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SUMMARYTwelve cases of 'spontaneous rupture' of the oesophagus occurring over a period of 20 years (195 1-71) are reviewed. The principal clinical and radiological features are described and the factors concerned in the pathogenesis of this condition are discussed. Although the mortality rate in this study was low (8 per cent) the incidence of severe postoperative complications was considerable, occurring in 10 of the 11 operative survivors. The importance of early diagnosis and adequate surgical treatment in the avoidance of this high morbidity is stressed.

Infirmary at LeedsIveson, J. M. I., Thadani, U., Ionescu, M., and Wright, V. (1975.) Annals of the Rheumatic Diseases, 34, 312-320. Aortic valve incompetence and replacement in rheumatoid arthritis. Five cases of aortic incompetence and nodular seropositive rheumatoid arthritis are presented. Four cases underwent aortic valve replacement. Two of these had granulomatous involvement of the aortic cusps similar to subcutaneous rheumatoid nodules, and another showed a nonspecific fibrosis. One case had definite coincidental rheumatic aortic and mitral heart disease. Two patients had undergone pericardectomy previously for constrictive pericarditis. Good results were obtained in all four operated cases and cardiac surgery enabled continuation of rehabilitation for the rheumatoid arthritis, including major orthopaedic procedures.A review of 22 cases from the literature with rheumatoid granulomata within the aortic valve shows that they are associated with mitral valve granulomata in 63-6%. Congestive cardiac failure was found in 75 %. Macroscopical evidence of aortic incompetence was seen in 36-8 % and of aortic stenosis in 15 8%. Associated pericarditis occurred in 59-1 %, which was severe or complicated in 13.6%. The associated arthritis was severe in 77-8% with subcutaneous nodules (71-5%), rheumatoid factor (83 6%), and episcleritis (66 6 %). From these cases and a review of the literature the following points are emphasized. (1) Both the granulomatous and nonspecific aortic valvulitis of rheumatoid arthritis may result in significant haemodynamic abnormality. (2) The valve lesions found are often clinically and macroscopically indistinguishable from rheumatic valve lesions. (3) Granulomata, when present, are usually found in the valve cusp or ring and only occasionally in the aortic wall. (4) Associated joint disease, although usually severe, may be mild. (5) The valve lesion may be accompanied by a severe pericardial involvement-either tamponade or constriction. (6) Aortic valve replacement for aortic incompetence in rheumatoid arthritis is both feasible and worthwhile, despite severe joint disease.

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patients had heart valve replacement with frame-mounted autologous or homologous fascia lata or with heterologous pericardial grafts. There were 111 single aortic, 95 single mitral, and seven tricuspid valve replacements.The incidence of hospital and late mortality was each 10% for the entire series and the main causes were myocardial failure and infective endocarditis.The majority of patients obtained significant symptomatic improvement. In patients with aortic replacement there was a statistically significant reduction in cardiothoracic ratio and in the voltage of the electrocardiogram.Regurgitant murmurs developed in 11 6y% of aortic patients and in 51'6% after mitral replacement (in 37-5 % the murmur has not increased in intensity while in 14-1 % it has gradually progressed). None of these mitral patients requires reoperation. Grafts in the tricuspid position have not shown signs of dysfunction or failure. Graft failure has not occurred in the aortic replacement series. From the mitral position six grafts have been removed due to failure. All six were made of autologous fascia and all showed varying degrees of thickening and retraction of cusps. There were six episodes of peripheral embolization (five transient) and one left atrial thrombosis. All seven patients are alive. Anticoagulants were not used.The results of haemodynamic studies and in vitro hydrodynamic experiments are discussed and an explanation for graft dysfunction in the mitral position is presented.The actuarial analysis of this series of patients over a period of up to 54 months postoperatively has shown encouraging results.

SUMMARYA case of ' spontaneous ' diaphragmatic rupture occurring during a normal delivery and resulting in herniation, incarceration, and gangrene of the stomach and omentum is described. Resection of incarcerated viscera was followed by complete recovery. T o the best of our knowledge this is the first report of such a complication of a 'normal' delivery.TRAUMATIC rupture of the diaphragm may occur as a result of blunt or penetrating injury to the chest or abdomen. The condition is well documented in the