Chapter 12
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.
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.