EYE STRAIN
Wherever school children's eyes have been examined, from six to nine
out of thirty are found to be nearsighted, farsighted, or otherwise in
need of attention. A child is dismissed from school for obstinately
declaring that the letter between _c_ and _t_ in "cat" is an _o_; "a
pupil in her fourth school year was recently brought to me by her
teacher with the statement that she did unreasonably poor work in
reading for an intelligent and willing child;" a boy is punished for
being backward. These three cases are typical. Examinations showed that
the first child was astigmatic and not obstinate; the boy had run a pin
into one eye ten years before and destroyed its sight; while the second
girl was found to be afflicted with diplopia, and in a friendly chat
told the following story: "I very often see two words where there is
only one. When I was a very little girl I used to write every word
twice. Then I was scolded for being careless. _So I learned that I must
not say two words even when I saw them._" As Miss Alida S. Williams,
principal of Public School 33 in New York City, has in many articles
and addresses freely illustrated from school experience, the art of
seeing is acquired, not congenital, and every human being who possesses
it has learned it.
The large proportion of children suffering more or less seriously from
eye trouble has led many persons to suggest physical deterioration as
the cause. Eye specialists, however, assure us that eye troubles are
probably as old as man. Our tardiness in learning the facts regarding
these troubles is due in part to the lack, until recently, of
instruments for examining the eye and for manufacturing glasses to
correct eye defects; in part, also, to the tendency of the medical
profession, which I shall repeatedly mention, to explain disorders by
causes remote and hard to find rather than by those near at hand.
About 1870 Dr. S. Weir Mitchell's attention was called "to the marked
relief of headache, insomnia, and other reflex symptoms following the
correction of optical defects by glasses." In 1874 and 1876 he wrote
two articles that "impressed upon the general profession the grave
significance of eye strain." Since that time, "in Philadelphia at
least, no study of the rebellious cause of headache or of the obscure
nervous diseases has ever been considered complete until a careful
examination of the eyes has included them as a possible cause of the
disturbance."
The new fact, therefore, is not weak eyes or strained eyes, but rather
(1) an increase in the regular misuse of eyes by school children,
seamstresses, stenographers, lawyers, etc.; and (2) the incipient
propaganda growing out of school tests that show the relation of eye
strain to headache, nervous diseases, stomach disorder, truancy,
backwardness.
Every school, private and parochial as well as public, should supply
itself with the Snellen card for testing eyes. Employers would do well
to have these cards in evidence also, for they may greatly increase
profits by decreasing inefficiency and risks. If there is no expert
optician near, apply for cards to your health board or school board;
failing there, write to your state health and school boards. In many
states rural teachers are already supplied with these cards by state
boards. In October, 1907, the New York state board of health sent out
cards, with instructions for their use, to 446 incorporated towns. The
state commissioner of education also sent a letter giving school
reasons for using the cards. Results from 415 schools having shown
that nearly half the children had optical defects, it is proposed to
secure state legislation that will make eye tests obligatory in all
schools. Such a test in Massachusetts recently discovered twenty-two
per cent of the school children with defective vision, and from forty
to fifty thousand in need of immediate care by specialists.
[Illustration: POSITIONS OFTEN SUGGEST EYE STRAIN]
Of course eye specialists,--oculists,--if skillful, know more about
eyes and eye troubles than general medical practitioners or teachers.
Preliminary eye tests, however, may be made by any accurate person who
can read. The Massachusetts state board of health reports that tests
made by teachers were "not less efficient" than tests made by
specialists. In June, 1907, a group of eminent oculists recommended to
the school board of New York City that teachers make this first test
after being instructed by oculists. Persons interested in the schools
nearest them can quickly interest teachers and pupils by starting tests
with this card. In cities oculists can be found who will be glad to
explain to teachers, individually or in groups, how the cards should be
used and what dangers to avoid.
Nature intended the human eye to read the last line of this card at a
distance of ten feet. This conclusion is not a guess, but is based upon
the examination of thousands of eyes. In making the test, the number of
feet the eye ought to see is written as the denominator of the
fraction; the distance the eye can see clearly is the numerator. If the
child's card reads, "Right eye 10/10, left eye 10/20," it means that
the right eye sees without conscious strain the distance it is intended
to see, while the left eye must be within ten feet to see what it ought
to see twenty feet away.
The practical steps for a teacher to take in making eye tests are:
1. Scrutinize the faces for a strained or worried expression while
reading or writing, for squint eyes, for unnatural positions, and
for improper distances (more or less than nine inches) from eye to
book.
2. Select for first tests the children who obviously need
attention and will be obviously benefited. Use the eye test to
help trace the cause of headaches, nervousness, inattention.
3. Let the children mark off the distances with a foot rule and
chalk, going as high as twenty. Be sure to get the best light in
the room.
4. Start all children on the ten-foot line. If a child cannot read
at ten feet the letter which should be seen at that distance, move
the child forward, have it step forward and backward, and note the
result carefully. It is better to have ten separate letters of
exactly the right size and the same size than a row of letters on
one card, as in the Snellen test, otherwise memory will aid the
eye, or, as happened recently, a whole class may agree to feign
remarkable nearsightedness or farsightedness by confusing letters
learned in advance from the card. If the Snellen card is used, and
if it is more convenient to have both child and card stationary,
satisfactory results will be obtained by having the child read
from large letters down as far as he can see.
5. Have the child read from right to left, from left to right, or
skip about so that memory cannot aid the eye.
6. Test each eye separately. I was twenty-five years old before I
learned that my left eye did practically all of the close sight
work. A grown woman discovered just a few days ago that she was
almost blind in the left eye; when she rubbed the right one while
reading she was shocked to find that she could see nothing with
the left eye.
7. If the card is stationary and the child moved, and if only one
size of the letter is used, put in the denominator the number of
feet at which the normal eye should see clearly, and in the
numerator the distance at which each eye and both together can
easily see. If the regular Snellen card is used containing letters
of different size, place in the denominator the number of the
lowest line each eye and both eyes together can read easily, and
in the numerator the number of feet from card to eye.
8. Explain the result to the child, to his fellows, to his
parents. If the left eye reads 10/20 and the right eye 10/30, it
means that neither eye is normal, and that reading small type is a
constant strain, even though unnoticed. The right eye must be
within ten feet to read what it should read at twenty feet. The
left eye must be within ten feet to read what it should read at
thirty feet. If the two eyes read at ten, it means that in working
together they successfully strain for a result that is not worth
what it is costing. When eyes thus unconsciously see what they are
not intended to see, it is only a matter of time when stomach and
nervous system will announce that the strain can no longer be
borne. Indigestion, dislike of study, restlessness follow. If,
however, the eyes are so near the normal that their story reads
12/10 or 8/10, the strain will be negligible _for the present_.
If, on the other hand, the only difficulty is a confusion of _x_
and _z_ with _c_ and _g_, it means that there is a strain due to
astigmatism, and that the child should be sent to an oculist.
9. Teach children and parents (and practice what you preach) the
urgent importance of periodic reëxamination, just as you would
teach them to visit a dentist twice a year. This is needed by
those who wear eyeglasses, and more particularly by those who have
recently put them on. Moreover, as shown below, it is needed by
children able to pass satisfactorily the Snellen test.
10. Acquire the habit of reading the eye for evidence of temperate
or intemperate living, sleeping, eating, dancing, drinking, and
smoking. Inflamed eyes are _results_,--signals of danger. "The
organ may be faultless in construction and in its work poor,
because of nerve exhaustion, or, in a less and more easily
recoverable degree, nerve fatigue." If unusual eye conditions are
not readily explained by mode of living or by eye tests, an
oculist should be consulted.
The limits of the card test must be constantly kept in mind: (1) it
does not register eye sickness due to dust, smoke, or disease germs;
(2) it does not show unconscious eye strain due to successful
accommodation. But it will discover a great part of the children who
most need care. Sooner or later, too, inflammation of the eyelids, due
to external causes, will affect the nerves of the eye and their power
to conceal by accommodation the eye's defects. Just as we unconsciously
open the mouth when a cold stops up the nose, the eye adapts itself to
our needs without our realizing it. We expect it to see. It sees. If
our eyes are not made alike, they do their best to work together. Like
a good team of horses, the slow one hurries, the fast one holds back a
little. But if one eye is 10/15 and the other 10/10, they will both be
unnatural and strained if both read the same type. The effects of this
strain frequently upset the stomach before the eyes rebel. I learned
that I needed eyeglasses after a case of protracted indigestion, first
diagnosed as "nervous" and later traced to eyes. Thousands of
upper-grade children and college students are dieting for stomach
trouble that will last until the eyes are relieved of the undue and
unrecognized strain. To prove the influence of eye strain on
indigestion, persuade some obstinate parent to wear improperly focused
glasses for a day; she will then be willing to have her child's eyes
attended to.
It is unfortunate that the eyes will overwork without protesting. For
years many persons suffer without learning that their eyes are unlike,
or, as often happens, that one eye does all the close range work. Even
when being tested, eyes will seem to see easily what requires a great
effort of "accommodation." To prevent this self-deception skilled
oculists do not trust the eye card, but put a drug in the eye that
benumbs the muscles of accommodation. They cannot contract or expand if
they want to. The oculist then studies the length of the eye and the
muscle of accommodation. With this absolute knowledge of how each eye
is made he knows what is wrong, exactly at what angle light enters the
eye, whether objects are focused too soon or too late, exactly what
kind of eyeglasses or what operation upon the eye is needed to enable
it to do its work without undue straining or accommodation. So
unconsciously do the eyes accommodate themselves to the work expected
of them that not infrequently a child with seemingly perfect sight may
be more in need of glasses than the child with imperfect sight.
Practically, however, it is out of the question at the present time to
have the majority of children given a more thorough test than that
provided by the Snellen card. Where eye strains escape this test
teachers will find evidence in complaints of headache, nervousness,
sick stomach, chorea, or even epilepsy. The constant strain may also
cause red or inflamed lids. Parents and teachers must be on the
constant lookout for these symptoms of good sight persisting in spite
of imperfect eyes.
An epidemic of eyeglasses is usually the consequence of eye tests. So
naturally do we associate eyeglasses with eye defects that some people
assert that the eye tests at school originate with opticians more
intent upon selling spectacles than upon helping children. In fact,
even among educators who proclaim the need for eye tests there has been
far more talk of eyeglasses than of removable conditions that cause eye
strain. The women principals of New York City have sounded an alarm,
and urge more attention to light and to reading position, more rest,
more play, more hand work, less home study and less eye work at school,
rather than more eyeglasses to conceal temporarily the effect of
abusing children's eyes. Putting glasses on children without changing
causal conditions is like giving alcohol to consumptives. The feeling
of relief is deceptive. The trouble grows worse.
For some time to come eye tests will find eye troubles by the wholesale
in every industrial and social class, in country as well as city
schools. In 415 New York villages 48.7 per cent of school children had
defects of vision,--this without testing children under seven,--while
11.3 per cent had sore eyes.
There are three possible ways of remedying defects: (1) changing the
eye by operation; (2) changing the light as it enters the eye by
eyeglasses; (3) decreasing the demands made upon the eye. To change
eyes or light requires a technical skill which few physicians as yet
possess. It will be remembered that it is but thirty years since the
medical profession in America first began to understand the relation of
eye defects to other defects. Until a generation of physicians has been
trained by medical colleges to learn the facts about the eye and to
apply scientific remedies, it is especially necessary that teachers and
parents reduce the demands made upon children's eyes; oral can be
substituted for written work, manual for optical work, relaxed and
natural movement for discipline, outdoor exercise for less home study.
Other requirements are suitable light and proper position, and
abolition of shiny paper, shiny blackboard, and fine print. Even after
it is easy to obtain the correction of eye defects it will still be
necessary to adapt the demands upon children's eyes to the strength and
shape of those eyes. Because we are born farsighted, nearsighted, and
astigmatic, we must be watchful to eradicate conditions that aggravate
these troubles. Finally, there is no excuse whatever for permitting the
parent of any school child in the United States to remain ignorant of
the fact that it is just as absurd to go to the druggist or jeweler for
eyeglasses as to the hardware store for false teeth.
The education of physician, oculist, and optician can be expedited by
eye tests in school and by the follow-up work of schools in removing
the prejudice of parents against glasses when needed. Because knowledge
of chemistry preceded knowledge of the human body, the teaching of
medicine still shows the effect of predilection for the remote, the
problematical, the impossible. This predilection has influenced many
specialists as well as many general practitioners, both overlooking too
frequently obvious causes that even intelligent laymen can be taught to
detect. Very naturally the man who makes money out of attention to
simple troubles has stepped into the field not as yet occupied by the
general practitioner and the specialist. Thus we have the optician, the
painless tooth extractor, and quack cures for consumption. Opticians
are placing before hundreds of thousands simple truths about the eye
not otherwise taught as yet. Because they make their money by selling
eyeglasses and because their special knowledge pertains to glasses
rather than to eyes they frequently fail to recognize their
limitations.
Physicians feel very strongly that it is as unethical for an optician
to fit eyeglasses without a physician's prescription as for a
pharmacist to give drugs without a physician's prescription. The
justification for this feeling should be based not upon the commercial
motive of the optician but upon his ignorance. A physician uninformed
as to eye troubles is just as unsafe as an optician determined to sell
glasses. It must be made unethical and unprofessional for physician and
optician alike to prescribe in the dark. Laymen and physicians must be
taught that it is just as unethical and unprofessional for oculists and
physicians to fail to bring their knowledge within the practical reach
of the masses as for the optician to advertise his wares. School tests
will not have been used to their utmost possibilities until optician
and physician alike take the ethical position that the first
consideration is the patient's welfare, not their own profits. It must
soon be recognized as unethical and unprofessional for an optician who
is also a skilled physician to refer patients to a medical practitioner
ignorant as to optical science.
Whether opticians and physicians are unprofessional or unethical may be
told by reëxamination if the _examiner_ is himself competent and
ethical. There is no better judge of their efficiency than the patient
himself, who can tell whether the results promised have been effected.
Whether the work of a country oculist is efficient and ethical can be
learned: (1) by teaching country school children to recognize eye
strain; (2) by comparing his results with those of other physicians. As
soon as one or two states have tested eyes, we shall have an average by
which to compare each class, school, and city with others of their size
under similar conditions. If a particular physician finds half as many
more or only half the average number, the presumption will be that his
results are inaccurate and warrant an investigation. The interested
teacher or parent can render an inestimable service to her local school
and to the children of her state by taking steps to secure state laws
compelling eye tests in all schools.
Finally, it must be remembered by teachers, employers, parents, and all
eye users that eyes are constantly changing; that eyes may need glasses
six months after they are examined and found sound; that glasses change
or develop the eye, so that they may be unnecessary and harmful six
months after they are prescribed, or the eye may require a stronger
glass; that eyeglasses become bent and scratched, so that they worry
and strain the eye; that a periodic examination is essential to the
health of the eye.
In caring for the health of the eye, we should also remember that our
eyes are our chief interpreters of the world that gives us problems,
profits, and pleasures. Out of gratitude, if not out of enlightened
self-interest, we owe our eyes protection, attention, and training, so
that without straining we shall always be able to see truth and
beauty.