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Published for the Royal Australasian College of Surgeons 

K: F. RUSSELL, Editor 
F. D. STEPHENS, Editorial Secretary 


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 


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 














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 


Vol. 28 —No. 1 



By Doucias G. McKay 




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- 

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 


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. 


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 

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 


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- 

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. 


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 

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). 


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 

(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 


Se we 

oe aes. 


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 

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 



No. of Cases: 1 


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 


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 


Type I without 


associated hernial sac. with short hernial sac. 

No. of Cases: 8 2 

bu bei 

Type Il 

with long hernial sac 


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 


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 



hagma/ Congenital Infantile Encysted Mya. of cord 




/nfant ile Lncysted 



Vaginal Congenital Infantile Encysted 


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 


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. 


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- 

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 


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

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. 


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 


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 



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. 


(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 

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 


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, 

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). 


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 

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 

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- 

a ee Me 


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. 


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 

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. 



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 

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 



_— a 


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 


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 

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.” 

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. 






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 

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 

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 

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. 


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 

During the operation, and for the first 

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



a ae 



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. 


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. 


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. 


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


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. 


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 

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- 

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 

i ih 

PAU Pi BAT. 2 







Em a 1 


‘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 

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. 




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 

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 


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. 


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- 


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 

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 

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 



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. 


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. 


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


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 


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. 


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, 


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 



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


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. 


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 


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


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 

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- 

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 



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. 


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- 

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. 


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, 


(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 



Muscle coat 


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). 


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 

(b) Combined orthotopic and ectopic ori- 

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 

(c) Ectopic orifice. 

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

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 

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. 

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 



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 

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 


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. 


The Ectopic Pathway 





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 


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 

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 + 








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 





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. 


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 

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 

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. 


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

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 


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

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 

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. 

(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- 



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 


(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 

(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. 


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 

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. 



ee Sere 


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


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

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

page 160. 
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 
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. 
—, (1878), Virchows Arch., vol. 72, page 130. 

70, page 


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 


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 

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



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. 


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


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 

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- 

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 



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 


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 


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- 


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 

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- 
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 

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. 


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 



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 


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 


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 

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 

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 

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 



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- 

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. 


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. 



Cause of Death 

Site of the Primary 

Period Between Completion 
of Surgery and Death 

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

Post-operative (cerebral haemor- 

Uncontrolled primary tumour 
Uncontrolled primary tumour 
Uncontrolled primary tumour 
Uncontrolled primary tumour 

Neck recurrence 

Side of the tongue 
Floor of the mouth 

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 


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 


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



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. 


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. 


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. 


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. 


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. 


(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 


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 

(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 


stage the upper small 



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 


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

A 8 
130 4 ° ° ° to 
= 120 ee © 
E £& 0 4 * °o 
g * 
t 5 100 4 ° 
8 8 
oe? 0 7 e ° e eS 
2 a 
a 80 +4 a e 
70 4 = e 
30 4 x x 
30 - 
= 26 4 x 
= 20 
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. 



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. 


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- 

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. 

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 





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

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, 

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, 

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 

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. 


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. 


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 


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). 


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 


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 


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- 

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 

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 


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. 


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

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


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 

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 

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 

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

page 330. 


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 


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 




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). 


twelve days post- 
leak of barium 


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

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. 


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 


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 

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 


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. 


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 


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). 


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

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. 


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 

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 

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. 


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 



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. 


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 

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


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calli sn 


By Tuomas H. ACKLAND 

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 


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


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. 


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


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 

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. 


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. 



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. 


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 


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. 


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- 


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 

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. 


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. 



Apair, F. E. (1933), Arch. Surg. (Chicago), vol. 
26, page 735. 

Bioopcoop, J. C. (1923), Surg., Gynec. Obstet. vol. 
36, page 486. 

CueatLe, Sir G. L., and Cutter, M. (1931), “Tu- 
mours of the Breast”. Philadelphia, J. B. Lippin- 
cott & Co., page 298. 

Cromar, C. D. L., and Docxerty, M. B. (1941), 
Proc. Staff Meet., Mayo Clin., vol. 16, page 775. 

Ewinc, J. (1940), “Neoplastic Diseases”. 4th Edition, 

Philadelphia, W. B. Saunders and Co., page 547. 

Frantz, V. K., Picken, J. W., Metcuer, G. W., and 
Aucuincioss, H., Jnr. (1951), Cancer, vol. 4, 
page 762. 

Gaston, E. A. (1947), Surgery, vol. 21, page 208. 

GescuickTER, C. F. (1945), “Diseases of the Breast”. 
Philadelphia, Lippincott, page 160. 

Lepper, E. H., and Weaver, M. O. (1937), J. Path. 
Bact., vol. 45, page 465. 

Haacensen, C. D. (1956), “Diseases of the Breast”. 
Philadelphia, W. B. Saunders and Co., page 198. 

Mitter, J. K. (1939), Amer. J. Surg., vol. 43, page 

Newton, N. C. (1949), Aust. N.Z. J. Surg., vol. 19. 
page 152. 

Parsons, W. H., Hentuorne, J. C., and CLARKE, 
R. L., Jnr. (1944), Arch. Surg. (Chicago), vol. 
49, page 86. 

Payne, R. L., Strauss, A. F., and Grassan, R. D. 
(1943), Surgery, vol. 14, page 719. 

Ropman, J. S., and IncLesy, H. (1939), Ann. Surg., 
vol. 109, page 921. 


By N. C. Tan 


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. 


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 


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. 



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. 


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. 


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 

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 



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 


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. 


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


By A. Distin Morcan 


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 


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. 


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 

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 



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 

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. 


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 


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 

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- 

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 




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 

(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 


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 

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. 


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. 


+ anna 



By Rowan WEBB 


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. 


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- 


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, 


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- 

3. Palpable thrill. 
4. Audible bruit. 

5. Parametrial pulsations in a 
malignant uterus. 


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 



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 

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. 


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- 

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- 


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. 


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 


1. The eighth recorded case cf cirsoid 

aneurysm involving the uterus is reported. 


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 

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. 

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- 

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 

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 


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. 

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 

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- 

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 

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 

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 

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. 


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 

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 

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. 

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. 

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 

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 

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. 

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 

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. 


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 

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 

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. 

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- 

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 

By ERIC GODWIN. Bristol: J. Wright & Sons Ltd., 
1957. 43° x 73”. 98 pp., 12 figures. Price: 
9s. 6d. stg.