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ON SOME PAINFUL AFFECTIONS FOLLOWING INFLUENZA.
14 In
Group
3
some
of the
patients
referred the
pain
ON SOME PAINFUL AFFECTIONS FOLLOWING which they suffered very closely to the region of the heart. In a few cases the pain was persistent, but in most INFLUENZA. BY A. ERNEST
PHYSICIAN TO THE LONDON
A lady aged forty-two, who had suffered from influenza nine months previously, described tha pain as constant and dull, limited to the heart region. A gentle. man aged thirty-six, whose attack dated sixteen months previously, waa wearied with such dull aching; it was rather more diffused than in the former case. In another gentleman, aged forty-two, the constant pain in the cardiac region was accompanied by a tingling down the left arm The most important and characteristic cases in this roup,
paroxysmal.
SANSOM, M.D , F.R.C.P., HOSPITAL, ETC.
I PROPOSE in this short communication to pursue the inductive method of reasoning in regard to some cases which at one time caused me considerable perplexity. I will first mention a case which initiated my difficulties. A gentleman aged fifty-three, who for many months previously had been in fair average health, was taken during the night with severe pain in the right hypochondrium. The signs simulated those of hepatic colic. He took a mild aperient, and the attack passed away after one to two hours and he slept. The following day the bowels were properly opened, there was no evidence of absence of bile from the motions, the urine was in all respects normal and contained no bile nor excess of colouring matter. The attacks of severe pain, however, recurred at intervals-mostly in the night, but sometimes during the day-for about ten days, treatment by opium and belladonna only relieving them. It seemed that the gall-bladder could be mapped out by the area of tenderness, but never was there the slightest jaundice. On I could only say that one night there was sharp diarrhoea. the attacks were those of hepatalgia of paroxysmal recurIn hunting about for a cause the only antecedent rence. which seemed at all probable in this direction was an attack of inflaenza contracted in Paris at the very earliest time of the epidemic, and followed by protracted enfeeblement. I computed that nearly twenty months must have elapsed between the original attack and these consequences, if they were consequences. There was no evidence of reinfection, but of course this was possible. The key seemed to be furnished by a number of experiences which came to me just about the same period as this first instance. In all there was fair evidence of an attack of influenza followed at intervals, extraordinarily variable, by signs of extreme pain and distress. In twenty-four such cases the sites of pain could be thus tabulated :-1. Epigastrium, nine cases; abdomen generally two cases; localised in hepatic area,one case. 2. Head, various sites, seven cases ; supra-orbital region, one case ; right inferior maxilla, 3. Heart region, seven cases. 4. Extremities : one case. hips and legs, two cases ; calves, two cases ; arms, two cases; right sciatic region, one case; fingers, one case; lumbar
however, simulated angina pectoris. A gentleman aged thirty-one, typically athletic, who had never suffered from illness before his attack of influenza, which was very severe,
was
taken five months afterwards with sudden and
pain at the heart, eventuating in syncope. He was standing with his back to the fireplace, talking with friends, when the attack seized him with violence, and he fell unconscious upon the hearth-rug. There was no epileptoid sign. Another attack occurred a week after. There could be no doubt from collateral evidence that the patient became violent
faint to unconsciousness. In the intervals no notable deviation from health could be detected; the left ventricle was slightly hypertrophied, but not more so than could be expected in an athletic subject The patient described the pain as of the character of a " gripor "screw ’ at the heart; he experienced no coldness, and repudiated any
impending death. There were occasionally also dyspnoea, occurring independently of exertion. Nearly at the same time at which this patient came under my observation a gentleman came under my care with like symptoms, in whom there was no evidence of an attack of influenza. He presented the appearance of typical good health, but suffered attacks of terrible pain at the heart, ending in complete unconsciousness. On some occasions the attacks were followed by wild excitement, and the patient sense some
of
attacks of
had to be restrained from self-violence. 1 havereason to believe that in both these cases there was complete recovery. In a lady, aged forty-one, attacks of intense pain were initiated by exertion. The pain was localised in the second left intercostal space-presuinably over the superior cardiac plexus-and here was a tender spot. The pulsations of the heart were painfully felt when in the recumbent position. In some other cases there was a feeling of impending death, as in true angina pectoris, though the pain was much less severe. This occurred in a gentleman aged thirty-three, sixteen months after an attack of influenza. Pain referred to the heart, however, had occurred at intervals ever since his attack. In the case of another gentleman aged thirtyseven, the sensation was described as of an arrest of the heart, as if the pendulum of a clock had been stopped at one swing. With this the patient said, "Ifeel as if I were going to die." In some cases there was a manifest slowing of the pulse ; in others an irregularity. Sometimes a slow alternated with a quick pulse. Fifteen months after an attack of influenza I counted the pulse of a lady aged
region, one case. In Group 1 in some cases the pain at the epigastrium was nearly constant. For instance, a man aged sixty-six, who had been previously quite healthy, caught influenza at Christmas 1890, and had never felt well since. Six months afterwards he had constant pain at the epigastrium, with craving for food. Food slightly relieved the pain, but soon after In most cases the pain was nausea occurred, with pyrosis. paroxysmal, and frequently nocturnal, sometimes attended ’, twenty-two as fifty-six. In most cases the rate was rapid, with vomiting or pyrosis. Peculiar symptoms occurred in i and 1 do not remember one case in which the arterial This absence of prolonged some of these cases, as " a feeling as of a cold wind over the I tension was unduly prolonged. chest, and inability to take a deep breath." In some the arterial tension, in my opinion, took the cases out of the signs of colic, as in the first case mentioned, were closely category of true angina pectoris. I have not heard that any frequently there was retching, but the tendency case was fatal. ,
simulated ; rather
to diarrhoea than to constipation. In one case, sixty-three suffering from intense epigastric pain, of heavy weight preventing sleep, and some vomiting, I found a small patch of herpes zoster below the angle of the right scapula. In Group 2 were various neuralgim. In one man aged thirty-eight there was intense supra-orbital neuralgia varying from side to side ; previously there had been rigor and abdominal pain like colic, and then sweating and was a man of with sense
palpitation.
He had suffered from influenza twelve months
previously, but no ailment since, In another case, a lady aged twenty-five, urticaria followed icnuenza, and twelve months afterwards attacks of vertigo, with palpitation of the heart and pain referred to the occipital regions. A lady of thirty-seven, who had suffered from an attack of influenza in May, 1891, averred that two months afterwards she com-
menced to have headache, from which she had never been free in her waking hours for three months subsequently ; she also suffered from pain on movement of the right lower jaw. She had tremors and tinnitus aurium, but no vertigo. In others headache occurred coincidentally with gastric
crises.
It is no part of my purpose to pursue the question of the cardiac phenomena of influenza. These furnish most interesting lessons, but I am concerned now only with the manifestations of pain. I turn now to Group 4, in which there were painful affections of the extremities. A lady aged twenty-five, who had an attack attended with high fever four months previously, complained of intense aching in both arms. This occurred chiefly at night, and she actually wept on account of the pain. Previously to the manifestation in the arms she had suffered pain in the calves of the legs resembling that of neuritis. In another case of a gentleman aged forty-one, the pain was referred to the lumbar regions more on the left side, to the right shoulder and the left wrist, to the course of the right sciatic nerve, and to the muscles of the thigh. There were fearful exacerbations, chiefly nocturnal, so that the patient, previously a healthy man, actually shrieked on account of the pain. In the case of a female aged thirty-three pain was localised in the muscles of the calves of the leg and of the thigh. The pain was strongly aggravated after food, especially meat. In another female, aged twenty-three, pain was extremely violent in the thighs and legs, and there
15 were attacks of faintness. Subsequently the suffering was localised in the course of the right sciatic nerve. 10 was subject to remissions with severe nocturnal exacerbations ; there were also shooting pains at the epigastrium. The case In a lady aged was of alarming intensity, but recovered. forty-eight pain was referred to the right hip and to the right arm; it extended from the right shoulders to the fingers, and all movement caused pain. There could be little doubt that in these cases there was I met with other analogous instances a form of neuritis. in which there had been no history of influenza : one case in a child in whom there was severe pain in the calves, dropped feet, absolute loss of motor power, and, in fact, all the signs of neuritis of the alcoholic form. Any causation by alcohol was in this case quite out of the question; no doubt it was due to some infectious cause, and resembled the cases of peripheral neuritis, due to no traceable contagion, recorded by Dejerine and others. In this summary of my personal experiences I have dealt with no cases of the earliest manifestations of influenza,; all were in patients whose attack had passed away and who were not confined to their homes. The periods between the attack of influenza, and the manifestations of symptoms of pain varied from a few weeks to twenty months. The evidence appears to me to confirm the view of Dr. Althaus that the rnateries morbi of inilueinza resembles
these
cases
which,
as my knowledge extends, has general use, and which consists, application of quinine; and secondly, as
far
not hitherto been in
first, in the local
a modification of the usual incision for the evacua. tion of the pus contained in the anterior chamber. I am able to speak of this method of treatment after an ex-
in
perience of several years, during which I think I have had ample reason to be satisfied with its results. As is well
met with among the debilitated of all ages, most frequently as the result of traumatism. Among the colliers of the Wigan district they occur with unusual frequency, and I venture to assert, therefore, that my experience of them is above the average. In their treatment I have employed a solution of quinine during a period of upwards of ten years. The following mixture is used in nearly all cases that come under my care: R. quinise sulph. neutr., gr. iv.; liq. atropise sulpb., g i. M.; ft. guttae. In simple ulcers without hypopion I am in the habit of prescribing eserine much oftener than atropine, but I invariably prescribe the latter drug where hypopion is present, because iritis is a common feature in this condition. I doubt if either eserine or atropine has any appreciable influence upon the suppurative process. On the other hand, there is hardly anything in medicine about which I entertain less doubt than that quinine locally applied has an immediate and powerful influence in arresting this process and in the syphilitic virus in its tendency to attack many parts ofI causing the absorption of the pus already cullected in the the nervous system after the attack is over, but surpasses anterior chamber. I believe I have had repeated evidence the syphilitic toxine in virulence and in rapidity of action. of this both in my private practice and public clinique. Dr. Althaus1 has adopted the deductive method in his It is not my intention to burden this paper with a number reasoning. Starting from certain probabilities, he has of cases which seem to me all to tell the same tale, but I worked out the problems of the effects of the niateries cannot refrain from quoting the following case. which I think morbi if it should specially attack certain areas of the not only shows the value of quinine, but also tends to prove central nervous system. He concludes that the different that atropine and eserine by themselves have no great, if forms of influenza are due to irritant poisoning of the bulb any, influence upon the process of pus formation D. J-, aged eighteen, was admitted into the Eye and a converse and the nerve nuclei contained in it. method, that of logical induction, and taking my argu- Ear Infirmary on June 24th, 1882, for capsular cataract (lue ments alone from personal experience, I have arrived at a to an injury five years previously. I am indebted to Mr. similar conclusion to Dr. Althaus in so far as the proposition Shears, who was then house surgeon, for the following is concerned--that the virus of influenza especially affects notes of the case :-Soon after admission the opaque capsule the nervous system. Leaving the question of the acute was removed en masse by means of the cannula forceps, and and early manifestations, however, which I agree with two days later the patient, whose vision before the operaDr. Althaus in considering to be due to involvements tion only amounted to perception of lighr, could count The following day a hypopion apof certain areas in the medulla oblongata, it appears fingers with ease. to me most probable that the consequent phenomena peared, and atropine and belladonna fomentations were ordered every three hours. On the 28th, the hypopion are better to be explained by inflammatory changes in certain peripheral parts of the nervous system. In still remaining, quinine was added to the drop.—29tln regard to the visceral neuralgiae, the hepatalgia, the "Hypopion much smaller. "-July 1st: "Hypopion gone." gastralgia, and cardialgia, there are signs of localisation The quinine and atropine drops were continued until and, in some instances, of local tenderness that point to a the 8th, and eserine substituted -12th: The hypopion local cause. In some such it seems probable that the reappeared, and the quinine and atropine drop was sympathetic fibres and ganglia are alone affected. In other again used.-14th: "Hypopion gone, muddy condition cases, as in those in which there seems to be temporary of anterior chamber clearing up."-17th: Atropine alone arrest of the heart’s action, retching, vomiting, and various was ordered.-19th: Hypopion reappeared with pain and disturbances of digestion, it is most probable that the vagus injection ; atropine and quinine drop again resorted to.is involved in greater or less degree; but here also the 22nd : "Hypopion gone."- 26th : Patient discharged. effects might be due to peripheral irritation. In the J. I, c. + 12 D. It will be noticed that in c. + 6 D. sensori-motor manifestations it can scarcely be possible to 30 avoid the conclusion that there is in existence a form of this case the hypopion made its first appearance while the neuritis analogous to that which is caused by many other was under atropine, and that it) quickly dispatient toxines. The conclusion, therefore, which I have come to when was added to the Its reis that the various affections I have briefly described are the appeared took quinine each time when thedrop. was appearance place quinine remote consequences of the influenza infection, and- that the atropine or eserine was still conomitted, although their proximate cause is a peripheral neuritis affecting tinued. In other respects the treatment was not varied, the the sympathetic ganglia and nerves, the vagus, and the patient taking quinine internally from the first appearance sensori-motor nerve trunks. of the hypopion. Harley-street, W. I may also mention a recent case recommended to me by Dr. Bouverie MacDonald of Liscard. Mr. MWW-,aged nineteen, had complained of his eye about thirty six ON THE TREATMENT OF SPREADING ULCER hours before heonly was sent to me. I found an abscess of the cornea and a large bypopion. The cornea generally was OF THE CORNEA WITH HYPOPION. hazy and the aqueous turbid. The conjunctiva was slightly BY RICHARD WILLIAMS, M.R.C.S., chernosed and discharging muco-purulent matter. In fact, SURGEON TO THE LIVERPOOL EYE AND EAR INFIRMARY, AND OPHTHALMIC the disease bad been sudden in its onset and extremely rapid SURGEON TO THE ROYAL ALBERT EDWARD INFIRMARY, WIGAN. in its progress, and I have no doubt that a delay of twentyfour hours would have seriously compromised the safety of the FEW affections of the eye are more rapid in their progress eye. I ordered quinine and atropine drops, to be used every two hours, and quinine internally three times a day. No or more destructive in their consequences than those cases of ulcer of the cornea with a collection of pus in the anterior other treatment whatever except a pad and bandage was Two days later there was a marked improvement, chamber, and yet I believe there are not many affections employed. and in four or five days the hypopion had completely dismore amenable to prompt and appropriate tieatment. I appeared. It may be argued that these cases often recover propose in this paper to introduce a method of dealing with under atropine or eserine, hot fomentations, and antiseptic lotions, and that they are no proof of the value of quinine 1 THE LANCET, Nov. 14th and 21st, 1891. locally applied. It is obvious that pogitive proof is practi.
known, these cases are
Adopting
V=20
Group
3
some
of the
patients
referred the
pain
ON SOME PAINFUL AFFECTIONS FOLLOWING which they suffered very closely to the region of the heart. In a few cases the pain was persistent, but in most INFLUENZA. BY A. ERNEST
PHYSICIAN TO THE LONDON
A lady aged forty-two, who had suffered from influenza nine months previously, described tha pain as constant and dull, limited to the heart region. A gentle. man aged thirty-six, whose attack dated sixteen months previously, waa wearied with such dull aching; it was rather more diffused than in the former case. In another gentleman, aged forty-two, the constant pain in the cardiac region was accompanied by a tingling down the left arm The most important and characteristic cases in this roup,
paroxysmal.
SANSOM, M.D , F.R.C.P., HOSPITAL, ETC.
I PROPOSE in this short communication to pursue the inductive method of reasoning in regard to some cases which at one time caused me considerable perplexity. I will first mention a case which initiated my difficulties. A gentleman aged fifty-three, who for many months previously had been in fair average health, was taken during the night with severe pain in the right hypochondrium. The signs simulated those of hepatic colic. He took a mild aperient, and the attack passed away after one to two hours and he slept. The following day the bowels were properly opened, there was no evidence of absence of bile from the motions, the urine was in all respects normal and contained no bile nor excess of colouring matter. The attacks of severe pain, however, recurred at intervals-mostly in the night, but sometimes during the day-for about ten days, treatment by opium and belladonna only relieving them. It seemed that the gall-bladder could be mapped out by the area of tenderness, but never was there the slightest jaundice. On I could only say that one night there was sharp diarrhoea. the attacks were those of hepatalgia of paroxysmal recurIn hunting about for a cause the only antecedent rence. which seemed at all probable in this direction was an attack of inflaenza contracted in Paris at the very earliest time of the epidemic, and followed by protracted enfeeblement. I computed that nearly twenty months must have elapsed between the original attack and these consequences, if they were consequences. There was no evidence of reinfection, but of course this was possible. The key seemed to be furnished by a number of experiences which came to me just about the same period as this first instance. In all there was fair evidence of an attack of influenza followed at intervals, extraordinarily variable, by signs of extreme pain and distress. In twenty-four such cases the sites of pain could be thus tabulated :-1. Epigastrium, nine cases; abdomen generally two cases; localised in hepatic area,one case. 2. Head, various sites, seven cases ; supra-orbital region, one case ; right inferior maxilla, 3. Heart region, seven cases. 4. Extremities : one case. hips and legs, two cases ; calves, two cases ; arms, two cases; right sciatic region, one case; fingers, one case; lumbar
however, simulated angina pectoris. A gentleman aged thirty-one, typically athletic, who had never suffered from illness before his attack of influenza, which was very severe,
was
taken five months afterwards with sudden and
pain at the heart, eventuating in syncope. He was standing with his back to the fireplace, talking with friends, when the attack seized him with violence, and he fell unconscious upon the hearth-rug. There was no epileptoid sign. Another attack occurred a week after. There could be no doubt from collateral evidence that the patient became violent
faint to unconsciousness. In the intervals no notable deviation from health could be detected; the left ventricle was slightly hypertrophied, but not more so than could be expected in an athletic subject The patient described the pain as of the character of a " gripor "screw ’ at the heart; he experienced no coldness, and repudiated any
impending death. There were occasionally also dyspnoea, occurring independently of exertion. Nearly at the same time at which this patient came under my observation a gentleman came under my care with like symptoms, in whom there was no evidence of an attack of influenza. He presented the appearance of typical good health, but suffered attacks of terrible pain at the heart, ending in complete unconsciousness. On some occasions the attacks were followed by wild excitement, and the patient sense some
of
attacks of
had to be restrained from self-violence. 1 havereason to believe that in both these cases there was complete recovery. In a lady, aged forty-one, attacks of intense pain were initiated by exertion. The pain was localised in the second left intercostal space-presuinably over the superior cardiac plexus-and here was a tender spot. The pulsations of the heart were painfully felt when in the recumbent position. In some other cases there was a feeling of impending death, as in true angina pectoris, though the pain was much less severe. This occurred in a gentleman aged thirty-three, sixteen months after an attack of influenza. Pain referred to the heart, however, had occurred at intervals ever since his attack. In the case of another gentleman aged thirtyseven, the sensation was described as of an arrest of the heart, as if the pendulum of a clock had been stopped at one swing. With this the patient said, "Ifeel as if I were going to die." In some cases there was a manifest slowing of the pulse ; in others an irregularity. Sometimes a slow alternated with a quick pulse. Fifteen months after an attack of influenza I counted the pulse of a lady aged
region, one case. In Group 1 in some cases the pain at the epigastrium was nearly constant. For instance, a man aged sixty-six, who had been previously quite healthy, caught influenza at Christmas 1890, and had never felt well since. Six months afterwards he had constant pain at the epigastrium, with craving for food. Food slightly relieved the pain, but soon after In most cases the pain was nausea occurred, with pyrosis. paroxysmal, and frequently nocturnal, sometimes attended ’, twenty-two as fifty-six. In most cases the rate was rapid, with vomiting or pyrosis. Peculiar symptoms occurred in i and 1 do not remember one case in which the arterial This absence of prolonged some of these cases, as " a feeling as of a cold wind over the I tension was unduly prolonged. chest, and inability to take a deep breath." In some the arterial tension, in my opinion, took the cases out of the signs of colic, as in the first case mentioned, were closely category of true angina pectoris. I have not heard that any frequently there was retching, but the tendency case was fatal. ,
simulated ; rather
to diarrhoea than to constipation. In one case, sixty-three suffering from intense epigastric pain, of heavy weight preventing sleep, and some vomiting, I found a small patch of herpes zoster below the angle of the right scapula. In Group 2 were various neuralgim. In one man aged thirty-eight there was intense supra-orbital neuralgia varying from side to side ; previously there had been rigor and abdominal pain like colic, and then sweating and was a man of with sense
palpitation.
He had suffered from influenza twelve months
previously, but no ailment since, In another case, a lady aged twenty-five, urticaria followed icnuenza, and twelve months afterwards attacks of vertigo, with palpitation of the heart and pain referred to the occipital regions. A lady of thirty-seven, who had suffered from an attack of influenza in May, 1891, averred that two months afterwards she com-
menced to have headache, from which she had never been free in her waking hours for three months subsequently ; she also suffered from pain on movement of the right lower jaw. She had tremors and tinnitus aurium, but no vertigo. In others headache occurred coincidentally with gastric
crises.
It is no part of my purpose to pursue the question of the cardiac phenomena of influenza. These furnish most interesting lessons, but I am concerned now only with the manifestations of pain. I turn now to Group 4, in which there were painful affections of the extremities. A lady aged twenty-five, who had an attack attended with high fever four months previously, complained of intense aching in both arms. This occurred chiefly at night, and she actually wept on account of the pain. Previously to the manifestation in the arms she had suffered pain in the calves of the legs resembling that of neuritis. In another case of a gentleman aged forty-one, the pain was referred to the lumbar regions more on the left side, to the right shoulder and the left wrist, to the course of the right sciatic nerve, and to the muscles of the thigh. There were fearful exacerbations, chiefly nocturnal, so that the patient, previously a healthy man, actually shrieked on account of the pain. In the case of a female aged thirty-three pain was localised in the muscles of the calves of the leg and of the thigh. The pain was strongly aggravated after food, especially meat. In another female, aged twenty-three, pain was extremely violent in the thighs and legs, and there
15 were attacks of faintness. Subsequently the suffering was localised in the course of the right sciatic nerve. 10 was subject to remissions with severe nocturnal exacerbations ; there were also shooting pains at the epigastrium. The case In a lady aged was of alarming intensity, but recovered. forty-eight pain was referred to the right hip and to the right arm; it extended from the right shoulders to the fingers, and all movement caused pain. There could be little doubt that in these cases there was I met with other analogous instances a form of neuritis. in which there had been no history of influenza : one case in a child in whom there was severe pain in the calves, dropped feet, absolute loss of motor power, and, in fact, all the signs of neuritis of the alcoholic form. Any causation by alcohol was in this case quite out of the question; no doubt it was due to some infectious cause, and resembled the cases of peripheral neuritis, due to no traceable contagion, recorded by Dejerine and others. In this summary of my personal experiences I have dealt with no cases of the earliest manifestations of influenza,; all were in patients whose attack had passed away and who were not confined to their homes. The periods between the attack of influenza, and the manifestations of symptoms of pain varied from a few weeks to twenty months. The evidence appears to me to confirm the view of Dr. Althaus that the rnateries morbi of inilueinza resembles
these
cases
which,
as my knowledge extends, has general use, and which consists, application of quinine; and secondly, as
far
not hitherto been in
first, in the local
a modification of the usual incision for the evacua. tion of the pus contained in the anterior chamber. I am able to speak of this method of treatment after an ex-
in
perience of several years, during which I think I have had ample reason to be satisfied with its results. As is well
met with among the debilitated of all ages, most frequently as the result of traumatism. Among the colliers of the Wigan district they occur with unusual frequency, and I venture to assert, therefore, that my experience of them is above the average. In their treatment I have employed a solution of quinine during a period of upwards of ten years. The following mixture is used in nearly all cases that come under my care: R. quinise sulph. neutr., gr. iv.; liq. atropise sulpb., g i. M.; ft. guttae. In simple ulcers without hypopion I am in the habit of prescribing eserine much oftener than atropine, but I invariably prescribe the latter drug where hypopion is present, because iritis is a common feature in this condition. I doubt if either eserine or atropine has any appreciable influence upon the suppurative process. On the other hand, there is hardly anything in medicine about which I entertain less doubt than that quinine locally applied has an immediate and powerful influence in arresting this process and in the syphilitic virus in its tendency to attack many parts ofI causing the absorption of the pus already cullected in the the nervous system after the attack is over, but surpasses anterior chamber. I believe I have had repeated evidence the syphilitic toxine in virulence and in rapidity of action. of this both in my private practice and public clinique. Dr. Althaus1 has adopted the deductive method in his It is not my intention to burden this paper with a number reasoning. Starting from certain probabilities, he has of cases which seem to me all to tell the same tale, but I worked out the problems of the effects of the niateries cannot refrain from quoting the following case. which I think morbi if it should specially attack certain areas of the not only shows the value of quinine, but also tends to prove central nervous system. He concludes that the different that atropine and eserine by themselves have no great, if forms of influenza are due to irritant poisoning of the bulb any, influence upon the process of pus formation D. J-, aged eighteen, was admitted into the Eye and a converse and the nerve nuclei contained in it. method, that of logical induction, and taking my argu- Ear Infirmary on June 24th, 1882, for capsular cataract (lue ments alone from personal experience, I have arrived at a to an injury five years previously. I am indebted to Mr. similar conclusion to Dr. Althaus in so far as the proposition Shears, who was then house surgeon, for the following is concerned--that the virus of influenza especially affects notes of the case :-Soon after admission the opaque capsule the nervous system. Leaving the question of the acute was removed en masse by means of the cannula forceps, and and early manifestations, however, which I agree with two days later the patient, whose vision before the operaDr. Althaus in considering to be due to involvements tion only amounted to perception of lighr, could count The following day a hypopion apof certain areas in the medulla oblongata, it appears fingers with ease. to me most probable that the consequent phenomena peared, and atropine and belladonna fomentations were ordered every three hours. On the 28th, the hypopion are better to be explained by inflammatory changes in certain peripheral parts of the nervous system. In still remaining, quinine was added to the drop.—29tln regard to the visceral neuralgiae, the hepatalgia, the "Hypopion much smaller. "-July 1st: "Hypopion gone." gastralgia, and cardialgia, there are signs of localisation The quinine and atropine drops were continued until and, in some instances, of local tenderness that point to a the 8th, and eserine substituted -12th: The hypopion local cause. In some such it seems probable that the reappeared, and the quinine and atropine drop was sympathetic fibres and ganglia are alone affected. In other again used.-14th: "Hypopion gone, muddy condition cases, as in those in which there seems to be temporary of anterior chamber clearing up."-17th: Atropine alone arrest of the heart’s action, retching, vomiting, and various was ordered.-19th: Hypopion reappeared with pain and disturbances of digestion, it is most probable that the vagus injection ; atropine and quinine drop again resorted to.is involved in greater or less degree; but here also the 22nd : "Hypopion gone."- 26th : Patient discharged. effects might be due to peripheral irritation. In the J. I, c. + 12 D. It will be noticed that in c. + 6 D. sensori-motor manifestations it can scarcely be possible to 30 avoid the conclusion that there is in existence a form of this case the hypopion made its first appearance while the neuritis analogous to that which is caused by many other was under atropine, and that it) quickly dispatient toxines. The conclusion, therefore, which I have come to when was added to the Its reis that the various affections I have briefly described are the appeared took quinine each time when thedrop. was appearance place quinine remote consequences of the influenza infection, and- that the atropine or eserine was still conomitted, although their proximate cause is a peripheral neuritis affecting tinued. In other respects the treatment was not varied, the the sympathetic ganglia and nerves, the vagus, and the patient taking quinine internally from the first appearance sensori-motor nerve trunks. of the hypopion. Harley-street, W. I may also mention a recent case recommended to me by Dr. Bouverie MacDonald of Liscard. Mr. MWW-,aged nineteen, had complained of his eye about thirty six ON THE TREATMENT OF SPREADING ULCER hours before heonly was sent to me. I found an abscess of the cornea and a large bypopion. The cornea generally was OF THE CORNEA WITH HYPOPION. hazy and the aqueous turbid. The conjunctiva was slightly BY RICHARD WILLIAMS, M.R.C.S., chernosed and discharging muco-purulent matter. In fact, SURGEON TO THE LIVERPOOL EYE AND EAR INFIRMARY, AND OPHTHALMIC the disease bad been sudden in its onset and extremely rapid SURGEON TO THE ROYAL ALBERT EDWARD INFIRMARY, WIGAN. in its progress, and I have no doubt that a delay of twentyfour hours would have seriously compromised the safety of the FEW affections of the eye are more rapid in their progress eye. I ordered quinine and atropine drops, to be used every two hours, and quinine internally three times a day. No or more destructive in their consequences than those cases of ulcer of the cornea with a collection of pus in the anterior other treatment whatever except a pad and bandage was Two days later there was a marked improvement, chamber, and yet I believe there are not many affections employed. and in four or five days the hypopion had completely dismore amenable to prompt and appropriate tieatment. I appeared. It may be argued that these cases often recover propose in this paper to introduce a method of dealing with under atropine or eserine, hot fomentations, and antiseptic lotions, and that they are no proof of the value of quinine 1 THE LANCET, Nov. 14th and 21st, 1891. locally applied. It is obvious that pogitive proof is practi.
known, these cases are
Adopting
V=20