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SUPRARENAL HÆMORRHAGE IN AN INFANT: ITS RELATION TO HÆMOPHILIA.1
1620
DR. B. G. AIORISON: SUPRARENAL HEMORRHAGE IN AN INFANT.
not observed any such effect in the numerous cases undler of protracted medication; and, indeed, this small dose suflices to maintain the compensation in suitable cases. my care. Since the introduction of digalen I have given it in all Now Cloetta’s experiments on animals have clear’ly demonstrated that there exists a difference between theisee suitable cases and always with satisfactory results. No preparations, inasmuch as after protracted digalen treaLt- disagreeable gastro-intestinal disturbances at any time ment no cumulative effect was observed in cats, where:as manifested themselves. Of all the allied preparations I crystallised digitoxin caused in the same animals vomitinjg, deem digalen most suitable for protracted medication. The salivation, and anorexia, besides arrhythmia. Cloetta hIas usefulness of this drug in cardiac disease has recently been shown that it is not the molecular weight of the substance highly spoken of by Dr. Ernest von Leyden, my friend and (280 as against 552 of crystallised digitoxin) which decid{es respected teacher. ’ the toxic effect produced, but the fact that the p’l’epa’l’atioonI has been orystallised. Several French preparations containing crystallised dig SUPRARENAL HÆMORRHAGE IN AN toxin, after trials made for the sake of verification, wer INFANT: ITS RELATION TO found to have a cumulative effect. By way of analog Cloetta refers to the behaviour of an amorphous form c HÆMOPHILIA.1 physostigmine, which also differs in its action from that c BY B. G. MORISON, M.D., C.M.EDIN. the crystallised form (Harnack). Hence the cumulativ effect observed by many authors to follow the use of digitali explains itself by the fact that in the digitalis leaves em THE following case of hemorrhage into the ployed the amorphous digitoxin contained in the fres]ih body presents certain features which may, I hope, suprarenal justify its preparations must have been transformed into a statbe publication. These are-the occurrence of the lesion very analogous to the crystallised digitoxin, a fact which haIs shortly after birth, its characteristic type, and particularly likewise been proved by Cloetta. the observation of a hsemophilic tendency prior to any of the Cloetta’s experimental researches are the first which havlree more obvious signs of adrenal injury. reliably demonstrated the fact that there is a digitalis preA male infant, a first child, was born about the middle of paration-namely, digalen-which does not possess an;y the ninth month of pregnancy after normal labour. The dangerous or disagreeable cumulative action. umbilical cord, a thick one, was tied three times in sucThe question now arises, In which of the cardiac diseaseiits cession on account of bleeding which appeared at the seat of is it advisable to resort to protracted medication ? Even th< The ligature was made thick and its material ligature. acute disorders frequently required a longer period o: in order to obviate damage to the vascular walls, but medication than that which was customary, and one ofter in vain. On the third occasion a little blood was had recourse to the expedient of giving strophanthus 0]r apparently seen to burst through the cord (aninjured here) above the camphor in between, resuming the digitalis medication afteir ligature. Finally, the cord was bound round with double an interval of several days. Even more than the temporaril3 kept dry, and regularly dusted with boric disturbed valvular defects do the chronic affections of theycyanide gauze, It is my practice to allow a child to cry before e powder. cardiac muscle need protracted treatment. Seeing that these etying the cord. I mention this because Kiwisch and others affections predominate in medical practice the prolonged useehave attributed haemorrhage in newly born infants to undue of digitalis assumes a still greater importance. In patiente3 haste in applying the ligature. Nothing further was noted suffering from fatty heart digitalis, as a rule, does not agree. in this case until the ninth day, when the child seemed weak In the case of fatty degeneration even digitalis cannot save and would not take the breast. There was some jaundice In neurotic diseases of theebut the stools were what has been lost already. and the cord was dry. There was healthy heart good results are but seldom seen except when the no umbilical redness. On the tenth day the infant was cardiac muscle is involved. Accordingly the followingr stronger; snuffling was noticed and small doses of grey powder indications are left as being the most important-viz., myo- were in view of any possible specific taint, though carditis in all stages and of any pathogenesis, myasthenia. the prescribed did not justify this suspicion. The stools history cordis chronica with or without dilatation and hypertrophy, were On the eleventh day the cord was nearly and weakness of the heart in the case of hypertrophy off butgreen. was still attached. Seen again on the seventeenth of the left side of the heart after nephritis of long the child was well; the cord had just fairly day feeding standing. become detached. On the two following days the parents Let me now describe briefly how the treatment is carried noticed some rather bright-red patches on the chin. The out. Kussmaul and Naunyn recommended protracted child became somnolent and refused nourishment, but had medication in all cases in which the usual mode of treat- neither sickness nor diarrhoea. On the day following I was ment did not produce long-lasting results and in which the sent for. The child had suddenly become much emaciated phenomena of cardiac insufficiency reappeared within a very and generally worse during the night. There were brightshort time. They prescribed the digitalis leaves in substance red patches on the chin, round the mouth, toward the back in the form of powders or pills, 0’ 05 to 0 1 gramme per day; of the and at the tips of the fingers and toes. The if required the dose was given twice a day. When the effect scrotumscalp, was rather full, red, and slightly eroded. The diminished the dose was afterwards increased. These still being dusted with boric powder, was surrounded navel, authors laid stress on the fact that after long-continued use by a red, rather prominent ring within which was an una lasting result might be ultimately obtained and then healed surface. At the circumference of this there was digitalis might be dispensed with. slight separation of cuticle. The heart beat was fairly This mode of treatment may, it is true, in conjunction and for the first time a rise of temperature was noted strong with strict supervision, be free from danger and be service(100.8°F.). The child was "slightly convulsed"all day, able, but in view of the unreliability of the drug one must as I learned afterwards. At 9 P.M. the temperature was always be prepared to face a cumulative effect. Seeing, 102°, the erythematous spots were disappearing, but the however, that in digalen we have at our disposal a prepara- scrotum was more full and livid. The stools were yellow for tion-in fact, the only one of the numerous digitalis prepara- the first time in ten days. Death occurred at 11 P.M. on this tions produced during the last few years-which is exempt the twentieth after birth. day from a cumulative effect, it is better than any other officinal Post-mortem examination showed a red lividity about the preparation suited for protracted medication, as here all the chin and mouth, the scrotum full and livid. The thoracic dangers inherent in the other preparations are absent. and abdominal viscera generally were apparently normal but As regards the pharmacology of this preparation I would for the presence of passive congestion ; the spleen was of a refer readers to Cloetta’s respective essay s.6 I would add a slate-blue colour, not softened, and on section showing deep few remarks about the dosage in the case of protracted nothing noteworthy ; the pancreas was normal. The right medication. Seeing that 0 ’15 gramme of folia digitalis corresuprarenal body was also normal though passively congested ; sponds to 1 cubic centimetre of digalen = 20 drops (16’ 9 the left was very dark slate-blue. Opened in situ it at once minims), from 7 to 14 drops (= say 6 to 12 minims) would collapsed and shed its fluid contents into the abdomen. On have to be administered once or twice per diem in the case examination it appeared to be converted into a blood sac, was very soft, and partly torn in removal. There were no signs prakt. Med. 1905; De Renzi (Nuova Rivista Clinico-Terapeutica, 1905, of inflammation spreading up from the umbilicus and the No, 7); Bozzolo (Gazzetta degli Ospedali e delle Cliniche, 1905, Nr. 9); Schwyzer (Medical News, 1905. No. 21); Silvestri e Fiorio (Gazzetta umbilical cord inside the abdomen was small, pale, and *"’
s e varied ir
’
’
’
,
.
.
I
Medica Veronese, Anno I., No. 7). 6 Munchener Medicinische
Wochenschrift, 1904,
No. 33.
1
From notes communicated to the
Æsculapian Society.
MR. GORDON N. MONTGOMERY: A CASE OF INDICANURIA.
1621
She had never The brain was not examined. Thes which was coloured when passed. the Clinical Research Association at passed urine like it before and has not done so since. The considerable time after hardening in formalin and methylatedl urine was of a dark blue-green colonr, with a specific of 1015; it was acid; there was no albumin or spirit is as follows : I I The right suprarenal shows no ab- gravity On normal appearances. The left suprarenal is much broken upsugar. adding a little chloroform to some urine in a but there are the remains of hæmorrhage in its medullaryr test-tnbe the chloroform became a blue colour. When substance, both in the form of extravasated corpuscles and as! some urine was added to some boiling nitric acid a bluish of the two liquids. There was granules of pigment. The condition is probably the result ofring was seen at the junction no history of eating or drinking anything that she had not strain and not of disease." The family history in this case is not a good one. BothL been accustomed to or of using carbolic acid in any form, or grandmothers had died from carcinoma and the maternall methylene blue. Professor William Osler,1speaking of indicanuria, says: grandfather from phthisis. I can find no evidence of specific: taint nor have I any reason to suspect this. Olinically the "The substance in the urine which has received this name is case is typical of haemorrhage into the adrenal medulla andthe indoxyl-sulphate of potassium, in which form it appears its character was verified by the necropsy. It appears to mein the urine and is colourless. When concentrated acids or that its chief interest and significance depend upon those strong oxidising agents are added to the urine this substance earlier evidences of failure of the vaso-tonic function of the is decomposed and the indigo set free. It is present only medulla which have been described; the signs of a hæmo- in small quantities in healthy urine. It is derived from the philic weakness, the general atony, the slight preliminary indol, a product formed in the intestine by the decomposi. pnrpura, and increasing lassitude which culminated in the final tion of the albumin under the influence of bacteria. When purpuric explosion, nervous and general collapse. It appears absorbed, this is oxidised in the tissues to indoxyl, which as if there had been present at birth, or possibly before it, in combines with the potassium sulphate, forming the abovethe medulla some premonitory congestion or slight hemorrhage named substance." Also: " It is not usually increased followed by a sudden final apoplexy, a condition of things in constipation, although it may be present in large amount which finds its counterpart at the opposite extreme of life in with no other discoverable cause....... Though, as a rule, the cerebrum. How far hemophilia is dependent on adrenal the urine is colourless when passed, there are instances in inadequacy remains to be proved, but the present case is which the decomposition has taken place within the body, suggestive in this connexion. So likewise is the fact that in and a blue colour has been noticed immediately after the a certain proportion of these cases hæmorrhages have been urine was voided." found in other parts of the body-e.g., small extravasations Dr. 0. J. Kauffmann2 writes: Indican is derived from in the floor of the lateral ventricles (F. E. Batten 2), purpuric indol, which latter is formed in the intestine by bacterial spots in the parietal pleura (F. W. Andrewes 3), small decomposition of albuminous substances. A very little hæmorrhages in the pleuræ, lung, epi- and peri-cardium indican is commonly present even in the urines of healthy (L. S. Dudgeon 4). It is also noteworthy that adrenal persons, but a considerable excess of the same, such asI been associated with a more general state of show you in these specimens, is always accompanied by hemorrhage has like nature in "hæmorrhage of the newly born," though the disturbed general health. We may, therefore, say that connexion in this latter case has not, as far as I know, been excess of indican in the urine is always associated with toxæmia and this toxaemia arises (with rare exceptions, in established. These observations point to a fairly constant relation which the source is decomposing pus) from the intestinal between hæmorrhage into the suprarenal medulla and the canal." The interesting points in this case, I think, are (1) the same condition elsewhere and our present physiological data the the former as for latter. to point accounting Dudgeon, deep colour of the urine; (2) the fact that it was coloured Riviere, and others are inclined to regard suprarenal bleeding when passed ; and (3) the circumstance that the patient was as of toxic origin, and it may be thus explained when in good health. associated with microbic diseases. I do not think that Dorchester. this interpretation is the only possible one. For my own case I am inclined to accept the view already quoted that A CASE OF strain or pressure during labour was the primary cause of the inherent with some assistance from APPENDIX RUPTURING DURING AN perhaps hemorrhage weakness of tissue related to the family history. The OPERATION AND AN ANALYSIS frequent failure to discover any micro-organisms in the OF THE MEANING OF THE suprarenals in these cases and the occurrence of "hæmoralso " would seem to born indicate that a in the newly rhage SYMPTOMS. toxic agent is not an indispensable antecedent. BY F. R. B. BISSHOPP, M.D. CANTAB., M.R.C.P. LOND., Green Lanes, N.
evidently not diseased. microscopic report by
.
________________
HONORARY CONSULTING
A CASE OF INDICANURIA. BY GORDON N. MONTGOMERY, M.R.C.S. ENG., L.R.C.P. LOND.,
PHYSICIAN, INFIRMARY; AND
TONBRIDGE UNION
JOHN D. MALCOLM, F.R.C.S. EDIN., SURGEON TO THE SAMARITAN FREE HOSPITAL, LONDON.
HOUSE SURGEON TO THE DORSET COUNTY HOSPITAL.
THE subject of the following history was a delicatethis subject seems rather scarce a few looking man of nervous type and 38 years of age. 14 years before the illness now recorded he suffered from an attack notes on a case may be of interest. of internal inflammation for which mustard was applied to The patient, a female, aged 32 years, is a servant at the above hospital. Her general health is good, except that she the right lower portion of the abdomen and during the last suffers at times from slight attacks of "petit mal." She two or three of the intervening years he occasionally felt a in the same position which, however, never says that she often has "trouble with her bowels," having to slight discomfort take pills sometimes to obtain an action. On March 2nd, attracted serious attention. On July 9th, 1906, he did not well in the evening but had no pain. On the 10th he having been constipated for several days, she took a pill of feel had breakfast as usual and the bowels acted. Immediately and usual This was her colocynth hyoscyamus. aperient. On the following day the bowels were relieved twice and she afterwards and throughout the day he felt slight pain along the top of the abdomen and, although getting about, he took experienced some abdominal discomfort during the day. no food except a little tea and a biscuit. He went to bed On this date the patient noticed that the urine was altered in colour and a specimen was brought to me. The colour early and, later, had a dose of castor oil which made him varied in density during the following three days until vomit. Soon after this, about 10 o’clock at night, he was March 6th, when it became much lighter, and on the suddenly seized with intense pain like a hot and heavy ball the centre of the abdomen but not near the next day it was quite normal. During these days the deep down in An alarming state of collapse followed and Dr. appendix. patient did her work as usual and felt quite well, Bisshopp was sent for. When he arrived, about half an except that she felt a little worried about the urine, hour after the attack began, recovery had to some extent 2 Transactions of the Pathological Society, 1898. 3 Ibid. and Practice of Medicine, p. 680. 1 Principles 4 American Journal of the 2 THE Medical Sciences, 1904. LANCET, July 14th, 1900, p. 75. z 3 As literature
on
DR. B. G. AIORISON: SUPRARENAL HEMORRHAGE IN AN INFANT.
not observed any such effect in the numerous cases undler of protracted medication; and, indeed, this small dose suflices to maintain the compensation in suitable cases. my care. Since the introduction of digalen I have given it in all Now Cloetta’s experiments on animals have clear’ly demonstrated that there exists a difference between theisee suitable cases and always with satisfactory results. No preparations, inasmuch as after protracted digalen treaLt- disagreeable gastro-intestinal disturbances at any time ment no cumulative effect was observed in cats, where:as manifested themselves. Of all the allied preparations I crystallised digitoxin caused in the same animals vomitinjg, deem digalen most suitable for protracted medication. The salivation, and anorexia, besides arrhythmia. Cloetta hIas usefulness of this drug in cardiac disease has recently been shown that it is not the molecular weight of the substance highly spoken of by Dr. Ernest von Leyden, my friend and (280 as against 552 of crystallised digitoxin) which decid{es respected teacher. ’ the toxic effect produced, but the fact that the p’l’epa’l’atioonI has been orystallised. Several French preparations containing crystallised dig SUPRARENAL HÆMORRHAGE IN AN toxin, after trials made for the sake of verification, wer INFANT: ITS RELATION TO found to have a cumulative effect. By way of analog Cloetta refers to the behaviour of an amorphous form c HÆMOPHILIA.1 physostigmine, which also differs in its action from that c BY B. G. MORISON, M.D., C.M.EDIN. the crystallised form (Harnack). Hence the cumulativ effect observed by many authors to follow the use of digitali explains itself by the fact that in the digitalis leaves em THE following case of hemorrhage into the ployed the amorphous digitoxin contained in the fres]ih body presents certain features which may, I hope, suprarenal justify its preparations must have been transformed into a statbe publication. These are-the occurrence of the lesion very analogous to the crystallised digitoxin, a fact which haIs shortly after birth, its characteristic type, and particularly likewise been proved by Cloetta. the observation of a hsemophilic tendency prior to any of the Cloetta’s experimental researches are the first which havlree more obvious signs of adrenal injury. reliably demonstrated the fact that there is a digitalis preA male infant, a first child, was born about the middle of paration-namely, digalen-which does not possess an;y the ninth month of pregnancy after normal labour. The dangerous or disagreeable cumulative action. umbilical cord, a thick one, was tied three times in sucThe question now arises, In which of the cardiac diseaseiits cession on account of bleeding which appeared at the seat of is it advisable to resort to protracted medication ? Even th< The ligature was made thick and its material ligature. acute disorders frequently required a longer period o: in order to obviate damage to the vascular walls, but medication than that which was customary, and one ofter in vain. On the third occasion a little blood was had recourse to the expedient of giving strophanthus 0]r apparently seen to burst through the cord (aninjured here) above the camphor in between, resuming the digitalis medication afteir ligature. Finally, the cord was bound round with double an interval of several days. Even more than the temporaril3 kept dry, and regularly dusted with boric disturbed valvular defects do the chronic affections of theycyanide gauze, It is my practice to allow a child to cry before e powder. cardiac muscle need protracted treatment. Seeing that these etying the cord. I mention this because Kiwisch and others affections predominate in medical practice the prolonged useehave attributed haemorrhage in newly born infants to undue of digitalis assumes a still greater importance. In patiente3 haste in applying the ligature. Nothing further was noted suffering from fatty heart digitalis, as a rule, does not agree. in this case until the ninth day, when the child seemed weak In the case of fatty degeneration even digitalis cannot save and would not take the breast. There was some jaundice In neurotic diseases of theebut the stools were what has been lost already. and the cord was dry. There was healthy heart good results are but seldom seen except when the no umbilical redness. On the tenth day the infant was cardiac muscle is involved. Accordingly the followingr stronger; snuffling was noticed and small doses of grey powder indications are left as being the most important-viz., myo- were in view of any possible specific taint, though carditis in all stages and of any pathogenesis, myasthenia. the prescribed did not justify this suspicion. The stools history cordis chronica with or without dilatation and hypertrophy, were On the eleventh day the cord was nearly and weakness of the heart in the case of hypertrophy off butgreen. was still attached. Seen again on the seventeenth of the left side of the heart after nephritis of long the child was well; the cord had just fairly day feeding standing. become detached. On the two following days the parents Let me now describe briefly how the treatment is carried noticed some rather bright-red patches on the chin. The out. Kussmaul and Naunyn recommended protracted child became somnolent and refused nourishment, but had medication in all cases in which the usual mode of treat- neither sickness nor diarrhoea. On the day following I was ment did not produce long-lasting results and in which the sent for. The child had suddenly become much emaciated phenomena of cardiac insufficiency reappeared within a very and generally worse during the night. There were brightshort time. They prescribed the digitalis leaves in substance red patches on the chin, round the mouth, toward the back in the form of powders or pills, 0’ 05 to 0 1 gramme per day; of the and at the tips of the fingers and toes. The if required the dose was given twice a day. When the effect scrotumscalp, was rather full, red, and slightly eroded. The diminished the dose was afterwards increased. These still being dusted with boric powder, was surrounded navel, authors laid stress on the fact that after long-continued use by a red, rather prominent ring within which was an una lasting result might be ultimately obtained and then healed surface. At the circumference of this there was digitalis might be dispensed with. slight separation of cuticle. The heart beat was fairly This mode of treatment may, it is true, in conjunction and for the first time a rise of temperature was noted strong with strict supervision, be free from danger and be service(100.8°F.). The child was "slightly convulsed"all day, able, but in view of the unreliability of the drug one must as I learned afterwards. At 9 P.M. the temperature was always be prepared to face a cumulative effect. Seeing, 102°, the erythematous spots were disappearing, but the however, that in digalen we have at our disposal a prepara- scrotum was more full and livid. The stools were yellow for tion-in fact, the only one of the numerous digitalis prepara- the first time in ten days. Death occurred at 11 P.M. on this tions produced during the last few years-which is exempt the twentieth after birth. day from a cumulative effect, it is better than any other officinal Post-mortem examination showed a red lividity about the preparation suited for protracted medication, as here all the chin and mouth, the scrotum full and livid. The thoracic dangers inherent in the other preparations are absent. and abdominal viscera generally were apparently normal but As regards the pharmacology of this preparation I would for the presence of passive congestion ; the spleen was of a refer readers to Cloetta’s respective essay s.6 I would add a slate-blue colour, not softened, and on section showing deep few remarks about the dosage in the case of protracted nothing noteworthy ; the pancreas was normal. The right medication. Seeing that 0 ’15 gramme of folia digitalis corresuprarenal body was also normal though passively congested ; sponds to 1 cubic centimetre of digalen = 20 drops (16’ 9 the left was very dark slate-blue. Opened in situ it at once minims), from 7 to 14 drops (= say 6 to 12 minims) would collapsed and shed its fluid contents into the abdomen. On have to be administered once or twice per diem in the case examination it appeared to be converted into a blood sac, was very soft, and partly torn in removal. There were no signs prakt. Med. 1905; De Renzi (Nuova Rivista Clinico-Terapeutica, 1905, of inflammation spreading up from the umbilicus and the No, 7); Bozzolo (Gazzetta degli Ospedali e delle Cliniche, 1905, Nr. 9); Schwyzer (Medical News, 1905. No. 21); Silvestri e Fiorio (Gazzetta umbilical cord inside the abdomen was small, pale, and *"’
s e varied ir
’
’
’
,
.
.
I
Medica Veronese, Anno I., No. 7). 6 Munchener Medicinische
Wochenschrift, 1904,
No. 33.
1
From notes communicated to the
Æsculapian Society.
MR. GORDON N. MONTGOMERY: A CASE OF INDICANURIA.
1621
She had never The brain was not examined. Thes which was coloured when passed. the Clinical Research Association at passed urine like it before and has not done so since. The considerable time after hardening in formalin and methylatedl urine was of a dark blue-green colonr, with a specific of 1015; it was acid; there was no albumin or spirit is as follows : I I The right suprarenal shows no ab- gravity On normal appearances. The left suprarenal is much broken upsugar. adding a little chloroform to some urine in a but there are the remains of hæmorrhage in its medullaryr test-tnbe the chloroform became a blue colour. When substance, both in the form of extravasated corpuscles and as! some urine was added to some boiling nitric acid a bluish of the two liquids. There was granules of pigment. The condition is probably the result ofring was seen at the junction no history of eating or drinking anything that she had not strain and not of disease." The family history in this case is not a good one. BothL been accustomed to or of using carbolic acid in any form, or grandmothers had died from carcinoma and the maternall methylene blue. Professor William Osler,1speaking of indicanuria, says: grandfather from phthisis. I can find no evidence of specific: taint nor have I any reason to suspect this. Olinically the "The substance in the urine which has received this name is case is typical of haemorrhage into the adrenal medulla andthe indoxyl-sulphate of potassium, in which form it appears its character was verified by the necropsy. It appears to mein the urine and is colourless. When concentrated acids or that its chief interest and significance depend upon those strong oxidising agents are added to the urine this substance earlier evidences of failure of the vaso-tonic function of the is decomposed and the indigo set free. It is present only medulla which have been described; the signs of a hæmo- in small quantities in healthy urine. It is derived from the philic weakness, the general atony, the slight preliminary indol, a product formed in the intestine by the decomposi. pnrpura, and increasing lassitude which culminated in the final tion of the albumin under the influence of bacteria. When purpuric explosion, nervous and general collapse. It appears absorbed, this is oxidised in the tissues to indoxyl, which as if there had been present at birth, or possibly before it, in combines with the potassium sulphate, forming the abovethe medulla some premonitory congestion or slight hemorrhage named substance." Also: " It is not usually increased followed by a sudden final apoplexy, a condition of things in constipation, although it may be present in large amount which finds its counterpart at the opposite extreme of life in with no other discoverable cause....... Though, as a rule, the cerebrum. How far hemophilia is dependent on adrenal the urine is colourless when passed, there are instances in inadequacy remains to be proved, but the present case is which the decomposition has taken place within the body, suggestive in this connexion. So likewise is the fact that in and a blue colour has been noticed immediately after the a certain proportion of these cases hæmorrhages have been urine was voided." found in other parts of the body-e.g., small extravasations Dr. 0. J. Kauffmann2 writes: Indican is derived from in the floor of the lateral ventricles (F. E. Batten 2), purpuric indol, which latter is formed in the intestine by bacterial spots in the parietal pleura (F. W. Andrewes 3), small decomposition of albuminous substances. A very little hæmorrhages in the pleuræ, lung, epi- and peri-cardium indican is commonly present even in the urines of healthy (L. S. Dudgeon 4). It is also noteworthy that adrenal persons, but a considerable excess of the same, such asI been associated with a more general state of show you in these specimens, is always accompanied by hemorrhage has like nature in "hæmorrhage of the newly born," though the disturbed general health. We may, therefore, say that connexion in this latter case has not, as far as I know, been excess of indican in the urine is always associated with toxæmia and this toxaemia arises (with rare exceptions, in established. These observations point to a fairly constant relation which the source is decomposing pus) from the intestinal between hæmorrhage into the suprarenal medulla and the canal." The interesting points in this case, I think, are (1) the same condition elsewhere and our present physiological data the the former as for latter. to point accounting Dudgeon, deep colour of the urine; (2) the fact that it was coloured Riviere, and others are inclined to regard suprarenal bleeding when passed ; and (3) the circumstance that the patient was as of toxic origin, and it may be thus explained when in good health. associated with microbic diseases. I do not think that Dorchester. this interpretation is the only possible one. For my own case I am inclined to accept the view already quoted that A CASE OF strain or pressure during labour was the primary cause of the inherent with some assistance from APPENDIX RUPTURING DURING AN perhaps hemorrhage weakness of tissue related to the family history. The OPERATION AND AN ANALYSIS frequent failure to discover any micro-organisms in the OF THE MEANING OF THE suprarenals in these cases and the occurrence of "hæmoralso " would seem to born indicate that a in the newly rhage SYMPTOMS. toxic agent is not an indispensable antecedent. BY F. R. B. BISSHOPP, M.D. CANTAB., M.R.C.P. LOND., Green Lanes, N.
evidently not diseased. microscopic report by
.
________________
HONORARY CONSULTING
A CASE OF INDICANURIA. BY GORDON N. MONTGOMERY, M.R.C.S. ENG., L.R.C.P. LOND.,
PHYSICIAN, INFIRMARY; AND
TONBRIDGE UNION
JOHN D. MALCOLM, F.R.C.S. EDIN., SURGEON TO THE SAMARITAN FREE HOSPITAL, LONDON.
HOUSE SURGEON TO THE DORSET COUNTY HOSPITAL.
THE subject of the following history was a delicatethis subject seems rather scarce a few looking man of nervous type and 38 years of age. 14 years before the illness now recorded he suffered from an attack notes on a case may be of interest. of internal inflammation for which mustard was applied to The patient, a female, aged 32 years, is a servant at the above hospital. Her general health is good, except that she the right lower portion of the abdomen and during the last suffers at times from slight attacks of "petit mal." She two or three of the intervening years he occasionally felt a in the same position which, however, never says that she often has "trouble with her bowels," having to slight discomfort take pills sometimes to obtain an action. On March 2nd, attracted serious attention. On July 9th, 1906, he did not well in the evening but had no pain. On the 10th he having been constipated for several days, she took a pill of feel had breakfast as usual and the bowels acted. Immediately and usual This was her colocynth hyoscyamus. aperient. On the following day the bowels were relieved twice and she afterwards and throughout the day he felt slight pain along the top of the abdomen and, although getting about, he took experienced some abdominal discomfort during the day. no food except a little tea and a biscuit. He went to bed On this date the patient noticed that the urine was altered in colour and a specimen was brought to me. The colour early and, later, had a dose of castor oil which made him varied in density during the following three days until vomit. Soon after this, about 10 o’clock at night, he was March 6th, when it became much lighter, and on the suddenly seized with intense pain like a hot and heavy ball the centre of the abdomen but not near the next day it was quite normal. During these days the deep down in An alarming state of collapse followed and Dr. appendix. patient did her work as usual and felt quite well, Bisshopp was sent for. When he arrived, about half an except that she felt a little worried about the urine, hour after the attack began, recovery had to some extent 2 Transactions of the Pathological Society, 1898. 3 Ibid. and Practice of Medicine, p. 680. 1 Principles 4 American Journal of the 2 THE Medical Sciences, 1904. LANCET, July 14th, 1900, p. 75. z 3 As literature
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