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RESEARCH IN GENERAL PRACTICE
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.
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.