Crisis following Corticotrophin in Addison's Disease without Pigmentation.

dialysis produced an effective biochemical adjustment and ultrafiltration of excess fluid. A chest X-ray subsequent to this dialysis demonstrated no evidence of pulmonary cedema. Diuresis commenced I4 days after the ingestion of mercuric chloride and an uneventful recovery ensued. Discussion Pulmonary cedema complicating acute renal failure is subsequent to hypervolemia produced by overhydration. Clinically, pulmonary cedema is recognised by tachypncea, dyspncea, cyanosis, the expectoration of frothy bloodstained sputum and the development of widespread crepitations throughout the lungs. The diagnosis may be confirmed by the characteristic radiological appearances. Both patients had initially developed an apical gallop rhythm and electrocardiographic evidence of left ventricular strain. The initial treatment of pulmonary cedema is to allay anxiety, reduce pulmonary capillary pressure and increase alveolar oxygenation. Morphine, aminophylline and oxygen were used with some benefit. If, however, the pulmonary cedema is due to hypervolemia following overhydration, the blood volume should be reduced directlv. The rapid removal of blood by venesection or aterial puncture may be sufficient but this procedure exacerbates the ansemia which invariably develops in acute renal failure. Its application is therefore limited as the resulting severe anemia impairs myocardial efficiency. The blood removed can be replaced by a smaller volume of packed cells in order to prevent the development of severe anmmia but such an exchange transfusion carries with it the danger of producing potassium intoxication. It is, however, possible to perform an exchange transfusion during dialysis, as in the first case, when the danger of hyperkaliemia is averted by the immediate removal of excess potassium. Hyper-volvemia can be effectively corrected by ultrafiltra-tion with the artificial kidney. We found that ultrafiltration is best effected by the Skeggs-Leonards Artificial Kidney if the pressure in the blood circuit is artificially elevated to about I 6o to i 8o mm. Hg. on the venous side and if the dialysing fluid pressure is reduced by limiting its flow to about 400 to 500 ml/min. The value of Dimercaprol given early in mercury poisoning has been pointed out by Longcope and Leutscher (I949). Augustine (1956) has found that the ingestion of more than i g. of mercuric chloride is fatal in 50% of patients. The survival of Case 2 after taking 2.84 g. of mercuric chloride was thought to be due to the early administration of dimercaprol and the use of the artificial kidney in the treatment of the pulmonary cedema. Summary i. Survival of two cases of …