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time. The eye was not enucleated at that time. I learned, though, that after eight or nine years the eye had to be enucleated; she suffered constant pain until the eye was enucleated; a traumatic cataract also developed. I believe now the proper thing would have been to enucleate the eye when she was first seen.
Dr. Wm. Cheatham: The cosmetic effect, I forgot to say, is of considerable importance. In a patient of this age, as some future growth will take place, if you remove the eye very likely that side of the face would not develop, so there would be more or less deformity, even although the patient might wear a glass eye.
Dr. S. G. Dabney: All the factors mentioned by Dr. Cheatham have been thoroughly considered, particularly the residence of the patient. She lives in the city, and is consequently near an oculist, and I told her it would be necessary for her to come to see me frequently, which she promises to do. I also inquired as to her condition fiuancially; her people are very well-to-do, and this part of the case is very satisfactory.
I disagree with Dr. Cheatham in regard to shrinking. I hardly think that likely; the amount of cyclitis she has had would be against it. Under simple protective and cleansing treatinent the wound healed very promptly. It is hard to lay down any rules in regard to these cases. Noyes claims his rule is, even in more severe injuries than this, where they are inflicted by glass, not to enucleate. Nettleship says his rule is not to enucleate provided the lens is not injured and the patient has not a traumatic cataract. Of course the presence of a wound in the lens means pressure upon the eye for weeks or months which keeps up a constant irritation.
There were several points about the case referred to by Dr. Evans which can not be considered similar to the case reported to-night. The young lady he mentioned happened to come from the same neighborhood in Virginia where I formerly lived; it was soon after I came to Louisville that the accident occurred; it must have been fully ten years ago that she received the injury. Her eye was enucleated last summer by Dr. Wilmer, of Washington, D. C. It was not a shrunken eye, as stated by Dr. Evans, but one that had undergone glaucomatous changes, the eye had swollen to enormous proportions. The lens was injured, she had a traumatic cataract, an extensive wound through the cornea and prolapse of the iris. The injury in my case was not nearly so extensive nor so dangerous, except that it is to the ciliary body; the
condition thus far is exceedingly favorable, the wound healed nicely and the inflammatory reaction has been slight. In the case Dr. Evans referred to the young lady carried the eye for ten years after the injury, when it became the seat of constant pain, the sight was destroyed and the eye was finally removed. In the case I have reported there has been no sign of trouble in the opposite eye; there is no increase or decrease of tension or any other evidence of sympathetic trouble.
A Peculiar Case. Dr. J. G. Cecil: I had hoped to have a patient here this evening to illustrate the report I wish to make, a colored man who lives in New Albany, Indiana, and I presume his condition is such that he could not come over as promised.
The history is that the man is a cart driver, thirty years of age, married, has a family; at about the age of fifteen he contracted syphilis, the remains of which are plain upon his skin at the present time, in the shape of copper-colored spots. However, he exhibits no symptoms of tertiary syphilis, or has not done so until quite recently, except possibly some which will be referred to later. Six weeks ago he appeared at my clinic at the Louisville Medical College with this line of symptoms: His appearance was that of cyanosis; his lips were very blue; he was breathing hard, at the rate of 38 or 40, but regular; his pulse was ranging from 30 to 36 per minute, perfectly regular and of good volume and strength; his temperature in the axilla was 97° F., in the mouth 94° F. The difference in temperature was extremely puzzling to me; I could not understand why there should be that difference between the axillary and mouth temperature; my first thought was that my thermometer was wrong; I tried several instruments and on several occasions took his temperature, always with the same result, respiration and heart action relatively the same; repeated examinations were made running over a period of three or four weeks. He also had some edema of the lower extremities the last time I saw him, some ascites. He had been in good health and strength, and was still strong, but could not sustain activity for any length of time. He could not climb a stairway except under the greatest difficulty; he could not walk more than a square without stopping to rest.
Close examination of the heart revealed what I took to be a presystolic murmur, and from the position, etc., I believed it was a mitral direct murmur. Whether the slow action of the heart was due to the existing condition of the heart itself, or whether it was the result of
syphilis, I do not know, but was disposed to think, although he had no evidence of brain implication in the shape of paralysis, etc., that it was probably syphilitic brain lesion near the origin of the pneumogastric, in that way causing the slow heart action.
As to the difference in temperature between the axilla and the mouth, I do not know any other way to explain it than to simply throw this out as a suggestion, which I would like to hear discussed, viz., that the aeration of this man's blood was so imperfect that it resulted in a cold breath, just as we get in cases of collapse from cholera and other diseases in which we have the same conditions. This is the only explanation I can offer, and it is the only case I have seen in which the mouth temperature was persistently lower than the surface temperature of the body which was also subnormal. I regret that I did not also take the patient's rectal temperature; I believe it would have been found nearly normal. Later rectal temperature was identical with axillary.
Discussion. Dr. Wm. Bailey: The case presents a series of symptoms which are exceedingly interesting, and I only wish to state what I should conclude if I was making the observation. If I should find an axillary temperature of 97° F. and a mouth temperature of 94° F., I should conclude that the man on account of his dyspnea was unable to keep his mouth closed, that really it was a faulty technique whether I endeavored to make it a correct one or not. I do not believe that it is possible for a man to have a lower temperature in the mouth, in his rectum, or in any internal part of the body than his axillary temperature. There is more blood going to the mouth than to the axillary region, and there is not so much exposure, therefore the mouth ought to give us if any thing a higher temperature than the axilla, as the. closer we get to the blood the higher the temperature is. Examination by the rectum or by the mouth should give a higher temperature than in the axilla, and I should simply conclude that I was unable to make a proper test of the temperature in the mouth if I were making the observation in such a case.
As to the cold breath mentioned by Dr. Cecil, that could not be colder than the lung, unless the air did not remain in the lung long enough to be warmed; the atmosphere during the ordinary process of respiration ought to be warmed at any rate.
As to the condition of the heart, it would seem that the involvement was one only of irritation, stimulating the inhibitory power.
Involvement of the center to such an extent as to paralyze the pneumogastric would result in inhibition being taken off entirely. It may be stimulation and irritation, and not mechanical change to the extent of causing paralysis. I presume from the condition of the heart, it being a direct mitral murmur, that it is simply congestion of the lung which gave the man dyspnea, in which the venous system was engorged, producing dilatation of the right side or the heart, because the blood could not be sent on into the left ventricle; but I can not understand how under these circumstances it would be possible to have a full pulse with a mitral direct murmur. I do not see how, with congestion sufficient to make dyspnea very marked, that we could get blood enough into the left ventricle to distend the aorta and its branches. That would be very unusual. This case is one of great interest.
Dr. J. B. Marvin: I would much prefer examining the patient before expressing an opinion. I agree with Dr. Bailey that the man probably did not keep his mouth closed, which might account for the variation of temperature between the mouth and the axilla. It was perhaps a faulty observation. As to the mitral direct murmur, I can hardly understand the condition of the pulse as indicated; if there was sufficient trouble there to produce the peculiarity stated, if it was dependent upon sclerotic changes of the valve due to syphilis, there ought to have been a very distinct thrill which could be easily felt. If the lesion was syphilitic, near the origin of the pneumogastric, why were there not some ocular symptoms? Syphilis attacking the base of the brain usually produces its effect upon the ocular muscles, either the third, fourth, or sixth, or it may be all three. With a sufficient lesion there, syphilitic in character, to give rise to bradycardia, it ought also to give absence of the reflexes. It ought to give rise to a fixed pupil on one side or the other. There are many points of interest and value that could be brought out by seeing the case. You might have a great many of the symptoms presented, dyspnea, etc., from syphilitic growths in the mediastinum without having them in the brain. This is quite a favorite place for syphilis, about the mediastinum, and pressure here might interfere with the venous return.
Dr. Turner Anderson: I rather suspect that the reason Dr. Cecil's patient has not gotten over from New Albany is that he has had a fit and died. When the pulse gets down to 30 to 36, the disturbance of the circulation is so positive about the base of the brain that the cerebral restraint is removed from the spinal cord and the patient is
likely to go into convulsions. If the man's pulse is as low as 30 I would suspect that he has lost control of the spinal cord and has had a convulsion, and death has resulted. A pulse of 30 to 36 is certainly very near the danger line.
Dr. James B. Bullitt: I was particularly struck with the phenomena of the axillary temperature being higher than the temperature in the mouth. In that connection I remember to have read the report of a case recently, in one of the medical journals, of abscess of the brain in which the temperature of one axilla was higher than that of any other portion of the body. No explanation of this phenomenon was offered, in fact there seems to be none; but I believe in abscesses of the brain it is recognized that this phenomenon does occur. It is a question in Dr. Cecil's case whether the axillary or the mouth temperature really represented the general temperature of the man's body. This would be a point of considerable importance to determine, and might have a direct bearing upon the other symptoms present.
Dr. John G. Cecil (closing the discussion): This man did not impress me as being a mouth-breather. He was exceptionally bright for one of his race, being a rather intelligent man, and did not have the appearance or facial expression of a mouth-breather. I examined him. carefully as far as it could be done subjectively. There were no ocular symptoms whatever as far as I could ascertain; he said he could read without any trouble. trouble. The heart's action was at first very puzzling, and it was only after repeated examinations that I was able to recognize what I took to be a mitral direct murmur. I do not claim to be a specialist in regard to the diagnosis of heart murmurs, and it was only after repeated examinations that I recognized the murmur. My first impression was, when I examined this man, that the heart trouble was due to some obstruction to the circulation with a pericardial effusion; the impulse was faint, the sounds far away, and the heart area was enlarged. After repeated examinations, though, I concluded that he did not have an effusion.
In regard to my observations of his temperature I was very careful, because it is a very striking thing to have a man walk into the clinic, and find the temperature between 94° and 95° F. I tried several thermometers, and kept one in his mouth for fully five minutes, but the temperature did not go above 95° F. at any time, whereas in the axilla it would always be about 97° F. In studying the case to arrive at a possible explanation of this difference in temperature between the