The lower oesophageal high pressure zone (HPZ) was studied in 5 non-refluxing and 3 refluxing Rhesus monkeys. The changes in HPZ and reflux status in response to infusion of various doses of secretin, cholecystokinin and glucagon were measured in all animals, and, in the 5 non-refluxing monkeys, after oesophagogastrectomy with replacement of the lower oesophagus by a stomach tube. All three hormones consistently produced a transient decrease in the HPZ pressure. The only change in response following oesophagagastrectomy and gastric tube replacement was a significant delay in the response to each hormone. Neither hormone infusion nor operation altered gastro-oesophageal reflux status. It appears that lower oesophageal competence in primates is more dependent on the presence of narrow, muscular, intra-abdominal tube than on a specialized segment of the lower oesophagus.

SUMMARY Seven patients are presented each with symptomatic malignant melanoma metastases to the alimentary tract. Where practicable, surgical excision of the metastases is justified because two patients have had worthwhile periods of survival.The metastases ofmalignant melanoma are notorious for appearing many years after the primary and for their myriad clinical manifestations. Even so, symptomatic metastases to the alimentary tract are uncommon. Seven patients are described who presented with alimentary tract lesions which proved to be late metastases from malignant melanoma.These patients were all initially treated at Frenchay Hospital during the last 20 years. In each case, the primary malignant melanoma of the skin was excised widely, subsequently confirmed histologically, and the defect covered with a split skin graft. The patients were regularly re-examined. However, from two to 12 years later each patient was urgently referred to a general surgeon or physician, usually with symptoms of weight loss, cachexia, and anaemia. The case histories are summarized in the Table. Two patients (cases 4 and 5) were unfit for surgery and soon died; the diagnosis of metastases in the

Two cases of cold injury to the lower extremities, ‘trench foot’, are presented. The management is essentially conservative, but in cases of severe damage, particularly in elderly people, amputation must be advised.

1. Direct surgical denervation of the carotid sinus would appear to offer the best long-term results for carotid sinus syncope. 2. Carotid sinus denervation should be done under temporary cardiac pacing for safety and for completeness of denervation. 3. Arteriography is indicated to eliminate those cases of cerebral vascular insufficiency that might mimic carotid sinus syndrome. Credit must be given to Dr. R. Hughes, Clearfield, Pa., who recognized this diagnosis and referred the patient for therapy.

SummaryWe report a case of primary malignant melanoma of the gallbladder with review of the literature and comment on the frequency of secondary deposits of melanoma within the small bowel.