Steenkamp, Willem P.

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524 S.A. MEDICAL JOURNAL 28 May 1955it is understandable that DADPS should also have afavourable action in dermatitis herpetiformis.SUMMARYNineteen cases of dermatitis herpetiformis were treatedwith DADPS for an average period of 3t months.All cases responded to treatment provided dosage wassufficient. The relief of itching and the control of therash is more pronounced with DADPS than withsulphapyridine.I wish to thank Drs. H. R. Vickers, 1. Sneddon, D. FIetcher,R. Church and M. McElligott of the Rupert Hallam Departmentof Dermatology, Royal Infirmary, Sheffield, for access to theircases and for their advice.REFERENCES1. Esteves, J. and Brando, F. N. (1952): Ann. Derm. & Sypb.(Paris), 79, 224.2. Cornbleet (1951): Arch. Derrn. Syph. (Berlin), 64, 684.3. Kruizinga, E. E. and Hamminga, H. (19)3): Derrnatol.,106, 387.THORACIC OESOPHAGEAL DIVERTICULUMWILLEM P. STEENKAMP, JNR.Surgeon, Cape TownThis is neither an article on a known though com-paratively uncommon condition nor a report on aseries of cases. The case reported however presentsetiological and clinical features that warrant reporting it.Oesophageal diverticula are classified into pharangeal,thoracic and epiphrenic according to locality. Etio-logically again they are divided into traction or pulsiondepending on the causative factor present. 'Boyd l thusstresses the point that, as in hernias and aneurysmsthe diverticulum owes its origin to pressure from withinor traction from without.To the writer's mind this theory holds good forpulsion only in the case of cervkal (pharangeal) diver-ticula, since in that region no traction is present.Thoracic oesophageal diverticula, i.e. those belowthe bifurcation of the trachea, are usually due to trac-tion exerted by old tubercular lesions, whereas epi-phrenic ones, i.e. those just above the diaphragm, aretrue pulsion diverticula due to obstructed deglutitioncaused by cardiospasm, or a low oesophageal obstruc-tion caused by the scar tissue resulting from syphilis,tuberculosis, or a high gastric ulcer involving the oeso-phageal entrance into the stomach. These diverticulaare small-often multiple. Lindskay and Liebow2consider an already existing weakness of the oeso-phageal wall as the main causative factor. Sellors3states that although pulsion diverticula are fairly com-mon phenomena they practically always occur at theupper end of the oesophagus, being so rare in otherparts of the oesophagus that they can safely be dis-regarded.Mogendie 4 found 10% of oesophageal diverticulato be thoracic but does not state whether these caseswere mid-thoracic, like the case presently to be described,. or epiphrenic. Lahey and Warren" report that outof a series of 374 cases there occurred 9 epiphrenicpulsion diverticula. Here again a truly thoracic one isnot mentioned.The case to be reported was interesting etioloticallyin that it conformed to neither of the etiological theoriesadvanced by the aforementioned authors. There wasno pulsion or traction factor present, nor was therea history or clinical evidence of lues or tuberculosisor obstruction lower down. Professor Saint6 howeveradvanced the very interesting theory that where therehas been a large intake of alcohol over a prolongedperiod of time an inflammatory reaction of the nervesupply of the oesophagus sets in. There is a resultingweakness of the oesophageal musculature followed bydiverticulum formation. The case reported conforms tothis theory.CASE HISTORYK. was kindly referred to me by Dr. P. Brink. Thepatient was complaining of a continuous feeling ofnausea followed by copious vomiting approximately2 hours after a meal. Two years previously he had onlynoticed epigastric discomfort, but the condition haddeteriorated till he now was forced to seek medicaladvice.The past history was good except for an intake ofalcohol well above usual extending over the past 6 or7 years. There were no serious illnesses or operations.Physical examination revealed a fairly well nourishedmale aged 46 years. Except for slight deafness all theother findings were within normal limits.Considering his age and the symptoms complainedof, peptic pathology was the first consideration and hewas referred to Drs. Le Roux and McCallum for abarium meal. Only one plate of an excellent series ofpre-operative films is here reproduced (Fig. 1) and thediverticulum is shown to be mid-thoracic, that is tosay the ostium, although oIVing to its size the belly ispractically resting on the diaphragm and partly posteriorto the heart, is just below the bifurcation of the trachea.Operative treatment was decided on. Since theblood supply of the oesophagus is none too copiousit was difficult to decide on the best operative approach,since simple extirpation would leave a very wide defectin the oesophagus and thus a great possibility of post-operative sloughing of the suture line with the com-plications following an intrathoracic leakage.A very feasible alternative would be anastomosisof the diverticular pouch through the diaphragm withthe stomach. This would be fairly easy technically28 Mei 1955 S.A. TYDSKRIF VIR GENEESKUNDE 525Fig. Ibut subsequent regurgitation of acid stomach contentsinto the pouch might then cause anastomatic ulcerformation.The last alternative would be amputation of theoesophagus above the diverticulum and arrastomosiswith the stomach drawn up through the diaphragminto the thorax.Since the last measure would be quite a formidableoperation equivalent in magnitude to an abdomino-thoracic total gasfrectomy with all its possible com-plications, extirpation of the sac was decided on asprobably being the lesser of many evils. 'The thoracic cavity was entered through the 10thinterspace after removal of the 9th rib. Adhesions orother signs of previous intra-thoracic pathology wereconspicuous by their absence.Oesophagus and vagi were identified but the diverticu-lum was nowhere to be seen. However, after the pul-monary ligament had been split, which enabled theassistant to lift the lower lobe of the lung upward andat the same time displace the heart to the left, thediverticulum was exposed in its entirety.The sac was lifted from its bed and put under tension-slight since it was found to be friable and startedbleeding where touched by the forceps. J;he diverticu-lum was now amputated but not too flush with theoesophagus wall, so as to leave a liberal edge whichcould be folded inwards and thus avoid future strictureformation. Mucosa was separated from media andserosa and the two cut edges joined with a continuous'catgut no. 00. Media and serosa were now joined in aseparate layer and reinforced with interrupted silkstay-sutures.There was no bleeding throughout the operation.But the old adage has it, 'When in doubt drain', and thethorax was accordingly closed in the usual mannerafter institution of underwater drainage.Two pints of blood were transfused during and afteroperation, although this was hardly necessary sincepatient's condition remained excellent throughout.Post-operatively a Ryall's tube was left in situ andsmall feeds given through the tube on the 2nd day.The patient, however, was very resttess and on thesecond post-operative night pulled the Ryall's tubeout. Realizing what he had done he tried to put thetube back again, and the resultant noise attracted theattention of the Night Sister! Needless to say the worstwas feared after this heroic effort. However, he wasnone the worse for his attempted co-operation and afterliberal doses of C2HsOH had been added to the milkhe settled down nicely and never looked back again.He made an uneventful convalescence and after 2weeks was enjoying a full meal.Pathological examination of the sac was made byDrs. Clegg and Finlayson who reported as follows:Specimen Received: A diverticulum removed from the oeso-phagus. It was flabby and pouch-like having a brown outersurface and a pink colour inside where the mucous membraneFig, 2526 S.A. MEDICAL JOURNAL 28 May 1955was situated. There was also a tiny yellow spot where there mayhave been an ulcer. .Microscopic Examination: The diverticulum is lined by stratifiedsquamous epithelium which appears orderly and benign. It isbroken at the place where the yellow spot was seen macroscopic-ally and an ulcer exists but there is very little evidence of activeinflammation although tbe floor is made of very congested con-nective tissue. The muscularis mucosae is well preserved but theouter muscle walls (both longtitudinal and circular) are practic-alJy non-existent, only traces being apparent here and there.The appearances are benign and no evidence of neoplasia couldbe seen.Fig. 2 is an X-ray photograph taken I month afterthe operation. At that time the patient was enjoyingnormal meals and gaining weight.SUMMARYThe etiology of oesophageal diverticulum is reviewed.A new theory is put forward, viz. that alcoholicneuritis leading to muscular degeneration is a causativefactor.A case is described which appears to support thistheory.I wish to thank Mr. H. Katz for his valuable assistance at theoperation as welJ as in post-operative care.REFERENCES1. Boyd, W. (1947): Surgical Pathology. London and Phila-delphia: William Saunders.2. Lindskog, G. E. and Liebow, A. A. (1953): Thoracic Surgery.New York: Appleton. "3. Sellors, T. H. (1933): Surgery of the Thorax. London: Con-stable and Co. Ltd.4. Magendie, J. (1950): J. med. Bordeaux, 127, 793.5. Lahey, F. H. and Warren, K. W. (1954): SllTg. Gynec. OQstet.,98, l.6. Saint, C. F.: . Personal communication..SITUS INVERSUS TOTALISA REPORT OF A CASE PRESENTING WITH AN 'ACUTE ABDOMEN'CHARLES MARKS, M.B., CH.B., M.R.C.P. (EDIN.), F.R.C.S. (END.)ANDMAX POKROY, M.B., CH.B.Salisbury, Southern RhodesiaComplete heterotaxy, situs inversus totalis or, as thisrare condition is more generally known, dextrocardiawith complete transposition of the viscera may in thecool quiet atmosphere of the routine clinical examina-tion provide a source of diagnostic difficulty, full dis-cernment coming perhaps after radiographic investiga-tion. When, however, the patient first presents as anacute abdominal emergency. in the early hours of themorning the problem becomes magnified by the necessityfor early surgical intervention with all the implicationsof accessibility and the difficulty of manoeuvring on amirror-image of the normal and conventional ana-tomical arrangement of the abdominal viscera.CASE REPORTMrs. A.T., aged 34 years and the mother of 2 children, hadenjoyed perfect health until the present acute episode, which hadpersisted for 4 hours before medical aid was sought. Two hoursafter the evening· meal she experienced an acute onset of severecolicky pain in the left hypochondrium lasting an hour. Thepain persisted with a waxing and waning in intensity and she wasstill in obvious distress when she was seen. She felt extremelynauseous and bloated, suffering repeated belching. Recognizablefood was vomited on 2 occasions and 2 loose bowel actions oc-curred "during- this time.. The past history was irrelevant; herappetite had always been good, without disinclination for friedor fatty foods. Her menstrual history was normal.She was a thin, young arid anxious-looking patient, with atemperature of 99°F, pulse rate .of 100 per ..minute and bloodpressure of 140/90 mm. mercury. The tongue was clean andmoist and there was no evidence of icterus. Routine examinationof the chest was carried out and on auscultation of the beart itwas startling to note the absence of heart sounds in the left chest,whilst clearly audible sounds emanated from the right praecor-dium. The absence of tracheal displacement and of signs ofpulmonary miscbief made a diagnosis of dextrocardia very prob-able.Abdominal examination disclosed a "ten<:\er mass in the lefthypochondrium which moved on' respiration, al!d abdomin~1rigidity was localized to the left. upper rectus. Vag~nal and r~talexamination demonstrated nothmg abnormal and It was decidedto explore the abdomen for acu~eleft~sided calculous cholecys~itis,the possibility of acute appendICitis m an undescended left-Sidedorgan also being considered.An upper mid-line incision was performed and 1?spection dis-disclosed the visceral anatomy to be a complete mrrror-Image oftbe normal. The stomach, spleen and splenic flexure of the colonwere situated in the right hypochondrium, the mesentery ranfrom right to left and the caecum and appendix w~re situated inthe left iliac fossa. The lesser liver lobe was on the fight, the mamhepatic organ with the biliary apparatus being situate<:\ in the-lefthypochondrium.Cholecystectomy was performed for acute calculous chole-cystitis, the anatomy of the cystic artery, cystic and commo? bileducts being a perfect mirror-image of the accepted normal WIthoutany variations. Appendicectomy was also performed and theabdomen was sutured with drainage of the gall-bladder bed.The patient made an uneventful recovery and was discharged fromhospital in fit condition on the 8th post-operatIve day. Examma-tion of the gall-bladder disclosed that cholesterosis had served asthe basis for the two large cholesterol stones which were con-tained within it.COMMENTARYThough de~trocardia may exist alone, it is usuallyassociated with complete transposition of all the thoracicand abdominal viscera, the st'ructures retaining a perfectmirror-image relationship to each other. The heart isstructurally and functionally healthy, the electro-I

Thoracic oesophageal diverticulum

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Thoracic oesophageal diverticulum

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