This report was stimulated by the fact that two middle-aged depressive male patients killed themselves in the same ward under identical circumstances within a fortnight. It was thought that it would possibly be instructive to examine the hospital records since its opening in 1866 to look at the available information about patients who had committed suicide whilst under inpatient care here. The total number of suicides to date has been 24 and in the years 1901, 1911, 1955, 1957 and 1965 there have been two suicides in each year. There was sufficient information available to suggest that there were certain similarities between those occurring in the years 1901, 1957 and 1965, so these cases are considered in greater detail in the following reports.

A 67-year-old man with a history of hypertension was referred to hospital with an isolated raised ALT (85 IU/l) on routine blood testing. On subsequent abdominal imaging with ultrasound, CT, and MRI, he was found to have bilateral adrenal masses, the largest on the right, measuring 9 × 6 × 4 cm. Urinary catecholamines were raised, and a provisional diagnosis of bilateral phaeochromocytoma was made. Following stabilisation with alpha and beta blockade, he underwent bilateral adrenalectomy via a large roof-top incision. The surgery was technically difficult due to a combination of body habitus (body mass index 34 kg/m 2 with extensive intra-and extraperitoneal adipose tissue, in a rather protuberant abdomen) extensive retroperitoneal dissection, and multiple adhesions. A concurrent splenectomy was undertaken for an adhesional splenic capsular tear not controlled by conservative methods. His roof-top incision was closed in the usual fashion and he was extubated postoperatively.On the first postoperative day, he complained of increasing amounts of abdominal pain, and was noted to have a tense, distended abdomen. He was hypotensive, oliguric and his intra-abdominal pressure (IAP) was markedly raised at 40 mmHg (normal, < 12 mmHg). A presumptive diagnosis of established ACS was made and the patient was taken back to theatre for an exploratory re-laparotomy through the existing roof-top incision (principally to exclude significant postoperative bleeding as a cause for the ACS) which was opened in its entirety. Apart from a nonischaemic, moderately distended transverse colon, there were no abnormal intraperitoneal findings. After opening the incision, the IAP reduced from 40 mmHg to 28 mmHg.At this time, a decision was made not to leave the rooftop wound open as a laparostomy, but to instead to close the incision in a standard fashion and to undertake prolonged neuromuscular blockade (atracurium) with mandatory ventilation as primary therapy for his ACS for a trial period. The patient was transferred to the ICU and, during this time period, his IAP started to decrease, which was accompanied by improvement in his physiological indices. After 48 h of neuromuscular blockade, his IAP had reduced to 19 mmHg, neuromuscular blockade was stopped and he was extubated. His IAP subsequently fell to normal levels over the following few days. He made a good recovery and was discharged home 12 days after his initial operation. Histology subsequently revealed bilateral phaeochromocytomas in the resected specimens. The patient remains well 18 months following his surgery, with no clinical herniation detectable in his roof-top scar. Abdominal compartment syndrome (ACS) is a recognised postoperative complication seen frequently in the intensive care unit (ICU). Surgical decompression and laparostomy remain the gold standard treatment for established ACS, combined with supportive non-surgical therapy, such as nasogastric decompression. In the following case report, we describe our successful management of a patient with established postop...

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too conservative a view has been taken of the benefits achieved. What emerges is a careful statement of the debits and credits in relation to the national exche quer, taking into account hospital and social security costs and tax, insurance and pension contributions.

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