Time-Certainly for Months, Often for Many Years-Before Admitted to the Metropolitan Hospital, Under the Care of Mr

1105 from the hydatid cyst extends usually over a long period of In June, 1906, a married woman, aged 22 years, was time-certainly for months, often for many years-before admitted to the Metropolitan Hospital, under the care of Mr. the patient comes under observation, and the capacity of the W. D. Harmer, for a severe attack of abdominal pain with human organism for reaction to the hydatid products may vomiting and constipation. The vomited material was deeply thus become exhausted. Moreover, the absorption of hydatid bile-stained but never fsecal. It was noted that the urine products may often be inadequate, and more often still it is was claret-coloured and that it contained a few blood cells, probably irregular both in amount and in time. On these though not nearly enough to account for the colour. A few grounds alone it is only reasonable to expect that the pre- granular and epithelial casts were present ; there was no cipitable content of hydatid antisera from the human subject bile or pus. No spectroscopic examination of the urine was should inevitably be small in the majority of cases, and made. Mr. Harmer decided that the patient was not suffer- it is not surprising that in some cases it should be in- ing from intestinal obstruction, so large enemata were appreciable. given, the patient being placed on milk diet. There was In regard to the hydatid fluid we must note (a) that not no improvement in her condition until the sixth day after all hydatid fluids are equally capable of interacting with admission, when the vomiting stopped and the bowels became hydatid antisera to give a precipitate, and that some appear fairly regular. The urine was still claret-coloured when she to fail altogether ; (b) that when hydatid fluid, filtered or was discharged. Soon after this she miscarried. The urine unfiltered, is allowed to stand in a sterile condition a deposit subsequently became normal in colour and she enjoyed her slowly separates out and may form a considerable layer, and usual health until April, 1907, when she had another attack that this spontaneous precipitation may be associated with of abdominal pain, vomiting, and constipation, for which deterioration of the capacity of the fluid for interaction with she was treated at an infirmary. During this attack the hydatid antisera ; and (e) that the low saline content of patient noticed that her urine again became dark. She was hydatid fluids may interfere with the precipitin reaction, quite well within a week and the urine soon regained its since precipitin interactions are very susceptible to variations natural colour. On Feb. 28th, 1908, she had her third in the saline content of the fluid in which the interaction attack of abdominal pain, vomiting, and constipation, takes place. There may, however, be some way of over- for which she was admitted to the Metropolitan Hos- coming the apparent unsuitability of some hydatid fluids for pital, under the care of Mr. Peter L. Daniel, who, deciding reaction with hydatid sera, for example, by modification of that there was no evidence of intestinal obstruction, trans- their saline content, but this last point did not occur to us ferred her to the medical wards, where she came under while carrying out these tests. our observation. She was very thin, of a dark complexion, Conclusions.—1. A precipitate was not obtained in any with a good deal of pigmentation on the face and abdomen. interaction between hydatid fluid and human serum from a The tongue was coated with a thick brownish fur. The patient not invaded by hydatid cysts. 2. Having regard to teeth were good. Nothing abnormal could be discovered in the long duration and probable irregularity of the inter- the chest and the reflexes were natural. The abdomen change of protein molecules between a hydatid cyst and its moved well ; there was no rigidity, no tenderness on palpa- human host, and having regard also to the possible un- tion, and no evidence of free fluid. The liver dulness was suitability of the hydatid fluid, we must expect a certain normal and the spleen was not palpable. The pain com- number of precipitin tests to fail to give a satisfactory pre- plained of was referred to the umbilicus. A small amount cipitate, and this has been our experience. 3. In the condi- of blood was found to be oozing from the anus, but nothing tions of a diagnostic precipitin test as above described for abnormal could be felt on rectal or vaginal examination. patients suspected to harbour hydatid cysts, a negative The temperature was 98°F., the respirations were 30, reaction is inconclusive, but a positive reaction is conclusive and the pulse was 90. The blood pressure was 110 and of hydatid invasion, and the latter may be obtained in the administration of two drachms of adrenalin chloride circumstances of clinical importance. solution by the mouth did not raise it. The patient small of urine which was dark Sydney. __ ________ passed only quantities brown in colour and strongly acid. It contained no blood corpuscles, albumin, sugar, acetone, or diacetic acid. On RECURRENT HÆMATOPORPHYRINURIA spectroscopic examination two bands were seen, identical in WITH TOXIC SYMPTOMS NOT position with those of oxyhæmoglobin, which were unaltered in position on the addition of reducing agents or glacial DUE TO SULPHONAL. acetic acid. Dr. A. E. Garrod reminded one of us in con- versation that was often in combina- BY W. LANGDON M.D. hasmatoporphyrin BROWN, M.A., CANTAB., tion with metals when present in the urine, in which F.R.C.P., condition it shows these two bands instead of thofee PHYSICIAN TO THE METROPOLITAN HOSPITAL ; MEDICAL REGISTRAR AND of acid or alkaline The urine was DEMONSTRATOR OF PHYSIOLOGY, ST. BARTHOLOMEW’S HOSPITAL; hasmatoporphyrin. accordingly treated with acid, when AND strong hydrochloric it became purple in colour and now showed the two H. O. WILLIAMS, M.R.C.S. ENG., L.R.C.P. LOND., bands typical of acid hæmatoporphyrin, their centres being CASUALTY OFFICER AND REGISTRAR TO THE METROPOLITAN HOSPITAL. approximately &lgr; 605 and 565. Both before and after treat- ment with acid the band of urobilin just beyond the F line in the blue was distinct. A of the urine was HÆMATOPORPHYRIN is in normal urine, in very specimen present though sent to Dr. Garrod, who confirmed the such small that it does not alter the colour or very kindly presence quantities of and urobilin in it. The was exhibit its bands on examination. The hæmatoporphyrin patient typical spectroscopic still and had become and delirious. term is reserved for those cases in vomiting very drowsy "hæmatoporphyrinuria" She had three fits for about five minutes which of this to render the urine epileptiform lasting enough pigment appears each. The was raised. Small doses of either of a colour or of a dark-brown when the temperature slightly port-wine hue, calomel were but the bowels acted in to will at once reveal the cause of the alteration. given, only response spectroscope enemata for the first five The combination of toxic Such occurs under two sets of condi- days. hasmatoporphyrinuria symptoms with hæmatoporphyrinuria naturally led to the tions : (1) after sulphonal, trional, or tetronal have been of poisoning, so large doses of alkali in administered, when it forms one of a of toxic suspicion sulphonal group symptoms the form of sodium bicarbonate were as advocated of and a disturbance of given, by grave import ; (2) pigment Franz Müller 2 and by Stockvis. On account of the scanty metabolism, continuous over or recurrent and long periods, urine and the low blood pressure citrate and tinc- for which in some cases diffused morbid condi- potassium paroxysmal, ture of were added. An examination of the blood tions of the liver to be 1 In the digitalis appear mainly responsible. by Mr. E. H. Shaw, pathologist to the hospital, showed majority of these instances it does not seem to have had any 5,920,000 red corpuscles, 100 per cent. of hasmoglobin, and evil significance. however, cases of hasmato- Occasionally, 9000 leucocytes. The differential count showed a curious porphyrinuria occur, which, not due to though any alteration in the proportions, 36 per cent. being polymorpho- administered drug, present definite toxic re- symptoms nuclear, 50 per cent. small lymphocytes, 12 per cent. large sembling the sulphonal cases in Of important particulars. mononuclear, 3 per cent. eosinophiles, and 1 per cent. baso- this the following appears to be an example. philes. On the next day she was much better and quite 1 Garrod : Transactions of the Pathological Society of London, 1894, vol. lv., p.142. 2 Wiener Klinische Wochenschrift, 1894, S. 252. 1106 clear mentally, though much prostrated. Recovery was timet were drugs of the nature of sulphonal or trional rapid, but the urine continued to be brown, thoughadministered. not so dark in colour, and it still showed well- The bleeding per rectum which occurred in Thornton’s marked bands of hæmatoporphyrin. Constipation was the case,( in Munro’s case, and in our case, is of interest in chief trouble and enemata had to be resorted to frequently. viewi of Stockvis’s suggestion that hæmatoporphyrinuria due The patient left the hospital apparently quite well on 1to sulphonal is the result of hæmorrhage into the intestinal March 26th. She continued to take a mild laxative and canal or its walls. Calvert has recorded a case of hæmato- periodically presented herself for examination.

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