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Two case histories are presented in each of which an unexpected postoperative death was associated with a previously unsuspected phaochromocytoma, and post-mortem examination disclosed the presence of myocarditis. It is suggested that the myocarditis and the gross cardiac arrhythmias leading to the death of the patients may be connected. It is urged that this diagnosis should be kept in mind when unexpected arrhythmias develop in relationship to operation, and that the alpha and beta adrenergic blockers may have a therapeutic value in these circumstances.

OBJECTIVES To develop a profile of rural surgeons for comparison with profiles of rural general practitioners in the light of shortages in the rural medical workforce. DESIGN Rural surgeons were surveyed by a postal questionnaire in November 1997. PARTICIPANTS Members of the Provincial Surgeons of Australia residing in towns with fewer than 50,000 inhabitants. RESULTS 239 questionnaires were sent and 137 surgeons replied, a response rate of 59%. Our survey showed that rural surgeons are predominantly male, middle-aged and married. They work long hours, and nominate as their major concerns difficulty in finding locum cover, continual on-call work, peer isolation, children's schooling, and lack of privacy. CONCLUSION Rural surgeons and general practitioners share similar characteristics and concerns.

1. A description is given of historical discoveries relating to intermittent claudication. Various theories that have been advanced are discussed. A hypothesis, based on the work of Lewis, is elaborated. 2. A classification of obliterative arterial disease is outlined. The three groups that are distinguished are: primary thrombosis of the popliteal artery; juvenile obliterative arteritis; and senile obliterative arteritis. 3. The methods adopted for assessment of the severity of disease, including study of the clinical features, arteriographic findings, results of novocain infiltration and examination of the patient on a walking machine, are reported. 4. Methods of treatment by Buerger's exercises, contrast baths, intermittent venous occlusion and suction pressure; by lumbar ganglionectomy ant paravertebral block with phenol; by vitamin E (α-tocopherol) therapy; by treatment with thiouracil antistin; by internal popliteal myoneurectomy and division of the external popliteal and posterior tibial nerves; and by tenotomy of the tendo Achillis, are discussed. 5. It is concluded that tenotomy of the tendo Achillis should replace myoneurectomy in Type 3 cases where the blood supply is so far reduced that vascular stability cannot be achieved, and that it might apply in Type 2 cases in which there is persistent pain at a steady level. 6. The results of treatment in 276 patients with intermittent claudication are recorded.

Summary 1. Thirty-four cases of Hashimoto's disease are presented, in some instances in association with Sjogren's syndrome, rheumatoid arthritis, and adrenal-pituitary atrophy. 2. The difficulties in diagnosis are stressed by reason of the frequent nodular nature of the enlargement and the lack of precision in pre-operative tests. 3. It is advocated that all patients prior to thyroidectomy should have antibody tests performed, and where the index of suspicion is high a surgical biopsy performed before a major ablation is proceeded with. 4. The place for surgery is well defined: pressure symptoms, cosmetic reasons, or pain, and this should be restricted to a limited subtotal resection without risk to the parathyroid glands or recurrent laryngeal nerves.

The relationship between the prolonged use of pneumatic powered tools and the development of Raynaud's phenomenon was first described by Loriga (1911), and subsequently by Hunter, McLaughlin, and Perry (1945), and by Lindqvist and Flemberg (1945). This association with high frequency vibratory tools was later extended to other industrial processes. Telford, McCann, and MacCormack (1945) and Agate (1949) described 44 outbreaks " in workers using flex-driven (Morris drive) rotary polishing tools, Middleton (1931) in workers on 44 pounding " machines in the boot and shoe industry, Gurdjian and Walker (1945) in those using light riveting hammers in aircraft construc tion, and Agate, Druett, and Tombleson (1946) in 44 hand-grinders " holding iron castings against revolving grinding wheels. Details of industrial techniques and the frequency and wave form of transmitted vibrations have been excellently reviewed by Agate and Druett (1947). The object of the present investigation was to determine whether sufferers from vibratory tool Raynaud's phenomenon can be distinguished by any objective criteria from normal subjects or from those who develop this condition from some other cause (Jepson, 1951). Its natural history was con sidered particularly in relation to the occurrence of nutritional or organic arterial lesions in the digits. An attempt was also made to evaluate the amount of disability which it causes, not only at work but also in leisure hours.

Summary 1. Six cases of subclavian artery aneurysms associated with cervical ribs are reported. 2. The natural history of progression from a fusiform dilatation to a grossly abnormal vessel liable to massive or mural thrombosis with embolization is described. 3. For those cases with thrombosis and significant ischaemia, aneurysmal formation of great size or fragility, containing mural thrombosis with embolization, it is recommended that the segment should be resected and a graft inserted. 4. A method of graft insertion without resection of the clavicle is described.

The pathology of pulp space infection is discussed. It is recommended that a direct incision which is localised precisely to the abscess site, even if the incision is in the tactile pad, is better than a lateral incision, which fails to maintain drainage, causes longer incapacity, and may injure the digital nerve and give rise to causalgia. Fifty cases of pulp space infection in which a direct incision was used are reviewed.

This paper is concerned with the fate of 112 patients with aorto-iliac disease who underwent surgery from 1959 to 1966. The patency rate for those who underwent endarterectomy was 92%, and for those in whom a prosthesis was placed, 26%. It is stressed that the operation should be designed to suit the special needs of the individual patient, and it is pointed out that provided the proximal occlusions are overcome and the profunda femoris artery is intact, the symptoms of additional femoro-popliteal disease are usually acceptable in elderly patients.

Summary 1. two cases, one successfully treated, of aorto-caval fistulae, due to rupture of an abdominal aneurysm are reported. 2. it is re-emphasized that such a lesion is compatible with life and the duration of symptoms and survival is in major part dependent on the size of the communication. 3. the syndrome of pain, abdominal mass, bruit and thrill, and high caval pressure leading to collapse, venous congestion and renal failure is described. 4. it is suggested that such cases are surgical emergencies: that infusions may be dangerous and the presence of cardiac failure should not automatically eliminate the possibility of surgical care. the fistula, which may be several centimetres in length can be managed with or without caval control.

Eight cases of chronic relapsing pancreatitis are reviewed. It is re-emphasized that at this stage of the disease the major duct is involved in multiple strictures and cannot be drained by terminal anastomosis. The advantages of longitudinal pancreatico-jejunostomy are outlined, particularly in regard to the preservation of pancreatic function. The outstanding result in this series has been the relief of pain and the considerable gain in weight and well-being, even though no patient has apparently stopped drinking.

1 . A technique for measuring venous pressure during exercise is described. 2. The findings in normal and abnormal conditions of the lower limb are recorded. 3. The mechanisms involved in the return of blood from the lower limb in various conditions are discussed, with particular reference to the post-phlebitic state. 4. The need for an objective method of assessing the results of surgical treatment of venous abnormalities in the lower limb is stressed.

Summary A case of tuberculous arteritis, with false aneurysmal formation in the popliteal artery is described. Certain arteriographic features are stressed which may help to differentiate a tuberculous lesion from the more common arteriosclerotic aneurysm. Why a tuberculous arteritis should occur at this site is discussed.

Summary Fifty-six cases of carcinoma of the gall-bladder occurring in two Adelaide teaching hospitals over a five-year period have been reviewed. Eighty-four per cent. of patients were over the age of 60 years at the time of diagnosis, and the majority of cases occurred in women. Gall-stones were present in all except one patient in whom this could be verified. The prognosis, as in other series, proved to be very gloomy, and 61 per cent. of all cases were dead within three months of presentation. The three patients who survived longer than eighteen months, had lesions which were diagnosed as carcinoma only when the specimens were opened after operation. The incidence of carcinoma of the gall-bladder in 0·5 per cent. of consecutiveroutine autopsies and 3·7 per cent. of patients undergoing surgery for gall-bladder disease, is greater than in most reported series. The question of cholecystectomy for symptomless gall-stones is discussed, and it is concluded that in otherwise fit patients this should be recommended, not only because of the risk of carcinoma, but also because of the numerous other troubles and hazards to which these patients are exposed. The more radical surgical approach to established disease by means of right hepatic lobectomy must have a very limited place in view of the age and poor general condition of the majority of patients.

A follow-up review of at least three years was carried out on 80 patients diagnosed as suffering from attacks of acute pancreatitis. Thirty had associated cholelithiasis, 28 were alcoholics, and in 22 instances the pancreatitis was classified as idiopathic. It is clear that there is a widely varying response to continued alcoholism; one group will suffer only a single episode of acute pancreatitis, a few patients will develop acute relapsing pancreatitis, and a smaller number will progress to gross pancreatic destruction associated with persistent low-grade pain, weight loss and endocrine insufficiency. In the group with gallstones, we were impressed by the association of stones with the recurrence of attacks, and in contrast the freedom from attacks endowed by a cholecystectomy or choledochotomy. In the idiopathic group, those patients aged over 50 years usually had one single attack without subsequent trouble; for patients aged below 50 years, the chances are highly in favour of further relapses. This series supports the view expressed by Howard and Jordan (1960) and Sarles et alii (1965) that pancreatitis associated with alcoholism, pancreatitis associated with gallstones and pancreatitis of unknown œtiology have greatly differing natural histories and clinical patterns.

This paper analyzes the syndrome of symmetrical digital gangrene that results from various pathologic processes. If a group of such patients is closely studied, it is apparent that among those who have suffered a sudden and widespread occlusion of the small arteries of the hands and feet some may be grouped apart by reason of the single nature of the attack and the good prognosis. Eleven such examples seen by the author are described and their differential diagnosis, causation, and treatment discussed.

The effects of external pneumatic pressure on muscle blood-flow through the calf have been estimated by a Xenon-133 clearance curve technique. Flow was found to be greatly reduced at 40 mm. of mercury external pressure, and it was concluded that for first-aid purposes inflation pressures in excess of 30 mm. of mercury should not be used.

Summary 1. A series of 40 reconstructive operations on 36 patients for aorto-iliac stenosis is presented. The stenotic lesions were divided into 2 groups: (a) Liriche syndrome (15); (b) isolated stenotic lesions elsewhere in the aorto-iliac system (21). The differential diagnosis of these 2 groups on clinical grounds has been discussed. 2. A follow-up of the 40 operations has been performed over a period of six years. Twenty-four of these operations were endarterectomies while the remaining 16 were arterial grafts. Only 50 per cent. of the grafts are patent at the present time while 92 per cent. of endarterectomies are working. In our hands the results of the latter operation are so superior that we tend to perform it in preference to grafting, where possible. 3. The mortality rate (3 to 5 per cent.) for these operations is surprisingly good considering the magnitude of some of these procedures and the fact that often the patients are not first-class operative risks. However, post-operative complications have been numerous and include pneumonia (6), pulmonary embolus (4), ileus and burst abdomen (3), incisional hernia (1), adhesive obstruction (2) and superior mesenteric artery thrombosis (1). A transverse subumbilical incision has been used in the last 10 cases and none of these patients has ruptured their wounds, This incision gives a good exposure and appears to heal more securely than paramedian incisions. 4. The symptom of impotence in cases of Liriche syndrome has been investigated. In this series 4 out of 10 patients (40 per cent.) questioned complained of either partial or complete importence. This figure is roughly similar to other published series. To our surprise only one of these improved following operation, in otherwise successful results. Inaddition, 2 of the other patients who did not complain of impotence before operation developed this symptom afterwards. Although impotence in Leriche syndrome may be due to inadequate blood supply to the pelvis, its incidence after operation suggests this may be due to disruption of the pelvicnerve plexus at operation.

Summary 1. Seventy-two members of the Ileostomy Association of South Australia were reviewed and 9 (12.5 per cent) found to have associated urolithiasis. The majority of stones (5 out of 7 chemically analyzed) proved to be uric acid in nature. 2. The main aetiological factor would seem to be the loss of alkaline fluid and electrolytes from the ileostomy, resulting in the passage of persistently acid urine of low volume and high specific gravity. 3. Prevention may prove difficult and the importance of a properly functioning ileostomy without stenosis is stressed.

This paper presents a collaborative survey of 108 instances of serious arterial injury which were seen over the period 1959–68. The commonest cause of injury was iatrogenic. followed by motor vehicle accidents, industrial accidents, and gunshot or knife wounds. The results of repair of iatrogenic injuries and of upper limb accidental injuries were good. The end-results of treatment of accidental major arterial obstruction in the lower limb were bad. The two major causes of failure of treatment were thought to be failure to recognize the arterial injury, and failure to repair it within six hours.