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Perforation of the oesophagus still carries a high mortality, despite chemotherapy and antibiotics; and whether the rupture be in the cervical or the thoracic oesophagus, conservative management seems to be unsuccessful in most cases. Conservative measures have included the administration of chemotherapeutic drugs, intravenous fluid, gastrostomy, and in some cases drainage of the pleural cavity and of the cervical and mediastinal tissues. Barrett (1946) has pointed out that in patients suffering from spontaneous rupture the slit in the wall of the oesophagus may be of a considerable size, whereas the communication into the pleura may be relatively small. In consequence there is inadequate drainage into the pleural cavity and severe mediastinitis results. Fluid in the pleural cavity may be secondary, a consequence of the irritation of the gastric juices, so that simple drainage of the pleura is insufficient to relieve the toxaemia of the mediastinitis. This fact may explain the generally poor results following simple drainage of the pleura. Nevertheless, this method has on occasion been successful, as shown by cases recorded by Churchill (1935), Benson and Penberthy (1938), White (1941), Graham (1944), Adams (1946), and Dorsey (1948). Moore and Murphy (1948) treated their patient at first on conservative lines by thoracotomy and drainage, and repaired the perforation three weeks later. Collis, Humphreys, and Bond (1944) recorded the first case of direct suture of a spontaneous oesophageal rupture. Unfortunately the outcome was not successful. Barrett (1946) reviewed the literature on spontaneous rupture of the normal oesophagus, and stressed the fact that its possible occurrence must always be kept in-mind in the differential diagnosis of any upper abdominal emergency, and that some success might attend prompt thoracotomy and suture when clinical signs supported by radiology had led to early diagnosis. In 1947 he was able to record the first successful suture of a spontaneous rupture of the oesophagus. This was followed by another success reported by Olsen and Clagett (1947), their repair being carried out only three hours after the onset of symptoms. Cliffton (1949) has reported a successful closure, and in Scholefield's (1949) case successful suture and recovery ensued despite perforation into both pleural cavities. Lynch (1949) has three successful cases to his credit, two treated by suture and one by drainage of the pleura, the patient recovering after a stormy convalescence. The most recently recorded success is that of Dunavant and Skinner (1951). Nevertheless, perforation due to instrumentation or by impaction of foreign bodies is commoner than spontaneous rupture, and there is a reluctance to report cases of this type. Mosher (1935) reported 19 perforations in a series of 938 oesophagectomies. Goligher (1948) recorded two cases of rupture in the postcricoid region after the passage of a gastroscope, and urged that prompt surgical

In4erted cervix Corn upper end Diagrammatic view of inversion of cervix uteri (as seen at time of the caesarean section). Comment The mechanism actually responsible for this complication, when it occurs in any patient, is perhaps very difficult to explain. Sometimes sheer unfamiliarity with very rare complications such as this may lead to perplexity in diagnosis as in this case.