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POLYNEURITIS ASSOCIATED WITH URTICARIA
239
little doubt that the benefit which results from the
I
REFERENCES 1. Schroeder, K. : THE LANCET, 1929, ii., 1081. 2. Loberg, Karl: Zeit. f. d. ges. Neurol. u. Psychiat., 1929, cxxiii., 449; Marcuse, H., and Karlmann, F. : Der Nervenarzt, 1929, ii., 149; Salinger, F. : Arch. f. Psychiat., 1929, lxxxvi., 723; Harris, N. G.: THE LANCET, 1930, i., 1068; Shilvock, W. H.: Ibid., 1930, ii., 347; Power, T. D. : Ibid., 1930, ii., 1289; 1932, i., 338 ; Fenwick, P. C. C.: Ibid., 1930, i., 241; Minski, L.: Jour. Ment. Sci., 1931, lxxvii., 792; MacMillan, D., and Wyllie, A. M. : THE LANCET, 1931, i., 909; Dhunjibhoy, J. E.: Ibid., 1931, ii., 1407 ; McCartan, W.: Ibid., 1932, i., 340. 3. McCowan, P. K., and Quastel, J. H. : Jour. Ment. Sci.,
largely, if not entirely, psychological, the physical illness, with its pain and general discomfort, and the incidental nursing attention interrupting the I phantasy life of the patient and forcing reality uponI treatment is
I
i him. It cannot be too strongly emphasised that occupational therapy should be instituted as early as possible in any case which has responded to the sulphur therapy, so that the new contact with reality may be ! maintained, and, if possible, increased.
CLINICAL AND POLYNEURITIS
ASSOCIATED URTICARIA
1931, lxvii., 525.
LABORATORY NOTES
WITH .
BY S. B. BOYD CAMPBELL, F.R.C.P. EDIN. PHYSICIAN
TO
M.C., M.D.,
THE ROYAL VICTORIA HOSPITAL, BELFAST
AND
R. S.
ALLISON, M.D., M.R.C.P.
LOND.
ASSISTANT PHYSICIAN TO THE HOSPITAL
THE following is an account of a young man who had an urticarial rash appearing at recurring intervals on different parts of his body. Shortly after the initial onset he began to feel weak and complained of numbness, loss of power, and swelling of legs. On examination he was found to have a severe -polyneuritis, and further investigation into the aetiology of the condition led us - to regard both the urticaria and the polyneuritis as anaphylactic. This view of the case coincides with that expressed in an article by Allen1 dealing with the neurological complications of serum treatment, and the peculiar case of a man who had been treated with serum for scarlet fever. Twelve days later he developed serum-sickness, and a brachial neuritis which persisted for 13 weeks. Allen stressed the rarity of such complications, and mentioned seven examples of polyneuritis from a similar cause which had been described by French and American writers. A few weeks ago another case was reported by Mackay2 of angioneurotic oedema with extensor paralysis of the forearm, and atrophy of the affected muscles. The puzzling nature of such cases, their comparative rarity, and the unusual features of our own case which differed from each of the above, has prompted us to report it. The details are as
On the back of the right hand there were several red, ring-shaped, raised patches, each about an inch in diameter. On the legs and trunk there were two or three similar patches. Circzzlatory.-Blood pressure 124/96. Radial artery not
hardened. Area of cardiac dullness not increased and heart sounds normal. Respiratory.-Chest resonant and breath sounds clear. Alimentary.-Tongue slightly furred, teeth good, throat healthy. No abdominal tenderness or rigidity ; liver and spleen not palpable. Urine.--Specific gravity 1030, acid. Albumin present, but no sugar or other abnormal constituents. Nervous system.-Patient is intelligent and unemotional. Reasoning and memory good ; right-handed. 6 Cranial nerves.--Sense of smell normal. Visual acuity 6,’6 R. and L. Field of vision full. Fundi: discs normal in appearance and edges well defined ; no exudates or haemorrhages in surrounding retina. Ocular movements full. Pupils react to light and accommodation; equal and central. Consensual response ; left greater than right. Left corneal reflex less than right, though both present. Sensation over face good. Other cranial nerves normal. Motor functions.-Rises easily with arms folded. Hand grips weak, and arms cannot be maintained for long in outstretched position. Cannot extend or dorsiflex foot against resistance. Fibrillation in left thigh. Coordination and muscular tone normal. No atrophy. Gait:’: walks On shutting on a wide base and stamps the ground heavily. eyes staggers, and would have fallen but for support. Sensation.--Sense of cotton-wool lost over lower extremities to about 2 inches above patella. Decreased sense of pin-prick over same area. Sense of position of toes deficient. Heat and cold normal. Similar changes in upper extremities, extending from fingers half-way up forearms. Reflexes.-In upper extremities supinator-jerks present, biceps-jerks and triceps-jerks lost. In lower extremities knee-jerks and ankle-jerks absent. Plantars indefinite flexor, abdominals present and equal. Sphincters controlled. INVESTIGATION AND TESTS
Subsequent specimens of urine norma.1. Throat-swab negative for diphtheria. Catheter specimen of urine sterile, no pus. Widal negative for typhoid, paratyphoid A, B, and C, and Brucella abortus. No pathogenic’organisms in stools. Serum agglutinated type B. enterococcus (1 in 25). No reaction of degeneration on testing muscles of arms and legs. Skin protein tests performed for all normal curve groups : negative. Fractional test-meal : follows :of acidity and rate of emptying of stomach. Temperature records: highest recorded 100° F. Course irregularlyMan, aged 21, joiner, single. On admission to hospital intermittent, usually 99° F. A slight elevation of temperaon Sept. 7th, 1931, complained of red itchy patches on skin, ture tended to persist on and off until discharge from weakness of arms and legs, with swelling of feet. 17 weeks after admission. hospital Family history.-A brother suffers from asthma ; another brother died from scarlet fever. Previoits illnesses.-No
previous illness of a similar nature.
TREATMENT AND PROGRESS
streptococcal and enterococcal vaccine ; intra; three intramuscular History of illness.-In June, 1931, was employed as a muscular injections of whole ablood joiner in repairing floors and woodwork of an old house. injections of Sulfosin (Leo) with view to promoting transient Bemax, Radiostoleum, and adrenaline Noticed red itchy patches on the forearms and ankles, hyperpyrexia; which lasted a few days and then disappeared, only to hypodermically. The urticarial rash was never marked, but usually present recur on some other part of the skin. A few weeks later the legs began to swell after standing, and there was somewhere on the skin. The patches became fewer and numbness and deadness in the feet and hands, with loss were noticed at longer intervals as time went on. Neuroof power. logical examination made a few days before discharge from hospital on Dec. 7th, 1931, showed sensation returning EXAMINATION EX.A.Ill.LiATION in the hands and feet. The knee-jerks could be obtained Pulse-rate 114, temperature 99-8. Face somewhat full with reinforcement. Muscular power in the sluggishly and puffy but no definite oedema. No enlargement of arms and legs had improved, though it was still not normal, glands. Well-built and average nutrition; no anaemia. but I the patient could walk without assistance. At no time was localised muscular wasting observed. After leaving 1 Allen, I. M.: THE LANCET, 1931, ii., 1128. hospital the patient attended as an out-patient at regular intervals. On April 17th, 1932, he had so far recovered as 2 Mackay, W.: Ibid., 1932, i., 777. Influenza 18 months ago.
A mixed
240 to inquire whether he might start work. Examination showed no signs of former urticaria. Knee-jerks present on reinforcement, left greater than right. Ankle-jerks absent; plantars absent. Sensation to pin-prick and cotton-wool normal over arms and legs. Muscular power normal.
A period of ten months has elapsed since the onset the illness with urticarial rash and multiple peripheral neuritis. Recovery was gradual. Sensory changes were more pronounced than muscular weakness. There was no reaction of degeneration or localised wasting of muscle. The legs were affected No cause was discovered for more than the arms. the neuritis other than that it was probably associated with the urticaria, which was likewise of unknown of
origin.
Discu8sion.-The condition of duodenal ileus is stated to be caused by the pressure of the superior mesenteric artery, or occasionally the right colic artery, on the third part of the duodenum. Any condition causing a drag on the mesentery may produce it, such as lack of fixation of the proximal caecum. In this case it appears to have been caused by the wedge of herniated small intestine between the superior mesenteric artery and the duodenum. It gives rise to a chronic " bilious " dyspepsia and may in time cause peptic ulceration or infection of the biliary or pancreatic passages. The surgical treatment of this condition is, in the
early
cases,
by performing
a
suspension operation
for the csecum, and in later cases by duodenojejunostomy. The latter procedure was not possible RETRO-PERITONEAL HERNIA in this case, since the first part of the transverse colon had no mesentery, but was in direct relationship BY V. C. J. HARRIS, M.B. CAMB., F.R.C.S. EDIN. with the duodenum, rendering it inaccessible. Resort HOSPITAL HONORARY SURGEON TO THE WEST CUMBERLAND had therefore to be made to a gastro-jejunostomy to relieve the obstruction. Hernia into the fossae round the end of the CASES of retroperitoneal hernia are relatively duodenum has only been described with any frequency uncommon and usually come under the notice of the surgeon when presenting symptoms of strangulation or obstruction. The following case exhibited features of interest from a diagnostic and developmental point of view. History.-The patient, a coal-miner aged 38, first came under observation at the end of 1930, when he had an acute attack of abdominal and
a
pain, with tenderness over the liver, palpable enlarged spleen. He also had some slight
enlargement of glands
in the axillae and groins. He was He gave a vague history of dyspepsia. He was thought to show evidence of some disturbance of the reticulo-endothelial system, which might possibly be benefited by a splenectomy, and he was sent to a physician for a more accurate diagnosis and advice on this point. He returned with the report that he had a duodenal ulcer, which had improved under medical treatment, and the suggestion that this treatment should be continued. He continued on this regime until at the end of 1931 he returned with a history of further attacks of pain, " bilious " attacks, and still vague dyspepsia. He consented to operation and this was performed at the beginning of the year. anaemic.
Operation.-The abdomen was opened by a right upper paramedian incision. No ulcer could be of the abdominal contents. The jejunum is discovered in the stomach or duodenum, but both Arrangement concealed in its sac behind the visible bowel. these organs were found to be greatly distended, up to the crossing of the superior mesenteric vessels, in two situations. Firstly, the commonest-over the veins of which system were found to be markedly 60 cases recorded-into been the left duodenal having enlarged (up to the size of a normal external iliac vein). or paraduodenal fossa of Landzert. The mouth of this The spleen was apparently normal. So far the case fossa looks to the right and its fundus extends upwards On to the was thought to be one of chronic duodenal ileus. towards the spleen. The inferior left, further examination the appendix was found to be mesenteric vein and ascending branch of the left missing from its usual situation, as were the caecum colic artery run in the anterior free margin. Secondly, and ascending colon, and it was located in the left the rarer variety, the right duodenal or parietohypochondrium near the spleen. The " ascending " mesenteric fossa of Waldeyer. The mouth of this colon was suspended on a mesentery and passed from looks to the left, its fundus extends downwards left to right, to turn at an acute angle and return on towards the right iliac fossa. It lies below the a posterior plane as the more or less normal transverse transverse portion of the duodenum, the aorta is colon. Finally the whole of the jejunum, from situated behind, and the superior mesenteric vessels its first part onwards, and part of the ileum, was run in its anterior free margin. found to be herniated into a sac, the mouth of which As far as the abnormal anatomy will allow, the looked to the left, the fundus extending down towards case under discussion would appear to be a hernia the right iliac fossa, with the superior mesenteric of the latter type. vessels in its anterior border. This hernia was reduced with some difficulty, the opening, which was SPRINGFIELD MENTAL HOSPITAL, TOOTING.—A quite small, was then closed. The mesenteries of both the ascending and transverse colons were new infirmary block has been opened by Mrs. De Salis. It was explained that, in so large a mental hospital, it had pierced and a gastro-jejunostomy was performed. been found necessary to provide a new building for the sole The appendix was removed. The extra accommodation purpose of treating the sick. Since operation the patient has been free from pain. thus provided will relieve congestion in the main building, will bring up the total number of beds approximately He has had occasional mild attacks of vomiting, and to 2000, exclusive of the annexe at New Malden. The new controlled by diet, and less frequent though more block accommodates 168 patients, and there are quarters for a staff of doubly trained nurses. interesting attacks of diarrhoea of a lienteric type. "
"
little doubt that the benefit which results from the
I
REFERENCES 1. Schroeder, K. : THE LANCET, 1929, ii., 1081. 2. Loberg, Karl: Zeit. f. d. ges. Neurol. u. Psychiat., 1929, cxxiii., 449; Marcuse, H., and Karlmann, F. : Der Nervenarzt, 1929, ii., 149; Salinger, F. : Arch. f. Psychiat., 1929, lxxxvi., 723; Harris, N. G.: THE LANCET, 1930, i., 1068; Shilvock, W. H.: Ibid., 1930, ii., 347; Power, T. D. : Ibid., 1930, ii., 1289; 1932, i., 338 ; Fenwick, P. C. C.: Ibid., 1930, i., 241; Minski, L.: Jour. Ment. Sci., 1931, lxxvii., 792; MacMillan, D., and Wyllie, A. M. : THE LANCET, 1931, i., 909; Dhunjibhoy, J. E.: Ibid., 1931, ii., 1407 ; McCartan, W.: Ibid., 1932, i., 340. 3. McCowan, P. K., and Quastel, J. H. : Jour. Ment. Sci.,
largely, if not entirely, psychological, the physical illness, with its pain and general discomfort, and the incidental nursing attention interrupting the I phantasy life of the patient and forcing reality uponI treatment is
I
i him. It cannot be too strongly emphasised that occupational therapy should be instituted as early as possible in any case which has responded to the sulphur therapy, so that the new contact with reality may be ! maintained, and, if possible, increased.
CLINICAL AND POLYNEURITIS
ASSOCIATED URTICARIA
1931, lxvii., 525.
LABORATORY NOTES
WITH .
BY S. B. BOYD CAMPBELL, F.R.C.P. EDIN. PHYSICIAN
TO
M.C., M.D.,
THE ROYAL VICTORIA HOSPITAL, BELFAST
AND
R. S.
ALLISON, M.D., M.R.C.P.
LOND.
ASSISTANT PHYSICIAN TO THE HOSPITAL
THE following is an account of a young man who had an urticarial rash appearing at recurring intervals on different parts of his body. Shortly after the initial onset he began to feel weak and complained of numbness, loss of power, and swelling of legs. On examination he was found to have a severe -polyneuritis, and further investigation into the aetiology of the condition led us - to regard both the urticaria and the polyneuritis as anaphylactic. This view of the case coincides with that expressed in an article by Allen1 dealing with the neurological complications of serum treatment, and the peculiar case of a man who had been treated with serum for scarlet fever. Twelve days later he developed serum-sickness, and a brachial neuritis which persisted for 13 weeks. Allen stressed the rarity of such complications, and mentioned seven examples of polyneuritis from a similar cause which had been described by French and American writers. A few weeks ago another case was reported by Mackay2 of angioneurotic oedema with extensor paralysis of the forearm, and atrophy of the affected muscles. The puzzling nature of such cases, their comparative rarity, and the unusual features of our own case which differed from each of the above, has prompted us to report it. The details are as
On the back of the right hand there were several red, ring-shaped, raised patches, each about an inch in diameter. On the legs and trunk there were two or three similar patches. Circzzlatory.-Blood pressure 124/96. Radial artery not
hardened. Area of cardiac dullness not increased and heart sounds normal. Respiratory.-Chest resonant and breath sounds clear. Alimentary.-Tongue slightly furred, teeth good, throat healthy. No abdominal tenderness or rigidity ; liver and spleen not palpable. Urine.--Specific gravity 1030, acid. Albumin present, but no sugar or other abnormal constituents. Nervous system.-Patient is intelligent and unemotional. Reasoning and memory good ; right-handed. 6 Cranial nerves.--Sense of smell normal. Visual acuity 6,’6 R. and L. Field of vision full. Fundi: discs normal in appearance and edges well defined ; no exudates or haemorrhages in surrounding retina. Ocular movements full. Pupils react to light and accommodation; equal and central. Consensual response ; left greater than right. Left corneal reflex less than right, though both present. Sensation over face good. Other cranial nerves normal. Motor functions.-Rises easily with arms folded. Hand grips weak, and arms cannot be maintained for long in outstretched position. Cannot extend or dorsiflex foot against resistance. Fibrillation in left thigh. Coordination and muscular tone normal. No atrophy. Gait:’: walks On shutting on a wide base and stamps the ground heavily. eyes staggers, and would have fallen but for support. Sensation.--Sense of cotton-wool lost over lower extremities to about 2 inches above patella. Decreased sense of pin-prick over same area. Sense of position of toes deficient. Heat and cold normal. Similar changes in upper extremities, extending from fingers half-way up forearms. Reflexes.-In upper extremities supinator-jerks present, biceps-jerks and triceps-jerks lost. In lower extremities knee-jerks and ankle-jerks absent. Plantars indefinite flexor, abdominals present and equal. Sphincters controlled. INVESTIGATION AND TESTS
Subsequent specimens of urine norma.1. Throat-swab negative for diphtheria. Catheter specimen of urine sterile, no pus. Widal negative for typhoid, paratyphoid A, B, and C, and Brucella abortus. No pathogenic’organisms in stools. Serum agglutinated type B. enterococcus (1 in 25). No reaction of degeneration on testing muscles of arms and legs. Skin protein tests performed for all normal curve groups : negative. Fractional test-meal : follows :of acidity and rate of emptying of stomach. Temperature records: highest recorded 100° F. Course irregularlyMan, aged 21, joiner, single. On admission to hospital intermittent, usually 99° F. A slight elevation of temperaon Sept. 7th, 1931, complained of red itchy patches on skin, ture tended to persist on and off until discharge from weakness of arms and legs, with swelling of feet. 17 weeks after admission. hospital Family history.-A brother suffers from asthma ; another brother died from scarlet fever. Previoits illnesses.-No
previous illness of a similar nature.
TREATMENT AND PROGRESS
streptococcal and enterococcal vaccine ; intra; three intramuscular History of illness.-In June, 1931, was employed as a muscular injections of whole ablood joiner in repairing floors and woodwork of an old house. injections of Sulfosin (Leo) with view to promoting transient Bemax, Radiostoleum, and adrenaline Noticed red itchy patches on the forearms and ankles, hyperpyrexia; which lasted a few days and then disappeared, only to hypodermically. The urticarial rash was never marked, but usually present recur on some other part of the skin. A few weeks later the legs began to swell after standing, and there was somewhere on the skin. The patches became fewer and numbness and deadness in the feet and hands, with loss were noticed at longer intervals as time went on. Neuroof power. logical examination made a few days before discharge from hospital on Dec. 7th, 1931, showed sensation returning EXAMINATION EX.A.Ill.LiATION in the hands and feet. The knee-jerks could be obtained Pulse-rate 114, temperature 99-8. Face somewhat full with reinforcement. Muscular power in the sluggishly and puffy but no definite oedema. No enlargement of arms and legs had improved, though it was still not normal, glands. Well-built and average nutrition; no anaemia. but I the patient could walk without assistance. At no time was localised muscular wasting observed. After leaving 1 Allen, I. M.: THE LANCET, 1931, ii., 1128. hospital the patient attended as an out-patient at regular intervals. On April 17th, 1932, he had so far recovered as 2 Mackay, W.: Ibid., 1932, i., 777. Influenza 18 months ago.
A mixed
240 to inquire whether he might start work. Examination showed no signs of former urticaria. Knee-jerks present on reinforcement, left greater than right. Ankle-jerks absent; plantars absent. Sensation to pin-prick and cotton-wool normal over arms and legs. Muscular power normal.
A period of ten months has elapsed since the onset the illness with urticarial rash and multiple peripheral neuritis. Recovery was gradual. Sensory changes were more pronounced than muscular weakness. There was no reaction of degeneration or localised wasting of muscle. The legs were affected No cause was discovered for more than the arms. the neuritis other than that it was probably associated with the urticaria, which was likewise of unknown of
origin.
Discu8sion.-The condition of duodenal ileus is stated to be caused by the pressure of the superior mesenteric artery, or occasionally the right colic artery, on the third part of the duodenum. Any condition causing a drag on the mesentery may produce it, such as lack of fixation of the proximal caecum. In this case it appears to have been caused by the wedge of herniated small intestine between the superior mesenteric artery and the duodenum. It gives rise to a chronic " bilious " dyspepsia and may in time cause peptic ulceration or infection of the biliary or pancreatic passages. The surgical treatment of this condition is, in the
early
cases,
by performing
a
suspension operation
for the csecum, and in later cases by duodenojejunostomy. The latter procedure was not possible RETRO-PERITONEAL HERNIA in this case, since the first part of the transverse colon had no mesentery, but was in direct relationship BY V. C. J. HARRIS, M.B. CAMB., F.R.C.S. EDIN. with the duodenum, rendering it inaccessible. Resort HOSPITAL HONORARY SURGEON TO THE WEST CUMBERLAND had therefore to be made to a gastro-jejunostomy to relieve the obstruction. Hernia into the fossae round the end of the CASES of retroperitoneal hernia are relatively duodenum has only been described with any frequency uncommon and usually come under the notice of the surgeon when presenting symptoms of strangulation or obstruction. The following case exhibited features of interest from a diagnostic and developmental point of view. History.-The patient, a coal-miner aged 38, first came under observation at the end of 1930, when he had an acute attack of abdominal and
a
pain, with tenderness over the liver, palpable enlarged spleen. He also had some slight
enlargement of glands
in the axillae and groins. He was He gave a vague history of dyspepsia. He was thought to show evidence of some disturbance of the reticulo-endothelial system, which might possibly be benefited by a splenectomy, and he was sent to a physician for a more accurate diagnosis and advice on this point. He returned with the report that he had a duodenal ulcer, which had improved under medical treatment, and the suggestion that this treatment should be continued. He continued on this regime until at the end of 1931 he returned with a history of further attacks of pain, " bilious " attacks, and still vague dyspepsia. He consented to operation and this was performed at the beginning of the year. anaemic.
Operation.-The abdomen was opened by a right upper paramedian incision. No ulcer could be of the abdominal contents. The jejunum is discovered in the stomach or duodenum, but both Arrangement concealed in its sac behind the visible bowel. these organs were found to be greatly distended, up to the crossing of the superior mesenteric vessels, in two situations. Firstly, the commonest-over the veins of which system were found to be markedly 60 cases recorded-into been the left duodenal having enlarged (up to the size of a normal external iliac vein). or paraduodenal fossa of Landzert. The mouth of this The spleen was apparently normal. So far the case fossa looks to the right and its fundus extends upwards On to the was thought to be one of chronic duodenal ileus. towards the spleen. The inferior left, further examination the appendix was found to be mesenteric vein and ascending branch of the left missing from its usual situation, as were the caecum colic artery run in the anterior free margin. Secondly, and ascending colon, and it was located in the left the rarer variety, the right duodenal or parietohypochondrium near the spleen. The " ascending " mesenteric fossa of Waldeyer. The mouth of this colon was suspended on a mesentery and passed from looks to the left, its fundus extends downwards left to right, to turn at an acute angle and return on towards the right iliac fossa. It lies below the a posterior plane as the more or less normal transverse transverse portion of the duodenum, the aorta is colon. Finally the whole of the jejunum, from situated behind, and the superior mesenteric vessels its first part onwards, and part of the ileum, was run in its anterior free margin. found to be herniated into a sac, the mouth of which As far as the abnormal anatomy will allow, the looked to the left, the fundus extending down towards case under discussion would appear to be a hernia the right iliac fossa, with the superior mesenteric of the latter type. vessels in its anterior border. This hernia was reduced with some difficulty, the opening, which was SPRINGFIELD MENTAL HOSPITAL, TOOTING.—A quite small, was then closed. The mesenteries of both the ascending and transverse colons were new infirmary block has been opened by Mrs. De Salis. It was explained that, in so large a mental hospital, it had pierced and a gastro-jejunostomy was performed. been found necessary to provide a new building for the sole The appendix was removed. The extra accommodation purpose of treating the sick. Since operation the patient has been free from pain. thus provided will relieve congestion in the main building, will bring up the total number of beds approximately He has had occasional mild attacks of vomiting, and to 2000, exclusive of the annexe at New Malden. The new controlled by diet, and less frequent though more block accommodates 168 patients, and there are quarters for a staff of doubly trained nurses. interesting attacks of diarrhoea of a lienteric type. "
"