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laity alone, for there are numerous physicians who have lacked both the time and the inclination to give this very important practical subject more than superficial study. All of these erroneous ideas seem to arise from a failure to appreciate the fact that glasses have to do only with aiding the refractive media of the eye, serving to direct the rays of light in such a way as to cause them to focus properly on the retina.
The most common objection the oculist hears is that if glasses are once put on they can never be dispensed with. If they are so effective in relieving the condition for which they were prescribed, render a clear image easily obtainable and increase the patient's capacity for near work, why should he wish to discontinue their use? The lens cannot, of course, produce any change in the structure of the eye, and the only thing to prevent the patient from discarding the glasses at will is his disinclination to do so, he preferring to correct his error of refraction by this simple procedure rather than return to his former laborious practice of depending entirely on ciliary effort, which was always fatiguing and often actually painful. When we have once learned to do a thing with greater ease or more satisfaction than we previously did it we are not content to return to the tedious method in use before.
In myopia it is only through the aid of a concave lens that the eye is enabled to secure a clear image, and when it is once accustomed to good vision through a glass of proper strength, it is not content to view objects with blurred outlines as it was in the habit of doing formerly.
There are also a considerable number of people who appreciate their need of glasses who refrain from their use on account of the impression that if they begin wearing them early, the strength of their lenses will have to be constantly increased, and that they should therefore postpone their use as long as possible. The function of glasses being purely a mechanical one, their early use can in no way, save in a few exceptional cases, affect the strength of lens required, and vision is not permanently affected by their use or disuse, they having to do only with the ease and efficiency with which a clear image is formed and maintained. I suppose that this idea has gained currency from the fact that when we become presbyopic near
the fortieth year the reading lenses do require to be made stronger occasionally to compensate for the declining elasticity of the crystalline lens, but this condition does not obtain until after we have passed the fortieth year.
This same idea often leads a patient to think that his lenses should be changed at certain stated intervals, but in the great majority of cases that are properly fitted to begin with, no change is necessary until their accommodation begins to fail from advancing years.
The most pernicious of all the fallacies concerning the use of glasses is in regard to their use by children, as it is here that a neglect of their use when needed is of most serious consequence. During the early years of life the eye is plastic and yielding, and if its delicate structures are subjected to continuous and severe strain to correct some error of refraction during the child's formative period, untoward results are sure to follow. In this "strenuous' age we are crowding more and more into the early years of life, and are exacting more and more of a child during this period, and if there be a defect in his vision that is amenable to correction it is almost criminal to deny him this benefit. Under the present requirements of expanding culture and an ever-increasing struggle for existence every possible handicap should be removed, and the prejudices of those who have been reared to consider the "three R's" (readin', 'ritin' and 'rithmetic) a sufficient acquisition of knowledge should not be permitted to prevail. Every oculist has seen numerous cases of children who have conceived an aversion for school work, and who have failed to take up the progressive spirit of the times solely because of existing uncorrected errors of refraction. These errors render continued study tedious, and often actually painful, and the ciliary effort required for their correction dissipates the mental energies, interferes with the concentration of thought necessary for the mastery of the subject in hand and, if continued, is productive of reflex disturbances ranging in severity from a slight conjunctival irritation to the gravest types of nerve disorders.
These reflex irritations of the lids are removed by a properly fitted lens, and the increased acuity of vision, with the
relief of the ocular strain, renders the eye bright and clear and gives rise to a sense of well-being that is reflected in the expression of the countenance. This consideration should go far to outweigh the prejudices of those who object to glasses on account of cosmetic effect.
I have heard far-sighted people who had not worn glasses until after their power of accommodation had failed, complain that their vision for distance was not so good without their glasses as before their use was begun, but on examination with the test type the vision will be found to be quite as acute as that recorded on the day they were fitted. This apparent diminution of vision is purely relative, for the glasses enable the patient to see clearly, while vision without them is comparatively poor.
Some believe that only gross errors of refraction should be corrected, but the oculist gets much more satisfactory results from the correction of the smaller errors, for in these perfect vision can usually be obtained by an accommodative effort, and the eye being accustomed to a clear image will be content with nothing less, consequently the ciliary muscle is overworked and the evidences of eyestrain become manifest. With a large error present no amount of strain on the ocular structures can secure a perfect image, and the eye becomes content to see objects indistinctly, but few demands are made upon the accommodative apparatus and the eye suffers but little from ciliary strain. It is often surprising to note the relief obtained from the correction of very small errors of refraction, and the increasing use of modern instruments of precision for doing the work has greatly extended its field of usefulness and has been effective in the relief of many cases that were not formerly recognized as amenable to such treatment.
It is not an infrequent occurrence for the family physician. to refer cases for refraction to an optician. In entering a protest against this reprehensible practice I do not believe that I can be accused of doing so from pecuniary motives, for the optician makes quite as much practice for the oculist as he takes from him. It is a frequent occurrence to find patients. fitted by them wearing minus lenses who, when refracted under a mydriatic, will accept and wear with comfort a plus lens, and
this difference in findings will sometimes amount to a very large number of diopters. The correction of errors of refraction is possibly the only exact science in the whole domain of medicine, and its proper performance necessitates a careful inquiry into the condition of all the delicate ocular structures. The fitting of glasses is therefore one of our highest medical privileges and can safely be entrusted only to those with the requisite medical training to insure its being properly done. Randolph Building.
FUNDAL INCIDENTAL and CERVICAL UNAVOIDABLE HEMORRHAGE.
New Descriptive Terms for the Two Types of Ante-Partum Hemorrhage from Placental Separation.
A Consideration of the Subject.
J. L. ANDREWS, M.D.
Quiz Master on Obstetrics, Memphis Hospital Medical College.
A BLEEDING pregnant woman affords a condition which easily takes rank with, or possibly heads, the list of those worrybringing, sleep-losing conditions, such as are afforded by a septic puerpera, a bad fracture into a joint, or post-operative hemorrhage in abdominal section. Hemorrhage during pregnancy must be caused by one of three conditions: placental dystocia, rupture of a blood vessel along the genital tract, or the abnormal continuance of the menstrual function. The two latter conditions are so infrequent as to be of little or no importance. Hemorrhage from rupture of a blood vessel is always external to the cavity of the uterus, is easily seen and its cause recognized. Menstrual hemorrhage is periodical and slight, and its occurrence after one or two periods have passed is very rare; though I have seen in the literature a report of a case in which the woman menstruated only during pregnancy.
Clinically, the most important classification of placental hemorrhage is from the standpoint of location of the placenta, whether normally located in the safe uterine zone, or lower in the dangerous zone. Gillemau and Mauriceau, 1609-1668, recognized this condition, but their idea as to the true pathol
ogy was incorrect. Schaller, 1709, demonstrated the condition in the dissection of a body. But it was reserved for Rigby, in the latter part of the seventeenth century, to give a definition of placenta prævia which has stood for more than a century: i. e., "the attachment of the placenta to that part of the uterine wall which always dilates as labor advances." Rigby also originated the terms, "unavoidable," to denote placenta prævial hemorrhage, and "accidental," to denote bleeding from the separation of a normally situated placenta. His descriptive name for placenta prævia is most appropriate, but the word "accidental" has proved a stumbling block to thousands of medical students. There is nothing in these two terms, "unavoidable" and "accidental," to denote or even suggest the cardinal point of difference in the two forms of hemorrhage, i. e., placental location.
Experience in obstetrical teaching has amply demonstrated that it is very difficult for the medical student to disassociate accidental hemorrhage from trauma, as the name would indicate. The term "unavoidable" is much more appropriate, though, in one sense, both hemorrhages are strictly unavoidable.
For many years the writers have realized the inadequacy of these terms. Quite recently, Holmes, of Chicago, in the American Journal of Obstetrics, vol. 44, 1901, has published a thesis upon this subject based upon two hundred cases in the literature, which has been quoted by Edgar in his comprehensive work on obstetrics. Holmes proposes a new name for the premature detachment of a normally situated placenta, “ablatio placenta." This name would seem open to criticism. It is not Anglo-Saxon. The word "ablatio," derived from the verb "aufero," means "a taking of" in active sense.
The word is used only by Hieronymus and other early Christian authors. The passive significance of this form of hemorrhage, frequently from internal causes, and practically always in connection with a diseased endometrium, is entirely lost sight of in the use of this word with its active significance. It would seem more appropriate to use a form of the original verb. As a teacher of medicine, the writer has strongly felt the need of terms which would be more descriptive. I thought