Emergency ligation of bleeding oesophageal varices using the Milnes Walker technique was performed in 38 patients. Haemorrhage continued or recurred in hospital in 11 patients, all of whom subsequently died. A further 10 patients died in hospital following operation from hepatic failure and a variety of other causes. Five patients were finally considered suitable for elective shunt surgery, but of 12 patients who were discharged without a further operation, only 2 have re‐bled. Although the overall 6‐month survival was 32 per cent, in patients with good preoperative liver function this rose to 71 per cent, and the simple scoring system for grading the severity of disturbance of liver function was found to be of value in predicting the outcome of surgery. Since the results of emergency ligation of bleeding oesophageal varices in our hands have been so disappointing we are currently using it less and are trying the mesenteric caval jump graft as an emergency operation for the control of bleeding varices.

These findings suggest an aetiological association between life stress and breast cancer.

The results of surgery in 48 patients with hepatic hydatid disease are described. In 26 out of 32 patients with uncomplicated cysts, conservative surgery with obliteration of the cyst cavity by omentoplasty gave satisfactory results. In contrast, 16 patients with cysts complicated by pyogenic infection or cholangitis required a variety of surgical procedures, including prolonged tube drainage, exploration of the common bile duct, sphincterotomy/plasty and hepatojejunostomy to achieve a satisfactory outcome. The group with complicated cysts also had a much longer postoperative stay (median 30 days) than those with uncomplicated cysts (median 14 days). Two patients died: in one, post-mortem examination revealed carcinoma in the wall of the cyst.

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SUMMARY Two cases with intractable vomiting due to gastroparesis, a rare feature of diabetic autonomic neuropathy, are described. Both required surgical treatment. In the first a gastroenterostomy was complicated by reflux gastritis requiring a revision operation; in the second a gastrojejunostomy was successful. Electron microscopic studies of the vagus nerve in one of the cases showed a severe reduction in the density of unmyelinated axons, the surviving axons tending to be of small calibre. The severity of the abnormalities supports the view that diabetic gastroparesis is related to vagal denervation. Postoperatively she has felt better, and she has had only two admissions in seventeen months with vomiting. On neither occasion has she been ketoacidotic and has been managed on oral fluids, intramuscular metoclopramide and elevation of the head of the bed. Three weeks postoperatively, a barium meal and video showed poor peristalsis as before with negligible emptying of the stomach via the gastrojejunostomy in the supine position, but free emptying in the semierect position.

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Surgical operations on deeply jaundiced patients are complicated by acute renal failure more often than comparable operations on non-jaundiced patients (Clairmont and Von Haberer, 1911;Aird, 1953 ;Zollinger and Williams, 1956). Considerable decreases in renal blood-flow have been shown to occur with traction on viscera during abdominal operations (de Wardener, 1955) or in shock (Lauson et al., 1944). It is possible that obstructive jaundice renders the kidney more sensitive to decreased blood-flow-that is, anoxia.Experiments were therefore carried out to test this hypothesis. Using unilaterally nephrectomized rats, the effect of clamping the remaining renal pedicle for 60 minutes was compared in jaundiced and non-jaundiced animals. Furthermore, observations were made on the effect of a mannitol diuresis on such a clamping in jaundiced rats.after the clamping a further 15 ml. of 10% mannitol was given intraperitoneally.In preliminary studies on unilaterally nephrectomized rats, using intraperitoneal injections, it was established that 5 ml. of 10% mannitol initiated a diuresis within four hours, and 15 ml. of 10% mannitol raised the urine output from between 7 and 14 ml. up to 25 to 30 ml.In all groups only those animals recovering from the pentobarbitone anaesthesia of the third operation were included in the final results.Blood samples (0.7 ml.) were taken from the tail vein immediately before the clamping operation for estimation of blood urea and bifirubin. On the first, second, third, fifth, and seventh post-operative days further samples (0.2 ml.) of tail-vein blood were taken for blood-urea estimation. The Scheme of experiments performed.The right kidney was removed in all animals. A second operation was carried out two days later. In the control animals, groups I and II, the common bile-duct was exposed but not ligated. In groups III, IV, and V the common bile-duct was ligated and divided to produce obstructive jaundice. For these operations ether anaesthesia was used.Seven days later, under intraperitoneal pentobarbitone sodium anaesthesia, the left renal pedicle was exposed. In groups I and III a bulldog clamp was laid alongside, but not occluding, the pedicle for 60 minutes. In groups II and IV the left renal pedicle was clamped with a bulldog clamp for 60 minutes.In group V the left renal pedicle was clamped for 60 minutes, but four hours before this operation an osmotic diuresis was started using 5 ml. of 10% mannitol intraperitoneally. After the clamping operation was completed a further 10 ml. of I0% mannitol was injected intraperitoneally. At 24 and 48 hours