Reprinted front Annals of Ophthalmology and Otology, April, 1895, 
PURULENT INFLAMMATION OF THE EYEBALL AND 
ORBITAL TISSUE, AND PARALYSIS OF THE 
OCULAR MUSCLES AS POSSIBLE COM- 
PLICATIONS OR SEQUEL.U OF 
INFLUENZA. 
By Charles Stedman Bull, M. D., 
NEW YORK. 
PROFESSOR or OPHTHALMOLOGY in the university of the 
CITY OF NEW YORK. 
IN discussing the localized complications of any general systemic 
disease, and especially of any infectious disease, we should 
beware of regarding all that follows a disease as its direct effect. 
This is particularly true of the complex of symptoms which we 
call influenza, and the French "la grippe." Many of those 
attacked and weakened by influenza become, in consequence of 
this weakness, the victims of diseases which have no connection 
with the original cause of the weakness. The more closely we 
observe this disorder the more convinced we become that the 
sequelae of influenza bear norelation to the severity of the primary 
disease. Another fact which has been made clear by the study 
and observations of cases of influenza is that the general number 
of eye diseases is not increased during the prevailing epidemic. 
So far as we know there is no ocular complication or sequela of 
influenza which is at all characteristic of the disease. Affections 
of the eyes in influenza are relatively not infrequent. They are 
polymorphous, of multiple variety, and many of them slight in 
nature and easily relieved. 
I think that it may be stated positively that no one specific 
infecting agent has been with certainty found in all cases of 
influenza. Among the bacteria found in the circulation, secretions 
or tissues of patients affected with influenza may be mentioned 
three varieties which are important from their consequences, viz: 
The diploeoccus, streptococcus and staphylococcus pyogenes. All 2 
these may induce embolic and thrombotic processes in any part of 
the body, and also give rise to toxic products which poison all the 
functions. 
It scarcely seems necessary to call in question the credibility of 
the belief that purulent processes occurring in the eye are depend- 
ent upon the toxic products of influenza. The question, very 
naturally, however, arises: is the connection between the diseases 
of the eye and influenza direct or indirect, primary or secondary. 
Do toxic influences play the main role or do they merely lower the 
general health and thus pave the way for eye troubles? 
The connection probably varies with different forms of eye 
disease. We start with the generally recognized assertion that 
influenza is an infectious disease in which capillary thrombosis 
have often been found. Emboli have been met with which are 
either infectious, or consist of simple clots. If they are infectious 
the streptococcus or the diplococcus or the staphylococcus pyogenes 
will be found. Many such cases have been reported in detail by 
the most careful observers, and there seems to be no reasonable 
doubt that purulent processes in the eye, the result in most cases 
of infectious embolism or thrombosis, are by no means infrequent 
complications or sequela? of influenza. Of these the most impor- 
tant and the most disastrous in its consequences is the septic 
choroiditis or irido-choroiditis. 
The most frequent purulent processes in the eye which 
accompany or follow influenza seem to be entirely external and are 
located in the lids, conjunctiva or cornea. In these cases Jaccourd 
has advanced the theory that the infection is intrinsic; that is, the 
numerous microbes of the conjunctiva, inoffensive when the patient 
is in good health, become noxious by the invasion of influenza. 
Fage, (Archiv. d'ophtal., 1890, p. 316, et seq.), has reported 
cases of purulent dacryocystitis and abscess of the cornea with 
hypopyon. Landolt, (Rec. d' Ophtal., 1890), has reported a 
case of abscess of the lid. Hosch, (Correspondenzbl. f. 
Schweizer Aerzte, 1890), reports a case of purulent irido- 
choroiditis with hypopyon. Eversbusch, (A/iinch. Med. Woch., 
1890), reports in detail an extremely interesting case of purulent 
choroiditis occurring on the ninth day of the influenza and 
ending in panophthalmitis and perforation. The staphylococcus 
pyogenes aureus was found in large numbers in the secretion, and 
infectious emboli were found in several of the blood vessels of the 
uveal tract. Fuchs, ( A7. Wo ch.. 1890), reports a case of 
purulent inflammation of the capsule of Tenon, beginning on the 3 
fourth day of the influenza with exophthalmos, loss of motility, 
swollen lids, and eventually a discharge of pus by two openings 
into the orbital tissue, and the pus showed pneumococci. Gazis 
(/?rc. cT O-phtal, 1890) reports- a similar case. Ehrlich {Inaug. 
Diss. Berlin. 1892) reports a case of abscess of Tenon's capsule, 
one of purulent orbital cellulitis, one of abscess of the lid, and one 
of purulent dacryocystitis. Laqueur (B&rl. KI. Woch.. 1890) 
describes a case of bilateral embolic iridocyclitis which came on 
suddenly on the eighth day of the disease and ended in complete 
blindness of both eyes which lasted four days. The patient sub- 
sequently regained a vision of one-half. Natanson {Petersb. Med. 
H'ocb., 1890) reports a case of influenza with pleuro-pneumonia 
and bilateral embolic irido-choroiditis ending in total blindness on 
the third day. and death on the fifth day. Finally in the mono- 
graph by Leyden and Guttmann on the influenza epidemic of 1889 
and 1890. Horstmann, who wrote the chapter on affections of the 
eye ,refers to cases by Pflueger, Greeff, Lyder-Borthem and him- 
self, showing the great variety of suppurative processes in the eye 
met with in patients sick with influenza. 
Among a number of cases of purulent diseases of the eye in 
patients suffering from influenza during the last three years which 
I have seen, the following recent case seems worth reporting in 
detail, on account of its severity and fatal termination. 
On January 28. 1895, a woman, 40 years of age, was brought 
to me suffering from a very severe type of orbital cellulitis and 
panophthalmitis, and she gave the following history: The right 
eve had been blind for many years from a traumatism. 
On January 23. she was attacked by many of the symptoms of 
influenza, coryza, obstinate cough, severe headache, high fever, 
pain in all her bones, and on the next day the eyelids began to 
swell and the eye to protrude. These symptoms rapidly grew 
worse, and when I saw her on the fifth day the eyelids were enor- 
mously swollen, the exophthalmos was extreme, the eyeball was 
very hard and immovable, and the pain was intense. Her tem- 
perature was iO3'2/5; her cough was violent and the expectoration 
profuse. She was put to bed. hot bichlorid fomentations were 
applied, leeches to the temple were ordered, and phenacetin and 
morphia were given to take down her temperature and allay the 
pain. The applications were continued for three weeks before the 
signs of cellulitis and panophthalmitis entirely subsided. As soon 
as softening began, two incisions were made into the orbital tissue 
on both sides of the eyeball, and the pus then discharged freely. 4 
The cornea had previously ruptured, and a large amount of detritus 
and pus was evacuated from the eyeball. After all signs of 
cellulitis had subsided and pus had ceased to be discharged from 
the orbital tissue, the eyeball was carefully enucleated, and a clean, 
apparently healthy cavity was left. On the evening of the second 
day after the enucleation, the wound appearing perfectly healthy, 
she began to develop symptoms of meningitis, and she died coma- 
tose on the fourth day. The autopsy showed purulent meningitis 
which involved not only the whole base of the brain, but also the 
entire convexity as well. The extensive character of the menin- 
geal inflammation led me almost to suspect that the meningitis had 
begun before the enucleation was done. At the autopsy no pus 
was found anywhere in the sheath of the optic nerve, but a subse- 
quent microscopic examination may give a different finding. 
There seems scarcely any doubt that this was an embolic process, 
whether starting in the cellular tissue of the orbit or in the uveal 
tract, it would seem impossible to say. 
In regard to the affections of the nervous apparatus of the eye 
which are said to complicate or follow the influenza, including the 
muscles, the retina and the optic nerve, the cases reported by 
competent observers are even more numerous than the cases of 
suppurative disease, and their actual connection with the general 
disease cannot be denied. The most frequent of these nervous 
sequela* is probably a paralysis of accommodation. Here the 
toxic agent of influenza resembles that of diphtheria. Then we 
meet, in the order of frequency, with paralysis of the sixth or 
abducens nerve : paralysis of the motor oculi or third nerve, and 
paralysis of the trochlearis or fourth nerve. The muscles supplied 
by the third, fourth or sixth nerves may be individually affected, 
or there may be complete external and internal ophthalmoplegia, 
either unilateral or bilateral. The paralysis of accommodation 
may occur alone without paralysis of the sphincter iridis, and in 
this peculiar effect the influenza resembles diphtheria. Three such 
instances have come under my own notice, and all regained the 
lost power of accommodation. 
Schirmer (Klin. Mon. f. Aug., 1890) reports a case of right 
unilateral complete opthalmoplegia. coming on during the 
height of an attack of influenza. There was loss of sensibility on 
the right side of the face and scalp, with paresis of the right 
masseter and temporalis muscles, and also of the muscles of the 
tongue on the same side. As there was paralysis of the third, 
fourth, fifth, sixth and seventh nerves, the lesion must have been 5 
central, and was possibly a hemorrhage at the base of the skull, in 
or near the middle fossa. It is a well-known fact that in many cases 
of influenza there is a strong tendency to hemorrhage in various 
regions of the body. 
Affections of the retina and optic nerve have been found to be 
almost as frequent complications of influenza as are paralyses of 
the ocular muscles, but they seem to be divided into two classes: 
one which accompanies the attack of influenza, and another which 
is a pure sequela, coming on several weeks after the onset of 
the disease. It is more obstinate in resisting treatment and 
leaves more disastrous results as to vision than the first' class, 
because there is not only inflammation of the sheath of the optic 
nerve, but also acute degeneration of the nerve fibers. The 
papillitis or retrobulbar neuritis met with during or after the attack 
of influenza resemble the same conditions met with in the course 
of other infectious diseases. Two interesting cases are reported 
by Landsberg {Centralbl. f. prakt. Aug.. 1890). The first was 
a man, who, on the fourteenth day of the influenza, suddenly lost 
the sight of his left eye, without any ophthalmoscopic evidence of 
disease. He could count fingers at two feet, had a very narrow 
field with total color-blindness, and regained his vision after 
eleven daily injections of pilocarpin. The other case was a 
woman who, during convalescence from influenza, had a sudden 
failure of vision of the left eye. with a central scotoma, proving 
the presence of a neuritis of the macular fibers, as the ophthal- 
moscopic examination was negative. She recovered under the 
administration of strychnia. 
Ehrlich {Inaug. Diss.. Berlin, 1892) reports cases of retrobulbar 
neuritis and papillitis, and Antonelli (ylwwaZz di Ottal.. XXI, p. 
119) the same. Snell {Trans. Ophthal. Soc. United Kingdom. 
1892) describes cases of optic neuritis ending in atrophy. Hart- 
ridge {idem. 1892) reports a case of bilateral neuro-retinitis. and 
Metaxas {Annates d'Oc., May, 1892) a case of retrobulbar 
neuritis, with hemeralopia, ending in atrophy. 
Remak {Centralbl. f. prakt. Aug., 1S90) reports a case of a 
man. with a severe catarrhal form of influenza, who, on the fourth 
day had a series of four convulsions within one hour, followed by 
loss of vision and atrophy of the optic nerves. 
Bergmeister reports cases of simple and inflammatory atrophy 
of the optic nerve, with concentric limitation of the field of vision 
and loss of the color sense. 6 
Graddy (Ophth. Rec., June, 1892) reports an interesting case 
of a woman who had a severe attack of influenza with pulmonary 
complications, and in the third week became suddenly blind, with 
a very small area of central vision for light. From this condition 
there was a slow improvement, followed again on the twelfth day 
by sudden failure of the vision, and right bilateral hemianopsia, 
which remained permanently. 
Gifford {Ophth. Rec., 1892) reports the case of a man who, 
during a severe attack of influenza, suddenly had an onset of 
violent pain in the occipital region, followed by bilateral right- 
sided hemianopsia. In each eye the line of demarcation followed 
the vertical meridian accurately and remained unchanged for 
nearly three years. 
The writer has recently had under his care the following case: 
A gentleman, 62 years of age, a literary man, badly nourished, 
and a victim for many years to intestinal catarrh, on the fourth 
day of a severe attack of influenza, suddenly noticed an obscura- 
tion of the vision of the right eye. I saw him within a few hours 
of the occurrence, found a central scotoma, positive in character, 
with a diameter of about 30° in all directions from the center of 
the field. Within the limits of the scotoma vision was absolutely 
lost. The ophthalmoscopic examination was entirely negative 
and has remained so. The scotoma for form gradually grew 
smaller and eventually disappeared, but the sense for color is still 
absent within the limits of the original scotoma. There was no 
pain caused by movements of the eye in the orbit, but considerable 
pain was produced by pressing the eye backwards into the orbit. 
He recovered under the use of strychnia and pilocarpin adminis- 
tered hypodermatically. This was undoubtedly a case of retro- 
bulbar neuritis, the fibers going to the region of the macula 
being involved.