- Email: [email protected]
CONGENITAL ADRENAL HYPOPLASIA
1065 the willingness to excrete sodium since a moderate rise in arterial be normal appears is followed by a induced blood-transfusion by pressure considerable natriuresis (Borst,12 fig. 6).
CONGENITAL ADRENAL HYPOPLASIA SiR,ŅIn 1959 you published our reportof two brothers, born in 1954 and 1958 respectively,. who were apparently normal at birth but in whom severe adrenal
Our hypothesis does not demand that hypertrophy of the heart maintains the high blood-pressure indefinitely. In the end, on the contrary, the blood-pressure level is solely determined by the pressure threshold level for renal sodium excretion. This is shown in our fig. 3. When the liquorice administration that raised the threshold level was stopped the renal response to the excessive performance of the (probably hypertrophied) heart was no longer held in check and renal sodium output increased. The cumulative sodium balance became negative and the central venous pressure fell to a subnormal level. The underfilling of the venous system preceded the fall in arterial pressure like the overfilling of the venous system in the first week of liquorice treatment had preceded the rise in arterial pressure. It is true that the sustained hypertension induced by unilateral narrowing of a renal artery that is found in rats and sometimes in man cannot be simply explained by our hypothesis. Since the hypertension is maintained not only the pressure threshold level of the " clamped " kidney must be too high but also that of the unaffected one. This could be due to excretion of small amounts of renin by the " ischxmic " kidney since Statius van Eps et al.16 have shown that infusion of amounts of angiotensin too small to raise the blood-pressure by direct vasoconstriction may significantly depress the renal sodium output in normal subjects. The fact that D.O.C. sometimes fails to produce hypertension in animals might be due to severe hypokalasmia that alters the responsiveness of the heart and the kidneys. In our patients D.o.c. and liquorice always caused hypertension when hypokalsmia was prevented. Finally, it may be relevant to raise two points. If it is true, that renal sodium output is not mainly determined by glomerular filtration-rate, estimations of this parameter are of minor importance in the study of renal sodium handling and therefore in the study of hypertension. If it is true that cardiac output, in the absence of circulatory failure, is adjusted to the metabolic require-
insufficiency developed in the neonatal period. The first congenital adrenal hypoplasia was found at necropsy. The second responded to the administration of adrenal steroids with correction of his electrolytic disturbance. When our report was published he was almost a year old and in good health on maintenance therapy. Others have reported adrenal hypoplasia in siblings recently,23 and, because more of these children are likely to survive in the future, we should like to record the progress of the surviving child who is now 51/2 years old.
patients with nephrosis to
ments, the determination of this parameter gives no more information than the estimation of the metabolic rate and cannot contribute much more to the unravelling of the pathogenesis of hypertension. On the other hand, it may be expected that long-term studies of the correlation of renal sodium output, central venous pressure, and arterial pressure in patients treated with mineralocorticoids, in parabiotic animals and in animals with clamped renal artery, will provide essential information about the cause of sustained elevated arterial pressure. Binnengasthuis, University of Amsterdam.
J. G. G. BORST.
TAPE AT THE BEDSIDE SIR,-Your annotation of Nov. 2 rightly concerned itself with recorded talks and sounds for demonstration purposes. The tape-recorder can, however, be of value in
bedside teaching
to
record
events
which
when the students (and teacher) may
occur at a
time
be present. practice is the
not
Foremost among these events in paediatric infant with a chest infection who coughs only occasionally and only at night. On many occasions now a tape recording of such a cough by the night nurse has led to a diagnosis of pertussis in the morning. R. R. GORDON.
16. Statius van Eps, L. W., Zurcher-Mulder, A., de Vries, L. A. in Boerhaave Symposium on Hypertension (edited by J. de Graeff and A.
Struyvenberg). Leiden,
1963.
infant died, and
At the age of 20 months he had
a severe
convulsion with
high fever, and he was treated with paraldehyde and hydrocortisone intravenously. A left-sided hemiplegia developed, which cleared up completely within a month, and a homonymous hemianopia, which persisted for almost a year. He was treated in hospital for 18 days after the convulsion, and he was discharged on maintenance treatment with 9-alpha-fluorohydrocortisone 0.2 mg. once daily and cortisone acetate 5 mg. twice daily, with an extra 1 g. of sodium chloride in his diet. At 3 years he had two slight " febrile " convulsions, for which again no cause was found, but these had no neurological sequelx. He has had no further seizures. At 4 years his height was 41 in. (104 cm.), his weight 45 lb. (20-5 kg.), and his blood-pressure 100/70 mm. Hg. During the next 12 months an attempt was made to determine whether substitution therapy was still necessary by gradually withdrawing the cortisone acetate, while the 9-alpha-fluorohydrocortisone and supplementary sodium chloride were continued. The cortisone acetate was finally withdrawn by the time he was 5, but within a short time he became increasingly listless-in contrast to his previous ebullience and energy-and pigmentation of the skin, especially of his hands, appeared. His condition was reassessed in hospital in March, 1963. As well as listlessness and pigmentation, his blood-pressure was only 90/50 mm. Hg, though his plasma-electrolyte and bloodsugar levels were normal. Injections of corticotrophin elicited EXCRETION OF 17-OXOSTEROIDS AND 17-HYDROXYCORTICOSTEROIDS IN THE URINE BEFORE, DURING, AND AFTER INJECTIONS OF CORTICOTROPHIN
adrenal response. As shown in the table, the amount of steroids in the urine before, during, and after the injections was consistently low and showed no significant rise; cortisol was undetectable in the plasma (less than 1 m[Lg. per 100 ml.) on days 2 and 3 of the test. These results are consistent with the original diagnosis of adrenal hypofunction, which we had attributed-in the light of the necropsy on the firstborn infant -to congenital adrenal hypoplasia. Cortisone acetate was again added to his regimen in a dose of 5 mg. twice daily, and very quickly his energy returned though the pigmentation has persisted. When he was seen on Aug. 24, 1963, at the age of 51/2 years, this treatment had restored him to good health. He was a well-grown sturdy child of average intelligence, weighing 571/2 lb. (26 kg.) and measuring 451/2 in. no
(115 cm.). 1. 2.
3.
Mitchell, R. G., Rhaney, K. Lancet, 1959, i, 488. Shepard, T. H., Landing, B. H., Mason, D. G. A.M.A. J. Dis Child. 1959, 97, 154. Boyd, J. F., MacDonald, A. M. Arch. Dis. Childh. 1960, 35, 561.
1066
At present it seems probable that maintenance therapy will have to be continued for the rest of this child’s life. We hope that, within the limits imposed by his condition, he will be able to lead a reasonably full and active life, and that no other hormonal deficiency will become
apparent We
are
at
puberty.
grateful
estimations, and
to
Dr. J. G. Sprunt for performing the steroid Prof. J. L. Henderson for helpful criticism.
to
Department of Child Health, University of St. Andrews.
R. G. MITCHELL* K. RHANEY.
RESEARCH IN GENERAL PRACTICE
SIR,-The letter from Dr. Fry (Nov. 9) is of the utmost significance. There is no doubt of the need for continuing operational and clinical research within the framework of general practice. Significant contributions have been made already by individuals, at the expenditure of their These resources are limited, and the which has been gained will be lost unless there is more support forthcoming. The establishment of research units in general practice is as important, and as logical, as the already existing units in other fields.
own
resources.
momentum
H. W. K. ACHESON. CARCINOID FLUSH
SiR,-Robertson and Andrews1 stated that the estimation of free plasma-serotonin (5-hydroxytryptamine, 5-H.T.) levels was essential in carcinoid disease. They obtained values in the range 20-60 ng. per ml. in 4 patients, and less than 10 ng. per ml. in 1. The estimation is difficult, because falsely high values may be obtained if platelets are damaged in preparation of the plasma. If the flush in carcinoid disease is due to a rise of 5-H.T. free in the plasma, it ought to be possible to demonstrate this by assay of platelet-free plasma. This has never been shown, except in the single case of Peart et al. in which during flushes the free plasma-5H.T. rose spectacularly to 900 ng. per ml. in the blood of the hepatic vein. Peart et al. do not state whether there was a rise also in arterial blood flowing to the areas which flushed; if so, the flush could reasonably be attributed to a direct peripheral action of 5-H.T. on the blood-vessels, but, if not, some other mechanism must be sought. Recently I was able to study a patient with carcinoid syndrome who flushed on intravenous injection of 2 g. of adrenaline as described by Peart et al. As shown in the accompanying figure, the flush was very striking, judged by measurement of the oxygen satura’ tion of venous blood drawn from an antecubital vein. Platelet-free plasma was prepared as described Free plasma - 5 - hydroxyby Hardisty and Stacey.4 Assays tryptamine in venous were performed as described by and arterial blood drawn Vane.5 Venous blood was drawn during an adrenalineinduced flush. by multiple clean venepunctures,
circulating
Present address: Department of Child Health, University of Aberdeen 1. Robertson, J. I. S., Andrews, T. M. Lancet, 1961, i, 578. 2. Peart, W. S., Andrews, T. M., Robertson, J. I. S. ibid. p. 577. 3. Peart, W. S., Robertson, J. I. S., Andrews, T. M. ibid. 1959, ii, 715. 4. Hardisty, R. M., Stacey, R. S. L. J. Physiol. 1955, 130, 711. 5. Vane, J. R. Brit. J. Pharmacol. 1957, 12, 344.
*
and arterial blood by a Riley needle which was left in the brachial artery during the experiment. The free plasma-5-H.T. in venous blood (antecubital vein) and arterial blood (brachial artery) remained within the range of normal values reported by Crawford.The values from the two vessels were similar. This shows that during the flush 5-H.T. is not abstracted from the plasma in large quantities, nor is it released free into the plasma as the platelets pass through the capillary bed.
If
may generalise from experience with a single it seems that the estimation of free plasma-5-H.T. does not throw light on flushing in the carcinoid syndrome. I am indebted to Dr. C. D. Needham and to Prof. George Smith for permission to investigate and report on this case. Surgery, DepartmentofofAberdeen. JOHN H. WYLLIE. University one
patient,
MYCOTIC ANEURYSM ASSOCIATED WITH COARCTATION OF THE AORTA
SIR,-Despite chemotherapy and antibiotics, bacterial aortitis and endocarditis are common complications of coarctation of the aorta. Mild cases may go undiagnosed and untreated. I report here a case with a 13-year history in which the lesion was successfully resected at operation. A girl, aged 19 in 1961, was first seen by her own doctor in 1948 with symptoms suggestive of rheumatic fever. So far as the patient remembered, this was a pyrexial illness associated with chest and back pains, but there was no response to salicylates. A chest X-ray showed an opacity above the hilum of the left lung. The diagnosis at that time was either a neurofibroma or a mass of tuberculous lymph-nodes. While under observation the patient ran a low-grade pyrexia, mainly in the evenings. All tests of sputa and specimens from gastric lavage were negative for tuberculosis. Bronchoscopy confirmed the expected widening of the carina, and this finding, associated with a positive Mantoux test, resulted in the transfer of the patient to a sanatorium, where she remained for 11 months. After her discharge she was regularly followed up. In the ensuing years progressive calcification was noted in the opacity, and this was taken as confirmatory evidence of the healing of tuberculosis of the hilar lymph-nodes. In 1961 routine X-ray revealed early rib-notching, and the patient was referred to the Norfolk and Norwich Hospital. When the patient was seen in March, 1961, she had no symptoms. The heart was clinically normal, except for an ejection systolic murmur grade 1/4 pulmonary area and strong suprasternal pulsation. The blood-pressure in both arms was 170-160/110-100 mm. Hg. Periscapular arterial pulsation was felt, and the femoral pulses were absent. The electrocardiograph tracing was normal. A week later the blood-pressure was 160/90 mm. Hg in each arm and ejection systolic murmurs were audible over both scapulse. Operation was advised. On June 7 left thoracotomy through the bed of the left 5th rib revealed aneurysm of the aorta enveloped by lung, mainly the upper segments of the lower lobe. There was eggshell crackling on palpation of the aneurysm. During the dissection numerous vessels were encountered passing to or from the aneurysm, and it was obvious that the lung had sealed a leak at some time. The ductus arteriosus was patent. The aneurysm arose from the wall of the aorta by a small opening, and most of the cavity was filled with soft laminated clot. The coarctation was an inch proximal to this with an internal diameter of 2 mm. The aneurysm was dissected free from the lung with diniculty, and the ductus was divided and sutured. The coarctation and segment of aorta containing the aneurysm were resected and replaced by a DeBakey knittedDacron ’ prosthesis. The femoral pulses became immediately palpable. The patient has since remained very well; her activities are unrestricted. Presenting symptoms, as in the case, are usually vague. The finding of a mediastinal opacity on X-ray in association with absent or delayed femoral pulses should suggest 6.
Crawford,
N. Clin. chim.
Acta, 1963, 8,
39.
CONGENITAL ADRENAL HYPOPLASIA SiR,ŅIn 1959 you published our reportof two brothers, born in 1954 and 1958 respectively,. who were apparently normal at birth but in whom severe adrenal
Our hypothesis does not demand that hypertrophy of the heart maintains the high blood-pressure indefinitely. In the end, on the contrary, the blood-pressure level is solely determined by the pressure threshold level for renal sodium excretion. This is shown in our fig. 3. When the liquorice administration that raised the threshold level was stopped the renal response to the excessive performance of the (probably hypertrophied) heart was no longer held in check and renal sodium output increased. The cumulative sodium balance became negative and the central venous pressure fell to a subnormal level. The underfilling of the venous system preceded the fall in arterial pressure like the overfilling of the venous system in the first week of liquorice treatment had preceded the rise in arterial pressure. It is true that the sustained hypertension induced by unilateral narrowing of a renal artery that is found in rats and sometimes in man cannot be simply explained by our hypothesis. Since the hypertension is maintained not only the pressure threshold level of the " clamped " kidney must be too high but also that of the unaffected one. This could be due to excretion of small amounts of renin by the " ischxmic " kidney since Statius van Eps et al.16 have shown that infusion of amounts of angiotensin too small to raise the blood-pressure by direct vasoconstriction may significantly depress the renal sodium output in normal subjects. The fact that D.O.C. sometimes fails to produce hypertension in animals might be due to severe hypokalasmia that alters the responsiveness of the heart and the kidneys. In our patients D.o.c. and liquorice always caused hypertension when hypokalsmia was prevented. Finally, it may be relevant to raise two points. If it is true, that renal sodium output is not mainly determined by glomerular filtration-rate, estimations of this parameter are of minor importance in the study of renal sodium handling and therefore in the study of hypertension. If it is true that cardiac output, in the absence of circulatory failure, is adjusted to the metabolic require-
insufficiency developed in the neonatal period. The first congenital adrenal hypoplasia was found at necropsy. The second responded to the administration of adrenal steroids with correction of his electrolytic disturbance. When our report was published he was almost a year old and in good health on maintenance therapy. Others have reported adrenal hypoplasia in siblings recently,23 and, because more of these children are likely to survive in the future, we should like to record the progress of the surviving child who is now 51/2 years old.
patients with nephrosis to
ments, the determination of this parameter gives no more information than the estimation of the metabolic rate and cannot contribute much more to the unravelling of the pathogenesis of hypertension. On the other hand, it may be expected that long-term studies of the correlation of renal sodium output, central venous pressure, and arterial pressure in patients treated with mineralocorticoids, in parabiotic animals and in animals with clamped renal artery, will provide essential information about the cause of sustained elevated arterial pressure. Binnengasthuis, University of Amsterdam.
J. G. G. BORST.
TAPE AT THE BEDSIDE SIR,-Your annotation of Nov. 2 rightly concerned itself with recorded talks and sounds for demonstration purposes. The tape-recorder can, however, be of value in
bedside teaching
to
record
events
which
when the students (and teacher) may
occur at a
time
be present. practice is the
not
Foremost among these events in paediatric infant with a chest infection who coughs only occasionally and only at night. On many occasions now a tape recording of such a cough by the night nurse has led to a diagnosis of pertussis in the morning. R. R. GORDON.
16. Statius van Eps, L. W., Zurcher-Mulder, A., de Vries, L. A. in Boerhaave Symposium on Hypertension (edited by J. de Graeff and A.
Struyvenberg). Leiden,
1963.
infant died, and
At the age of 20 months he had
a severe
convulsion with
high fever, and he was treated with paraldehyde and hydrocortisone intravenously. A left-sided hemiplegia developed, which cleared up completely within a month, and a homonymous hemianopia, which persisted for almost a year. He was treated in hospital for 18 days after the convulsion, and he was discharged on maintenance treatment with 9-alpha-fluorohydrocortisone 0.2 mg. once daily and cortisone acetate 5 mg. twice daily, with an extra 1 g. of sodium chloride in his diet. At 3 years he had two slight " febrile " convulsions, for which again no cause was found, but these had no neurological sequelx. He has had no further seizures. At 4 years his height was 41 in. (104 cm.), his weight 45 lb. (20-5 kg.), and his blood-pressure 100/70 mm. Hg. During the next 12 months an attempt was made to determine whether substitution therapy was still necessary by gradually withdrawing the cortisone acetate, while the 9-alpha-fluorohydrocortisone and supplementary sodium chloride were continued. The cortisone acetate was finally withdrawn by the time he was 5, but within a short time he became increasingly listless-in contrast to his previous ebullience and energy-and pigmentation of the skin, especially of his hands, appeared. His condition was reassessed in hospital in March, 1963. As well as listlessness and pigmentation, his blood-pressure was only 90/50 mm. Hg, though his plasma-electrolyte and bloodsugar levels were normal. Injections of corticotrophin elicited EXCRETION OF 17-OXOSTEROIDS AND 17-HYDROXYCORTICOSTEROIDS IN THE URINE BEFORE, DURING, AND AFTER INJECTIONS OF CORTICOTROPHIN
adrenal response. As shown in the table, the amount of steroids in the urine before, during, and after the injections was consistently low and showed no significant rise; cortisol was undetectable in the plasma (less than 1 m[Lg. per 100 ml.) on days 2 and 3 of the test. These results are consistent with the original diagnosis of adrenal hypofunction, which we had attributed-in the light of the necropsy on the firstborn infant -to congenital adrenal hypoplasia. Cortisone acetate was again added to his regimen in a dose of 5 mg. twice daily, and very quickly his energy returned though the pigmentation has persisted. When he was seen on Aug. 24, 1963, at the age of 51/2 years, this treatment had restored him to good health. He was a well-grown sturdy child of average intelligence, weighing 571/2 lb. (26 kg.) and measuring 451/2 in. no
(115 cm.). 1. 2.
3.
Mitchell, R. G., Rhaney, K. Lancet, 1959, i, 488. Shepard, T. H., Landing, B. H., Mason, D. G. A.M.A. J. Dis Child. 1959, 97, 154. Boyd, J. F., MacDonald, A. M. Arch. Dis. Childh. 1960, 35, 561.
1066
At present it seems probable that maintenance therapy will have to be continued for the rest of this child’s life. We hope that, within the limits imposed by his condition, he will be able to lead a reasonably full and active life, and that no other hormonal deficiency will become
apparent We
are
at
puberty.
grateful
estimations, and
to
Dr. J. G. Sprunt for performing the steroid Prof. J. L. Henderson for helpful criticism.
to
Department of Child Health, University of St. Andrews.
R. G. MITCHELL* K. RHANEY.
RESEARCH IN GENERAL PRACTICE
SIR,-The letter from Dr. Fry (Nov. 9) is of the utmost significance. There is no doubt of the need for continuing operational and clinical research within the framework of general practice. Significant contributions have been made already by individuals, at the expenditure of their These resources are limited, and the which has been gained will be lost unless there is more support forthcoming. The establishment of research units in general practice is as important, and as logical, as the already existing units in other fields.
own
resources.
momentum
H. W. K. ACHESON. CARCINOID FLUSH
SiR,-Robertson and Andrews1 stated that the estimation of free plasma-serotonin (5-hydroxytryptamine, 5-H.T.) levels was essential in carcinoid disease. They obtained values in the range 20-60 ng. per ml. in 4 patients, and less than 10 ng. per ml. in 1. The estimation is difficult, because falsely high values may be obtained if platelets are damaged in preparation of the plasma. If the flush in carcinoid disease is due to a rise of 5-H.T. free in the plasma, it ought to be possible to demonstrate this by assay of platelet-free plasma. This has never been shown, except in the single case of Peart et al. in which during flushes the free plasma-5H.T. rose spectacularly to 900 ng. per ml. in the blood of the hepatic vein. Peart et al. do not state whether there was a rise also in arterial blood flowing to the areas which flushed; if so, the flush could reasonably be attributed to a direct peripheral action of 5-H.T. on the blood-vessels, but, if not, some other mechanism must be sought. Recently I was able to study a patient with carcinoid syndrome who flushed on intravenous injection of 2 g. of adrenaline as described by Peart et al. As shown in the accompanying figure, the flush was very striking, judged by measurement of the oxygen satura’ tion of venous blood drawn from an antecubital vein. Platelet-free plasma was prepared as described Free plasma - 5 - hydroxyby Hardisty and Stacey.4 Assays tryptamine in venous were performed as described by and arterial blood drawn Vane.5 Venous blood was drawn during an adrenalineinduced flush. by multiple clean venepunctures,
circulating
Present address: Department of Child Health, University of Aberdeen 1. Robertson, J. I. S., Andrews, T. M. Lancet, 1961, i, 578. 2. Peart, W. S., Andrews, T. M., Robertson, J. I. S. ibid. p. 577. 3. Peart, W. S., Robertson, J. I. S., Andrews, T. M. ibid. 1959, ii, 715. 4. Hardisty, R. M., Stacey, R. S. L. J. Physiol. 1955, 130, 711. 5. Vane, J. R. Brit. J. Pharmacol. 1957, 12, 344.
*
and arterial blood by a Riley needle which was left in the brachial artery during the experiment. The free plasma-5-H.T. in venous blood (antecubital vein) and arterial blood (brachial artery) remained within the range of normal values reported by Crawford.The values from the two vessels were similar. This shows that during the flush 5-H.T. is not abstracted from the plasma in large quantities, nor is it released free into the plasma as the platelets pass through the capillary bed.
If
may generalise from experience with a single it seems that the estimation of free plasma-5-H.T. does not throw light on flushing in the carcinoid syndrome. I am indebted to Dr. C. D. Needham and to Prof. George Smith for permission to investigate and report on this case. Surgery, DepartmentofofAberdeen. JOHN H. WYLLIE. University one
patient,
MYCOTIC ANEURYSM ASSOCIATED WITH COARCTATION OF THE AORTA
SIR,-Despite chemotherapy and antibiotics, bacterial aortitis and endocarditis are common complications of coarctation of the aorta. Mild cases may go undiagnosed and untreated. I report here a case with a 13-year history in which the lesion was successfully resected at operation. A girl, aged 19 in 1961, was first seen by her own doctor in 1948 with symptoms suggestive of rheumatic fever. So far as the patient remembered, this was a pyrexial illness associated with chest and back pains, but there was no response to salicylates. A chest X-ray showed an opacity above the hilum of the left lung. The diagnosis at that time was either a neurofibroma or a mass of tuberculous lymph-nodes. While under observation the patient ran a low-grade pyrexia, mainly in the evenings. All tests of sputa and specimens from gastric lavage were negative for tuberculosis. Bronchoscopy confirmed the expected widening of the carina, and this finding, associated with a positive Mantoux test, resulted in the transfer of the patient to a sanatorium, where she remained for 11 months. After her discharge she was regularly followed up. In the ensuing years progressive calcification was noted in the opacity, and this was taken as confirmatory evidence of the healing of tuberculosis of the hilar lymph-nodes. In 1961 routine X-ray revealed early rib-notching, and the patient was referred to the Norfolk and Norwich Hospital. When the patient was seen in March, 1961, she had no symptoms. The heart was clinically normal, except for an ejection systolic murmur grade 1/4 pulmonary area and strong suprasternal pulsation. The blood-pressure in both arms was 170-160/110-100 mm. Hg. Periscapular arterial pulsation was felt, and the femoral pulses were absent. The electrocardiograph tracing was normal. A week later the blood-pressure was 160/90 mm. Hg in each arm and ejection systolic murmurs were audible over both scapulse. Operation was advised. On June 7 left thoracotomy through the bed of the left 5th rib revealed aneurysm of the aorta enveloped by lung, mainly the upper segments of the lower lobe. There was eggshell crackling on palpation of the aneurysm. During the dissection numerous vessels were encountered passing to or from the aneurysm, and it was obvious that the lung had sealed a leak at some time. The ductus arteriosus was patent. The aneurysm arose from the wall of the aorta by a small opening, and most of the cavity was filled with soft laminated clot. The coarctation was an inch proximal to this with an internal diameter of 2 mm. The aneurysm was dissected free from the lung with diniculty, and the ductus was divided and sutured. The coarctation and segment of aorta containing the aneurysm were resected and replaced by a DeBakey knittedDacron ’ prosthesis. The femoral pulses became immediately palpable. The patient has since remained very well; her activities are unrestricted. Presenting symptoms, as in the case, are usually vague. The finding of a mediastinal opacity on X-ray in association with absent or delayed femoral pulses should suggest 6.
Crawford,
N. Clin. chim.
Acta, 1963, 8,
39.