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Old blood clots in the brain may produce the signs and symptoms which may mimic those of cerebral tumours discount cleocin gel 20gm with mastercard skin care with hyaluronic acid. Injury to the front or back of the head cheap 20gm cleocin gel amex acne 2015, particularly in elderly individuals order cleocin gel online from canada acne, may lead to subdural haemorrhage. The cerebral hemispheres move while the superior cerebral veins draining from the cerebral hemispheres to the lower part of the superior sagittal sinus remain fixed (See Fig. The acute form of this condition produces cerebral compression which is fatal and demands immediate surgical interference. In subacute or chronic varieties, the symptoms are less dramatic and consist of headache which is unduly severe and prolonged, mental apathy, slowness to respond to questions; the patient may go into coma when the midbrain pressure-cone is developed. The injury in force is generally a blow from the lateral side which may cause fracture of the temporal bone and injury to the said artery. The anterior branch bleeding is more significant and occurs mostly at a point when it leaves the bony canal at the pterion. At this time the temporal lobe is displaced medially and its inner portion presses on the 3rd nerve above the edge of the tentorium causing contraction, rapidly followed by dilatation of the pupil on the side of haemorrhage. Gradually the opposite crus of the brain stem is pressed against the opposite rim of the tentorium (See Fig. Finally impaction of the mid-brain cone leads to decerebrate rigidity and fixed dilatation of both the pupils. Extradural haemorrhage can also occur from internal maxillary or anterior meningeal vessels by fracture of the anterior fossa. Supratentorial haemorrhage produces its effect partly by local pressure on the brain underlying the haematoma, but more importantly by herniation of the uncus of the temporal lobe through the tentorial hiatus causing mid-brain compression. The mid-brain compression leads to (i) deterioration in the level of consciousness by damaging the reticular activating system; (ii) pupillary changes due to the effect of pressure on the oculomotor nerves and lastly (iii) hemiplegia due to compression on the opposite crus of the mid-brain with continuing pressure. Signs of damage to the pons may develop, which are (i) elevation of the blood pressure, (ii) slowing of the pulse and (iii) irregular respiration. The pupil on the side of the lesion dilates after initial contraction with poor reaction to light. In the last stage both the pupils become dilated and fixed without reacting to light. Cerebral compression mainly results from haemorrhage from intracranial vessels or oedema from local injury to the brain. The mid-brain is not initially compressed, therefore consciousness is not impaired. The effects of this haemorrhage are: (i) elevation of blood pressure, (ii) slowing of the pulse, (iii) irregular respiration, (iv) ataxia, (v) nystagmus and (vi) lower cranial nerve palsies. It must be remembered that infratentorial haemorrhage is by far less common than its supratentorial counterpart. During this lucid interval the duramater is slowly stripped off the skull by the accumulating blood, but the intracranial pressure continues to be normal by displacement of the cerebrospinal fluid into the spinal canal. When this compensation fails, intracranial pressure increases and the medial aspect of the temporal lobe herniates through the tentorial hiatus to compress on the mid-brain. This damages the activating reticular system in the brain stem with deterioration in the level of consciousness. In subdural haemorrhage, on the other hand, blood accumulates more quickly and does not allow much time for compensation to take place. This causes paralysis on the other side of the body starting from the face, then the arm, trunk and gradually towards the leg. When the medial aspect of the temporal lobe herniates through the tentorial hiatus by increasing intracranial pressure, the contralateral crus of the midbrain is pressed against the edge of the tentorial hiatus causing hemiplegia of the same side as the lesion. This occurs late in extradural haemorrhage but occurs earlier in cases of unilateral subdural haemorrhage. X-ray of the skull — may reveal fracture line in the temporal bone across the groove for middle meningeal vessels in case of extradural haemorrhage. Echo-encephalography will indicate a shift of the midline structures towards the opposite side in case of extradural haemorrhage and unilateral subdural haemorrhage. Of these complications, post traumatic headache and epilepsy deserve special mention. One thing must be remembered that headache may be due to injury to upper cervical vertebrae pressing on the great occipital and posterior auricular nerves supplying the vertex, the temple and the forehead. In this condition the patient will complain of pain during flexion of the cervical spine and tenderness can be revealed at the upper cervical spines. A type of early post traumatic epilepsy may be seen in the first 24 hours and is mainly caused by bruising and oedema of the brain near the site of injury. True post traumatic epilepsy due to the scar tissue formation in the brain or between the brain and the membranes will take no less than 6 months to develop. Post traumatic epilepsy is mainly Jacksonian type, uncontrollable twitching may affect the thumb or the hand in the beginning. Astrocytomas occur at any age — in the frontal lobes in adults and at other sites of the hemispheres in young subjects. These are of the following types:— Focal or localizing symptoms, symptoms due to raised intracranial pressure and due to cone formation. When this symptom is associated with hallucination of taste or smell, the uncinate process is probably involved with the tumour. In cerebellar hemisphere tumours there will be in co-ordination of the corresponding side of the body (deviation to the affected side on walking). Tumours of the frontal lobe generally push the ventricles back and the symptoms of raised intracranial pressure appear late. Intracranial tumours increase the intracranial pressure due to their own bulk and due to retained ventricular fluid. Occipital headache with a tendency towards radiation down the neck is commonly encountered in subtentorial growth. This type of vomiting is usually not preceded by nausea and may sometimes become aggravated by coughing and straining which increase cerebral congestion. It occurs early in the subtentorial growth and growth affecting the inferior aspect of the frontal lobe or temporal lobe. These symptoms are : (i) Drowsiness, (ii) Slow pulse rate, (iii) Neck stiffness, (iv) Paroxysmal headache and (v) Pupillary dilatation. Occasionally localized tenderness may be present over the underlying tumour, particularly the meningiomas. This is not specific for intracranial tumours which may not show any neurological deficit. Examination of the whole nervous system is more carefully taught in the department of medicine.

Multiple cavities of various sizes are Fig C 22-1 superimposed on a diffuse pulmonary infiltrate order discount cleocin gel on line skin care zits. A mycetoma (solid arrow) appears as a ball almost fills the large cavity in the right upper lobe homogeneous rounded mass that is separated from the (arrows) cheap cleocin gel on line skin care 45 years old. A right pleural effusion is also seen in this thick wall of the cavity by a crescent-shaped air space patient with chronic lymphocytic leukemia purchase 20 gm cleocin gel overnight delivery acne 10. Intracavitary blood clot Blood clot in a tuberculous cavity, infarct, or pulmonary laceration. Usually arises near of patients have myasthenia gravis (approximately the junction of the heart and great vessels 15% of patients with myasthenia gravis have (displacing them posteriorly). Lymphoma (especially Enlargement of anterior mediastinal and The presence of anterior mediastinal nodes in Hodgkin’s)/leukemia retrosternal lymph nodes commonly occurs. A striking lucency (Fig C 23-6) suggests a lipoma or lipomatosis (steroid therapy). Parathyroid tumor Smooth or lobulated mass that may be too May displace the esophagus. Aneurysm of ascending Saccular or fusiform mass that tends to extend May erode the sternum. Calcification is relatively aorta or sinus of Valsalva anteriorly and to the right. The hernia appears as a homogeneous opacity if it is filled with liver or omentum (mimics a fat pad or a pericardial cyst). Pericardial cyst Round or lobulated, sharply demarcated lower Typically touches both the anterior chest wall and (Fig C 23-8) mediastinal mass that is usually located in the the anterior portion of the right hemidiaphragm. The metallic clip overlying the region of the spleen (small arrow) and the small amount of free intraperitoneal gas seen under the right hemidiaphragm (large arrows) are evidence of a recent exploratory laparotomy and splenectomy for staging of the lymphoma. Mediastinitis Generalized widening of the mediastinum, Acute mediastinitis is most often because of (see Figs C 25-6 usually most evident superiorly. A lobulated esophageal rupture and may be associated with and C 25-7) paratracheal mass predominantly projecting to mediastinal air. Although most common in the middle and poste- (Castleman’s disease) rior compartments, in the anterior mediastinum the lesion tends to be lobulated (suggesting a thymoma or teratoma). Excess fat deposition in the mediastinum may be associated with moderate obesity, steroid therapy, Cushing’s syndrome, or diabetes or may be a normal variant in nonobese patients. Fat deposition localized to the superior portion of the anterior compartment may simulate a mass or aortic dissection. Lipoma Benign collection of fatty tissue that is most (Figs C 24-1 and C 24-2) common in the anterior mediastinum although it can also occur in the middle and posterior mediastina and adjacent to the diaphragm. Thymolipomas are anterior mediastinal masses that may be indistinguishable from lipomas. Liposarcomas are extremely rare, more commonly occur in the posterior mediastinum, generally have a higher density than benign fat, are inhomo- geneous, and tend to show features of mediastinal invasion. Large, relatively inhomogeneous mediastinum that has a homogeneous attenuation similar to that mass in the right side of the mediastinum. The mass extended into the right side of the neck to involve the recurrent laryngeal nerve, paralyzing the right vocal cord. Water density (0 to 15 H) Thymic cyst True congenital thymic cysts are rare and originate (Fig C 24-4) from the thymopharyngeal duct. Although usually asymptomatic, large cysts can produce tracheal or cardiac compression. Sagittal reformatted image shows that the anterior mediastinal mass is Fig C 24-8 closely attached to the pericardium with loss of Thymic carcinoid. Lobulated, heretogeneously the fat plane (arrow) between the two entities, enhancing mass. Retrosternal thyroid There is usually evidence of a connection between (Fig C 24-10) the mass and the thyroid gland in the neck. Multinodular goiters typically show a marked, rapid, and prolonged enhancement after the injection of intravenous contrast material. Parathyroid tumor Typically a small rounded mass that enhances (Fig C 24-11) more than muscle or lymph nodes but less than the great vessels. Bilobed, homogeneous soft-tissue lesion (arrows) in a patient with Graves’ disease. Cystic teratomas often demonstrate fat-fluid interfaces and may contain calcifications and soft-tissue nodules in the mass. Lymphoma Involvement of anterior mediastinal lymph nodes (Fig C 24-13) lying ventral to the aorta and superior vena cava. The presence of enlarged nodes in this region is a differential point from sarcoidosis that also affects hilar nodes (as does lymphoma) but not nodes in the anterior compartment. Mediastinitis/abscess Suggested by the presence of bubbles of gas or a discrete cavity with a thick, shaggy wall. Morgagni’s hernia A hernia containing fluid-filled bowel or part of the liver produces a mass of soft-tissue density. Mediastinal Uniform, symmetric widening of the mediastinum hemorrhage/hematoma (especially the superior portion) in a patient with a history of trauma, surgery, or dissecting aneurysm. Note that the lung interfaces with the hilar vessels (arrow) and aorta (arrowhead) are well preserved. Thus, on plain radiog- Fig C 24-12 raphs these middle mediastinal structures were clearly seen Mixed germ cell tumor. Contrast scan shows a huge tumor through the mass (hilum overlay sign), indicating that the that is primarily solid, thought there is a relatively large cystic lesion was either in the anterior or posterior portion of the component (arrow). Although often idiopathic, many cases are thought to be the result of an abnormal immunologic response Histoplasma capsulatum infection. Aneurysm of aorta or Various patterns depending on the location of Transverse arch aneurysms typically obliterate the major branch the aneurysm. Medias- tinal masses may also be caused by pseudocoarc- tation of the aorta and by dilatation of the superior vena cava or azygos vein. Mediastinitis Generalized widening of the mediastinum, Acute mediastinitis is most often due to esophageal (Figs C 25-6 and C 25-7) usually most evident superiorly. A lobulated rupture and may be associated with mediastinal paratracheal mass predominantly projecting to air. Chronic mediastinitis (granulomatous or sclero- the right may develop in chronic disease. Pleuropericardial Round, oval, or teardrop mass with smooth Fluid-filled cyst that is almost always asymptomatic (mesothelial) cyst margins. Intrapericardial hernia Gas-filled loops of bowel that lie alongside the Extremely rare congenital or posttraumatic lesion (Fig C 25-8) heart and remain in conformity with the heart that can contain (in decreasing order of fre- border on multiple projections (including quency) omentum, colon, small bowel, liver, or decubitus views).

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Consequently buy genuine cleocin gel on line skincare for men, skin necrosis should be anticipated when purple discoloration Leave the two closed suction drainage catheters in place until appears in the skin flap on the fifth or sixth day following the daily drainage diminishes to 30–40 ml/day or about mastectomy 20gm cleocin gel sale acne 39 weeks pregnant. We use a standardized series of graded ensued buy cleocin gel mastercard acne hoodie, and primary healing of the skin graft may be antici- physical exercises to ensure that the woman regains full pated. It is, of course, Take appropriate steps throughout postoperative treatment to far preferable to prevent skin necrosis in the first place by ensure the patient’s emotional and physical rehabilitation. Wound Infection Aspirate any significant collections of serum underneath the skin flaps with a sterile syringe and needle as Wound infection is uncommon in the absence of skin necessary. Refer the patient for adjuvant chemotherapy or for participa- tion in one of many clinical trials. Follow the patient for local recurrence or the development of Seromas cancer in the opposite breast. Once the initial period of close follow-up is completed, we Collections of serum underneath the skin flap, seromas occur follow these patients annually for life. This problem edema, which can become a disabling complication if appears more commonly in obese patients. On rare occa- trauma, including sunburn, to the arm and forearm of sions, this process continues for several months. If at any time the hand is traumatized case, it is preferable to make an incision under local anesthe- or there is any evidence of infection in the hand or arm, sia and insert a drain. Repeated aspiration over many weeks prompt treatment with antibiotics for 7–10 days, followed may result in infection of the seroma. Lymphedema Lymphedema of the arm is more common in obese patients, Postoperative Complications in those who have undergone axillary radiotherapy, and in those who have experienced skin necrosis, wound infection, Ischemia of Skin Flap or cellulitis of the arm. Lymphedema in the absence of any sign of This is a serious, partially preventable complication. These sleeves should be changed whenever emia is permitted to develop into gangrene of the skin, a they lose their elasticity, generally after 6 weeks. This treat- process that takes 2 weeks or more, some degree of celluli- ment should be instituted whenever one detects an increase tis invariably follows. Generally, elas- collateral lymphatic channels through which the lymph fluid tic compression keeps the condition under control if it has from the arm manages to return to the general circulation. Once the edema has been permitted Blocking these channels increases the incidence and severity to remain for many months, subcutaneous fibrosis replaces 1014 C. Total skin-sparing mastectomy: complications and local recur- compression has been recommended, but few patients toler- rence rates in 2 cohorts of patients. Nipple and areola-sparing mastec- necessary before significant progress is demonstrated with tomy. No data are available comparing these two sequences, so the choice is based on personal preference. Radical mastectomy is occasionally useful in highly selected patients for local control of advanced disease. Operative Technique Preoperative Preparation Incision Same as for modified radical mastectomy (see Chap. Pneumothorax may be produced by perforation in the chest cavity during attempts to control branches of the inter- nal mammary artery. Operative Strategy After elevating the skin flaps by the usual technique, radical mastectomy can be accomplished in one of two sequences. With the technique described below, axillary lymphadenec- tomy precedes removal of the breast from the chest wall. It is also feasible to remove the breast and the major pectoral muscle from the chest wall prior to doing the axillary dissection, as described for modified radical mastectomy. When the breast is removed proceeding from medial to lat- eral, gravity provides sufficient retraction and facilitates C. Adequate excision of advanced disease and nerves are divided between hemoclips during this may necessitate that considerable skin be excised and the dissection. Also detach the upper 2–3 cm of the major pecto- resulting defect closed by a split-thickness skin graft or a local ral muscle from the upper sternum. Incise the areolar tissue and fascia over the surface of the coracobrachial muscle and continue in a medial direction until the coracoid process is reached. This move exposes the Elevation of Skin Flaps junction between the coracobrachial muscle and the inser- tion of the minor pectoral muscle (Fig. Just caudal to The same technique as for modified radical mastectomy is the coracobrachial muscle are the structures contained in the used to elevate the skin flaps (see Chap. They are covered not only by fat and lymphatic tissue but by a thin layer of costocoracoid fascia. Clearing the fascia away Exposing the Axilla from the inferior border of the coracobrachial muscle serves to unroof the axilla and expose the insertion of the minor To perform a complete axillary lymphadenectomy, it is not pectoral muscle. Detach this muscle from its insertion after necessary to remove the portion of the major pectoral muscle isolating it by encircling it with the index finger; use the that arises from the clavicle. Preservation of the clavicular coagulating current to divide the muscle near the coracoid head of this muscle improves the cosmetic appearance of the process (Fig. Consequently, develop a line of separation near the entrance of the cephalic branch can be swept down- by blunt dissection between the sternal and clavicular heads ward by blunt dissection, exposing the axillary vein. Continue this separation to the point where the major pectoral muscle inserts on the humerus. Place the left index finger underneath the sternal head of the Dissecting the Axillary Vein muscle near its insertion and divide the muscle from its insertion with electrocoagulating current (Fig. It is not necessary to clean the fat off the brachial plexus or Complete the line of division between the two heads of the to remove tissue cephalad to the axillary vein. Pick up the muscle proceeding in a medial direction until the sternum is sheath of the axillary vein with Brown-Adson or DeBakey reached. A number of lateral anterior thoracic arteries, veins, forceps and use Metzenbaum scissors to separate the 115 Radical Mastectomy: Surgical Legacy Technique 1017 Fig. Continue this dissection laterally until the unopened scissors have been inserted underneath the adven- subscapular space has been reached; then clear the areolar titia to establish the plane, remove the scissors and insert one tissue from the subscapular space using a gauze pad, bluntly blade of the scissors under this tissue. Continue this dissection along the location of the long thoracic nerve descending from the bra- anterior wall of the axillary vein from the region of the latis- chial plexus in apposition to the lateral aspect of the thoracic simus muscle to the clavicle. Identify the thoracodorsal nerve anterior to the axillary vein are some thoracoacromial, lateral that crosses the subscapular vein and travels 2–3 cm laterally anterior thoracic, and pectoral blood vessels and nerves. In the absence of obvious lymph the conclusion of this step, the branches of the axillary vein node metastases in this area, dissect out the thoracodorsal have been fairly well skeletonized. Now divide each of the nerve down to its junction with the latissimus dorsi muscle. The silk sutures to apply labels to mark the apex and the lateral entire lymphadenectomy specimen should be freed from the portion of the lymphadenectomy specimen.

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In the United States cheap cleocin gel acne needle, the locus for decision-making about health care resides with the patient 20 gm cleocin gel mastercard acne xia, not the physician purchase cleocin gel australia acne 7 months postpartum. Tarasoff Decision: Duty to Warn and Duty to Protect A student visiting a counselor at a counseling center in California states that he is going to kill someone. When he leaves, the counselor is concerned enough to call the police but takes no further action. The court found the counselor and the center liable because they did not go far enough to warn and protect the potential victim. The counselor should have called the police and then should also have tried in every way possible to notify the potential victim of the potential danger. In similar situations, first try to detain the person making the threat, next call the police, and finally notify and warn the potential victim. An understanding of these concepts is fundamental to the comprehension of medical literature. Systems failures due to the complexity of health care delivery Health care is not a single system, but rather multiple systems which all interact. These clinical microsystems are defined as a group of clinicians and staff working together with a shared clinical purpose to provide health care for a population of patients. Individual health care organizations contain multiple microsystems which evolve over time. It is the complexity of these systems that predispose patients to harm from medical error. Health care in the United States is capable of achieving incredible results for even the most severely ill patients. In addition to the toll that this takes in the form of human suffering, medical errors also represent a significant source of inefficiency and increased cost in the health care system. The causes of these adverse events are not usually from people intentionally seeking to harm patients, but rather from the complexity of the health care system together with the inherent capability for human error. The causes of these errors are varied and can include failures made in administering medication, performing surgery, reporting lab results and making a diagnosis, to name a few. A sentinel event is an adverse event in which death or serious harm to a patient has occurred; it usually refers to an event that is not at all expected or acceptable (e. It is unacceptable for patients to suffer preventable harm caused by a health care system whose purpose is to provide healing and comfort. Improving patient safety is the responsibility of every health care professional and requires a comprehensive team effort. Systems in health care delivery can be redesigned to make it difficult for health care personnel to do the wrong thing and easier for them to consistently do the right thing. She is treated with steroids and nebulizer treatments to stabilize her respiratory status. During her course of treatment it becomes evident that the patient is not able to get time off from work to see her primary care physician during clinic hours, did not receive an influenza vaccination this year, and continues to smoke 1 pack of cigarettes per day. Incredible advances have been made in these areas and outcomes from acute presentation of disease have steadily improved over the years, with outcomes among some of the best observed in any health system in the world. However, the health care system here has lagged significantly in the area of disease prevention and health maintenance. Major disparities in access to preventative care services such as prenatal care, cancer screening and diabetes management; together with social inequalities with respect to patient education and income; as well as persistent individual behaviors such as poor diet, lack of exercise and cigarette smoking have contributed to the very poor overall health status observed in the United States. Ironically, the United States spends more on health care than any other nation in the world, yet ranks among the lowest in health measures, compared to other developed nations. Furthermore, the current rate of health care spending in the United States is unsustainable. Population health is an approach to health care that addresses both individual and public health concerns in order to achieve optimal patient results. It is an approach to patient care which understands that health is influenced by several factors outside of traditional health care delivery models, including (but not limited to) social, economic, and environmental factors. Population health management is fundamental to the transformation of health care delivery. Its principles recognize the importance of focusing attention not only on improving individual patient care, but also on improving the health of an entire population. In fact, direct health care accounts for only a small proportion of premature deaths in the United States. For example, the leading causes of premature death—smoking (435,000 deaths/year), obesity (400,000 deaths/year), and alcohol abuse (85,000 deaths/year)—are all preventable through interventions driven by population health management. Population health management is, in effect, about coordinating care and improving access in order to enhance patient/family engagement and reduce variation in care to achieve better long-term outcomes at a reduced cost. Another important step is to identify the specific health status and needs of that group and deploy interventions and prevention strategies to improve the health of the group. A key factor for the success of population health programs is automation, as managing populations can be highly complex. Technology-enabled solutions are essential to the efficient management of a program. Let’s say a primary care clinic is interested in improving population health for its diabetic patients. First, the clinic analyzes the patient registry generated by its electronic health record to identify high-risk type 2 diabetic patients who are not compliant with their medication and who frequently fail to keep their clinic appointments. Next, those patients are offered enrollment in a home hemoglobin A1c monitoring program, using a system which digitally records hemoglobin A1c levels taken in the home and then electronically transfers the results to the clinic. The system sends an alert to the clinical team when patients’ hemoglobin A1c levels are consistently higher than a predetermined threshold. A nurse coordinator contacts these patients by phone to help manage medication compliance, answer patient questions, and encourage timely follow-up with clinic visits. A nutritionist works with patients to encourage healthy dietary choices, while a social worker addresses any financial constraints to following medical recommendations. The airway is considered intact if the patient is conscious and speaking in a normal tone of voice. An airway is considered unprotected and/or compromised if there is an expanding hematoma or subcutaneous emphysema in the neck, noisy or “gurgly” breathing, or a Glasgow Coma Scale <8. Emergent airway control is best done by rapid sequence induction and orotracheal intubation, monitoring oxygen saturation with pulse oximetry. In the presence of a cervical spine injury, orotracheal intubation can still be done if the head is secured and in-line stabilization is maintained during the procedure. If severe maxillofacial injuries preclude the use of intubation or intubation is unsuccessful, cricothyroidotomy may become necessary. In the pediatric patient population (age <8), tracheostomy is preferred over cricothyroidotomy due to the high risk of airway stenosis, as the cricoid is much smaller than in the adult.

Though it is a congenital condition yet it may not be manifested before puberty or even adult life discount cleocin gel american express acne hacks. Such attacks are characterized by abdominal pain cheap cleocin gel 20 gm free shipping acne at 30, nausea order genuine cleocin gel on-line acne era coat, vomiting and pyrexia besides usual extreme pallor and jaundice. These crises may be precipitated by acute infection and may be as dangerous as to cost lives. The liver may be palpable and chronic ulcers of the legs are often seen in adult sufferers. Faecal urobilinogen is increased as most of the urobilinogen is excreted by this route. Measurement of faecal urobilinogen, if made possible, is the best guide to the extent of haemolysis in this condition. The liver may also be palpable and there is sometimes generalized enlargement of the lymph nodes. Acute episode consists of cutaneous purpura, bleeding from the oral mucous membrane and epistaxis. Ecchymoses or purpuric patches in the skin and the mucous membrane are the main manifestations of this disease. These lesions are mainly seen in the dependent areas due to increased intravascular pressure. Sustained bleeding from the wounds which may even be trifle is also a noticeable feature. Bleeding from the mucous membrane either from the gums or in the form of epistaxis or in the form of menorrhagia is not uncommon. On examination there is hardly any abnormality detected except that the tourniquet test becomes positive. Enlargement of spleen is hardly noticed if so the spleen becomes just palpable and never hugely enlarged. In the tourniquet test, the cuff of a sphygmomanometer is applied to the upper arm and inflated to just below the systolic blood pressure for 10 minutes. The main surgical importance is the association of abdominal crisis with this condition. Enlargement of the spleen with hypochromic anaemia, eosinophilia, leukopenia and lymphocytosis are the usual features. In late cases there will be enormous enlargement of the spleen and ascites due to liver atrophy. Associated pyogenic infections, infected ulcers around the ankles, anorexia, loss of weight and enlargement of lymph nodes help in the diagnosis. The spleen is grossly enlarged in case of the former and not so in case of the latter. The blood count will reveal large number of white cells in both the types with more percentage of myelocytes in myeloid leukaemia and very high percentage of lymphoblasts in lymphatic leukaemia. Swellings in connection with other organs are discussed under the right hypochondrium. The hernia is reducible and tympanitic, whereas the abscess is partially reducible and dull on percussion. The features of caries spine — deformity, tenderness, and rigidity will clinch the diagnosis. Sometimes a granulomatous mass resulting from deep seated infection, may look an adenoma. The hernia is usually seen just above the umbilicus where the two recti divaricate and this allows the hernia to come out. Irreducibility and incarceration (obstruction) are the two frequent complications. The clinician is warned against the diagnosis of incarceration, as the real event may be strangulation and valuable time may be lost by giving enema, waiting for the result and doing this or that. Incidence of strangulation is less in this hernia than in inguinal or femoral hernia. The wall of this hernia consists of fibrous tissue and the contents may be adherent. These are readily diagnosed by the presence of scar with a history of previous operation, expansile impulse on coughing and reducibility. Tearing of the inferior epigastric artery will cause haematoma in the lower abdomen below the arcuate line. Following a severe bout of coughing or a sudden blow to the abdomen may cause an exquisitely tender lump in relation to the rectus abdominis. There will be bruising of the skin with discolouration suggesting a haematoma underneath. Some form of trauma either stretching of the muscle fibres during pregnancy or operational wound will cause haematoma within the muscle fibres which may initiate the tumour formation. Matted coils of intestine with tuberculous mesenteric lymphadenitis is generally presented with a lump. A pale looking child with loss of appetite, loss of weight and evening pyrexia is probably suffering from this condition. Sometimes the pain becomes the main symptom and on deep palpation infected mesenteric lymph nodes may be palpable. So absence of calcified lymph node radiologically does not exclude this condition. Adenoma, submucous lipoma and leiomyoma are the benign tumours but they do not produce any palpable swelling. The tumours which may produce palpable lumps are lymphosarcoma and spindle-cell sarcoma. Cysts of the mesentery may be of various types of which chylolymphatic, enterogenous (derived from a diverticulum on the mesenteric border of the intestine) and dermoid (teratoma) cysts deserve mentioning. Besides these, tubercular abscess of the mesentery and hydatid cyst of the mesentery are rarely seen. These present as painless abdominal swellings, which are fluctuant and are situated near the umbilicus. The swellings move freely at right angle to the line of attachment of the mesentery but a little along the line of attachment. These cysts will be dull on percussion but will be surrounded by band of resonance. Temporary impaction of a food bolus in a segment of bowel narrowed by the cyst may produce features of intestinal obstruction. Torsion of the mesentery may produce acute abdomen which demands immediate relief. Rupture of the cyst and the haemorrhage of the cyst are the two complications of this condition which may give rise to acute abdominal catastrophe. These cysts may be derived from remnants of the Wolfian ducts when the containing fluid will be clear or the cyst may be a teratoma when it is filled with sebaceous material.

By U. Delazar. Massachusetts School of Professional Psychology.