CEREBRAL MENINGITIS FOLLOWING INFLUENZA

478 the thermometer and the presence of other actual living microbe could be suspended so long and yet It is impossible preserve its vitality, but no doubt its spores, which would no lesions were apparent. to believe that the primary colony can alone form toxine rest in the cells like inert particles of pigment might do so. enough to cause the rise of temperature, ansemia, Such a condition I take to be one of real latency. As long leukaemia, and bone pains seen during this period. as a living microbe exists I imagine that toxine must be On the contrary, I think that during the whole of formed, but of course spores would be inactive in that this period secondary foci are continually being started by respect. Since gummata very frequently depend on some the implantation of microbes shed off from the primary traumatism for their establishment the spores must be focus, this being shown by the fact that when secondaries scattered throughout the organism, just waiting for a local do appear the rash is polymorphous, showing lesions of vary- depression of vitality to burst into growth. Once having ing size and acuteness. It is probable that each secondary done so toxine will again be formed, chemiotaxis again will focus starts from a single microbe which has been carried in occur, hosts of round cells will be attracted into the focus, the blood-stream and stranded in a capillary vessel. If all and a gumma will result; or, in a parenchymatous organ, foci start practically equal it follows that the larger an infiltration will follow the distribution of the fixed the focus and corresponding lesion the older it is, and that fibrous tissue cells. In consequence of the immense overconsequently these foci are in process of formation through- crowding the gumma will probably disintegrate, while the out this period of latency. If this be so, why do not the infiltration with better blood-supply will organise. Thus I older foci develop lesions first ? Why do large and small think the varying latencies of this mysterious disease may stand revealed at the same time as a polymorphous eruption ? be explained. The microbes may be destroyed and the I suggest that the explanation is this. The toxine formed in disease ended, they may cause repeated outbreaks with these foci is the irritant which causes the lesions to appear. intervals of apparent latency, they may be reduced to spores As long as it can diffuse freely into the blood-stream no and the disease rendered really latent, or they may be irritation is apparent. When, however, the toxine in circula- allowed to flourish and kill the patient. Dr. Parkes Weber in an interesting paper3 associates tion reaches a certain degree of concentration further diffusion of toxine from the foci will be impeded, con- lardaceous disease in syphilis with chronic toxine poisoning, sequently the irritant will be kept hanging about the foci, and describes a zone of lardaceous change surrounding causing degrees of irritation proportionate to the size of each gummata. He also speaks of tabes and such profound focus, large and small alike, and the consequent lesions will nervous degenerations as being due to the same cause and not to gummatous infiltration. I have no doubt but that he be equally large or small. The period which corresponds to the above in congenital is correct. I have already touched on the early latency of syphilis, when the child inherits from the father, extends congenital syphilis. The further latency between the first from the time of conception to two cr three weeks after year and the onset of tertiary symptoms I believe to be birth. In such a case the child is infected from the first, explainable on similar lines to the corresponding adult but develops well, and is born apparently healthy, the period. It is to be remembered that the child at birth has reason being that during intra-uterine life the toxine can already had the disease for nine months. The occurrence of diffuse freely into the mother’s circulation (incidentally keratitis and internal ear disease almost special to congenital rendering her immune and so explaining Colles’ law). After syphilis can, perhaps, be thus accounted for. Since the birth, however, the toxine will begin to accumulate and will microbes invade the ovum from the earliest stage they may soon, as in the adult, render further diffusion difficult, and well permeate the embryonic tissues more thoroughly than in consequently will establish an outbreak of lesions, together the adult. Those tissues, ultimately to become extrawith general toxaemio symptoms. There is, of course, no vascular and to undergo little developmental change, may primary incubation in such a child, as the microbes im- thus become the resting place of spores, which here only planted on the uterine mucosa will grow into the ovum when will escape the chances of destruction which the processes of it is quite small, and the infection be generalised from the growth and development may bring ; consequently the first. The fact of the immunity conferred on the mother can cornea, or the labyrinth alone, may suffer from syphilitic be accounted for on the same lines as that produced in the infiltration, the rest of the organism being free from the horse in the preparation of diphtheria antitoxin. It seems infection. Hertford-street, W. quite fair to infer the formation of antitoxin in the one case as in the other, and a similar development of antitoxin will, I suggest, be at the bottom of the subsequent periods of ,latency seen in secondary syphilis. I suggest that what may well happen is something like this : the toxine tide has risen - in the patient to the point of establishing secondaries ; AND .at the same time an antitoxin tide will also develop, .and the phagocytes will consequently become tolerant THERAPEUTICAL. . and fall upon the microbes in the foci. These will ’-be encapsuled, and either arrested or reduced to - the spore state or destroyed. Consequently the pro- CEREBRAL MENINGITIS FOLLOWING INFLUENZA duction of toxine will largely cease, that circulating will BY DAVID LIVINGSTONE DAVIES, M.R.C.S. ENG., be eliminated, the lesions will fade away, and another period L.R.C.P. LOND., The antitoxin tide will also of apparent latency set in. SURGEON TO THE FESTINIOG QUARRIES; LATE ASSISTANT MEDICAL OFFICER TO THE BOROUGH ASYLUM, NOTTINGHAM. fall, and its protecting power gradually cease, as If the microbes have in the immunisation of the horse. all been destroyed the disease will be at an end ; but except THE following case presented such unusual symptoms that in the most resistant individuals that consummation does I think it worthy of recording ; and I should be glad also to not take place. Sooner or later the arrested microbes start :growing again, the toxine tide again rises, and a further learn if anything similar has been observed in the practice of - development of lesions follows ; these die down in time and others during the last influenza epidemic. I was called on another period of quiescence supervenes. At each succeed- March 12th, 1895, to see a young girl aged fourteen years. Her ing outbreak the lesions tend to become more localised friends informed me that she had been ailing for some days till, perhaps, the palms of the hands alone are the with influenza. She had been taken ill whilst at school with In less favourable cases, when seat of manifestations. rigors, pain in the head, and general pains in the back and the individual is susceptible by nature or in any way limbs. When seen by me she still complained of these debilitated, things are different. The periods of latency are pains ; her temperature was 103.4° F., the pulse was 114, the much shorter and may be altogether suppressed. The phagotongue was furred, the bowels were constipated, she had lost cytes do not attain the power of arresting the microbic her appetite, and had been vomiting that day. After taking growth, outbreak follows outbreak, profound anagmia sets a mixture containing bicarbonate of potassium and liquor in, and the patient finds an early grave. An intermediate ammoniæ acstatis she improved, and by the next day the course may be imagined, however, in which a certain pains were much better, the temperature fell to 101°, and degree of toleration is acquired which enables the cells the pulse to 99. During the succeeding days she was to seiye on the microbes and reduce them to spores, apparently recovering, her tongue became clean, her appetite and to keep them in that condition. This is the only returned, and she said she felt hungry. The temperature, wav in which I can account for the suspension of activity 3 American Journal of Medical Science, November, 1895. for a period of, for instance, forty years. I doubt if an

indicated

by

symptoms while

________________

Clinical

Notes :

MEDICAL, SURGICAL, OBSTETRICAL,

,gradually

479 1 base of the skull and may have penetrated the sheath of however, remained stationary at 101°, in spite of the anti- the pyretics, &c., as detailed below. She remained in this con-one of the nerves. The child vomited several times after the dition until the 21st, when she began to show symptomsaccident, and this may account for the extraordinary situa-

of

some

disturbance.

nervous

became

She

dull andtion in which the needle Plymouth.

apathetic and had a gloomy, melancholy expression ; the pupils were widely dilated, she did not seem to comprehend what elicit any

was

said to her, and

it

was

difficult

to

questions put to her. At times she sighed and moaned loudly, and she took her food in a She recognised her relatives and conravenous manner. answer

to

was

found.

__________________

CASE OF CALCULUS FORMING ROUND SILK SUTURE USED TO CLOSE WOUND IN THE BLADDER AFTER SUPRAPUBIC LITHOTOMY.

BY W. H. BROWN, F.R.C.S. IREL., versed with them at intervals. I examined the eyes with the TO THE LEEDS GENERAL INFIRMARY. but there were no of SURGEON neuritis. ophthalmoscope, signs optic She remained in this She had no intolerance of light. condition until April 25th, when Dr. E. Roberts of A MAN aged twenty-two was admitted under my care into Penygroes was called in consultation. He agreed with me the Leeds General Infirmary suffering from retention of that there were evidently symptoms of cerebral mischief the nature and prognosis of which were doubtful. During the urine. Ten months previously I operated upon him for vesical evening of the same day she began to toss her limbs about, calculus, removing the stone by the suprapubic operation the movements being quite typically choreic. One symptom and afterwards closing the bladder by a continuous silk in particular appeared to me very interesting and curious- suture. The case did well, union took place by first intene.g., that if a lighted candle was brought into the room she tion, and he left the infirmary quite relieved from all symwould immediately attempt to get possession of it, and she ptoms. On examining for the cause of retention I found a had to be held in bed to prevent her doing so. Unfortunately calculus impacted in the prostatic portion of the urethra, a sudden change for the worse set in about two o’clock on and it was necessary to perform perineal section for its the morning of the 26th, when she was seized with tonic removal. The stone was about an inch and a half in length spasms which affected most of the muscles of the body, but and somewhat cylindrical. On making a transverse section more so on the left side, the sterno-mastoid muscles in i of the calculus a piece of silk suture, apparently part of the particular standing out prominently. She then became continuous suture used ten months before, was found forming comatose, and the spasms occurred more and more frequently the centre and nucleus of the calculus, the silk evidently until her death, which occurred at two o’clock in the after- having passed entirely through the mucous membrane of the noon, or just twelve hours from the onset of the tonic spasms. bladder into its cavity. Remarks.-The usual symptoms of meningitis were conI think it right to publish this result as evidence of a their and absence the the spicuous by symptoms during possible disadvantage of using silk as a means of closing greater part of her illness were very indefinite. There was the bladder in such cases. no vomiting after March 12th, when I first saw her, she Leeds. did not complain of any particular pain, she had no strabismus or paresis, and her temperature never rose above 102° after March 12th. I cannot offer any opinion as to how the meningitis was caused, as she had no hyperpyrexia, neither was there any evidence of ear mischief which might OF cause it. About three hours before death she discharged about an ounce of sa,nious pus from both nostrils, the source of which I was unable to ascertain as no necropsy was AND FOREIGN, allowed. I have no doubt in my mind that when I first saw her she was suffering from influenza, and several children at the same school were laid up with it at the same time. I Nullaautem est alia pro certo noseendi via, nist quamplurimas et moret dissectionum historias, tum aliorum turn proprias collect aa Treatment, briefly, consisted in giving liquid nourishment and borum et inter se comparare.—MORGAGNI De Sed. et Caus. Morb., stimulants at regular intervals of an hour. Bicarbonate of habere, iv. Prooemium. potassium, bromide of potassium, liquor ammoniæ acetatis, LONDON HOSPITAL. salicylate of soda, quinine, aconite, and antipyrin, with cold sponging and counter-irritation to the spine during the last FIVE CASES OF RADICAL CURE OF FEMORAL HERNIA ; stage, were all tried, but with no effect. REMARKS.

A Mirror

HOSPITAL PRACTICE, BRITISH

lib.

of Mr. C. W. MANSELL MOULLIN.) THIS series of cases of operation for the radical cure of MENINGITIS AS A SEQUEL TO "SWALLOWING" A femoral hernia will again draw attention to a method of NEEDLE. operating which, in the hands of Mr. Moullin and others, BY CHARLES J. COOKE, M.D., M.CH., R.U.I., has given very satisfactory results. Mr. Moullin refers in MEDICAL OFFICER TO THE PLYMOUTH WORKHOUSE. his remarks to other methods which have been employed for ON Feb. 3rd last I was called to see a girl aged eight years this purpose. We would remind our readers also that some who was said to have swallowed a needle four days pre- surgeons find simple ligature of the neck with excision of the sac sufficient in the less severe cases, whilst others use some viously. She was in great distress, crying out when moved form of suture such as that suggested by the late Mr. John and holding her head strongly flexed towards the left side. Ward, with the object of diminishing the size of the canal. Her temperature was 102° F. ; the tongue was furred, and We endorse fully what is said in the remarks on the case as the skin was hot and dry. Failing to detect any foreign to the advisability of operating for irreducible hernia in this body I sent her to the local hospital, where she was examined, situation. A patient with such a hernia, although it may be but without result. She was sent home, and on the following small, is always in great danger, which is not lessened by day I again examined her carefully, but failed to find any- the application of a hollow pad truss. It is much better that

(Under the

and from that time until her death, on Feb. 9th, the treated as one of meningitis, which it undoubtedly was. At the necropsy a careful search was made for the needle, as I felt sure that the illness was not merely a coincidence, and on passing my finger along the pharynx I felt a hard substance behind it, which proved to be an ordinary sewing needle one inch and a half in length. It was somewhat firmly fixed, the "eye"end was embedded in or slightly projecting through the posterior wall of the pharynx at the level of the floor of the nasal cavity, and the point was directed upwards and somewhat backwards behind the pharynx. Unfortunately it became dislodged during the dissection, so that I was unable accurately to discover its situation, but it must have been in very close proximity to

thing,

case was

care

radical cure should be performed when it can be done quietly and under the best conditions, rather than when the patient is very ill and possibly exhausted as the result of vomiting and want of food. CASE 1.-A woman twenty-eight years of age was admitted into the hospital in September, 1893, sundering from double femoral hernia. The one on the right side had existed for ten years and had been irreducible for eight years. That on the left had only been noticed for a twelvemonth. For some years the patient had worn a truss (of late a double one) with relief ; but in spite of this the right hernia continued to increase in size, little by little, and there was such a feeling of weakness when she tried to lift anything that she was advised to come to the hofpital. The patient was