which pre-
sented many interesting features. It was
situated away from the open wound in the
chest wall and was directed laterally in the
mid-axillary line extending the whole length
of the left lower lobe. Thus it was at right
angles to the chest wound both in its situation
and direction. On further examination of the
lower lobe, it was noticed that the bronchus
to the medial basal segment was split open
and was lying in the depths of the laceration
and the bronchus to the apical segment was
torn across. The lobe down to the ruptured
bronchus appeared to have been split apart
as if in a plane of cleavage and there was
complete lack of bleeding from the raw sur-
faces of the lobe. An examination of the chest

TRAUMATIC RUPTURE OF THE LUNG

65

wall showed that it was relatively mobile as
5 ribs were fractured both anteriorly and pos-
teriorly. This indicated the possibility that
the left pleural cavity must have been greatly
deformed at the moment of the impact.

In view of their findings, it is considered
that the most probable mechanism causing
such an extensive and unusual lesion was a
sudden steep rise in pressure within the lung
parenchyma splitting it open. The force of the
impact on the chest wall causing an open
pneumothorax, fractures of 5 ribs and a de-
formation of the thoracic cage could very
well kink the bronchus to the lower lobe and
result in such a rise in pressure. The element
of surprise was probably a contributing fac-
tor here as the patient was totally relaxed and
unprepared for the catastrophe. In an expec-
tant subject the lesion might have been
different.

ACKNOWLEDGEMENTS

I am grateful to Prof. G. S. Yeoh for his
encouragement and guidance, to Mr. H. H.
Eddey for his helpful criticism and to the
Director of Medical Services of Singapore
for permission to publish this case.

REFERENCES

Bourer, J. V. (1941), Surg. Clin. N. Amer., vol. 21,
page 371.
Epwarps, T. (1938), Brit. J. Surg., vol. 26; page 167.

ANAESTHETIC PROBLEMS IN SURGERY OF THE NEWBORN

By A. Distin Morcan

Sydney

N ORE human beings die in the first year

of life than in any other year before
senescence. Although in recent years there
has been a great decrease in infant mortality
rate, i.e. deaths during the first year per one
thousand of live births, this pleasing improve-
ment is almost entirely limited to a decrease
in deaths of infants between the ages of one
month and one year, whilst the mortality rate
in the first month of life still remains very
high and contributes about 80 per cent. of
those who perish in the first year.

Many are suffering from abnormalities
and emergencies requiring the assistance of
surgery and the associated anaesthesia. Sur-
gical knowledge and skill have advanced very
rapidly in an attempt to meet the challenge
of the high mortality in these early weeks.
Along with the surgical advances have come
the demands by the surgeons for a wider
scope of anaesthesia. Indeed there seems to
be no limit to the magnitude and duration
of the operations for which we are asked to
provide anaesthesia.

A discussion of the problems invoived
seems appropriate. I propose to refer to the
problems posed by the physiological and
anatomical peculiarities of the newborn and
then to those problems which arise from the
nature of the disease requiring surgery, and
finally I hope to relate these to the anaesthesia
itself.

Physiology

A few breaths taken in as many seconds
change the parasitic foetus into a separate
individual, but many months elapse before
all of the associated physiological changes
are completed. During the first days and
weeks many of the normal adult physiological
processes are still immature.

When the child is born and breathes there
is an area of alveolar membrane brought into
use which is adequate to meet the immediate
needs of the baby, but at the end of a week
there still remain quite large areas which are
not being used.

Some degree of atelectasis

may persist for more than a week after birth
in quite normal babies. The infant seems able
to withstand oxygen lack for long periods
without taking a breath and without suffer-
ing the damage to cerebral tissues which
would occur in older children or adults fol-
lowing a similar period of anoxia. This
characteristic is most marked in premature
babies and it gradualy diminishes as the child
gets older. It is regularly present in the
early weeks and is frequently a feature asso-
ciated with the induction of anaesthesia for
operations to relieve pyloric stenosis.

Alkalaemia may be brought about by ex-
cessive breathing as in crying or by an
increase in the bicarbonate content of the
blood. It is seen in the newborn in cases of
vomiting associated with pyloric stenosis, high
intestinal obstruction and other cases where
vomiting may be severe. When alkalaemia is
superimposed on the infant’s ability to with-
stand oxygen lack and the consequent breath
holding it may be virtually impossible to in-
duce anaesthesia by any inhalation technique.
Alkalaemia may also be brought about during
anaesthesia by too vigorous manipulation of
the bag under which circumstances the re-
sumption of automatic respiration may be
long delayed when wishing to relinquish con-
trol. Alkalaemia is corrected pre-operatively
by giving sodium chloride intravenously.

In the mature newborn the respiratory rate
is 44 per minute with variations from 20 to
100; tidal air is 20 mls., the minute volume
880 mls., and the vital capacity 170. The
need for greater oxygen is met by an increase
in rate without any increase in volume of
tidal air. Further evidence of absence of
fully developed control of respiration is
shown by the many variations of rhythm
which occur at this age all of which are re-
garded as being normal. Normal though they
may be, Cheyne-Stokes breathing, cogwheel
and sobbing variations of respiratory rhythm
make the anaesthetist’s task very difficult when
they persist throughout an anaesthetic.

i
{

The mechanism controlling heat regula-
tion is one which takes some days to become
properly developed. Until it becomes efficient
the child lacks the protection it affords and
may sustain serious rises or falls of tempera-
ture. Exposure to the usual atmospheric
temperature of an operating theatre of the
large area of body surface necessary for sur-
gical access may lead to great loss of body
heat. In very young babies exposed in this
way the fall of temperature is often 5°F, and
it may be impossible to record the tempera-
ture of some of them after return to bed
following operation. If cooling of this mag-
nitude is added to prematurity, handling of
the bowel and blood loss, shock is severe and
the restoration of normal body heat may be
prolonged and difficult. If the elevation of
the temperature of theatre atmosphere is un-
desirable an electric blanket provides some
protection during operation. Pre-operatively
and post-operatively the warming is done by
means of warm blankets or by placing the
baby in one of the modern tents. Elevation
of temperature adds greatly to the dangers of
anaesthesia. Each one degree rise of Fahren-
heit temperature raises the oxygen require-
ments by 7 per cent. If the temperature
is high it may happen, therefore, that the
oxygen in the air under an ether mask is
inadequate to meet the additional oxygen
requirements, and without added oxygen the
onset of convulsions might follow. Post-
operative hyperthermia may also occur. Both
forms are met by inhalation of oxygen and
by the application of cold sponging.

The adjustment of the balance of hormone
activity is delayed, and the absence of circu-
lating corticoids until the end of the second
week leaves the patient less able to ward off
shock and to recover from it once present.

A percentage of the foetal form of haemo-
globin is still in evidence at seven months of
age and at one month may still be as high as
50 per cent. The various factors concerned
with coagulation of blood are deficient during
the first days of life. So that the need for
prompt and adequate blood transfusion is
imperative.

Defective concentrating power of the kid-
neys, and nutritional defects, particularly
protein lack which results from infection,
easily lead to upsets of fluid and electrolyte
balance, if the patient has to bear the added

ANAESTHETIC PROBLEMS IN SURGERY OF THE NEWBORN

67

strain and stress of vomiting or surgery. The
balancing of blood and electrolyte levels pre-
ferably before operation, is a matter of such
delicacy and importance that it generally re-
quires the skill and experienced judgment of
the expert. With tissue fluid volume at about
1,000 cc. and circulating blood volume at
approximately 300 cc. there is no margin for
error.

Although accurate assessment of the physio-
logical processes in the newborn is difficult
and although the results reported by different
physiologists vary greatly, it can be accepted
that there is in the newborn some immaturity
of its physiology. That the degree of this
immaturity of physiology is greatest in pre-
mature infants and becomes less as the babies
grow older and stronger, can also be accepted.
Just when some particular baby reaches the
point where its heat regulating mechanism
is able to protect it from exposure to cold:
or where its adrenal cortex is able to exert its
normal role; or where there is no longer any
atelectasis present in the lungs; and where
the delicate controls of respiration are func-
tioning, is a question that any anaesthetist
will find difficulty in answering. However,
he can safely assume that there is sure to be
present in the newborn some degree of im-
maturity of physiological processes and some
lack of those mechanisms which protect the

older child.

An awareness of the shortcomings to be
expected should be followed by attempts to
do everything possible to bring the babies to
the operating theatre as well prepared as
possible to withstand the added hazards of
anaesthesia and surgery.

Anatomy

Normal anatomy of the newborn has
interest for the anaesthetist largely because
the smallness of the airways and veins make
difficult some of the technical details. The
infant’s head compared with the size of the
body is very much larger than that of an
adult. This, I believe, is the reason why the
entrance to the larynx of a newborn always
seems to be just a little anterior to the end
of the laryngoscope blade when attempting
intubation. External pressure to push the
larynx and trachea posteriorly generally

facilitates the intubation without applying
force. The trachea has an average length of
35 mm. and an average width of 5 mm. Such

68 THe AusTRALIAN AND New ZEALAND JOURNAL OF SURGERY

a short trachea in which to fasten and main-
tain a tube leaves little margin between in-
tubating the right bronchus and withdrawing
the tube altogether. The insertion of any
tube into such a small trachea cuts down the
diameter appreciably. In an endeavour to
minimize this it is best to use a thin walled
stepped or composite tube and rely on a close
fit to keep it gas tight.

Diseases requiring surgery

The diseases requiring surgical interven-
tion which give rise to special problems fall
into three main groups. They are

(a) congenital malformations,
(b) trauma, and haemorrhage, and
(c) new growth.

(a) The congenital abnormalities form by
far the largest group of those requiring sur-
gery. An added hazard likely to be associ-
ated with any of this group is the frequency
of multiple abnormalities. The successful
correction of one may be spoilt by a second
causing the death of the patient. Whatever
the original abnormality may have been this
group provides two main types of problems
for the anaesthetist, viz., alimentary and
respiratory.

In the alimentary group the problems
centre round a baby suffering from vomiting,
distension, constipation, in varying degree,
and possibly infection as well. The resulting
disturbances of physiology are added to those
already discussed. The mortality rate in this
group is very high indeed. If the anaesthetist
is to make a worthwhile contribution the
following details should receive considera-
tion.

There is seldom enough urgency associated
with these cases to prevent thorough, and if
necessary, prolonged preparation to get them
to the maximal condition before they are sub-
jected to surgery. Where the abnormality is
high and vomiting is the predominant feature
—emptying of the stomach by the passing of
a large bore catheter and by intermittent
suction should be followed by careful restora-
tion of fluid, blood and electrolyte levels
before operation. When the obstruction is
lower, distension is more marked. If severe
it may diminish vital capacity and endanger
life. Decompression should be secured as

far as is possible before operation by all

methods including inhaling of high percent-
age of oxygen. Rupture of the bowel is a
possibility in these cases, and should be
thought of if transport by air is suggested.
Many of these babies are cold when they
reach hospital or may become chilled by
exposure for X-ray and other examinations.
Remembering the immaturity of their heat
regulating mechanisms thorough warming is
needed and may take five or six hours.
Failure to warm a child adequately before
operation and to keep it warm during opera-
tion is in my opinion a frequent cause of
shock. Anaesthetic details should include
emptying of stomach with a large bore tube,
intubation of the larynx, and facilities for
control of respiration. After trial over the
years of most types of anaesthesia for these
cases my present opinion is that cyclopropane
with minute doses of a relaxant, disturbs the
physiology of these babies least. It permits
high concentrations of oxygen and simplifies
control of respiration.

When obstruction is low and the distension
is so great that the diaphragm is pushed high
up and the vital capacity seriously lessened,
the respiratory embarrassment may endanger
life. Intubation of the larynx followed by
positive pressure respiration may become a
life-saving necessity at any time, and has
much to recommend it as a preliminary to
induction of anaesthesia.

In those babies where the presenting sign
is respiratory insufficiency there is often an
element of urgency. Included in this group
are such simple abnormalities as Pierre Robin
syndrome and macroglossia. On occasions
either of these conditions may produce a
degree of respiratory obstruction which en-
dangers life and requires intubation for its
relief. These two conditions are unique in
my experience because they may cause for the
anaesthetist such technical difficulties of in-
tubation as to test his skill to the limit.

Others in this category are tension lobar
emphysema, tension pneumothorax, diaphrag-
matic hernia, and severe abdominal disten-
sion. In all except tension lobar emphysema
intubation before induction is necessary
following which positive pressure respiration
will quickly relieve the embarrassment. Such
a happy result is not so easily secured in the
case of tension lobar emphysema. Positive
pressure respiration only further distends the

a eee

emphysematous lobe, thus adding to the com-
pression of the normal lung and further
limiting vital capacity. Although intubation
pre-operatively is necessary, the administra-
tion of oxygen must be carried out by the
most gentle pressure on the bag. Thora-
cotomy under local anaesthesia allows the
distended lobe to escape from the thorax.
After this the normal lung tissue may be
filled with oxygen from the bag. Lobectomy
is then performed.

In the surgery of diaphragmatic hernia the
removal from the thorax of bowel and, more
especially, the spleen, may be followed by a
sudden inrush of air and extensive medias-
tinal shift. On one occasion the shift was so
great as to cause kinking and complete occlu-
sion of the trachea which defied all attempts
to force air to the lungs.

The anaesthetic for this group requires
intubation with control of respiration. The
choice of drugs does not differ from those
employed for older patients. Diathermy pre-
cludes the use of any of the explosive agents.
The technique in vogue at the moment is
thought to be giving good results. It consists
of induction with a minute dose of thiopen-
tone (0.2 mg. per pound) and a relaxant
(Flaxedil 1 mg. per pound). These are of
course given into the intravenous tubing. As
soon as relaxation occurs the trachea is in-
tubated, if this was not done before induction,
and respiration is controlled immediately
using nitrous oxide and oxygen to maintain
anaesthesia. It is hardly ever necessary for
any other anaesthetic to be given, but Trilene
or cyclopropane may be added if desirable.

(b) There are extremely few conditions
which require intervention in the neonatal
period for relief of trauma or haemorrhage.
I recall only one such condition which poses
any special problems for the anaesthetist. It
is acute sub-dural haematoma of the newborn.
Once diagnosed the neurosurgeon expects to
treat this condition by craniotomy so that he
can remove the blood clot before it becomes
organized into a membrane. The rather

severe blood loss associated with firstly the
formation of the haematoma and secondly
the removal of it, adds greatly to the hazard
of the operation. The accurate estimation of
the amount of blood loss and its immediate

ANAESTHETIC PROBLEMS IN

69

SURGERY OF THE NEWBORN

replacement provide even the most ex-
perienced with a delicate mathematical exer-
cise. Failure to get the right answer may
seriously handicap the recovery of the
patient.

(c) There are few new growths which are
diagnosed and operated on in the first month
of life. When this does occur they offer no
special problem that has not already been
covered by (a) and (b).

The anaesthetic

The surgical requirements to be met by the
anaesthetic include a full range of intra-
thoracic, abdominal and other procedures of
magnitude and duration equal to anything in
adult surgery. The subject may be only five
or six pounds weight, or even less, and is
known to have certain characteristics normal
for its age which leave it poorly equipped to
withstand the exposure, blood loss and shock
which must accompany such surgery. Prepa-
ration of the patient must be so thorough that
no detail is overlooked which might assist in
reaching the maximum condition before
operation. This standard can only be attained
by complete understanding between surgeon,
anaesthetist and paediatrician. Skill, ex-
perience and patience will need to be shown
by all members of the team. Never should it
be possible for babies, cold from exposure
and handling and still half-full of barium, to
proceed from the X-ray department to the
operating theatre. Restoration of warmth,
emptying of the stomach and restoration of
fluid and electrolyte balance are the main
requirements. There is seldom sufficient
urgency to warrant any curtailment of this
programme of complete resuscitation before
operation. The only cases demanding urgent
attention are those with respiratory distress
already referred to.

Premedication with atropine provides pro-
tection against reflex disturbances consequent
upon handling of gut, and against reflex
vagal effects. Sedation may depress vital
centres and unless required for some specific
purpose should not be given.

Fluid and electrolyte balance having been
adjusted before operation, blood should
actually be running into a vein when the

70 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

anaesthetic commences. The aim should be
to immediately replace every drop of blood
loss as it occurs.

Inhalation of vomitus is a tragedy no
matter under what circumstances it occurs.
It has proved helpful over and over again to
pass a catheter into the stomach just prior to
induction of anaesthesia. Although emptying
of the stomach has previously been carried
out to everybody’s satisfaction, further suc-
tion at this last minute often produces most
unexpected results. The procedure is simple
and harmless and should never be omitted in
this age group. Intubation of the larynx and
a readiness to control the respiration if neces-
sary afford the best means of safeguarding
the patient against many of the possible
hazards. All problems of posture or of
changes of posture during operation cease to
exist once intubation is carried out, as also
do those problems which might arise from
the inadvertent or intentional opening of a
pleural sac. It may be argued that intuba-
tion of the newborn is itself difficult and may
be harmful. I feel certain that the benefits
so far outweigh any risk and that there is no
reasonable excuse for omitting it. Any tube
placed inside so small a trachea narrows the
lumen and leads to the usual undesirable con-

sequences. For this reason cuffed tubes are
1

not used and the largest thin walled com-
posite or armoured tube is used. A reason-
ably tight fit is quite airtight and any form
of throat pack can be dispensed with. As
the respiration is to be controlled from the

induction of anaesthesia until the pleura or
the peritoneum is closed, the old bogies of
resistance and accumulation of carbon dioxide
are not of such importance as previously.
The emphasis is on providing a perfectly free
airway and an anaesthetic permitting a high
concentration of oxygen which is brought to
the alveoli by control of respiration. What-
ever the technique employed, whether it be
infant circle, to and fro through a small
canister or an open technique using Ayre’s
T piece, provision must be made for suction
to clear the tube. Suction by a small poly-
thene catheter inserted through the intra-
tracheal tube is desirable to keep the tube
fully patent. In tracheo-oesophageal fistula
suction may be needed frequently.

Provided the essential details referred to
are carried out any drug or combination of
drugs may be used so long as the dose is
small enough and the oxygen concentration is
high enough. The only limitation upon the
choice of technique and drugs to be em-
ployed is imposed by the intention of the
surgeon to use diathermy. I believe it is no
exaggeration to say that the vigilance, com-
petence and experience of the anaesthetist are
more important to a happy result than any
arbitrary selection of drugs and technique.

REFERENCES

Smirn, C. A. (1951), “The Physiology of the New-
born Infant.” 2nd Edition. Oxford, Blackwell.

Wricut, T. S. (1952), “Applied Physiology,” 9th
Edition. Oxford University Press.

Pr

+ anna

HYDATID CYST OF THE LIVER

EXTRUSION OF INTACT CYST

By Rowan WEBB

Melbourne

N 1952 Hueston reported the observation

at autopsy, of extrusion of an_ intact
hydatid cyst of the liver into the peritoneal
cavity. This has always been regarded as
an uncommon phenomenon, and it is there-
fore felt that a further example, observed
during life, should be recorded.

Case report

A male patient (J.C.), aged 63 years, presented
with a history of waking with an unsatisfied urge
to defaecate, followed by the development of a con-
stant ache deep in the epigastrium. At 10 a.m.,
when he was first examined, localized epigastric
tenderness and rigidity were found, and the systolic
blood pressure was 180 mm. of mercury. At 2 p.m.,
the patient was found to be in a state of grave
collapse, with a systolic blood pressure of 70 mm.
of mercury, which was maintained with difficulty
by transfusion after his admission to hospital. The
tenderness and rigidity of the abdomen were now
generalized and a provisional diagnosis of perforated
peptic ulcer was made. It was noted at the time
that there was no history of dyspepsia, and that
shock was much more profound than might have
been expected in simple perforation of a_ peptic
ulcer, in the absence of coincident severe haemor-
rhage. There was no pruritus or urticaria.

The abdomen was explored under general anaes-
thesia through a paramedian incision, and as soon
as the peritoneum was opened, free blood escaped,
followed by the spontaneous delivery of a large,
thin-walled cyst, expelled by the patient’s respira-
tions. The cyst measured approximately 7” x 5” x 4”
and its identity was later confirmed as a hydatid
cyst (Dr. R. Motteram). A cavity rather larger

than a fist was found on the under surface of the

right lobe of the liver and this was packed with
ribbon gauze. No other hydatid cysts could be felt
in the liver or peritoneal cavity.

A little blood drained for the first three days after
operation. The gauze was then removed. Drainage
rapidly ceased, and at no stage was any drainage
of bile observed.

The patient made a good recovery, save for post-
operative retention of urine, requiring prostatectomy
during the third week. This was survived without
incident, and he soon resumed an active life as an
orchardist. Subsequent examinations have revealed
no further symptom or sign of hydatid disease.

Comment

It would appear likely that had the patient
survived this episode without operation, the
cyst would have become established in the
peritoneal cavity, deriving blood supply from
surrounding tissues. Subsequent contraction
and obliteration of the cavity in the liver
in such a case might lead one to an erroneous
diagnosis of a cyst arising primarily on the
peritoneum. Dew (1928) has stressed the
rarity of this phenomenon and emphasized
the importance of a searching examination
of the liver, spleen and other abdominal
organs, whenever such a diagnosis is enter-
tained.

REFERENCES

Dew, H. R. (1928), “Hydatid Disease.” Australian
Medical Publishing Co., Sydney, page 247.

Hueston, J. T. (1952), Aust. N.Z.J. Surg., vol. 22,
page 149,

CIRSOID ANEURYSM OF THE PELVIS
A CASE REPORT WITH A BRIEF REVIEW OF THE LITERATURE

By Ian A. McDonacp and G. R. McLetsu

Royal Melbourne Hospital

IRSOID aneurysm, a rare disease, occurs
more frequently in the limbs than in the
viscera. It seems that its origin in the pelvis
is particularly uncommon. Dubreuil and
Loubat (1926) reported the first case of
cirsoid aneurysm of the uterus. Gardner
(1954) reported one case and reviewed four
others. Williams (1954) added a seventh
case. The present report therefore represents
the eighth known case of cirsoid aneurysm
arising in the uterus.

This case was reported first by Chambers
and Tymms (1931) when the patient pre-
sented with excessive menstrual loss at the
age of 40. They observed a doughy feeling
to palpation and transmitted pulsation over
the lower abdomen at this time. Pelvic ex-
amination revealed a mass, apparently the
uterus, which was enlarged to the size of a
foetal head. On the right side of the uterus
distinct pulsation could be felt. A provisional
diagnosis of fibroid of the uterus was made
and hysterectomy advised.

Subsequently the abdomen was opened
through a lower midline incision and “a
most extraordinary condition” presented. The
following is Chambers’ and Tymms’ descrip-
tion of the findings:—

“A large mass of coiled, intertwined, dis-
tended, pulsatile vessels, some of which were
the size of one’s little finger, was seen. The
mass was about the size of a coconut and
occupied the upper part of the pelvis and
lower abdomen. Closer inspection showed
that a number of the vessels were running
into the omentum. These communicated with
a large sinus which was attached to the
uterus on the right side and which appar-
ently communicated with the right femoral
vein. The mass was quite free in the perito-
neal cavity except for its attachment to the
uterus and to the omentum.” (Fig. I).

At this laparotomy it was deemed not ad-
visable to remove the uterus and the abdomen
was closed. The patient afterwards was given
an intra-cavitary application of radium (the
dosage was not reported) and no further
bleeding occurred for twenty-seven years.

FIG. I. Photograph taken of the aneurysm at the
operation performed by Chambers and Tymms
(1931). (A.—The broad ligament. B.—-The greater
omentum.) (Reproduced with permission from the
Royal Melbourne Hospital Clinical Reports.)

From his analysis of the literature, Gard-
ner (1954) concluded that such lesions show
some or all of the following features :—

1. Severe menorrhagia or metrorrhagia.

2. Uterine enlargement, softness and com-
pressibility.

3. Palpable thrill.
4. Audible bruit.

5. Parametrial pulsations in a
malignant uterus.

non-

In this case, the majority of these features
were found.

General clinical manifestations of an
arterio-venous shunt, such as cardiac hyper-
trophy or decompensation, high pulse pres-
sure and raised venous pressure sometimes
appear in association with cirsoid aneurysm
at any site. Adams (1951) showed that these
changes are not essential and that localized
aneurysms do not always produce circulatory
effects. There were no such changes in the
case under review.

Davies-Colley (1940) believed that cirsoid
aneurysms follow a developmental defect in
the capillary barrier between arteries and
veins. He considered that the majority follow
an intermediate stage of cavernous angioma
when the sinus-like communications between
arteries and veins become defined arteries,
some of the calibre of the femoral artery.
Trauma sometimes may be an accessory factor
in their formation.

Although developmental in origin, Adams
(1951) found that the majority of lesions
are slow to present their fully established
picture. Thus there was a delay in the onset
of symptoms in this patient.

Case Report

Mrs. L.S., aged 67, had been bleeding per vaginam
for six weeks, At first brief episodes of slight
bleeding with a few small clots occurred every four
or five days but later bleeding became continuous.
In the last week malaise and weakness had appeared
and in the twenty-four hours prior to admission,
rigors and sweating.

She had a bad obstetric history. From five preg-
nancies only two infants survived, there having been
on each occasion an ante-partum haemorrhage before
premature delivery.

The patient looked pale and sick when she was
admitted to hospital on 20 Dec., 1957. The pulse rate
was 84 per minute and the temperature 101.2°F, Her
heart was slightly enlarged, her blood pressure
175/105 mm, of mercury and her chest was normal.
Her abdominal wall bore an old midline scar.
Apart from some generalized lower abdominal ten-
derness, no focal signs were present.

Vaginal examination revealed a normal vulva and
vagina. The cervix, pointing downwards and back-
wards, was of normal size, colour and consistency.
A sound passed easily into the uterus. The uterine

Cirsoi ANEURYSM OF THE PELVIS

73

body was anteverted, regular, mobile and slightly
enlarged. There was a palpable pulsation in the
right fornix.

The haemoglobin was estimated as 12 grams per
cent,

Two days after admission, when her elevated
temperature had subsided and the patient stated
she felt better, diagnostic curettage of the uterus
was proposed, Under a general anaesthetic, palpa-
tion of the right fornix confirmed the presence of
pulsation. A sound, passed cautiously, perforated
the anterior uterine wall. The cervix was torn by
the passage of a dilator and haemorrhage was so
profuse that, when an intra-uterine pack did not
control it, immediate hysterectomy became necessary.

FIG. II.

The cirsoid aneurysm exposed in the
right broad ligament. The uterus is held forwards
by clamps.

An intravenous infusion having been set up, the
abdomen was quickly opened. A_ large cirsoid
aneurysm was found arising from the region of the
posterior surface of the right broad ligament. This
comprised several tortuous, calcified vessels, some
a centimetre in diameter, rising from the pelvis and
ascending in the greater omentum as far as could
be palpated. The whole omentum, placed on the
operator’s hand, executed a rhythmical writhing
movement with each pulse beat. The uterus was
moderately enlarged and extremely spongy and
friable (Fig. I[). A normal external iliac artery
was present but no internal iliac system nor external
iliac vein on the right side. The ovarian vessels on
this side, though greatly enlarged, appeared to run
their normal course.

The feeding vessels to the aneurysm having been
doubly ligated and divided within the omentum, a
total hysterectomy and bilateral salpingo-odphorec-
tomy was performed with considerable difficulty
owing to the friability of the uterus and to a large
sinus coursing down the right side which connected
with the aneurysm, This was inadvertently torn
during the operation. The abdomen was closed after
haemostasis was complete and the pelvic floor reperi-
tonealized.

The post-operative course was stormy with periodic
febrile episodes. A blood culture on the third day
grew B. Coli which responded only after five weeks
of varied antibiotic therapy. The patient was dis-
charged from hospital finally six weeks after opera-
tion,

74 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

Macroscopic examination of the specimen
showed an enlarged, spongy uterus with nor-
mal adnexae. The cirsoid aneurysm was at-
tached to the right side and apparently re-
placed the normal uterine vessels between the
layers of the broad ligament (Fig. III). His-
tological examination showed the vessels to be
similar in structure to arteries with many
areas of calcification in the tunica media.
There was practically no supportive stroma.

The post-operative specimen showing the
aneurysm on the right side of the uterus.

FIG, IIl.

DISCUSSION

Chambers and Tymms (1931) showed dis-
cretion when on accidentally finding the
aneurysm at laparotomy they decided to close
the abdomen and to exhibit radiotherapy.
This resulted in the cessation of bleeding for
twenty-seven years. The necessity for hys-
terectomy was precipitated by the dramatic
haemorrhage which followed diagnostic
curettage of the uterus for post-menopausal
bleeding. Reynolds et alii (1949) reported a
similar case. It was necessary for them to
re-open the abdomen and ligate several large
vessels for secondary haemorrhage.

In the light of the pathological examination
of the uterus, the troublesome obstetric his-
tory of our patient is worthy of comment.
Though pregnant five times she produced only
two living children and these followed termi-
nation after a severe accidental ante-partum
haemorrhage on each occasion. The other
pregnancies miscarried after three months
with considerable bleeding. It is tempting
to suggest that the spongy, excessively vas-
cular endometrium offered a poor nidus for
attachment of the placenta.

Most cases of cirsoid aneurysm of the
pelvis have presented with heavy bleeding
following curettage of the uterus. Four of the

five cases reviewed by Gardner (1954) pre-
sented in this way. It appears that such a
procedure in a patient with a known aneurysm
of this type must be undertaken only when
necessary and then with great caution.

We conclude from experience gained in this
case that only when the life of the patient is
jeopardized by such lesions should surgical
excision be necessary. Adams (1951) stressed
the hazards of surgery in all areas. These may
be multiplied in the pelvis where exposure is
difficult and where large vessels feeding the
aneurysm may not be visible. The viability
of the lower limb must be borne in mind also
before large vessels are ligated.

Practically all cases recorded have had a
stormy post-operative convalescence. This
patient contracted septicaemia which was all
but fatal. The physician who looked after
her is to report details of this separately. The
patient owes her life to the use of modern
antibiotics.

SUMMARY

1. The eighth recorded case cf cirsoid

aneurysm involving the uterus is reported.

i)

Laparotomy was performed twenty-seven
years before for menorrhagia. The ab-
domen was closed when the aneurysm was
found and radium was inserted into the
uterus.

3. Hysterectomy became necessary on_ the

present occasion when excessive haemor-
rhage followed diagnostic curettage of the
uterus for post-menopausal bleeding.

4. The authors conclude that surgical ex-
cision of these lesions should be under-
taken only as a life-saving procedure.

5. A brief review of the literature is made.
REFERENCES

Apams, H. D. (1951), Surg. Gynec. Obstet., vol. 92,
page 693.

Cuampers, R. W., and Tymms, E. M. (1931), Roy.
Melb. Hosp. Clin. Rep., vol. 2, page 58.

Davies-Coutey, B. (1940), Guy’s Hosp. Rep., vol. 90,
page 134.

DusreutL, G., and Louspat, E. (1926), Ann. Anat.
path., vol. 3, page 697.

Garpner, H. L. (1954), Amer. J. Obstet. Gynec.,
vol. 68, page 845.

Reyno tps, R. P., Owen, C. [L., and Cantor, M. O.
(1949), J. Amer, med. Ass., vol. 141, page 841.
Wittiams, G. A. (1954), Amer. J. Obstet. Gynec.,

vol. 67, page 198.

Bonks Reviewed

AORTOGRAPHY — It’s Application in Urological and
some other Conditions.
By W. BARR STIRLING, Ch.M., _ F.R.C.S.Ed.,
F.R.F.P.S.G. Edinburgh: E. & S. Livingstone, 1957.
10” x 7”, vii plus 291 pp., 155 figures. Price:
50s. stg.

This volume brings together much relevant infor-
mation on the subject of aortography and is illus-
trated by examples from an experience of 500
aortograms. The author, an urologist, concentrates
on renal arteriography and uses the translumbar
route exclusively. In fact he seems rather biassed
against the retrograde method of Seldinger and fails
to mention its advantages, viz., selective filling of the
posterior branches of the aorta, the supine position
of the patient with consequent clearer definition of
the kidneys and, as a rule, the use of only local
anaesthesia. Current opinion favours the Seldinger
method as a routine and reserves the translumbar
approach as an alternative. An excellent historical
survey of angiography is followed by a description
of the procedure and the risks involved. The author
has not had a death or any serious complication in
his series. However, it must be remembered that
McAfee in a collected review of 13,000 aortograms
found 37 deaths and 98 serious complication as
sequelae, i.e., an accident in 1 per cent. of cases.
Gaylis and Laws (1956) have attributed traumatic
dissecting aneurysms to intra-mural injection of some
of the medium, and paraplegia has been produced, as
described by Boyarsky (1954) and Hare (1957). Not
all radiologists will agree with minor details of the
technique described. In particular, a film following
a small test injection is not employed and this seems
an omission in view of the higher incidence of com-
plications following injection into a branch of the
aorta. Also, no warning is given against the danger
of repeated injections and the summation effect of
dye in the tissues. The major portion of the book
described aortography in specific conditions and
some very fine reproductions of aortograms are in-
cluded.

The author’s enthusiasm for this type of investiga-
tion appears to have marred his clinical judgment.
In one case aortography was performed before
urography or any other radiographic examination had
been carried out. In another, a large mass was felt
in the left hypochondrium at laparotomy and was
thought to be of renal origin. Excretion urography
showed a large, non-functioning left kidney contain-
ing calcified debris, yet an aortogram was considered
necessary to make a diagnosis of closed hydro-
nephrosis. In congenital renal lesions aortography,
as well as indicating the site of the renal arteries,
outlines the parenchyma and is the most conclusive
means of showing fusion. A group of cases of hydro-
nephrosis is included in which the examination
was of value in accurately outlining the amount of
functioning renal tissue present and the site of
aberrant arteries. Partial nephrectomy for calculus
or tuberculosis was aided by giving prior information
regarding distribution of the renal arteries and in
tuberculosis, showed the extent of parenchymal in-
volvement. Where renal hypertension is suspected,
the author advocates aortography as the most direct

method of investigation and shows cases to support
it. Although others have commented on the difficulty
of differentiating renal cyst and neoplasm, the author
states that no incorrect diagnosis was made in his
cases. This publication is recommended as a basis
for thought on a subject which is by no means
clarified.

EXTENSILE EXPOSURE.
By ARNOLD K, HENRY, M.B Dublin; M.Ch.(Hon.),
Trinity College, Dublin, and Cairo, F.R.C.S.I.
Chevalier de la Legion d’Honneur, Second Edition.
Edinburgh: E. & S. Liginstone Ltd., 1957. 9” x 7”,
308 pp., 298 illustrations Price: 45s. stg.

A distinguished Q.C. in answer to the query “how
are things at the Bar ” replied “wonderful, never
before have people been in so much trouble.” It all
depends on the point of view. We like our fare
plain and ungarnished —like Sam of immortal
memory “we eats our biled mutton without capers
and don’t care for horse-radish wen ve can get beef.”
Anatomy, clothed in strange garb, beset with
obliquities and riddled with references many of
obscure relevance is to us a labour certainly not of
love. Imagine the consternation at home if a mes-
sage, received and deciphered, seemed to indicate
12 guests for dinner when actually the author had
gone North for the grouse. It could happen.

And yet this book is an absolute “must” for all
surgeons, and particularly orthopaedic surgeons. This
edition which contains all the original chapters —
altered very littlke—has been expanded to nearly
double the original size. In doing so the author has
enlarged its scope and will, in consequence, greatly
increase the number of addicts.

Superbly illustrated descriptions of the surgical
anatomy of the neck, particularly the vertebral
artery and the main vessels in the root of the neck
are of absorbing interest. Australian surgeons will
be gratified at the reference to the late W. A. Hailes’
famous case in which he ligated the first part of
the subclavian artery from behind —a method advo-
cated by the author since 1923. At the second left
costal arch he also exposes the stellate ganglion —
also from behind — and by resection of an anterior
segment gains access to the pulmonary vessels for
embolectomy as well as the upper thoracic ganglia,
sympathetic and spinal nerve roots.

Another new chapter concerns the pelvis. Genito-
urinary surgeons will find much of interest in the
midline extra-peritoneal hypogastric route, particularly
“prelusive vascular ligation” in prostatectomy. By
the same approach, or with a slight addition, dener-
vation of the hip joint can be performed. As a
reward for diligence we find the thigh adductors
referred to as “the muscles of chastity” and all, or
nearly all, is forgiven. In fact the author is now
right back in favour particularly so as he appears to
solve a problem that has worried many, including
the great, for years. It reads like a “whodunnit,”
as clue after clue is considered and discarded, and
finally the true function of the gluteus maximus
established. Or is it? Perhaps in the next edition

76 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

he will explain the part, if any, played by the gluteus
maximus in that all-important component of the
oarsman’s stroke — the leg-drive.

And so on to the leg. A third head of the rectus
femoris is described but without conviction. Ad-
ditional chapters concern the exposure of the femoro-
popliteal vessels from behind including the deep
femoral artery. The “moorings of the talus” are
beautifully described, illustrated and tabulated, and
if we ever have to perform talectomy (we would
never do it for pleasure) the reference is here.
Finally the contents of the foot are displayed to-
gether with an operation that looks too terrifying
even to contemplate.

Most surgeons in this country—and there are
Guy’s men amongst them — associate BIPP with the
name of Rutherford Morison. As usual E. & S.
Livingstone Ltd. have produced a book up to their
best standards and there can be no higher praise.
Doubly welcome because of its wider appeal, the
author once again has given us something in his own
inimitable style which though irritating, aggravating
and even annoying, is yet at all times and in every
page, maddeningly magnificent.

MODERN TRENDS IN NEUROLOGY. Second Series.
Edited by DENIS WILLIAMS, C.B.E., M.D., D.Sc.,
F.R.C.P. London: Butterworth & Co. (Publishers)
Ltd., 1957. 10” x 7”, xi plus 374 pp., 79 figures.
Price: £5 stg.

“Modern Trends in Neurology” (second series),
edited by Denis Williams, will be welcomed by those
who found value in the first, published in 1951.
Although it cortains four more contributions they
are shorter, and the volume is much smaller. Only
two contributors are shared in common.

The essays are said to be a contribution of the
epoch, and no attempt has been made to dovetail
them into the former series. A good deal more at-
tention has been paid to the basic sciences, and in
particular to the chemistry of the nervous system.
The authors selected have all made some contribution
to the chosen subjects; this choice has been on the
whole satisfactory, although naturally there has been
some disparity in the techniques of communication
and in clarity. To this the subjects also contribute.
Neurology, as used in the title, means more than the
craft of the neurologist-physician or surgeon, and
includes the basic sciences underlying nervous
disease.

P. W. Nathan discusses the anatomy of the nervous
system, emphasizing such modern concepts as the
non-specificity of end-organs, and the connections of
the fronto-pontine tract and of the thalamus and
hypothalamus. All are well covered.

C. E. Lumsden, in a valuable article, discusses the
formation of the myelin sheath in both central
nervous system and peripheral nerves, and its re-
lations to the axis cylinder, the Schwann cell and the
oligodendrocyte, the importance of which is becom-
ing more fully established. Studies in electron-
microscopy, cell physiology and chemistry are
utilized, one important objective being the evasive
problem of disseminated sclerosis. It is by no
means impossible that such methods may yet resolve
this enigma. The same author in one of the most
important contributions in the volume points to the

great number of studies made in the chemistry of
the nervous system during the last ten years, and
selects from it for examination, three main types of
enzyme associated with medullated nerve tissue and
pathological demyelination. He discusses the roles
of porphyrins, cations in enzymatic reactions in the
white matter, and trace substances with special
reference to disseminated sclerosis and allied dis-
orders. He makes an excellent case for the im-
portant place of neuro-chemistry in the solution of
problems once considerea largely clinical.

J. N. Cuming’s article on some metabolic disturb-
ances affecting the cerebrum is a further example of
the value of this approach. He reviews hepato-
lenticular degeneration and its relation to copper
metabolism; hepatic coma and its association with
the metabolism of ammonia; and phenyl pyruvic-
oligophrenia. Finally, there is a recurrence of the
theme of demyelination in its various forms, and a
discussion of the lipoidoses.

Problems concerned with the cerebro-spinal fluid
are considered in two articles, the first by W. H.
Sweet, dealing with recent observations made upon
the interchange of water electrolytes and protein
particles through cell membranes and sheets of cells
throughout the cerebro-spinal fluid pathways. This
has been rendered possible by studies on the be-
haviour of their isotopic counterparts. It offers an
explanation of the varying proportions of con-
stituents of the fluid in such conditions at spinal and
ventricular block. That the older methods of study
have not lost value is emphasized in a contribution
by John Foley on the physiology of intra-cranial
pressure. The clinical side is here well integrated
with the physiological and the anatomical. Some of
these aspects recur later in the volume in a valuable
study by R. T. Johnson on the pattern of mid-brain
deformity in expanding intra-cranial lesions, and
in J. D. Spillane’s discussion of developmental
anomalies in the region of the foramen magnum.
Both articles are most informative.

R. W. Gilliatt presents a well ordered account of
the newer science of electromyography. Although
brief, it is a useful presentation and indicates those
fields in which it may be best employed.

The discussion on primary diseases of muscle
by F. J. Nattrass is largely concerned with the
dystrophies about which there is little‘new. Perhaps
too much space is given to classification which can-
not be satisfactorily resolved until more is known
of causation. Polymyositis and muscular hypotonia
in infancy are also considered. Hugh Garland
writes on diabetic amyotrophy. Its recognition is
important in that it may be incorrectly diagnosed,
and is usually reversible with treatment. Un-
fortunately there is yet no pathological material
available for study, and the sites of the lesions be-
tween cord and muscle are unknown. At this stage,
the reviewer might express some disappointment that
no article dealing with the relation of carcinoma to
the various lesions, nervous and muscular, with which
it may be associated, has been included in a volume
on modern trends.

Disease of the vascular system is one of the major
unsolved problems of the age. The pathogenesis of
cerebral athero-sclerosis, and in particular the role
of lipoid metabolism is introduced briefly by T.
Crawford. The possible significance of the phospho-

es on ah OOo

Books REVIEWED 77

lipid content of the diet, and of the relative pro-
portions of certain fatty acids are clearly indicated.
Disease of the cerebro-vascular system in its clinical
aspects is continued in several articles. Sir Charles
Symonds gives a lucid and well set out account of
the important subject of occlusion of the internal
carotid artery. He mentions the dangers of carotid
angiography when the vessels are already athero-
sclerotic; indicates other indirect methods of diag-
nosis, and hints that direct exploration may yet
become the method of choice, particularly in the
young and otherwise healthy.

The clinical aspects of intracranial “angioma”
are considered by Hamilton Patterson although
realizing that these lesions are vascular malforma-
tions. The article is a very useful one, but it seems
illogical to retain the name angioma when it is
plainly incorrect.

L. S. Walsh carefully analyses the result of treat-
ment of spontaneous sub-arachnoid haemorrhage. He
makes an excellent case for early operation on
selected cases of aneurysm, based on the region
involved as shown by angiography, and the time
since occurrence

H. Miller studies the neurological complication of
serum sickness, prophylactic inoculation, poly-
arteritis nodosa, certain of the exanthemeta, and
discusses acute disseminated encephalomyelitis. He
believes in the allergic basis of many of these con-
ditions.

Helen Dimsdale briefly describes some infections
of the central nervous system proven, or strongly
suspected to be, of virus origin. Her description of
the occasional epidemics, institutional or more widely
spread, is of special value: they are practically with-
out fatality, and of unproven virus origin; yet form
an important group clinically.

Sarcoidosis of the nervous system is well described
in all its aspects by Michael Jefferson, who wisely
does not commit himself as to its aetiology. He
presents calciferol and cortisone as the chief con-
tenders in medern treatment with considerable
emphasis on the second.

Aural vertigo, largely a clinical study, could
hardly be better done than in the contribution of
T. Cawthorne. His intimate knowledge of this con-
dition is shown in every paragraph.

Cevical spondylosis has assumed such importance
of recent years that it is good to see such a clear
and wel! balanced account of that of Valentine
Logue. He does not assume that our knowledge is
complete, and predicts that the problem of the
anterior ridge may yet be overcome by a safer tech-
nique for its removal anteriorly.

The neurosurgical treatment of diseases of the
affect, by which is meant the various types of
lobotomy and lobectomy which have been, or are
being practised, are described, or perhaps over-
described, by J. Lawrence Poole. There are many
useful observations, and no one can doubt that such
operations can be of great value; but it requires a
somewhat more philosophical approach than in this
article to put the matter into proper perspective.
The operation is a simple one, but its results are
not.

Another important topic of the day, epilepsy, and
in particular temporal lobe epilepsy, is well covered
by contributions by three authors. A. Meyer's
analysis of hippocampal lesions in epilepsy is of
particular value as an example of putting things
into perspective. The main problem is to what
degree sclerosis of Ammon’s horn and neighbouring
areas are the result of epileptic attacks, and par-
ticularly of early status epilepticus; and to what
degree they are a cause, primary or aggravating, of
their occurrence. It is disconcerting to observe how
much recent work on the subject is based on in-
complete examination of pathological material. The
thoughtful article of the editor, Denis Williams, on
the temporal lobe and epilepsy, which ends the
volume could be studied with advantage by all
interested in the subject; and his final observation
that “when foci of electrical discharge are seen in
the temporal lobe they are also arising in an epileptic
brain” reflected upon. Otherwise too much will be
expected of surgical excisions of foci for the control
of epilepsy.

Donald Tower’s discussion of the status of the
medical treatment of seizures is particularly useful,
even if humbling to the physician. It is well docu-
mented, thoughtful, and contains several valuable
tables.

Altogether this book is of great value. There is
no neurologist or neurosurgeon who should not be
able te learn semething from it, and there is much
to interest the general physician

THE COLLECTED PAPERS OF HUGH TRUMBLE.
Edited by LEONARD COX, R. S. LAWSON and T. E.
LOWE. Melbourne: Melbourne University Press,
1957. 52” x 93”. xxi plus 301 pp. Price: £4 4s.
It is only very occasionally that a medical group
decides to honour one of its members by the pro-
duction of a Festschrift or a volume of an author’s
“Collected Papers.” The last one which approxi-
mated to this second type, in Melbourne, was pro-
duced (nearly 35 years ago) as the result of urgent
demand of colleagues and students of one of our
greatest surgeons who was, interestingly enough, also
an Alfred Hospital surgeon. This was the Papers
and Addresses in Surgery by R. Hamilton Russell,
which appeared in 1923.

It is thoroughly appropriate that the Hugh Trumble
papers should have been chosen from contemporary
surgical publications in this manner. It is unneces-
sary to emphasize Trumble’s pre-eminence in original
and progressive thinking in surgery in Australia —
his works speak for themselves. This collection
shows both the wide range of his interests as well
as the penetration of his observation, thought and
his remarkable insight.

Any who were privileged to be associated with him
in the early days were impressed by his catholic
interests and the apparently easy (and obviously
“common sense”) manner with which he coped with
problems of all kinds. The construction of plaster
splints, the consideration of fundamental principles
underlying surgical treatment of many conditions
(well exemplified in the treatment of constipation)
and the application of general physiological and
pathological principles to such mundane conditions
as pressure sores, were equally and simultaneously
considered and weighed.

78 THE AUSTRALIAN AND New ZEALAND JOURNAL OF SURGERY

It is significant that, thirty years ago, he developed
much of his first-hand knowledge and many of his
techniques as the result of work on the experimental
animal. This was done at a time when such work
demanded pioneering effort in the production of
facilities, quite apart from anything else, of a high
order.

Trumble was mechanically inclined and _ the
application of this faculty, in many directions,
was exemplified in his extra-articular arthrodeses,
positioning of patients for thoracoplasty and the pro-
duction of weight-bearing instruments; these all show
his facility with metals and plaster of paris to be as
great as his capacity for dealing with living tissues.
His application of engineering principles in the
production of his craniotome and his abdominal
retractor are worthy of special mention.

Some idea of the scope of Trumble’s work is
given by the sections into which it has been divided
by the editors. They have chosen orthopaedic sur-
gery, the surgery of tuberculosis, surgery of the
autonomic nervous system, surgery of intercranial
tumour and general surgery. These could well have
been divided into other groups or various sub-
divisions could have been made without introducing
any artificial considerations. This all indicates the
astonishingly wide range of interests.

This volume is of importance in that it honours
one of our great surgeons and thinkers but, also, it
will be found of great value to the younger reader
in two ways. It shows the possibility of surgery for
real contributions to the subject beyond the call of
everyday work. As well, almost all of what was
written, even nearly thirty years ago, is still true and
some of it is still almost new; it will repay perusal
and careful thought.

The clarity of statement and succinctness of style
of all the papers makes them a pleasure to peruse.
The students and colleagues who were primarily
responsible for the reproduction of these papers
deserve high commendation.

The volume is strongly recommended to all sur-
geons and prospective surgeons.

THE ISLAND CAMPAIGNS. Australia in the War, 1939-
1945. Medical Series.
By ALLAN S. WALKER, M.D., Ch.M., F.R.A.C.P.
Sydney: Angus and Robertson, 1957. 94” x 64”,
xvi plus 426 pp., 87 illustrations, 45 diagrams and
maps. Price: 35s.

There are three types of military historians. The
first gives the facts to his reader and allows him to
draw his own conclusions. The second makes
criticisms as he records, while the third shows his
reader what could have happened if certain prin-
ciples and ideas had been followed. It is to the first
group that Colonel Allan Walker belongs. This is
not surprising to those of us who knew him as a
consultant physician in the Australian Army since
it was not his nature to be critical. He follows this
policy scrupulously in the third volume of the history
of the Australian Army Medical Corps in the Second
World War. This book is mainly concerned with
medical services from the middle of 1942 until the
conclusion of hostilities. With a few minor ex-
ceptions, it is a masterpiece of accurate reporting

and reflects the greatest credit on the author. Here
for all to read is the story of ceaseless war against
the tremendous difficulties of terrain, supply and
endemic disease, almost unknown in temperate Aus-
tralia. The evolution of modern military surgery in
forward areas under appalling and primitive con-
ditions is discussed but the factual type of writing
detracts from the human aspects of this triumph of
our Australian surgeons. Let us make no mistake
about the magnitude of the task they faced un-
flinchingly. There is nothing said of the degree of
improvization involved. As I write this review, I
remember clearly seeing one of my friends on his
way to Myola without any equipment except a pair
of scissors, yet he carried out first-class surgery using
the slender equipment of a field ambulance. Not the
slighest hint of the personality of the officers and
men of the medical services peeps out of these pages
which may be correct in a volume of this type
but, to my mind, detracts from its value for future
generations. Our generation can fill in the gaps by
merely closing our eyes and remembering.

It seems unfair to the men of the Army Medical
Corps that so little is mentioned of their efforts.
Here were Australians who had been fitters or
farmers in peace time and who became highly trained
nurses, theatre orderlies or technicians by stress of
circumstances. They did this unusual work with a
rare degree of devotion and skill. This would seem
to be much more important history than all the
eternal changing of generals that occurred in the
last three years of the War, to the confusion of
those serving in the Army.

To understand the peculiar conditions of medicine
in the Island campaigns, it is necessary to have some
idea of the strategy and tactics involved and Colonel
Walker does this very well. He has made this easier
for the reader by the use of very clear maps and
the illustrations are of the highest order. It makes
fascinating reading. The author shows very clearly
how the conditions of New Guinea forced the Army
to modify medical units to suit conditions never
previously encountered by the medical services.

The problems of supply and production, on the
solution of which depended our success, are well!
covered. How desperate was this situation in 1942.
Yet, again, the drama of the situation is missing
particularly in describing the effects of penicillin.
No one who treated casualties in the campaigns of
1942 and 1945 will ever forget the unbelievable im-
provement this made in dealing with wounds and
trauma. It was the beginning of a new era in
military (or for that matter, civilian) surgery. It
seems a loss to history that some experiences of the
surgeons in forward areas on this subject were not
included.

The reviewer did not find any mention of the part
played by the 46 Camp Hospital in the treatment of
casualties from the first Kokoda campaign. But it
is always easy to be critical. Colonel Walker must
have been faced with great difficulties in compiling
this volume and he has overcome them in a masterly
manner. Here, for all to read, is a great epic in
Australian history. It should be read with a sense
of pride in medical achievement by all doctors. It
should be read by all Australians, particularly those
who are wont to decry our achievements. It should

~- ~~ ©

Books REVIEWED 79

make us realize how much we owe to men of the
calibre of Fairley, Hailes, Littlejohn, Newton and
Burston who engineered this triumph.

MANAGEMENT OF ABDOMINAL OPERATIONS.
By RODNEY MAINGOT. Second Edition, in two
volumes, London: H. K. Lewis & Co. Ltd., 1957.
10” x 6}”, xvi plus 1,432 pp., 444 figs. Price: £8.

This excellent work on abdominal surgery has
been enlarged in the second edition which now
appears in two volumes.

The first volume contains a most comprehensive
account of all the general aspects of abdominal sur-
gery, including pre-operative treatment, anaesthesia,
surgical shock and resuscitation, post-operative care
and complications. There is a useful chapter on the
use of antibiotic drugs in abdominal surgery.

The remainder of the volume and the whole of
the second volume are devoted to regional considera-
tions. Descriptions of operative technique are well
illustrated and problems peculiar to a_ particular
operative procedure are discussed in detail.

The impression is given that the surgeon using this
work as a book of reference would rarely consult it
in vain. It can be recommended without reservation
to all those practising abdominal surgery.

TUMOURS OF THE SOFT SOMATIC TISSUES.
By GEORGE T. PACK and IRVING M. ARIEL. New
York: Hoeber-Harper, 1958. 104” x 7”, x plus 820
pp., 652 illustrations. Price: $30.00.

This is a portentous volume which contains a large
amount of information on the subjects discussed. It
is described as a clinical treatise and this being so,
it is perhaps a pity that so much time has been given
to what is, in point of fact, an inadequate considera-
tion of other aspects of the problems.

It contains an odd collection of conditions which
might be expected from a study of tissues whose
main characteristic is that they are soft. Incidentally,
this is not necessarily true of some of the structures
included and the confusion of thought exemplified
here is shown by several actual or implied contra-

dictions. Indeed, the presentation does not entirely
do justice to the quite remarkable amount of
material.

There is a good general statement about each of
the conditions and the various groups, and the dis-
cussion of the clinical features is adequate. In most
cases there is a good description of the macroscopic
appearances and both the clinical features and the
actual specimens are well illustrated. These probably
constitute the most valuable part of the book. The
problems are dealt with essentially from the practical
viewpoint so that naturally the various features just
mentioned are most significant; other characteristics
are less well dealt with.

In many cases some details of operative treatment
are given and these also are well illustrated. In
most parts of the work short illustrative cases are
interpolated.

The sections dealing with the fundamentals of the
subjects are not so well presented and, indeed, seem
to indicate a lack of appreciation of basic problems.
Certainly in these sections nothing is added to the
understanding of the subject.

However, viewed as a purely practical contribution,
this work has a good deal to recommend it. The
statements are clear and brief and the material is
throughout well illustrated. Within the limits of the
manner (and probably intention) of presentation, it
can be said that the subject is well and clearly com-
municated. It can be recommended as a useful
reference book for the experienced surgeon who is
interested in this field.

GASTRO - DUODENAL ULCER, PHYSIO - PATHOLOGY,
PATHOGENESIS AND TREATMENT.
By J. JACQUES SPIRA. London: Butterworth & Co.
(Publishers) Ltd., 1956. 10” x 7”, xvi plus 549 pp.
Price: £5.

This is a most extraordinary volume. It is a
strange collection of opinions expressed all over the
world in the last century on all aspects of alimentary
physiology and pathology, seasoned at occasional
intervals by the author’s quaint ideas. How can any
book that sets out to be a treatise on gastro-duodenal
ulcer (a horrible word in any context) be regarded
seriously when it devotes a bare four pages to treat-
ment and dismisses haematemesis almost with a wave
of the hand. Indications for surgery in haematemesis
are only two— (a) definite proof of a chronic ulcer,
(b) the age of the patient (over fifty). How I wish
it were as simple as Dr. Spira would make us
believe.

There are 167 pages of references out of a total of
536, but opinions by various authors are quoted in
a haphazard fashion, without the least idea appear-
ing of what Dr. Spira thinks of these opinions. In
a treatize on peptic ulcer, it is fascinating to read
that bile is lethal to spermatazoa or to find oneself
confronted by a classification of lipoidoses. Naturally,
the modern controversy on fats and atheroma is dis-
cussed in detail, but it is hard to see any justification
for this in its present setting. No attempt is made
to separate gastric and duodenal ulcers as separate
entities, except where dealing with malignant trans-
formation, and there he avoids giving any opinion by
disappearing into a semantic cloud. The suggestion
that inflammation in the appendical region can be
a factor in haemorrhage or perforation is extra-
ordinary. The glib description of chronic appendicitis
as a medical entity and a cause of complications in
peptic ulcer is surely out of place in 1957.

Dr. Spira cannot have looked at many gastric
ulcers through a gastroscope. If he had, he would
not make the indefensible statement — “the crater
will disappear before the oedema and irritability of
the structures.” His remarks on the effects of
irradiation on the gastric mucosa shows that he can
have had little experience in this subject. In the
same way, the author denies any effect of mal-
nutrition on gastric ulcers; this is probably a corol-
lary to his lumping all ulcers together, but surely,

it has been well established that malnutrition is
often associated with gastric ulcers. It is quite

useless for Dr. Spira to attack more orthodox
physicians for using the Sippy regime for most
doctors interested in the ulcer problem have aban-
doned this years ago and have advocated a normal
diet, with avoidance of food fried in dripping or
greasy foods.

This is not a book that can be recommended.

80 THE AUSTRALIAN AND NEw ZEALAND JOURNAL OF SURGERY

LEHRBUCH DER SPEZIELLEN CHIRURGIE.
By PAUL ROSTOCK. Third Edition.
de Gruyter & Co., 1957. 93” x 73”.
figures. Price: D.M.58.

This third edition of Rostock’s textbook has been
completed by Dr. Bramann, following the death of
the original author in 1956, and it has evidently been
well brought up to date.

It is difficult to quite see the significance of the
qualification “Special Surgery” in these German text-
books. This one is a very good general textbook of
surgery, intended primarily for medical students. In
its scope it is reminiscent of the well-known “Rose
and Carless” in the days when it was in single
volume form; and as such it is a very good book.
The clinical descriptions are clear and concise and
the paragraphs on pathology are adequate to the
purpose. Treatment in general, when it is not
operative, is fairly fully set out. When it is opera-
tive in nature it is, with some peculiar exceptions,
indicated rather than described, which is as _ it
should be in a students’ manual.

A criticism is that it is perhaps a little poorly
balanced. For instance the thyroid gland, from mal-
formations to malignancies, including a much fuller
technical description of the operation of thyroidectomy
than is usual, occupies twelve pages; the liver and
gall-bladder and ducts fifteen, but hernias receive
thirty. Space has been given to subjects which seem
rather outside the scope of general surgery. There
are full clinical descriptions of idiopathic epilepsy,
mumps and faucial diphtheria for example; and a
description, illustrated by three half-page diagrams,
of the extraction of teeth.

Treatment advocated in general seems to follow
much the generally accepted lines that British Sur-
gery follows, with the exception that there is a much
greater preference expressed for local anaesthesia
than we would agree with, and also a preference
(which is rather genera! among German surgeons)
for the internal splinting of fractured long bones by
pins running the length of the marrow cavity. In
discussing vesical calculus the author advocates
lithotrity, crushing and washing out the fragments.
In his text he says this should be done under endo-
scopic vision, but his illustration shews the old-
fashioned lithotrite in blind action.

These criticisms are however minor in discussing
a work of high quality, which does very effectively
what it sets out to do, namely to present a good
overall view of surgery to medical students and
general practitioners.

Berlin: Waiter
667 pp., 379

DIE LUNGENZYSTEN — PATHOLOGIE UND KLINIK.
Rv |. ZADEK and H,. RIEGEL. Berlin: Walter de
Gruyther & Co., 1958. 94” x 6}, x plus 138 pp.,
67 illustrations. Price: DM34.

This is a valuable presentation of present-day
knowledge of lung cysts. The subject has been dealt
with from the fundamental as well as the practical
point of view.

There is an introductory chapter on definition and
terminology which covers the important problems of
the relation of cysts to bronchiectasis on the one hand
and emphysema on the other. The structural features
of the cysts are discussed not only from the macro-
scopic and histological point of view but, in addition,
the radiological features are given considerable
attention.

The aetiology and pathogenesis is also dealt with
in some detail and in subsequent chapters a study of
the mechanism of formation of some of the cysts
is given. The clinical features and complications
are also discussed in detail.

The diagnosis of the cysts occupies an important
section and the methods of investigation discussed
range from bronchography, angiography, puncture
of the cysts, pneumothorax to thoracoscopy. The
advantages, disadvantages and dangers of the various
procedures are adequately dealt with. Similarly, the
treatment of cysts is dealt with thoroughly, the
methods ranging up to pneumonectomy.

The work is well produced and the material is
well presented. The illustrations are clear and there
is a useful bibliography. This book can be well
recommended to anyone who is interested in this
important subject of lung cysts.

THE MEDICAL ANNUAL.
By SIR HENRY TIDY and R. MILNES WALKER.
75th issue. Bristol: John Wright & Sons Ltd., 1957.
81" x 64”, xi plus 570 pp., 52 plates, 46 illustra-
tions. Price: 38s. 6d. stg.

The 1957 edition of “The Medical Annual” con-
tinues a fine tradition. Those who like their medical
literature pre-digested will find it gives concise and
well-balanced reviews of recent advances in many
fields of surgery.

The sections which will appeal to most surgeons
are the following: “Surgery of the Prostate” (re-
viewed by Norman Matheson), “Prostatic Enlarge-
ment” (a special article by E. W. Riches), “Surgical
Diseases of the Colon” and “Carcinoma of the
Rectum” (reviewed by J. C. Goligher) and “Surgical
Diseases of the Stomach,” by Norman Tanner.

The section on prostatic enlargement is the perfect
examination answer to this question, and for students
this alone is well worth the cost of the book.

Surgeons will also enjoy some of the non-surgical
parts of the book, and no doubt find entertainment
in reading of such problems as the investigation into
the question of whether the spirochete has a left- or
right-hand thread.

The book is well produced and has a number of
excellent illustrations culled from the articles re-
viewed.

SURGERY OF THE BILIARY TRACT.
By CHARLES B. PUESTOW. Second Edition. Chicago:
Year Book Publishers, 1957. 83" x 52”, 381 pp.,
72 plates. Price: $9.75.

This is a particularly good number of the Hand-
books of Operative Surgery series. It is intensely
practical, very sound, and an excellent guide to the
good practice of surgery in this sometimes difficult
field. The discussion of such problems as the relief
of chronic pancreatitis, the factors causing per-
sistence of symptoms after biliary tract surgery and
the management of portal hypertension, are valuable
contributions in a thoroughly good handbook.

Book Received

ANAESTHESIA FOR NURSES.
By ERIC GODWIN. Bristol: J. Wright & Sons Ltd.,
1957. 43° x 73”. 98 pp., 12 figures. Price:
9s. 6d. stg.