Part 8

Again, the time comes in the life of every one who is not near-sighted, and who lives to a good old age, when he cannot see near objects well without glasses. Between the ages of 40 and 50, the crystalline lenses of his eyes having hardened along with the other tissues of his body, he finds it impossible to focalize as he used to. He holds his book farther and farther away from his eyes, and finally he finds that he cannot read fine print at all, or without straining his eyes. Then he must accept the unpleasant fact that he is getting old-sighted, and if he wishes to use, and not abuse, his eyes, he must get glasses to take the place of his lost accommodation and with which he can read easily. Some persons who are near-sighted in one eye and far-sighted in the other never need glasses, but always do their reading and other near work with the near-sighted eye and their distant seeing with the far-sighted eye. I believe I read a long time ago, in an article by himself in the New York _Ledger_, that this was the case with the late Rev. Henry Ward Beecher. But the vast majority of persons who wear glasses, both for the distance and for the near, can see quite as well without them. They do not wear them in order to be able to see, but in order to have the strain removed from their eyes, and to be relieved from the many disagreeable symptoms, both direct and reflex, that result from eye strain.

FOCALIZATION.

The act of focalization is a muscular act and requires an effort, an output of nervous energy, just as much in proportion as any other muscular act, such as lifting a weight or shoving a saw or a jack plane. The eye that is normally shaped forms pictures of objects, more than a few feet distant, on its back wall without any muscular effort, and has to focalize only when engaged in near work. But the oversighted eye is compelled to do this extra work all the time, except when closed. If it did not focalize, it would see indistinctly. This it refuses to do, independently of any volition on the part of its owner. The eye that _can_ see distinctly _will_ see distinctly, no matter how great the strain, and this by a volition apparently entirely its own. The results are headache, vertigo, nausea, nervousness, irritability, and other disagreeable reflex conditions, besides the pain and inflammation, and other symptoms manifested in the eyes themselves. Of course, the only remedy in such cases is glasses, and these glasses should be carefully selected by a competent person, and should be worn as much of the time as is necessary to relieve the eye strain. I find in _Taggart's Times_, February 5, 1888, the following: "A French philosopher has said that a man who wears gold-bowed spectacles always admires himself, and it would seem as though spectacles were becoming a sort of badge of distinction, since young and old who have the slightest excuse for using them put them on.

HEADACHE.

"When one suffers from headache, he is told that he overstrains the nerves of the eyes, and must relieve this by the use of spectacles. When things dance before the sight, the cure for that is also spectacles; and when tired with close attention to work, the cure for wearied eyes is not rest, but spectacles.

"People who live much out of doors are usually very keen-sighted, owing probably to the ever-varying impressions made on the eyes, and this might reasonably suggest that the proper relief for a great many eye troubles would be a change from overwork."

I can only say that the person who wrote it seems not only to be prejudiced against glasses, but to know very little of the anatomy and physiology of the eye. The fact is that oversighted and astigmatic eyes, needing glasses to relieve the constant and severe strain upon the accommodative muscular apparatus, are benefited by rest and by change of air and occupation only to a limited degree. Real rest for such eyes is possible only from the use of glasses. Moreover, it is not possible for all who suffer from fatigue of the eyes to take the time for rest. It is necessary for many to use their eyes daily and almost constantly in order to make a living for themselves and for those dependent upon them. There is much more good sense in the paragraphs which follow and which are extracted from the same article.

"It is not surprising that so many school children suffer with weak eyes when we consider the conditions under which they are forced to use them. The very fact that the light in many school rooms is twice strained through glass partitions before it penetrates the inside rooms is in itself a severe test of sight. The preponderance of sash-wood over the panes of glass is anything but propitious to clear seeing. With heads bent over desks doing arithmetical examples, or studying the fine printed school books, or reading their own imperfect handwriting from which many of the lessons must be learned, the only wonder is that all the little ones are not purblind before they reach the grammar schools.

FLUFFY BANGS.

"But this is not all. Girls wear long and fluffy bangs, intercepting the sight, and both boys and girls seldom bathe their faces with clear cold water. In the matutinal face washing the eyes are usually closed, while a wet towel is delicately passed over the eyelids. Few persons can bear the pain of opening their eyes wide in a basin of cold water, yet Mr. A. M. Spangler told, in his interesting lecture on Nassau, how the native population would dive to the bottom of the sea and bring up shells, sponges, etc., that had been pointed out to them by curious visitors through a sea glass. Not only men divers, but also little boys and girls could keep their eyes open in the water and search for cents which had been thrown in for them to pick up. This shows that even salt water is not injurious to eyes accustomed to it, and that habit makes the eye unnaturally sensitive."

As to the statement that "people who live much out of doors are usually very keen-sighted," it is an expression of a popular idea, but, like most popular ideas, is true only to a limited extent. The fact is that persons who do not live much out of doors generally use their eyes more for near work, such as reading, sewing, drawing, etc., and hence are more likely to develop near-sightedness. Persons living indoors who are not near-sighted are able to see as well and as far as those who live outdoors. It is true that the old sailor will recognize a ship in the horizon, or any other distant object at sea, sooner than a landsman. But it is not because he is any more "keen-sighted." It is because he knows just what to look for. He has seen such objects amid similar surroundings a thousand times, and recognizes them, even though his vision be considerably impaired by disease. I have often found, on testing the vision of such persons, that it was not more than one-half the normal, and yet they declared, and, I believe, conscientiously so, that they could discern a ship at sea as far as any one. A very large proportion of the North American Indians, who live much out of doors, have poor sight from inflammatory diseases of their eyes caused by exposure to smoke in their wigwams, and by contagious eye diseases, the propagation of which is favored by their unsanitary methods of living. But, no doubt, many of them can discern distant objects upon the prairies and in the forests farther than their white brothers because of their greater familiarity with the appearances of such objects.

It seems to me that the practice of opening the eyes under water is not to be specially recommended, except in cases of necessity. While many bear it well, to others it is more or less painful and irritating. Moreover, nature furnishes a fluid with which to wash the eyeballs, and applies it herself. It is only necessary to keep the eyelids scrupulously clean, and especially the edges of the eyelids where the eyelashes grow out. For bathing the eyelids when uninflamed, nothing is better than pure cold water. When the eyes become red and inflamed, the best domestic remedy is salt and water, about a teaspoonful to the pint, and applied warm or cold, or at whatever temperature seems most agreeable to the eyes in any particular case.

NO POULTICES.

Under no circumstances should poultices be applied to the eyes unless ordered by a physician. I have seen many cases in which a simple inflammation of the inside lining of the eyelids had been greatly aggravated by bread and milk poultices, or tea leaves, bound upon the closed eyelids and left on overnight. In fact, a distinguished professor of diseases of the eye has formulated the results of his observations thus: "Poultices spoil eyes."

All patent eye washes, eye salves, and other remedies advertised to cure all diseases of the eye should be avoided. Different diseases require different remedies. What will benefit one may injure another. When one gets something the matter with his eyes and resorts to the use of a patent medicine for its relief, he is in danger of losing valuable time. He may lose an eye from want of proper treatment at the outset of the disease. In a great city like New York, every one may easily avail himself of the services of the most skillful physician. If unable to visit them at their offices and pay their fees, they may consult them at the numerous dispensaries, hospitals, and medical schools and colleges, where it will cost them nothing.

USE OF INFLAMED EYES.

A lesson that is very difficult for many of us to learn is that inflamed eyes should not be used actively. Children with sore eyes should not be allowed to go to school for two reasons. First, the use of their eyes in reading will prevent or retard their recovery. Secondly, sore eyes are usually communicable, and one such child may infect a whole school. It is highly important that all persons with inflamed eyes should use only their own wash basins, towels, and handkerchiefs, and so avoid spreading the disease. We not infrequently see a catarrhal inflammation of the eyes run through a whole family. Of course, they catch it one from another, and, as there is no disease of the eye which is, like measles, or scarlet fever, or smallpox, communicable through the air, such spread of the disease might easily be prevented by proper care of the person first affected. Persons whose eyes are sensitive to light should not be kept in dark rooms, which are always unhealthy. They may have their eyes protected by shades or by smoke colored glasses, but should keep them open and exposed to the air, and should remain out of doors as much as possible.

EFFECT OF ALCOHOL AND TOBACCO UPON THE EYES.

I must not close without warning my hearers against the baneful effects of alcohol and tobacco upon the eyes. It is not uncommon for the eye surgeon to meet with persons who have become partially blind from the effects of these poisons upon their optic nerves. Of course, only a small proportion of those who use alcohol and tobacco to excess are affected in this way, but this renders it none the less certain that impaired sight is one of the dangers that we may avoid by abstaining from the use of these unnecessary and poisonous luxuries.

TUMORS OF THE BLADDER.

DIAGNOSED BY MEANS OF THE ELECTRO-ENDOSCOPIC CYSTOSCOPE.

By Dr. MAX NITZE.

In the following lines I wish to direct the attention of my English _confreres_ to the value of the electro-endoscopic mode of examination of the male urinary bladder, invented by me. I believe I could not have chosen a more suitable theme for that purpose than a short report of the bladder tumors diagnosed by me cystoscopically; for the diagnosis of these new formations offers the greatest difficulty, and in most cases it has been impossible till now to prove their existence with accuracy without digital exploration of the bladder. By the new method of cystoscopical examination the conditions have entirely changed. One look into the bladder, illuminated as if by daylight, is generally sufficient to afford means for forming an opinion of all the questions coming into consideration--viz., size, form, and site of the tumor. The accompanying diagrams (Figs. 1, 2, 3, 4) may give an idea of the appearances which the different forms of bladder tumors present endoscopically. I regret that they cannot show the brightness of the light by which one sees the tumors during examination. The celebrated Vienna specialist, V. Dittel, is right in saying that "they offer sometimes truly charming pictures;" especially certain kinds of villous tumors, whose long slender villi floating in the liquid often present a splendid appearance. The following are the cases cystoscopically diagnosed by me.

_Case 1._--A man, aged fifty-five, under the care of Dr. Ch. Mayer, suffered from attacks of hæmaturia for thirty years. During the last six years he has had dysuria and inability to empty the bladder completely. The patient had been examined by the sound repeatedly by eminent surgeons and specialists, but none could give a certain diagnosis. On Nov. 11, 1886, I undertook the cystoscopic examination. I found on the anterior wall of the bladder a puffy swelling covered with white masses of mucus. (See Fig. 1.) The trigone was covered by a mass consisting of pointed papillæ. On account of the weakness of the patient extirpation was impossible. The patient became weaker and weaker, and died in June, 1887. The post mortem examination showed the internal orifice of the urethra surrounded by a swelling representing a continuous tumor as large as a small apple. It was found that the instrument had penetrated through the middle of this swelling, which bled easily on pressure. In spite of this, the clearness of the picture was not interfered with in the least.

_Case 2._--A man, aged fifty, was obliged to exert a strong pressure in order to empty the bladder. The flow of urine often stopped. He himself introduced a catheter, and on withdrawing it a piece of villous tissue was found. On Dec. 10, 1886, I saw, on cystoscopical examination, directly and immediately over the internal orifice of the urethra, a villous swelling hanging from the anterior wall of the bladder. (See Fig. 2.) On Jan. 15, 1887, extirpation of the tumor by means of the high section was performed by Professor v. Bergmann. The size of the tumor (which was as large as a pigeon's egg) and its position corresponded exactly to the endoscopic picture. The patient recovered.

_Case 3._--A patient under the care of Professor Madelung, aged fifty-five, suffered from attacks of hæmaturia. Examination by sound and rectal palpation had given me negative results. On Feb. 20, 1887, cystoscopical examination was made. On the left side of the trigone a tumor with a broad base was seen, which resembled somewhat a strawberry in size and form. (See Fig. 3.) On March 1, Professor Madelung undertook the extirpation of the tumor. The appearance corresponded exactly to the cystoscopic picture. The patient recovered.

_Case 4._--This was a patient on whom Dr. Israel had performed the high section a long time before, on account of a bladder tumor. The extent was so great that only its most prominent part could be removed. The microscopical examination proved the diagnosis of cancer. Quick healing took place. The patient became free from pain, and the urine became clear. In order to see what had become of the remaining part, the cystoscopical examination was undertaken on April 3. It was easy to see that the right lateral wall was covered to an extent of from three to four centimeters with thick masses of verrucous and fungiform excrescences. (See Fig. 4.)

[We omit the description of the additional cases.]

The above shortly described fifteen[9] cases of bladder tumors have been diagnosed by me cystoscopically during the last sixteen months. This is a proof, on the one hand, of the value of the cystoscopic examination; on the other hand, of the fact that the new formations in question are not of so rare occurrence as has been hitherto thought. I would like to emphasize that the important results were often obtained under the most difficult circumstances. In several cases the external orifice of the urethra was found abnormally small; in others (Cases 8 and 11) the examination was made during the occurrence of a continuous hemorrhage from the tumor; in one case (Case 1) I introduced the instrument through the center of the tumor, which bled on the slightest pressure. In spite of this the appearances were seen satisfactorily. In the first case a post mortem examination was made; in eight other cases (Cases 2, 3, 9, 10, 11, 13, 14, and 15) the tumor was extirpated, seven times by the high section--in one case, that of a woman, through the dilated urethra. In these nine cases the endoscopic appearances were in every important respect confirmed in the most perfect manner. In every case my opinion regarding the size, position, and form was found to be correct. It is only in those cases where the edges of the tumor overlap the short pedicle that the latter cannot be observed. Besides, the relative good results of the operations undertaken on account of the cystoscopic appearance may be emphasized. Of the eight patients from whom the tumors had been extirpated, none died from the result of the operation. Case 9 proved fatal on account of the progressive extension of the growth. In the eleventh case there was a recurrence, but the patient is still alive. Five patients (Cases 2, 3, 10, 13, 14) must be considered entirely cured. Case 15 is still under treatment, and, as the conditions of the patient are at present (ninth day after operation) in every way satisfactory, a complete recovery is anticipated.

[9] The first eight cases are more fully described in the Arch. fur Chirurgie, vol. xxxvi., Part 3 (Dr. Nitze, Beitrage zur Endoscopie der mannlichen Harnblase). The full account of the last seven cases will be published soon.

Finally, on comparing the above cystoscopic appearances with the results obtained by other methods of examination, it must be observed that the examination of the urine, in most cases carefully made, had only in two cases shown the presence of villous tissue, which in one instance was brought out by the catheter. The rectal palpation, when made, had always given negative results. Further, the examination by means of the sound had been made in nine cases before the cystoscopic examination. In none of the cases had the sound revealed the presence of a tumor (which in two had attained the size of a small apple), although the examination was made by most experienced surgeons and eminent specialists. Those cases show how imperfect an instrument the sound is for the diagnosis of bladder tumors.

Only one method can compare with the cystoscope in giving valuable information regarding the size and nature of a bladder tumor--viz., the digital exploration of the internal surface of the bladder after a previous _boutonniere_, or the high section. The superiority of the cystoscopic method over the latter, on account of the smaller amount of inconvenience it causes the patient, need not be insisted on. The latter involves a cutting operation not free from danger, as well as deep narcosis, while the cystoscopic method is similar to a simple catheterization.

The accompanying diagram (Fig. 5) shows the instrument used by me for cystoscopic examination. It has been made by the Berlin instrument maker, Hartwig, according to my instructions. The source of the light (Mignon lamp) is cemented in a silver capsule, which is screwed into the distal end of the cystoscope. This instrument is superior to that made by Leiter, the Vienna instrument maker, because of its greater simplicity in construction, which allows the lamp to be easily replaced when necessary, and also on account of the greater length of the shaft.

I mention this because it differs from the explanation which Mr. Fenwick gave in his speech concerning my method of examination at the meeting of the Medical Society of London on Jan. 23, 1888. I must also strongly contradict Mr. Fenwick's statements concerning the share which he attributed to the Vienna instrument maker in the construction of the instrument. Leiter's connection with our instrument will be best explained when I say that he had to buy the patent[10] from me first in order to be allowed to make the instrument. Leiter has had no share in those peculiarities which characterize it as new. The introduction of the source of light into the organ had been practically brought about, the optical apparatus enlarging the view designed, the whole construction perfected, the instrument had proved itself useful in examining patients, and had been demonstrated by me in the Saechsisches Landes Medicinal Collegium before Leiter had any idea of the new invention! Also the eventual replacement of the first source of light (platinum wire) had been provided for.[11] Leiter has only made a few technical modifications on the finished instrument. I protest most emphatically against the incorrect explanations given by Mr. Fenwick, and against every connection of Leiter's name with my instruments. I hope to obtain in England the same generous recognition of my labors in this field that has been accorded to me in Germany.--_Lancet._

[10] Deutsche Patentschrifte, No. 6, 853.

[11] Ibid.

PAPILLOMATOUS TUMOR OF THE BLADDER, DEMONSTRATED BY MEANS OF LISTER'S ELECTRO-CYSTOSCOPE.

By F. N. Otis, M.D., Clinical Professor, College of Physicians and Surgeons, New York.

A. G----, aged twenty-three, United States; single; barber.

The young man was referred to me by his former medical attendant, March 16, 1883. His urine was found to be slightly but distinctly tinged with blood, and contained some small clots as well as some pus and mucus. He complained of exquisite pain on urination, increased at the close, recurring every half hour. Through examination per rectum (_a posteriori_) unusual tenderness was found. Distinct increase in the density and thickness of the right inferior section of the bladder was recognized by the bimanual touch; a catheter was introduced, and three ounces of bloody urine removed. The bladder was then irrigated gently with a saturated solution of boric acid until the fluid returned clear. The catheter was then withdrawn, leaving about four ounces of the solution, of a temperature of 80°, in the bladder, as a preparation for its examination by the electro-cystoscope of Lister. The required current was furnished by the small six-cell battery of the Galvano-Faradic Co. The cystoscope was then introduced into the bladder, and the current turned on. The illumination was complete. Through the slightly rosy medium the small blood vessels in the bladder mucous membrane were distinctly seen. On the right side a deep red, granular-looking mass, with a wavy outline, was then distinctly observed, covering about one-fourth of the cystoscopic field. This appearance was verified by Drs. Abbe, Bangs, and W. K. Otis--the unanimous opinion being that it represented a papillomatous growth, to some extent covered by coagulated blood. Two days later a similar examination was made, under the influence of an anæsthetic, which corroborated the previous observations in every particular. (See illustration.)