DiscussionAlthough mid-diastolic apical murmurs may be heard in cases of anomalous pulmonary venous drainage (Gardner and Oram, 1953; Whitaker, 1954), a confident diagnosis of mitral stenosis was made in this patient because of the presence of an enlarged left atrium fluoroscopically, and a well-marked opening snap clinically. In view of the grave condition of the patient it was decided to perform a mitral valvotomy before undertaking any special investigations such as cardiac catheterization. The findings at subsequent cardiac catheterization confirmed the presence of partial anomalous pulmonary venous drainage into the right atrium via the superior vena cava.In a patient with mitral stenosis the presence of anomalous pulmonary venous drainage would probably add to the disability by increasing the pulmonary artery pressure. Relief of the mitral stenosis would be expected to result in improvement in the patient's condition, though perhaps not to the same extent as in a patient with normal pulmonary venous drainage. The result in this case has been excellent and most gratifying.Taussig (1947), Snellen and Albers (1952), and Whitaker (1954) noted that the typical " figure-of-8 " or " cottageloaf" cardiovascular shadow was diagnostic of total anomalous pulmonary venous drainage into a left superior vena cava. Grishman et al. (1951) reported a case of partial anomalous pulmonary venous drainage, and the teleradiogram reproduced in their report showed the typical " figureof-8" appearance. However, as the difference in oxygen content between blood from the right atrium and the femoral artery was only 0.5 vol. %, which might be within the range of experimental error, it is possible that their patient in fact had total pulmonary venous drainage into a left superior vena cava. The normal arterial oxygen saturation in their patient would not exclude this possibility, as a similar finding was noted in a proved case by Gardner and Oram (1953). In the case reported here, although only part of the venous drainage of the lungs was into the left superior vena cava, the typical " cottage-loaf " cardiovascular shadow was present and was explained by the additional presence of tricuspid incompetence with subsequent increased prominence of the superior vena caval shadow. Summary A case is reported of the association of mitral stenosis and partial anomalous pulmonary venous drainage into a left superior vena cava. An excellent result was obtained by mitral valvotomy.The radiological appearance was suggestive of total drainage of pulmonary veins into a left superior vena cava, and was explained by the additional presence of tricuspid incompetence. I thank Dr. K. Shirley Smith, in whose department the cardiac catheterization was performed, and Mr. J. R. Belcher for permission to record this case.

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BRITISH-MEDICAL JOURNAI, has not been encountered in the lung in the absence of an accompanying adrenal tumour. Nevertheless, we concede that the question is debatable. On the wider subject of bronchial invasion by metastatic tumours in general, it was formerly thought that this phenomenon was rare. Seiler, Claggett, and McDonald' reviewed

Nov. 15, 1958 TEMPERATURE AFTER BIRTH ASPHYXIA BLRNL 1199Group C comprised 18 babies who received N-allyl morphine, and 17 who breathed in three minutes without it. These subgroups were analysed separately, and as there was very little difference between them they have been taken together to give the total 35 group C babies. The failure of N-allyl morphine, used as an antidote to pethidine apnoea, to influence the later temperature is the subject of comment below.There was no clinical disorder in any of the babies, apart from the need for brief resuscitative measures at birth in a minority of the apnoeic ones, as has already been noted. Cyanosis both of the lips and of the extremities occurred to a varying degree, as did variations in respiratory rate. DiscussionThe fact that there is a significant difference in temperature over several hours between group A and group D suggests that asphyxia causes a fall in oxygen consumption and energy production as in the experiments on pure anoxia (15% oxygen) already quoted. It is worth speculating on the degree of anoxia our subjects had met, as Brodie et al. noted no fall in rectal temperature in infants breathing 15% oxygen for 50 minutes. The pronounded fall in heat production suggested by the low rectal temperature points to an incident of considerable severity.There is no apparent difference between the temperatures of the two groups of babies whose mothers had received pethidine (B and C), whether the babies were apnoeic for three minutes after birth or not. Their pattern of temperature change after birth is very similar to that of babies with pure asphyxia. Either the initial asphyxia or mild persisting respiratory depression from the drug could explain the similarity to the group D babies. A second possibility is vasodilatation, since J. Ginsburg (1958, personal communica-tion) has found an approximate doubling of skin-blood flow in the human subject for periods up to an hour after 100 mg. of pethidine intramuscularly. Thus the temperature of babies after maternal pethidine might be lowered both by diminished heat production and by increased heat loss.To some extent the absence of a difference between groups B and C may be due to artificial selection, because severely asphyxiated babies who were felt to need oxygen for a number of hours after birth have not been included in the series, although some of them had much lower temperatures and these would have enlarged group B.When the babies in group C were divided according to whether or not they had received N-allyl morphine, the fall in temperature was the same in each subgroup. While the drug proved a very effective antidote to pethidine in the initiation of breathing (Paterson and Prescott, 1954) it did not appear to have any subsequent effect on the course of temperature. Roberts et al. (1957) similarly found that the reduction of the baby's minute-volume after maternal pethidine was not influenced by this antidote.We conclude that a somewhat reduced rectal temperature is a natural phenomenon in babies suffe...

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