Ernest Watson Cushing.

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sumably infectious origin, so that a confused conception is af-
forded of the nature of the conditions included under the name
of acute glossitis. It is now justifiable, in virtue of several re-
cently published reports with which my own observations agree,
to attempt a separation of these conditions in a manner consistent
with their etiology and pathological anatomy.

We have seen that a certain form of acute parenchymatous in-
flammation of the tongue owes its origin to an infection by the
bacillus of diphtheria, and we have also seen that another macro-
scopically similar condition is brought about through infection
by the streptococcus pyogenes. Still other inflanmiations, gen-
erally of a more localized type, and with a tendency to abscess for-
mation, are due to an invasion of the lingual parenchyma by
forms of staphylococci.

When now with these facts in mind we examine the various
conditions and recorded cases which have generally passed under
the comprehensive term of acute glossitis, it will be seen that a
certain number bear clinically the stamp of infection. Such are
the cases of moderately, rapidly or comparatively slow onset ac-
companied by fever, prostration, and constitutional symptoms,
preceded often by a reddening or inflammation in the faucial re-
gion, exhibiting enlargement of the neighboring glands, and oc-
curring in a large proportion of cases in individuals already the
subject of disease, or in those exposed to depressing or infectious
influences. Leaving, therefore, such conditions out of present
consideration, we shall find left a number of acute, lingual en-
largements exhibiting in common the characteristics of extreme-
ly rapid onset, generally a febrile course, slight or no constitu-
tional symptoms, with a swelling at times sharf>ly limited to one-
half of the organ, or accompanied by a herpetic eruption in the
immediate neighborhood, unattended by glandular enlargement,
and terminating abruptly. These swellings stand evidently in
some relation to a disturbance of the nervous system. A consid-
eration of their characteristics shows, furthermore, that the special
part of the nervous system involved is the vasomotor, and that the
condition is therefore to be included in the group of affections
known as angioneuroses.

The swellings may affect both sides of the tongue simultane-
ously (Totheric's case), or be limited to one-half of the organ



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614 J. L. GOODALE.

(Giiterbock), or finally, it may involve one-half at the beginning,
and suddenly shift its seat to the opposite half. In a few in-
stances, an herpetic eruption, together with neuralgia, has accom-
panied the swelling, particularly in cases of unilateral enlarge-
ment, so that the picture is present of angioneurotic oedema plus
lingual zoster.

The pathological anatomy of the condition is not known from
microscopic examination.

The lips may be the seat of a similar acute oedema, the lower be-
ing the more frequently affected. Among several cases seen by
the writer, the following presented the most conspicuous example
of this condition: Male, 39 years of age, came to the clinic with
negative previous history except that he had had last year an at-
tack similar to the present one, and stated that two days ago, dur-
ing very hot weather, he had fallen asleep with his head on the
window sill. After having slept thus an hour, he awoke to find
a strong wind blowing in, and immediately noticed that the left
side of the lower lip was somewhat swollen, together with the
neighboring part of the cheek, and a portion of the region be-
neath the chin. The swelling progressively increased during that
day, the lower lip becoming enlarged to three or four times its
normal thickness, and so greatly occluding the oral aperture that
food could be introduced only through a narrow space on the
right side. There was simply a tight feeling in the parts, but no
pain. Constitutional symptoms were absent. The swelling has
since persisted, although diminishing somewhat under hot fomen-
tations. Examination showed a healthy man without abnor-
mality, except for the following conditions: The lower lip is swol-
len over its left half to three times its natural size, so that it ex-
tends greatly over the middle line and renders the essentially
normal right half, insignificant in comparison. The affected por-
tion is everted, firm, tense, not pitting on pressure, and nearly
closes the opening of the mouth so that introduction of the finger
is possible only through a small space on the right. The swelling
extends for four or five centimeters under the chin, and for about
the same distance into the left cheek, gradually merging into nor-
mal tissue. The mucous membrane of the everted lip is some-
what reddened and denuded opposite the lower incisors with
which it comes in contact. There was no elevation of tempera-
ture. No medicine was given, beyond a glycerine wash. The
swelling rapidly diminished in the next forty-eight hours, and



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SCHOOL HYGIENE. 615

two days later had wholly disappeared. The Up resumed its
customary soft, pliable condition, and no induration or local thick-
ening was left.
3 Fairfield Street, Boston.



THE HYGIENE OF THE PUBLIC SCHOOLS.*

LEE WALLACE DEAN, M.S., M.D.,
Professor of Physiology and Hygiene, University of Iowa.

Sanitary science can have no more important or fruitful field
of application than is presented in our educational institutions.
We had in 1890, according to the school statistics of our census
bureau, over fourteen millions of pupils in the various schools
and colleges of the United States, — fourteen millions of boys and
girls, to whom the destiny of a nation is about to be entrusted.
What can be more important than that the training of these chil-
dren during their period of physiological growth shall be such
that there shall be the least possible amount of physical or mental
degeneracy, that they shall become well built, strongminded men
and women.

AVhy is it that we expect when a child begins its tasks in the
schoolroom that it will undergo more or less physical degenera-
tion? Why is it that a large percentage of those who enter upon
the educational process in good health soon manifest impaired
general vigor, acquire distorted spines and develop near sight? It '
is simply because the hygienic surroundings of the child are not
perfect; that the work of the child is not so regulated as not to
interef ere with the growth of the organism.

Every now and then one hears of a student who must leave
the University because of his or her eyes. What is the trouble?
In nine out of ten of the cases it is simply the neglect of the or-
dinary laws of hygiene. They have had some error of refrac-
tion, which, if it had been attended to in season, would have caused
no trouble whatever; but which, when left alone, has produced a
spasm of ciliary muscle, a beginning short-sightedness, and has

I
•Read before the Iowa State Medical Society at Cedar Rapids, May
17. 1899.



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616 L. W. DEAN.

caused the student to lose a year or more of the most important
time of his or her school life. If this student^s eyes has been
investigated when he or she was in the primary schools, and the
error corrected, then by the loss of but two weeks of a very un-
important time in their life, all this could have been avoided.

How much of life is wasted, and how much poor work is done
because of the neglect of these rules 1 It is nothing uncommon
to find students here in our University, working at drawing, wh^
they can't tell a straight line. It is a most ordinary thing for an
instructor in the dental department to have a student bring to
him a crown which he maintains to be perfect. The instructor
sees dents and scratches, and points them out to the student, who
is unable to see them. While not common, it has happened tiiat
an instructor in our University has come to me and said: '^y
eyes are perfect, but I wish you would look at them." The eyes
have been examined and glasses prescribed; the instructor has
gone out and looked at the world, and for the first time has seen
the world. He had traveled through Italy, France and Switzer-
land, but he has not seen them. Now, if he wishes to know these
countries, he must go over the ground again, simply because his
educators have neglected to observe the simple laws of hygiene.

The subject of school hygiene was first studied by Cohn in the
early part of the present century. He examined the eyes of 10,-
000 school children in the vicinity of Breslau, and published the
results of his investigations. Since then other observers have
made a more or less critical study of the ocular conditions of over
200,000 school children. Stated on general terms, it has been
shown that the eyes with hypermetropic refraction, that is, far-
sighted eyes, greatly outnumbered emmetropic, that is, normal
eyes, particularly during early childhood; that the emmetropic,
or normal eye, was comparatively rare, but that the state of re-
fraction most nearly approaching this ideal condition retained an
almost uniform percentage during life; that myopia, or short-
sightedness, extremely rare or entirely absent before the begin-
ning of the educational processes, was found to advance steadily
in percentage with the progress of the pupils in the school, while
the percentage of hypermetropia diminished in approximately
the same degree.

Cohn found in the University of Breslau the percentage of
myopes to be 59.5. He concludes that not only does the number



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SCHOOL HYGIENE. 617

of short-sighted pupils increase from the lowest to the highest
schools, but that the increase is in direct proportion to the length
of time devoted to the strain of school life. What Professor Cohn
has foimd to be true in Europe, has been found to be true in
America- The same problem confronts us in the United States
as was presented to European observers. The problem which pre-
sents itself in America is not quite so serious as the European.
Most of the American children are raised in smaller towns and in
the country. Their surroundings are such that as soon as they
leave the schoolroom they look off into the distance, and as w©
say, rest the eyes. Children in large cities, however, find them-
selves hemmed in by buildings and objects so close that the eye
is constantly in a more or less state of accommodation. The prob-
lem in America is much more important, however, than the
European. Because of years of neglect, the Germans are said to
be a race of myopes. The damage has been done and the results
are almost incurable. In America, however, the people have lived
an out-door life, and now the effects of abusing the laws of hy-
giene are just appearing. In short, we are in the position where
an oimce of prevention is worth a pound of cure. We are in the
position where care on the part of our educators will keep us from
the catastrophe which has befallen European nations.

Before we go further with our discussion, it might be well to
get a clearer idea of what we mean by the terms myopia^ hyper-
metropia and emmetropia. Briefly speaking, the emmetropic eye
is one in which parallel rays of light entering the eye are focused
upon the retina; a myopic eye is one in which the rays are focused
in front of the retina, and a hyperopic eye is one in which the
focus is back of the retina.

The objective examination of the short-sighted eye shows that
it is longer than normal. The lengthening is due, as can be
readily shown by making a longitudinal section of the eye, to a
bulging of the sclera, or protective coat of the eye at its posterior
pole. In high-graded myopia the enlargement of the eyeball can
be seen when the eye is in its socket; the eye protrudes, the patient
is said to be goggle-eyed. If we cause the patient to look toward
his nose so as to expose the outer equatorial region, it is seen to be
almost flat, not curved like the anterior surface of the eye.

Certain changes have a great tendency to take place within the
myopic eye, which produce disturbances of vision much more



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618 L. W. DEAN.

serious than the mere loss of distant vision. The myopic eye, be-
cause the posterior pole of the eye is bulging, allows the choroid
which covers that portion to be stretched. This stretching of the
choroid usually results in the production of a diseased or atrophic
condition of the choroid, which we call choroiditis centralis. As
the choroid is intimately concerned in vision, and as the part which
is affected, is located as the posterior pole of the eye, which is the
centre of vision, one can readily see what a catastrophe such a
change would be. It produces total blindness in the fovea cen-
tralis, or centre of vision, and objects which are looked at directly
are not seen. Another change which occurs quite frequently in
the myopic eye, is the so-called ablatio retinse — or elevation of the
retina. The retina is the inner lining of the eye. It lies on the
sclera and contains the vitreous or jelly of the eye, just as the
membrane of an egg lies upon the shell and contains the ^g-con-
tents. Now as the sclera of the eye increases in size the retina
becomes separated from its firm background, the sclera, serum
collects between the two, the retina is forced further and further
away from the sclera until finally a large portion is elevated.
That portion becomes insensible to light and we cannot see objects
in the external world whose rays of light strike upon it If only
a small portion became elevated it would not be so serious, but an
elevation once begun generally spreads until the whole of the
retina is affected. It is then not the myopia itself, which is pro-
duced by not adhering to the rules of hygiene in the schoolroom,
which causes the great trouble, but it is the changes which have
a tendency to take place in the myopic eye, namely, choroiditis
centralis and ablatio retinae.

Now, how. is it that myopia is produced in our public schools.
Myopia is but rarely congenital. The rule is that myopia de-
velops in the youth. As the result of many investigations it has
been found that myopia occurs almost exclusively in those per-
sons who have used their eyes for near work, as in tailors,
seamstresses, typewriters, lithographers, jewelers, and in people
who have read a great deal. There can be no doubt but that the
production of myopia is due to the carrying on of too much near
work. Two factors come into play, namely: the accommodation
and the convergence of the eye, which together produce the j

bulging of the posterior part of the eye. If straining the eves
in doing near work produces short-sightedness, why is it that all



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SCHOOL HYGIENE. 619

people who do such work do not become short-sighted? With
those affected we must conclude that certain factors in addition
to the near work are present. As such factors we recognize : 1. A
predisposition to myopia; as such we have a weak sclera or a short
optic nerve which pulls upon the back of the eye, etc. Children
of short-sighted parents are not bom short-sighted, but if they
are exposed to circumstances favorable to the production of
myopia, they have a greater tendency to become myopic than
children of parents with normal eyes. 2. Conditions in or about
the eye, which cause the person to hold the work too close to the
eyes in order to see distinctly. For instance, sewing by poor light
causes the work to be held close to the eyes and tends to the pro-
duction of myopia. Or any trouble in the eye, as astigmatism,
cataract, or anything interfering with acuity of vision, which com-
pels the person to hold the work close to the eyes, increases the
convergence and accommodation and is productive of myopia.
This is the chief factor: People who come from families where
there is no myopia, and have had their cornea scarred, so as to
interfere with their sight,become short-sighted because they have
to hold things so close to the eyes in order to see them at all. It
is by eliminating this factor that the application of hygienic rules
does most good. We will treat of this later on.

Wben an object is held close to the face in order to be seen
distinctly, two things are necessary: First, an excessive con-
vergence of the eyes; second, an excessive accommodation of the
eye.

The excessive convergence of the eyes tends to produce myopia,
because when the eyes are turned far in, the balls' are pressed
upon and the intra-ocular tension is increased; an increase in the
intra-ocular tension, of course, having a tendency to push out the
back part of the eye. Likewise an increase in intro-ocular tension
is produced by excessive accommodation. When looking at an
object held close to the eye the ciliary muscle contracts. The
greater the contraction the more blood sent to the inner coats of
the eye and the greater the intra-ocular tension.

Many of the German writers until recently have viewed
myopia rather as a manifestation of a normal evolution than as an
evil. One thing is certain, a myope of but three diopters, that is,
one with distant point at 80 C. M., is much better fitted for students'
work, than an emmetrope. When an emmetropic or normal-



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620 L. W. DEAN.

sighted person is reading they usually hold the book about 30
centimeters from the eye. In order to see the letters plainly at
this distance he must accommodate 3 diopters. The person, how-
ever, who is myopic 3 diopters, has his far point at 33 1-3 centi-
meters; that is, rays of light coming from a point 33 1-3 cent-
meters from the eye are exactly focused on the retina. As the
book is held at about this distance from the eye, he reads without
his ciliary muscle working at all and the tiring of the eyes is pre-
vented. In the same way a person myopic 10 D. is especially
fitted as a jeweler, because they hold their work about 10 centi-
meters from the eye. Not only do these people not have to ac-
commodate to see objects at this distance, but the image of the ob-
ject thrown on the retina is larger in the elongated eye and ob-
jects are seen more distinctly.

Myopia is said to be simply the adaptation of the organism to
its work. The German ophthalmologists are the strongest sup-
porters of this theory. The supporters of this theory say that the
American Indian, the South African and other imcivilized tribes
are far^ighted; that children are bom far-sighted and only de-
velop near-sight as they grow older and use the eyes. That peo-
ple living in rural districts have but a very small per cent of
myopes among themselves, while if their children leave their
homes and go to work in counting houses, a large number soon
develop myopia. Further, that myopia, as a rule, appears only
in those who use their eyes for near work, as students, book-
keepers, jewelers, artisans, etc.

However, before it can be proven that myopia is an appropriate
adaptation, It. must be shown that the increase in refraction of the
eye is consonant with the health of the organ, and that it is con-
ducive to the greater comfort and usefulness of the individual.
If we examine a patient when myopia is just beginning, or when
it is progressing, we will find the patient complaining of head-
ache, of mists before the eyes and undue sensitiveness to light.
All of these symptoms are made worse by near work. An ob-
jective examination of the eye shows a spasm of the accommoda-
tion, and a hypersemia of the optic nerve and retina. If the
patient rests the eyes all these symptoms disappear. When they
resume their near work they soon reappear. As the myopia con-
tinues to advance, in many cases decided pathological changes
make their appearance in the intra-ocular membranes of the eye.



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SCHOOL HYGIENE. 621

Of eighteen hundred and seventy-eight myopes observed by
Homer, over 34 per cent developed dangerous complications,
either diseases of the vitreous, inflammations of the choroid, de-
tachment of the retina or cataract These facts certainly show
that myopia is not consonant with the health of the organ. The
best proof, however, that myopia is not an appropriate adaption
of the organism to its work is as follows: It has been found by
observation that those eyes which are emmetropic and those eyes
which most nearly approach the conditions of the (emmetropic eye
do not become myopic. That it is those eyes which have some
error in refraction or some defect in the eye which diminishes
the acuity of vision and causes the person to strain the eyes or
hold the work too close, which become near-sighted.

If what we have said about the causes of myopia be true, it is
obvious that the most painstaking attention to the details of gen-
eral hygiene of the schoolroom and the adoption of the most ap-
proved educational methods should be adopted in order to arrest
its spread.

TVe have found the main cause of myopia is some defect of
vision, which causes the student to hold his book close to his eyes.
To overcome this, some systematic method of inspection should
be adopted in the schools which would be effectual at the very
outset in detecting anomalies of vision, and at least, make it pos-
sible to warn the parents of existing unfavorable conditions and of
the probable injury to the eyes if neglected. That children are
entered without question as to the state of their vision, is doubtless
due in lai^e measure to ignorance of any necessity for such in-
quiry. Parents who are careful of their children's welfare in
other respects are unmindful in this, and educators thoroughly
versed in the improved methods of mental training accept the
important trust committed to them, not knowing whether the
vision of the child is sufficient to sustain the coming struggle with
books. There is great need, therefore, for popular education in
this respect. When parents come to understand that the vision
of their children may be defective, and in consequence their
school life fraught with danger to the eyes and their educational
process retarded, there will be less negligence in this direction.

When a child is brought for admission to the school, one of the
first questions should be, 'TIave your eyes been tested?" If an-
swered in the negative, such investigation should be urged upon



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62!^ L. W. DEAN.

the parents, or made at the time by the teacher or some person
detailed for this duty and instructed in the proper methods of ex-
amination. Such inspection would at once eliminate all those
pupils with considerable errors of refraction, with corneal opaci-
ties, or with serious pathological conditions of the fundus. If, at
the beginning of the school life, these congenital anomalies of re-
fraction could be carefully corrected by suitable glasses, we should
hear much less complaint of the harmful influences of the schools
upon the eyesight of our children.

Children with red or inflamed eyes should never be permitted
to enter the school until a physician^s certificate of the non-in-
fectious nature of the disease has been presented. This precaution
is especially necessary in our modem schoolhouses, with their
lavatories, where the children find facilities for bathing the hands
and face in wash basins which of necessity must be used by all
in common.

Passing from the study of the eyes, we come to the considera-
tion of hygiene of the schoolroom, so far as it may affect the
vision of the children. The type in the text-books, especially
those employed in the lower grades, is good, and the paper used in
most of the books is not open to adverse criticism.

In many of the schoolhouses glaring defects are present. The
arrangement of the seat and desk is, in many cases, to be con-
demned. At the lower part of the pelvis are the two ossa in-
nominata or seat bones, which are curved and rock easily back-
ward and forward. It is only when the line of gravity of the body
falls perpendicularly upon a line joining the centre of thet^ two
bones, that the body can remain at rest in a sitting posture. Any
movement which displaces the centre of gravity must carry the
line of gravity in front or behind this line and make it necessary
to seek a third point of support. In the forward sitting posture
it is obvious that this third point of support must be the front edge
of the seat or some point between it and this line. The farther
forward it falls, the more imstable is the support and the greater
the exertion required of the muscles of the pelvis to maintain the



Online LibraryErnest Watson CushingAnnals of medical practice → online text (page 53 of 77)