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A CASE OF UVEO-PAROTITIC PARALYSIS.
CL-INICAL AND LABORATORY NOTES.
906
A CASE OF UVEO-PAROTITIC PARALYSIS.
Clinical and
Laboratory Notes.
BY MACDONALD CRITCHLEY, M.D. BRIST., HOUSE PHYSICIAN, NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, QUEEN-SQUARE, LONDON;
SENIOR
A CASE OF AORTIC ANEURYSM. BY
C.
CHIEF
BURGOYNE SURGEON, PERAK,
PASLEY,
AND
PERCY
F.R.C.S. IREL.,
SENIOR
FEDERATED MALAY STATES.
PHILLIPS, M.Sc., M.B., CH.B. BRIST.,
ASSISTANT
MEDICAL
OFFICER,
SOUTHMEAD
HOSPITAL,
BRISTOL.
THE
photographs
which
this
note under
THE syndrome iridocyclitis-parotitis-polyneuritis is sufficiently rare to justify the publication of another The recognition of this disease is attributed to ase. and other cases have been recorded by Eleerfordt,l The patient was a very debilitated Chinaman, who and Viner, Daireaux and Pechin, Mackay,2 Feiling tumour with a a furnished gradually enlarging history of Brewerton and Dopter.3 The name " Uveo-parotitic considerable pain. There was also a very definite history paralysis " we owe to Macbride,4who published a very of long-standing and untreated syphilis. The Wassermann complete account of one case. and there was marked evidence of blood-test was accompany
illustrate a very remarkable case which my notice in the Ipoh Hospital, Perak.
came
positive,
The enormous tumour showed marked expansile auscultation over it a very loud bruit was on pulsation, audible, and puncture with a needle proved the sac to contain blood. On these findings the diagnosis, which was confirmed post mortem, was made.
Clinical Note.
atheroma.
FiG.l.
,
The present case occurred in a married woman of 51, who was admitted to Southmead Hospital, March 18th last, complaining of arthritis of her knees and intense dryness of the mouth. Two years ago the right side of the face began to swell but caused her no pain. Dryness of the mouth became much appeared and worse three months later, when the left side commenced to swell. FiG. 2. For the past six months she has suffered from soreness of her eyes, photophobia, lacrymation, and mistiness of vision. She has lost weight during the past two years. Her previous illnesses included an operation for vaginal haemorrhage performed when she was 25, in which both ovaries were removed. She had a " nervous breakdown" in 1921. Her family history revealed nothing of importance except that a sister died of diabetes and a brother of phthisis. Patient was a’ thin, anaemic woman, looking older than her Her face was somewhat age. asymmetrical and there was marked some ptosis with marginal blepharitis. There was no mental or temperamental
abnormality. Cranial Nerves.-The fields of were full, but corneal opacities did not permit of
vision a
thorough
ophthalmoscopic
examination. The pupils were small and equal: circular in shape, central in position, but there was some slight irregularity in the edges. Reaction to light was sluggish, and there was no reaction on accommodation. The eye movements
normal; ptosis was present, especially in the right eye.
were
Jaw
and facial movements were normal. There was some facial asymmetry, the left naso-labial fold being more prominent than the and emotional right. Voluntary Reproductions of photographs of a case of aortic aneurysm, showing dorsal view full and movements were and lateral view of tumour. Taste was unimpaired. equal. Hearing was somewhat poor, bone conduction being better air. Weber’s test was normal. There was no tinnitus. Aneurysm is quite a common disease among the than Chinese mining coolies, the vast majority of whom Patient complained of some dysphagia. The eleventh and Their avocation, twelfth nerves were normal. suffer from untreated syphilis. Motor System.-The musculature was everywhere poorly which entails the carrying of heavy burdens, is no and there was distinct atrophy, localised to the doubt an important contributory cause of aneurysm. developed, the dorsal thumb muscles, and the flexor brevis interossei, I have seen and operated on many such cases. A on both sides. No fibrillation was noted. Motor pollicis remarkable case of the kind operated on by me in power was feeble in the hands and extensors of the elbows. Kuala Lumpur in 1917 was that of an enormous Tone was normal ; coordination good. No involuntary I tied aneurysm of the left common carotid. 1 the artery at the arch of the aorta by opening Heerfordt, C. F. : Archiv für Ophthal., 1909, lxx., 254. 2 Mackay, G. : Trans. Ophthal. Soc., 1917, xxxvii., 208. the anterior mediastinum. The patient surup 3 Dopter : Gaz. des hôp., 1904, lxxvii., 857. vived for eight days, but died from oedema of 4 Macbride, H. J. : Jour. Neurol. and Psychopathol., 1923, the brain. vi., 242.
sensibility
’
MEDICO-LEGAL SOCIETY. movements. In the somewhat feeble.
legs
all movements
were
present
907
but
Discussion. It appears that the symptoms in uveo-parotitic Sensory System.-Responses to light touch, pin-prick, heat and cold, passive movements and alterations in position paralysis may appear in any order ; the facial muscles There was no appreciation, are the most were everywhere normal. usually affected, but in this case there however, of a vibrating tuning-fork applied to the ankles. was but little impairment of the seventh nerve. abdominal were No present. Reflexes.-All tendon-jerks reflexes were obtained ; plantar stimulation evoked a flexor Dysphagia occurred in this case as in those reported by Macbride and Heerfordt, though this symptom might response. Trophic.-There was an operation scar over the abdomen possibly be due to the dryness of the mouth. Macbride and a mark due to an old electric-battery burn. The knees called attention to weekly bouts of pyrexia as in showed some arthritic changes. No cutaneous eruption was Hodgkin’s disease : the present case showed a constant found. rise of temperature up to 100° to 1005° F. Lungs.-At both apices the breath sounds were harsh and evening vocal resonance was increased. Points of special interest in this case are: (1) the Parotid.-There was a visible enlargement of both parotid of the right-sided manifestations; preponderance glands, especially the right, involving all lobes. They were (2) the slight involvement of the cranial nerves and and on The overhard, non-fluctuating, painless palpation. lying skin was not involved. No other lymphatic or salivary the mildness of all subjective phenomena; (3) the absence of any rash, as reported by Feiling, Viner, and liver were not palpable. glands were enlarged. Spleen Eyes.-Both eyes, especially the right, showed some muco- and Brewerton ; (4) the association of uveo-parotitic purulent conjunctival exudate. The irides were muddy and paralysis with absence of the ovaries. the pupillary margins a little irregular. Both comese were The nature of this disease is almost certainly that of hazy. Pupillary reaction was lost on accommodation, and On dilating the pupils a circle of a chronic infection, although the exact aetiology is was sluggish to light. pigment was seen in both eyes on the anterior lens capsule unknown. Syphilis appears to take no part in the at the site of former posterior synechise. Photophobia and neither does the previous occurrence pathogenesis, blepharitis were present. of mumps. In our case the pulmonary signs, the Teeth had all been extracted over three years ago. Examination of a blood-film showed a normal leucocyte pyrexia, and the family history suggest that tubercle count, the red cells numbering 3,500,000. Wassermann might be the causative agent, but the coexistence of a septic arthritis rather obscures the picture. reaction was negative in the serum. between the second and third. The second dislocation have occurred on a rebound from the first drop. Death appeared to be instantaneous. Sir WILLIAM WILLCOX agreed with Prof. Littlejohn that judicial hanging was a painless form of death MEDICO-LEGAL SOCIETY. and that the victim immediately became quite unconscious even if convulsive movements were A MEETING of this Society was held at 11, Chandos- shown. He considered it the best method of execution, street, in the rooms of the Medical Society of London, and more reliable than electrocution. Earl RUSSELL considered that a better method, on Oct. 21st, Lord Justice ATKIN, the President, less unpleasant anticipation for the victim, giving in the chair. being and a less disagreeable spectacle for the onlookers, Prof. HARVEY LITTLEJOHN read a communication on would be the introduction of coal gas into the Judicial Hanging as a Humane Method of prisoner’s cell at night during sleep. This would be painless and not disagreeable. Execution. Dr. G. ROCHE LYNCH said he thought it unwise to He said that he had recently been able to examine leave the decision as to the length of drop needed to fully six cases of execution, and he thought that the the executioner. details were of enough scientific interest to be worth Dr. JAMES ScoTT said that he had seen many recording. He then described ijn detail the procedure executions, and fully agreed with Prof. Littlejohn and the in these cases. adopted post-mortem findings that was a quick and sure method of execution The drop used varied from 6 feet to 7 i feet, and with hanging The length of drop no evidence of suffering. in every case death appeared to be instantaneous. was now to tables drawn up by regulated according In five cases no movements at all were perceptible ; a committee which had investigated the subject. in one case a few convulsive movements of the i He considered the methods used in other countries shoulders were seen. In most cases the heart con- less satisfactory. tinued to beat vigorously for about 10 minutes, The PRESIDENT closed the discussion by remarking giving a strong radial pulse of 80-150 beats per that he thought it most important that the public minute at first, but later becoming irregular and should feel assured that judicial hanging was painless, stopping altogether after 15 to 20 minutes. In one and that complete unconsciousness, if not death The case the heart appeared to stop immediately. itself, was instantaneous. He thought that provision bodies were allowed to hang for one hour before by the authorities for post-mortem examination by being taken down. Post-mortem examination showed competent persons, with publication of the results, considerable injury to the muscles of the neck, and would a good deal of public unrest. He conin five cases dislocation of the spinal column by sidered allay Lord Russell’s proposal objectionable, because separation between the second and third cervical if the prisoner did not know on which night he was vertebrae. In one case the body of the third vertebra to be poisoned he would lie awake many nights was fractured and dislocation occurred lower down. death. If, however, he was forewarned, In some cases the spinal cord and membranes were ’ expecting he would certainly not sleep on the given night, but torn across ; in others they appeared intact. After would be slowly suffocated while conscious. reference to the older and less humane method of Prof. LITTLEJOHN, in reply to a question, said hanging by strangulation without a drop, and to the ’, that even the thickest neck could be overcome by methods used in other countries, Prof. Littlejohn I suitably lengthening the drop, and that, as carried out concluded by saying that in his opinion the modern no accidents occurred. nowadays, method used in this country was the most humane LITTLEJOHN then read a paper entitled Prof. of all. It was performed very expeditiously (the whole proceedings only taking a few seconds), was What is a Fatal Dose of Strychnine ? painless, and undoubtedly caused instant death. describing cases of fatal poisoning from known small Sir BERNARD SPILSBURY described a recent case of doses of strychnine.
might
Medical Societies.
I
judicial hanging in which the post-mortem findings closely resembled those described by Prof. Littlejohn except that the spinal column was dislocated between the sixth and seventh cervical vertebrae,
as
well
as
I
CASE I.-A woman of 25 swallowed a powder containing 1 gr. of strychnine. This powder had been dispensed by a
chemist who kept his exalgin and had used
strychnine bottle next strychnine in mistake
a
bottle of
for
exalgin.
906
A CASE OF UVEO-PAROTITIC PARALYSIS.
Clinical and
Laboratory Notes.
BY MACDONALD CRITCHLEY, M.D. BRIST., HOUSE PHYSICIAN, NATIONAL HOSPITAL FOR THE PARALYSED AND EPILEPTIC, QUEEN-SQUARE, LONDON;
SENIOR
A CASE OF AORTIC ANEURYSM. BY
C.
CHIEF
BURGOYNE SURGEON, PERAK,
PASLEY,
AND
PERCY
F.R.C.S. IREL.,
SENIOR
FEDERATED MALAY STATES.
PHILLIPS, M.Sc., M.B., CH.B. BRIST.,
ASSISTANT
MEDICAL
OFFICER,
SOUTHMEAD
HOSPITAL,
BRISTOL.
THE
photographs
which
this
note under
THE syndrome iridocyclitis-parotitis-polyneuritis is sufficiently rare to justify the publication of another The recognition of this disease is attributed to ase. and other cases have been recorded by Eleerfordt,l The patient was a very debilitated Chinaman, who and Viner, Daireaux and Pechin, Mackay,2 Feiling tumour with a a furnished gradually enlarging history of Brewerton and Dopter.3 The name " Uveo-parotitic considerable pain. There was also a very definite history paralysis " we owe to Macbride,4who published a very of long-standing and untreated syphilis. The Wassermann complete account of one case. and there was marked evidence of blood-test was accompany
illustrate a very remarkable case which my notice in the Ipoh Hospital, Perak.
came
positive,
The enormous tumour showed marked expansile auscultation over it a very loud bruit was on pulsation, audible, and puncture with a needle proved the sac to contain blood. On these findings the diagnosis, which was confirmed post mortem, was made.
Clinical Note.
atheroma.
FiG.l.
,
The present case occurred in a married woman of 51, who was admitted to Southmead Hospital, March 18th last, complaining of arthritis of her knees and intense dryness of the mouth. Two years ago the right side of the face began to swell but caused her no pain. Dryness of the mouth became much appeared and worse three months later, when the left side commenced to swell. FiG. 2. For the past six months she has suffered from soreness of her eyes, photophobia, lacrymation, and mistiness of vision. She has lost weight during the past two years. Her previous illnesses included an operation for vaginal haemorrhage performed when she was 25, in which both ovaries were removed. She had a " nervous breakdown" in 1921. Her family history revealed nothing of importance except that a sister died of diabetes and a brother of phthisis. Patient was a’ thin, anaemic woman, looking older than her Her face was somewhat age. asymmetrical and there was marked some ptosis with marginal blepharitis. There was no mental or temperamental
abnormality. Cranial Nerves.-The fields of were full, but corneal opacities did not permit of
vision a
thorough
ophthalmoscopic
examination. The pupils were small and equal: circular in shape, central in position, but there was some slight irregularity in the edges. Reaction to light was sluggish, and there was no reaction on accommodation. The eye movements
normal; ptosis was present, especially in the right eye.
were
Jaw
and facial movements were normal. There was some facial asymmetry, the left naso-labial fold being more prominent than the and emotional right. Voluntary Reproductions of photographs of a case of aortic aneurysm, showing dorsal view full and movements were and lateral view of tumour. Taste was unimpaired. equal. Hearing was somewhat poor, bone conduction being better air. Weber’s test was normal. There was no tinnitus. Aneurysm is quite a common disease among the than Chinese mining coolies, the vast majority of whom Patient complained of some dysphagia. The eleventh and Their avocation, twelfth nerves were normal. suffer from untreated syphilis. Motor System.-The musculature was everywhere poorly which entails the carrying of heavy burdens, is no and there was distinct atrophy, localised to the doubt an important contributory cause of aneurysm. developed, the dorsal thumb muscles, and the flexor brevis interossei, I have seen and operated on many such cases. A on both sides. No fibrillation was noted. Motor pollicis remarkable case of the kind operated on by me in power was feeble in the hands and extensors of the elbows. Kuala Lumpur in 1917 was that of an enormous Tone was normal ; coordination good. No involuntary I tied aneurysm of the left common carotid. 1 the artery at the arch of the aorta by opening Heerfordt, C. F. : Archiv für Ophthal., 1909, lxx., 254. 2 Mackay, G. : Trans. Ophthal. Soc., 1917, xxxvii., 208. the anterior mediastinum. The patient surup 3 Dopter : Gaz. des hôp., 1904, lxxvii., 857. vived for eight days, but died from oedema of 4 Macbride, H. J. : Jour. Neurol. and Psychopathol., 1923, the brain. vi., 242.
sensibility
’
MEDICO-LEGAL SOCIETY. movements. In the somewhat feeble.
legs
all movements
were
present
907
but
Discussion. It appears that the symptoms in uveo-parotitic Sensory System.-Responses to light touch, pin-prick, heat and cold, passive movements and alterations in position paralysis may appear in any order ; the facial muscles There was no appreciation, are the most were everywhere normal. usually affected, but in this case there however, of a vibrating tuning-fork applied to the ankles. was but little impairment of the seventh nerve. abdominal were No present. Reflexes.-All tendon-jerks reflexes were obtained ; plantar stimulation evoked a flexor Dysphagia occurred in this case as in those reported by Macbride and Heerfordt, though this symptom might response. Trophic.-There was an operation scar over the abdomen possibly be due to the dryness of the mouth. Macbride and a mark due to an old electric-battery burn. The knees called attention to weekly bouts of pyrexia as in showed some arthritic changes. No cutaneous eruption was Hodgkin’s disease : the present case showed a constant found. rise of temperature up to 100° to 1005° F. Lungs.-At both apices the breath sounds were harsh and evening vocal resonance was increased. Points of special interest in this case are: (1) the Parotid.-There was a visible enlargement of both parotid of the right-sided manifestations; preponderance glands, especially the right, involving all lobes. They were (2) the slight involvement of the cranial nerves and and on The overhard, non-fluctuating, painless palpation. lying skin was not involved. No other lymphatic or salivary the mildness of all subjective phenomena; (3) the absence of any rash, as reported by Feiling, Viner, and liver were not palpable. glands were enlarged. Spleen Eyes.-Both eyes, especially the right, showed some muco- and Brewerton ; (4) the association of uveo-parotitic purulent conjunctival exudate. The irides were muddy and paralysis with absence of the ovaries. the pupillary margins a little irregular. Both comese were The nature of this disease is almost certainly that of hazy. Pupillary reaction was lost on accommodation, and On dilating the pupils a circle of a chronic infection, although the exact aetiology is was sluggish to light. pigment was seen in both eyes on the anterior lens capsule unknown. Syphilis appears to take no part in the at the site of former posterior synechise. Photophobia and neither does the previous occurrence pathogenesis, blepharitis were present. of mumps. In our case the pulmonary signs, the Teeth had all been extracted over three years ago. Examination of a blood-film showed a normal leucocyte pyrexia, and the family history suggest that tubercle count, the red cells numbering 3,500,000. Wassermann might be the causative agent, but the coexistence of a septic arthritis rather obscures the picture. reaction was negative in the serum. between the second and third. The second dislocation have occurred on a rebound from the first drop. Death appeared to be instantaneous. Sir WILLIAM WILLCOX agreed with Prof. Littlejohn that judicial hanging was a painless form of death MEDICO-LEGAL SOCIETY. and that the victim immediately became quite unconscious even if convulsive movements were A MEETING of this Society was held at 11, Chandos- shown. He considered it the best method of execution, street, in the rooms of the Medical Society of London, and more reliable than electrocution. Earl RUSSELL considered that a better method, on Oct. 21st, Lord Justice ATKIN, the President, less unpleasant anticipation for the victim, giving in the chair. being and a less disagreeable spectacle for the onlookers, Prof. HARVEY LITTLEJOHN read a communication on would be the introduction of coal gas into the Judicial Hanging as a Humane Method of prisoner’s cell at night during sleep. This would be painless and not disagreeable. Execution. Dr. G. ROCHE LYNCH said he thought it unwise to He said that he had recently been able to examine leave the decision as to the length of drop needed to fully six cases of execution, and he thought that the the executioner. details were of enough scientific interest to be worth Dr. JAMES ScoTT said that he had seen many recording. He then described ijn detail the procedure executions, and fully agreed with Prof. Littlejohn and the in these cases. adopted post-mortem findings that was a quick and sure method of execution The drop used varied from 6 feet to 7 i feet, and with hanging The length of drop no evidence of suffering. in every case death appeared to be instantaneous. was now to tables drawn up by regulated according In five cases no movements at all were perceptible ; a committee which had investigated the subject. in one case a few convulsive movements of the i He considered the methods used in other countries shoulders were seen. In most cases the heart con- less satisfactory. tinued to beat vigorously for about 10 minutes, The PRESIDENT closed the discussion by remarking giving a strong radial pulse of 80-150 beats per that he thought it most important that the public minute at first, but later becoming irregular and should feel assured that judicial hanging was painless, stopping altogether after 15 to 20 minutes. In one and that complete unconsciousness, if not death The case the heart appeared to stop immediately. itself, was instantaneous. He thought that provision bodies were allowed to hang for one hour before by the authorities for post-mortem examination by being taken down. Post-mortem examination showed competent persons, with publication of the results, considerable injury to the muscles of the neck, and would a good deal of public unrest. He conin five cases dislocation of the spinal column by sidered allay Lord Russell’s proposal objectionable, because separation between the second and third cervical if the prisoner did not know on which night he was vertebrae. In one case the body of the third vertebra to be poisoned he would lie awake many nights was fractured and dislocation occurred lower down. death. If, however, he was forewarned, In some cases the spinal cord and membranes were ’ expecting he would certainly not sleep on the given night, but torn across ; in others they appeared intact. After would be slowly suffocated while conscious. reference to the older and less humane method of Prof. LITTLEJOHN, in reply to a question, said hanging by strangulation without a drop, and to the ’, that even the thickest neck could be overcome by methods used in other countries, Prof. Littlejohn I suitably lengthening the drop, and that, as carried out concluded by saying that in his opinion the modern no accidents occurred. nowadays, method used in this country was the most humane LITTLEJOHN then read a paper entitled Prof. of all. It was performed very expeditiously (the whole proceedings only taking a few seconds), was What is a Fatal Dose of Strychnine ? painless, and undoubtedly caused instant death. describing cases of fatal poisoning from known small Sir BERNARD SPILSBURY described a recent case of doses of strychnine.
might
Medical Societies.
I
judicial hanging in which the post-mortem findings closely resembled those described by Prof. Littlejohn except that the spinal column was dislocated between the sixth and seventh cervical vertebrae,
as
well
as
I
CASE I.-A woman of 25 swallowed a powder containing 1 gr. of strychnine. This powder had been dispensed by a
chemist who kept his exalgin and had used
strychnine bottle next strychnine in mistake
a
bottle of
for
exalgin.