ABDOMINAL malignant disease is a common condition, and yet gross intraperitoneal bleeding from a malignant tumour is remarkably rare. Four patients, however, have recently been seen here with gross haemorrhage from a n abdominal neoplasm: I bled from the spleen which had ruptured at the site of a metastasis from a primary small bowel carcinoma; I bled from a leiomyosarcoma of ileum; and 2 from a granulosa-cell tumour of the ovary. CASE REPORTSCase 1.-Mr. A, S. was a man aged 67 years, who had had epigastric pain unrelated to meals for four or five weeks; shortly before admission he was seized with sudden severe pain in the left upper abdomen and felt sick, but did not vomit. On examination he was pale and shocked, and lay on his side with his knees bent. His temperature was 97" F., his pulse Ioo/min., and his blood-pressure 190/100 mm. Hg; the abdomen was tender and rigid, especially in the left upper quadrant, and an abdominal radiograph showed some elevation of the left diaphragm.He was thought to have bled into the peritoneal cavity, possibly from a rupture of an aneurysm of the splenic artery, and immediate laparotomy was performed. This disclosed an enormous effusion of partly clotted blood, and the spleen was found to be ruptured; it was removed and the peritoneal cavity cleared of blood.The patient was an asthmatic, and partly because of this he did poorly after the operation. In spite of energetic supportive therapy, he deteriorated steadily and died thirty-six hours later with pulmonary edema.PATHOLOGY.-The spleen showed an extensive subcapsular haematoma, in the centre of which was a round greyish-white tumour 2 cm. in diameter, which was shown microscopically to be a cellular anaplastic carcinoma. At autopsy, a soft, round, sessile papilloma 3 mm. high was found in the anterior wall of the duodenum just distal to the pylorus, and around it, encircling the intestine, many small round mucosal thickenings. In the proximal jejunum there were three oval transverse ulcers with rolled thickened edges, each 3 cm. long and 0.5 cm. broad. Metastatic deposits were found in the adrenals, which were practically destroyed, in the lymph-nodes of the omentum, porta hepatis, and mediastinum, and in the lungs, liver, and perinephric fat.Microscopically the papilloma of the duodenum and the jejunal ulcers were all highly cellular anaplastic carcinomata, practically confined to the mucosa, and showing only early invasion of the muscularis, but extensive invasion of both veins and lymphatics. The primary tumour was considered to be a small bowel carcinoma of multicentric origin.Case 2.-Mrs. M. C. was aged 46 years and had been unwell for the past month, first with thrombophlebitis in both legs, and then with a pulmonary embolism; she was admitted with abdominal pain for the previous 24 hours, and was pale and shocked and looked extremely ill. Her temperature was 99.8" F., pulse roo/min., bloodpressure 95/70 mm. Hg; her Hb 70 per cent (Sahli), and her white-cell count zo,ooo/c.mm. The whole of the lower abdomen was very ten...
The loss of N following thermal burns in rats is largely abolished after thyroidectomy.
Decompression sickness is an illness which occurs in divers and caisson workers on return to normal atmospheric pressure after working at very high pressures, and in aiRMEN on reaching very low pressures at great altitude. The disease seen after exposure to high pressure is described and compared with that seen on exposure to great altitude. Mild cases show little difference, but serious ones vary sufficiently to justify division of the disease into two distinct syndromes, high-pressure and high-altitude decompression sickness. Both syndromes are caused by the formation of gas bubbles in the blood and body fluids when the tension of dissolved gases becomes sufficiently greater than that of the surrounding atmosphere. These bubbles are composed of a mixture of gases, but their formation is determined mainly by the degree of supersaturation with nitrogen. The diver must first absorb excess nitrogen on exposure to pressure, and it is the subsequent release of this excess on return to the surface which causes decompression sickness; since his stay at pressure is limited, bubbles arise mainly from tissues which can absorb the excess gas readily. In the airman, on the other hand, all tissues are completely saturated with nitrogen before he is exposed to low pressure, and bubbles may arise equally well from any tissue. Nitrogen is much more soluble in fat than in water, so that fatty tissues can form a large reservoir of dissolved nitrogen which may later form a source of bubbles; but the blood supply of fat is poor and nitrogen diffuses slowly through it, hence although the potential capacity of the fatty tissues for excess nitrogen is great, they can only absorb it slowly. Obesity is therefore a major hazard in high-altitude decompression sickness, but relatively unimportant in the high-pressure syndrome. Liability to the airman's sickness increases markedly with age, but the incidence of the diver's syndrome is affected both much less and later in life. Decompression also involves great changes in the working atmosphere, and the effects of these and their possible influence on decompression sickness are discussed.
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