Spontaneous intramural rupture or intramural haematoma of the oesophagus is a rare cause of acute pain in the chest and upper abdomen. Much less ominous than spontaneous complete rupture from which it must be distinguished, it seldom if ever necessitates operation. Five new cases are described and reviewed together with 15 collected from published reports. The dominant symptom of every case was severe and constant retrosternal or epigastric pain; concomitant dysphagia was mentioned in 11 cases. In seven the pain was preceded by or coFincided with vomiting. The condition was related to other stresses in three and appeared to be truly spontaneous in 10. In approximately one-third of cases it started suddenly but more often it began as discomfort worsening rapidly. Fourteen patients vomited blood after experiencing pain but only four were given transfusions. In contradistinction to complete rupture, none had surgical emphysema and plain chest radiographs were unremarkable. All had abnormal gastrografin or barium swallows. Intramural haematomas with or without mucosal tears were seen in the 11 cases in which oesophagoscopy was performed. Fifteen patients made rapid and complete recoveries on conservative management. Of the four who did not respond satisfactorily, one had the oesophagus repaired, two had drainage of the mediastinum after failure to find the false lumen at thoracotomy, and one had only an abdominal exploration. The only death in the whole series occurred after a disastrous emergency exploration and subsequent total oesophagectomy.The first editor of Thorax wrote for the first issue of this journal the article that was largely responsible for transforming spontaneous perforation or rupture of the oesophagus, the Boerhaave syndrome, from a little-known necropsy finding to a generally recognised clinical entity.' After describing the symptoms and signs by which the diagnosis could and should be made during life, Barrett argued that immediate repair was the logical method of treatment and offered the best hope of survival, and a year later he himself had the satisfaction of proving his thesis by recording the first succesful operation for that catastrophic condition.2 While there can be few nowadays who would recomend conservative management for

In the treatment of stenosis of the valves of the heart, it is common surgical practice to pass an expanding dilator or valvulotome through the cavity of the ventricle to the affected valve. To permit insertion of the instrument an incision about 1 cm. long is made near the apex of the ventricle, avoiding small coronary vessels, and the wound is repaired afterwards with two or three silk or linen sutures. The advantages and the immediate difficulties and dangers of such a procedure have been well documented and widely discussed, but latecomplications attributable to the ventriculotomy itself have attracted scant attention. We therefore report the occurrence of three left ventricular aneurysms following ventriculotomy and discuss their development, diagnosis, and treatment. Of these three incisional aneurysms, one was false and two were true. CASE REPORTS Case 1. A 50-year old Yugoslav man was admitted early in 1958 with severe aortic stenosis and mild aortic regurgitation. The first operation (12/2/58, Mr. W. P. Cleland) was a transventricular dilation of the heavily calcified aortic valve, using a 3-bladed dilator. The ventriculotomy was repaired with two silk sutures and the pericardium was sutured over the wound in the heart. Recovery from the operation was retarded by a staphylococcal pulmonary infection, the first signs of which appeared on the third day after operation. A course of erythromycin and novobiocin was started. The following day the clinical and radiological appearances suggested a collection of fluid at the left lung base, but aspiration yielded only a small quantity of turbid yellow fluid which on culture produced a heavy growth of Staphylococcus pyogenes, sensitive to erythromycin and novobiocin. His temperature settled to normal within the next few days and thereafter progress was satisfactory.The assessment of his condition on discharge from hospital was that there had been good relief of the stenosis at the expense of some increase in regurgitation. Re-expansion of the left lower lobe was incomplete and there was a good deal of residual thickening of the pleura.On 27/3/58, i.e. two weeks after his discharge, and six after the operation, he was readmitted. He had been well until three days earlier, when he began to shiver and feel ill, with pains all over his body. There had been anorexia and vomiting, but no cough and no sputum. A few hours before readmission he had begun to suffer pain in the anterior end of his scar where previously there had been only mild discomfort. His temperature was 100.40 F. Except for tachycardia and a small rise in jugular venous pressure the physical signs were the same as when he left hospital and the X-ray appearances (Fig.

Thoracotomy causes severe postoperative pain, which is difficult to manage since the use of systemic analgesics often causes respiratory depression. Cryoanalgesia of the intercostal nerves has been advocated as an effective means of local analgesia without serious side effects. A prospective randomised blind trial to investigate the efficacy of the technique was carried out. A total of 53 patients undergoing thoracotomy were allocated to either the trial or a control group. At thoracotomy the surgeon was informed of the patient's trial allocation. The trial group received one minute of direct cryotherapy to at least five intercostal nerves related to the incision. All patients received methadone via the lumbar epidural route in a dose calculated according to their weight. A linear analogue assessment of postoperative pain was made by the patients as soon as they were sufficiently awake. An independent record of all postoperative analgesia was kept. After discharge from hospital further assessments were made at least six weeks after operation. Statistical analysis of the scores of postoperative pain and analgesic consumption showed that there was no significant difference between the trial and the control group. There was, however, a suggestion of an increase in the long term morbidity, although these figures were not amenable to statistical analysis. Thus it has not been possible to demonstrate a role for cryoanalgesia in the control of post thoracotomy pain.The control of postoperative pain is particularly important in thoracic surgery. Adequate postoperative analgesia must be provided without impairing the remaining respiratory function. There has therefore been some recent interest in local methods of pain relief. It has been shown by this unit that the use of epidural methadone is an effective and safe way of providing analgesia during the early postoperative phase.' It cannot, however, be used for a prolonged period and therefore interest has been focused on cryoanalgesia, which has been said to provide pain relief for up to 26 days.2 Although there are favourable reports of its efficacy,34 the impression in this unit was that there was no subjective benefit. A prospective randomised trial was therefore devised to investigate the effect of adding cryoanalgesia to a standard postoperative analgesic regimen.

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