MYOPIA IN ITS VARIOUS PHASES. BY JULIAN J. CHISOLM, M. D, Professor of Eye and Ear Diseases in the University of Maryland, Surgeon-in Charge of the Presbyterian Eye and Ear Charity Hospital, etc., etc., BALTIMORE, MD. MYOPIA IN ITS VARIOUS PHASES BY JULIAN J. CHISOLM, M. D„ Professor of Eye and Ear Diseases in the University of Maryland, Surgeon-in Charge of the Presbyterian Eye and Ear Charity Hospital, etc., etc., BALTIMORE, MD. [Reprint from September No., 1880, Virginia Medical Monthly.] Xear-sightedness, or, as it is more properly called, myopia, is well understood by those who have made the diseases of the eye a special study, but to the greater number of medical men this common disease is enveloped in a vaguely-defined and misty pathology. Most physicians are aware that in myopia there is some defect of the focusing of the eye as an optical apparatus, but why the machinery of the visual organ does not work as it ought to do is not so clearly appreciated. Some have a settled impression that the eye-ball is elongated, and hence a disturbance of those nice relations which the varied contents of the eye should have with each other. They speak of the eye as a long eye, with alteration in shape from the typical eye, which is nearly as round as a ball. The world has assumed that in all near-sighted persons the front of the eye is more convex, and many members of the profession hold to this erroneous opinion which they had imbibed before they had entered the medical ranks, and which error has never been corrected. The MYOPIA IN ITS VARIOUS PHASES. junior members who have recently pursued their med- ical studies in the large cities, have had better advan- tages for obtaining an insight into the specialties in med- icine. They have been taught that in most near-sighted eyes there is an elongation in the long diameter of the eye from the pupil backwards, and not simply in the increased convexity of the cornea. There is a rare form of near-sight- edness in which the elongation of the eye is due to the pro- jection forwards of the cornea, the centre of which projects out as a cone—a disease called conical cornea. This patho- logical condition is so rare that it would not explain one case of near-sightedness out of one thousand. Where a perfect eye has become myopic, this elongation is usually found in the bulging of the back wall or sclerotic coat near the en- trance of the optic nerve, and to which the most elaborated portions of the retina, with choroidal backing, is attached. This explanation, viz.: the pushing out of the back of the eye-ball, which is applicable to so many adult near-sighted persons, does not, however, cover the entire field of myo- pia. Some old persons, markedly near-sighted, whose sharp vision extends to a very few inches beyond their noses, have experienced no change whatever in the length of the ocular diameter. In such myopes an explanation of the optical de- fect is found in the change of shape in the lens alone. Again, in a very large number of those who have restricted distant vision, especially in young persons, near-sightedness is found associated with an eye that is actually shorter in this antero- posterior diameter than a good eye should be. It is in the act of habitually straining such a flat eye to make it see sharply small, near objects, that the ciliary or accommo- dating muscles within the eye-ball become irritable, and finally are thrown into a spasmodic contraction, with ina- bility to resume voluntarily a passive or relaxed state. It is this excessive muscular contraction that is continuously kept up which makes the lens too convex, puts an end to dis- tant vision, shuts out the definition of objects across the street, and induces near-sightedness. All of these varied conditions cause myopia. They represent functional as well as organic changes, and are MYOPIA IN ITS VARIOUS PHASES. 3 found at various stages of life. Some only show them- selves in persons well advanced towards extreme old age, while others are restricted to childhood or school days. We must now add to this list of acquired near-sighted- ness a number of eyes, congenitally defective in shape, which, in intra-uterine development, had become longer than a typically good eye should be. Such transmitted pe- culiarities of an elongated eye-ball form, however, the ex- ception in the great list of myopes, as comparatively few of the great number of near-sighted persons are- as yet indebted to their parents for this peculiarity. Near sightedness is capable of easy recognition in its va- rious forms—sharp near sight with foggy distant vision es- tablishing the diagnosis. The first natural division among the myopics would be into those who are born with long, misshaped eyes (congenital myopia), and those who acquire near-sightedness, whether from changes occurring in the shape of the eye or from variations in form of the crystalline lens. Some of these conditions are permanent, while others are very transient. Observation teaches us that myopia runs in families, and that some children are near-sighted because their parents were so before them. Peculiarity of features are clearly in- heritances, and a long eye is a well-detined individual pecu- liarity, which places itself in the hereditary list for transmis- sion. Every child born of near-sighted parents is not of ne- cessity near sighted, and fortunately myopic parents are not so very numerous as to establish a heavy percentage of con- genital cases. In this respect, however, nations differ. In some parts of Continental Europe, especially in the largest and oldest cities, we find a larger percentage of myopes among the adult population than we would find among the agricultural classes, and correspondingly in such cities a larger number of children who commence life with near- sighted eyes. The defective eye-sight of the human race has been care- fully investigated in most of the civilized countries, and with this well-established result, viz.: that myopia is not often met with among the peasantry of a country. It is found most 4 MYOPIA IN ITS VARIOUS PHASES. commonly in the large cities, in which is felt the necessity for more mental exertion among young persons, in prepara- tion for securing a more comfortable living in the future. This exertion is expressed by the closer and longer-contin- ued daily application of eye-sight in study. The collecting of children in the public schools in all parts of the civilized world, offers great facilities for the study of eye defects, and the relative frequency of such eye diseases in the cities and in the country. From Germany, Russia, Switzerland, France, England and America we are now in possession of such accurate data; and all of these investiga- tions, made by the scientific specialists of these respective countries, singularly confirm the above statement. With reference to near-sightedness, a striking difference is found between the smaller children entering the schools and the graduating classes in the same schools; and a similar pro- portion is sustained if the same children are followed up in the successive classes from theiradmission to their graduation. In country schools, the number of near-sighted children in the lowest classes may not reach 2 per cent, of the pupils. As these little people came with near sighted eyes into the school, and have not advanced beyond their alphabet in ed- ucation, they clearly should be classified with cases of in- herited myopia, as the offspring of myopic parents. This percentage is much increased in the infantile classes of city schools until 13 per cent, is reached in the largest and oldest cities of Germany, making this their starting point for eye defects in school life. Every year of study adds to the percentage of myopic chil- dren. This condition of the eyes shows a steady increase in all literary institutions, growingpan passu with the amount of application and intellectual development of the young persons, until it attains its highest degree in applicants for collegiate honors. Some of the graduating classes in the highest schools of the Continent of Europe exhibit 70 per cent, of near-sighted students. If we take 5 per cent, as an average of city and country schools among the pupils six years of age, meaning those in the primary classes, as mark- ing the near-sighted children by inheritance, and 50 per cent. MYOPIA IN ITS VARIOUS PHASES. 5 as the average of the graduating classes in the highest schools, we have 45 per cent, as indicating the acquired cases of near-sightedness. This number of near-sighted or weak-eyed persons is being continually added to the intellec- tual and learned population of the civilized globe. From these figures it would really appear as if our higher education was ruining the eye-sight of our race. The observant citizen sees many more young persons using spectacles now than formerly, and hears constant com- plaints of defective eyes among his young friends, apparently out of all proportion to his former experience. That eye diseases are on the increase there can be no question, and our school system has justly charged with the growing trouble. The eye, like any other very delicate instrument, is capable of abuse, particularly during its growing period. Although it may attain its full size at 12 or 14 years of age, its protecting walls do not secure the full powers of resistance until the maturity of the rest of the body. Up to twenty years of age, the eye is liable to injury from over-work, and this is more especially the case between the years of 8 and 16. In studying the anatomy and physiology of the eye, we find a ready explanation for those organic changes which are brought about in myopia. At the commencement of school life—say from 6 to 8 years—we find the eye-ball a hollow organ, filled with fluid, and very richly supplied with blood- vessels. It has already nearly attained its full growth as to size and the development of its intricate contents; but its outer sclerotic wall, which is to fix the shape of the organ, is not as dense, tough and resisting as it will be when the body attains maturity. At this stage of bodily development the lens of the child is well formed and is of so elastic a nature, from the juiciness of its fibres, that it can readily change its shape and approach the globular form when strongly acted upon by the accommodating muscle. This increased con- vexity prepares it for condensing light upon the retina for near and small objects. It must be remembered that the eye is a microscope, with lens adjusted by nature to the retinal surface, the distance 6 MYOPIA IN ITS VARIOUS PHASES. from the inner face of the lens to the rod and cone layer of the retina being tixed. Any change in these relations must seriously affect the eye for near or distant vision. When the retina is removed from the fresh eye, it is recognized as the thinnest of membranes ; yet it is only the outer surface of the membrane that is called the percipient layer. It alone can re- ceive the image of objects looked at. Any other part of the many layers of varied structure which enter into the thick- ness of the retina, will not answer this purpose of vision. When a transverse section of this thin film of tissue of re- tina is put under the microscope, it exhibits a heterogeneous structure of seven or eight transparent layers. It is only the outer one, representing abou^one-fourth the thickness of the entire membrane, which is subservient to the reception of an image, viz.: the rod and cone layer. Should the lens focus on any other part of the retinal thickness, no clear sight would result, as no other part of the retina but that surface, backing upon the pigmented choroid coat, is designed for the reception of visual impressions. In a normal eye of proper dimensions, with the full powers of accommodation for distant and near objects, the relation of lens to percipient layer of the retina must not only be of a certain determined character, but must also be immovably fixed in this relation : and the outside, thick, tough, resisting, inelastic, sclerotic envelope of the eye-ball is the brace which must keep up these accurate relations by preventing the eye from changing in any wise its shape. We have referred to the eye-ball as a hollow organ nearly an inch through its various dimensions, a shade deeper in its an- tero-posterior diameter than in its horizontal or vertical diam- eter. Its outer shell of clear cornea in front, and the opaque sclerotic coat for five-sixth of its surface, gives it shape. This is lined within bv the extremely vascular and pigmented layer called the choroid, with the colored muscular septum of iris attached to its anterior border. The retina, as the especial organ for perception, lines this choroid on its inner side. These three layers of sclerotic, choroid and retina, bear the respective relation of brick wall, plaster coat and papering of an ordinary room, and in about the same relative propor- MYOPIA IN ITS VARIOUS PHASES. 7 tionate thickness. The entire cavity of the eye-ball is tilled with a transparent liquid between lens and cornea, and a more consistent, clear fluid, as the vitreous mass, filling up the bulk of the cavity, with a crystalline lens of a denser, transparent substance placed directly behind the pupil and fixed in this intermediate place by the suspensory ligament. This lens is made up of hundreds of layers of elastic, trans- parent fibres, giving the whole mass the shape of a bi-convex lens of about f of an inch focal power, which corresponds to an exceedingly strong magnifying glass. The ciliary bodies which change the shape of the lens, are well secured to the inner face of the eye-shell at the junction of the iris and the choroidal linings. Through their agency, the sur- faces of the crystalline lens become more convex as nearer objects are viewed, and this physical change, which increases the strength of the lens, is recognized as the accommoda- tion of the eye. The cornea, lens, and fluid contents of the eye, all act as condensing media, and all, therefore, possess magnifying properties. They are classified together as the dioptric media, or the light-condensing apparatus. Although the retina or sensitive nerve layer lines the en- tire back chamber of the eye-ball, and covers nearly a square inch of surface, very little of it is used for our best vision. All the light which passes into the eye is condensed by the lens upon a point not larger than a small pin head, and as we face everything that we desire to see well, this small area of the retina is placed in a straight line directly behind the pupil. This little section of the retina, not more than a half line square, is worth all of the rest of the retina put to- gether. It is the most elaborately developed part of this sensitive nerve layer, and is known as the fovea centralis or the yellow spot of Soemmering. This yellow spot in a good eye, capable of work at all distances, must be fixed at a de- termined distance from the back of the lens so as to catch the concentrated light. It must undergo no change of place, and hence it is supported by a very heavy backing of the thickest part of the eye-walls. The entrance of the optic nerve into the eye-ball is within two lines of the yellow spot. During the accommodation of the eye for near objects and 8 MYOPIA IN ITS VARIOUS PHASES. the changes in the shape of the lens, needful for this act, the posterior pole of the lens never moves from its fixed posi- tion, however much the curved sides of the marginal edges of the lens may vary in place. In the working of the eye as an optical apparatus, the ad- justing of the lens to focus light at varied distances is the es- pecial action of the muscular elements of the ciliary bodies. When an eye-ball has been cut in half midway between the cornea and the optic nerve entrance, the curious collarett which is seen approaching the circular edge of the lens, is the accommodating apparatus for changing the focal power of the lens. The radiating bodies of prismatic shape, and about sixty in number, which form this deeply pigmented circular layer, are made up chiefly of blood vessels and mus- cular fibres hid away under and between masses of pigment cells. It is the muscular element of the ciliary bodies which, in the living eye, plays the part of the adjusting screw of the opera glass. By the varied muscular contractions of these bodies, acting upon the lens, during our waking hours, all light passing through the pupil is at once concentrated upon the yellow spot, regardless of the various distances from which the light comes, or the object upon which the normal eye may be directed. The working of the eye is a muscular act. Muscles, when overworked, will exhibit fatigue, which is often expressed by painful sensations. They can also become irritable when over-used, and then will work irregularly, sometimes even spasmodically. Such irritable contractions may become more or less permanent, and keep the lens in an unrelaxed condi- tion of greatest convexity. All organs, when in use, need an over blood supply. Im- mediately after taking a hearty meal, the stomach requires so much blood from the rest of the body that, with many per- sons, a sensation of chilliness is occasioned. After much walking, our legs swell, as evidenced by our boot tops tight- ening around our engorged calves. After much mental work, the head feels full, and the brain, if visible, would appear reddened from an increased circulation. So is it with the eye. Eye-work is inseparably connected with the ordinary MYOPIA IN ITS VARIOUS PHASES. 9 wear and tear of the organ in use, which calls for an addi- tional amount of the nutrient fluids of the body to repair the loss. The intensity of eye work is measured not only by the length of time that the eye is being used, but also by the degree of contraction of the ciliary muscle; and both con- ditions are inseparably connected with local congestion. When the intra ocular muscles are thrown \nt6 spasmodic action, they induce and ensure a temporary hypersemia of the interior of the eye ball; and, necessarily, an increase in the contents of this hollow organ. Should this condition of muscular activity be frequently and for a long time kept up in an eye not yet hardened by the complete development and maturition of its protecting layers, the comparatively soft eye shell, as found in the child, shows a disposition to yield at the opening where the optic nerve fibres enter the sclerotic coat, and the foundation for a posterior staphyloma is laid. Staphyloma is the term given to the bulging of the walls at the back of the eye, which, by elongating the antero-pos- terior diameter of the eye-ball, makes the organ permanently near-sighted. WTien once the beautiful symmetry of the ocular walls is disturbed by this bulging, the eye never can regain its normal shape. It is ever afterwards liable to be- come further distorted, until it is seriously disturbed in its working capacity, and becomes a very near-sighted eye, which is altvays a diseased one. The working of the ciliary or accommodating muscles is always associated with the action of the outside recti muscles. When the four recti muscles clasp the eye-ball, they strengthen the sides of the organ, but concentrate the strain at the weak optic nerve entrance. Unfortunately, there is no great distance between the optic nerve entrance and the yellow spot of Soemmering—that elaborated portion of the retina which is designed for all sharp vision. Very little over a line in measurement marks the distance of this all-impor- tant portion of the sensitive layer from the point where the eye is giving way. In the bulging, especially if excessive, this yellow spot must he displaced backwards. In using a powerful microscope, a very slight motion im- 10 MYOPIA IN ITS VARIOUS PHASES. parted to the cylinder by a turn of the adjusting screw, al- though it causes no visible movement in the body of the in- strument, materially affects the focus of the lenses, and blurs the object which before was so sharply defined. So is it with the eye. We have already said that to see distinctly, light must be sharply concentrated by the crystalline lens, on the back layer of the thin film of tissue called the retina or sen- sitive nerve layer of the eye. Should this accurate focusing of light fall on the middle or the inner surface of this deli- cate membrane, it would produce a blurring of the image, such as is seen by near-sighted persons when they look at distant objects. It does not, therefore, require much draw- ing back of this membrane to cause a positive impairment of vision. A fraction of a line will produce decided dis- turbances in the condensation of light coming from a dis- tance, and give a very foggy horizon. Should this retinal membrane recede for the space of a line, it would make the eye so very near-sighted that one could hardly see beyond his nose. This tendency to yielding of the human eye from study is peculiar to its growing state. When the eye is well hardened, as it is at maturity, a much greater amount of eye application can be borne continuously without fear of bulging the eye shell and injuriously changing the shape of the organ. At the age of 20, a good eye can be abused by over-work without producing myopia; while one-fourth of the same application at the age of 10, with an eye yet soft in the structure of its sustaining envelopes, would cause the eye to give way in its back wall, and bring about the disease of near-sightedness- Myopia is most frequently an acquired condition, dependent upon the over-use of the eyes at an early aye, and especially during school life. This condition, although excited immediately by the over-work of the organ, can be hastened and augmented by the physical condition of the scholar and his surround- ings. Nothing is so conducive to defective health of the body, the eye included, as the crowding of many7 children into badly-ventilated and defectively-lighted school-rooms, in which they are made to sit day after day, and for many consecutive hours. This atmosphere is tainted with the ex- MYOPIA IN ITS VARIOUS PHASES. 11 halations from their own bodies, and in winter with the nox- ious gases of defective stoves. Into these school-rooms, during the many long winter months, air is admitted only through the accidental opening of a door to give entrance or exit to some of the numerous inmates. Living for so many hours a day in this impure air of the school-room, the body be- comes slowly enfeebled, and the tissues lose their power of resistance. They become flabby and soft, and when pressure is made upon them from over-exertion, they give way. In most of our public schools, there seems to be one para- mount object before the minds of the teachers, and it absorbs every other consideration. The children are sent to have their brains developed, or, rather, crammed with book knowledge, much of which is worthless, and the rest of their bodies is of secondary consideration. School-books are, there- fore, multiplied ad nauseam, and lessons lengthened without mercy, necessitating additional hours of prolonged study out of school, which can be so much more spent in bodily exercise. Teachers will not be sufficiently impressed with the important fact that the eye, especially in its growing state, is capable of abuse; and that while excessive use tends to in- crease the fluid contents of the visual organ, it requires a matured eye-ball to resist the injurious distension to which the growing eye of a child so readily yields. When the walls of a house bow out from the perpendicu- lar, the strength of the structure is seriously impaired, and so is it with the human eye. As an additional weight causes the wall of the building to yield the more—even to the final destruction of the edifice—so does increased study during school life with a yielding wall of an eye cause an increase in the bulging, and a serious disturbance in the organic structure, as well as in the functions of the organ. As no one expects the bowed wall of a house to right itself, so the bulging eye has no chance of ever shrinking back to its normal dimensions, the popular opinion to the contrary notwithstanding. A stretched mem- brane, that cannot regain its normal position, becomes neces- sarily a weak one, and acquired near-sightedness by weak- ening the structural envelopes of the eye, lays the founda- tion for many diseases. 12 MYOPIA IN ITS VARIOUS PHASES. Nature, as a rule, makes the eye right, over-exertion of it at too early an age brings on disease. We have already stated that the examination of the students in the public schools in country and city conclusively proves this. It has also been shown that near-sightedness is greatest among the most studious, so that the number of persons wearing glasses can be, in a measure, taken for the intellectual standard of a community. Near-sightedness may be considered one of the signs of mental culture in reference to small as well as large communities. I do not mean by this that only the weak-eyed of a town are the book-worms, for all eyes do not, fortu- nately, give way under abusive work. Some of the school statistics give curious data in support of the established fact that a higher education threatens se- rious injury to the eye-sight of our race, both through ac- quired and afterwards transmitted near-sightedness. Start- ing with normal eyes so constantly found among all primi- tive people, and, to a large extent, with the properly-shaped eyes so common among the inhabitants of rural districts, who, with limited education, devote their lives to tilling the soil, we will find an increased number of misshaped eyes among the children of the inhabitants of the older cities and in special countries, as a starting point for the greatest increase in acquired near-sightedness in the public schools, Germany heading the list for its largest cities in the greatest number of myopic children. As an evidence of the transmitting of these defects to offspring, we can readily trace in our largest American cosmopolitan cities the influ- ences of a foreign population in disseminating these eye de- fects. The largest number of near-sighted children in the primary classes of our public schools are of German pa- rentage. Dr. Macnamara’s experience in India as regards the ab- sence of myopia among the uneducated classes of that coun- try, I can fully endorse, in reference to the negro race, as forming the uneducated and laboring class of the Southern States. I cannot recall a single instance in which I have detec- ted myopia in a full-blooded negro. With nearly the total ab- MYOPIA IN ITS VARIOUS PHASES. 13 sence of intellectual culture 10 years ago among the 3,000,000 of negro population of the Southern States, there was nearly a total absence of myopia. A similar statement has been made in reference to the absence of near-sightedness among the American Indians. They have, on the contrary, been always noted for their very sharp, distant vision. When the public-school system has been widely introduced among these primitive people, as is now being done among the colored population of the South, it will be found that with book knowledge will come eye defects as a regular sequence. American children of mixed, native and foreign parentage now start school life in the large cities with an aggregate of about 3 per cent, of near-sightedness, while the similar schools in Germany exhibit 11 per cent, of near-sightedness among the primary classes of young school children. We have already stated that children of German parents in America give the largest percentage of myopic children to our public primary schools. From these data, we prove not only that inherited eye troubles are greatest among the German population of any country, but that among all cultured nations this inherited disease, which the children exhibit before their ej’es are taxed with any hard work, was at one time acquired by their progen- itors on account of eye abuse. In countries where the eyes are most taxed in early life b}’ forced education, and where this has been going on for some generations, we find marked evi- dences of the gradual eye deterioration, not only in the num- ber of spectacled parents, but also in their young offspring. This state of things augurs badly for the coming generations. Luxurious living, and the desire to secure it for their fam- ily on the part of some, with the struggle for existence on the part of the masses, induces parents to accept the system of forced education for their children, and to prepare them for the great struggle by a very early beginning. In propor- tion to the study which these young people indulge in, their tendency to have yielding eye-balls is developed. In analyzing with care the eye-sight of a large number of school children, and determining the cause of near-sighted- ness in connection with their daily mental work, it was dis- 14 MYOPIA IN ITS VARIOUS PHASES. covered that the idle escaped this heavy tax, which bore most heavily upon the most industrious. Let us take the series of public schools in St. Petersburg, where, according to l)r. Erismann, the aggregate of the children start with 13 per cent, of inherited myopia. He selected out of several thous- and children all those who studied two hours a day outside of the school-house, and found, by examination, that among these studious little ones near-sightedness had increased al- ready to 17 per cent. Of those who studied four hours out of school, 29 per cent, of them had become near-sighted; and of the most industrious, who worked at their books six hours at home to ensure perfect marks from their teachers, over 40 per cent, had injured their eyes, and needed concave glasses for distant vision. This is a very serious exhibit, especially when it is consid- ered that an eye thus injured never recovers from this bulg- ing of its protective walls. It must remain ever afterwards, during the whole lifetime of the individual, a weak organ, exposed to many diseases which it would otherwise have es- caped from, or not be liable to. If these data be correct, and, unfortunately, we cannot make them otherwise, as they are capable of mathematical demonstration at any of our city public schools, are not the demands of a higher education threatening the eye-sight of the race ? Myopia, which is a diseased condition of the eye, is immediately appended to the intellectual advancement of the growing population, and by them will be transmitted to their posterity. Each generation, in its turn, will increase the percentage of near-sighted children. This proposition of transmitted, acquired diseased condi- tions has been questioned on fallacious data. It has been said that a defect acquired through an accident is not trans- missible, and that should the children, from the time of Moses, have had the left forefinger of the left hand cut off, the present generation would still be born with a finger ready for the amputating knife. Such, no doubt, is the law of accidents, and fortunately the accidental mutilations of the body are not forecast in the successive embryos. But ac- quired diseases are not to be placed in this category. MYOPIA IN ITS VARIOUS PHASES. 15 Our first parents were, no doubt, types of health in every respect, with every organ properly formed and with perfect working power; yet, we find every species of inherited dis- ease acquired by some of their offspring and then trans- mitted to after generations as the established condition of families. To a very appreciable extent, pathological changes do impress their kind or tendency on future gen- erations, so that the facility to acquire seems to belong to certain families, classes, races or nations, although not exhibited by all the members of the family. Hence, when some peculiar pathological change in cerebral mat- ter has sent the head of the house to a lunatic asylum, although insanity has not been heretofore known in the family, we would not be surprised to find it hereafter developed in one or more of the children under special cir- cumstances. A parent dies of acquired phthisis. The fam- ily tradition up to this time gives no record of such diseases; hereafter it establishes itself, and becomes the recognized hereditary family weakness. The same can be said of can- cer, weak throats and other acquired diseases. So is it with near-sightedness. Human eyes were originally good, and among primitive races are still so. Under the pressure of early and close study, troubles first came, and are being extended to poster- ity as hereditary transmissions. From a cancerous parent, all children are not necessarily cancerous; so from a myopic parent all the children are not necessarily near-sighted, but, at the same time, all do not invariably escape. One or more will likely show the parental defect. How bring in the forced education under defective hygiene, badly printed sohool- books, poor lights, etc., which has been clearly shown to create additional cases of myopia, and we see that there is good ground to fear that the coming race cannot have as good eyes as had their progenitors, and that eye disease must be on the increase. A near-sighted eye is a weakened organ, and will ever remain so; and an excessive degree of near-sightedness often induces diseases of so destructive a character as to cause the loss of all useful vision, and may lead to 16 MYOPIA IN ITS VARIOUS PHASES. blindness. Should the acquired myopia of youth mark a great degree of yielding of the outer walls of the eye, the contents of this distorted eye-shell cannot avoid being seriously disturbed, to the detriment of the visual or- gan. If at the age of bodily maturity the eye has not yielded much, then the stiffening of the coats will protect against excessive changes, and the myopia may be arrested in its fur- ther progress. Should the eye-walls have bulged much before the sclerotic had attained its full resisting power, then the myopia continues to increase, which means a still further attenuation of the walls, and an increased structural weaken- ing of the organ, with advancing age and the constant use of the eye in the ordinary avocations of life. I have before said, that if myopia has not been acquired in the early years of school life, it it not likely to appear in the adult, however closely the fully matured eye is worked. Other eye annoyances may supervene in an over-worked adult organ, but myopia is not often found in this list. The needle woman, with matured eyes, can sew from early morn- ing till near midnight, and the eye shell will perfectly resist this long kept up ocular congestion, although Sunday alone breaks the persistency of the ciliary muscular action, while weeks, months and years, and even a long lifetime, express the monotony of the every-day and all-day application. In the young, growing, yielding eye-ball, we have seen that two, four, or six hours of steady application in acquir- ing book knowledge, not counting school hours, will have produced, respectively, 5, 15, and 30 per cent, of myopia, so that the tendency of myopia in the young can be measured with some certainty by the number of hours of close appli- cation. All near-sighted persons, regardless of the cause producing the defective focusing, see distant objects as if in a fog. This fog increases with the degree of elongation of the eye- ball, or with the convexity of the lens, until even compara- tively near objects have very blurred outlines. Many mod- erately near-sighted persons are so little inconvenienced that they are not aware of their defect until contrasted with the sharper sight of others. On the other hand, many who ex- MYOPIA IN ITS VARIOUS PHASES. 17 hibit a very advanced myopic condition, cannot define the features of a person placed three feet from them. The first intimation that a child’s eyes are defective, or are becoming so, come in the form of complaints that the dis- tant blackboard in the school-room, which could be so dis- tinctly seen last year, is now very much blurred when viewed from their accustomed seat, and that the teacher has had to move their seat nearer to the board so that the pupil may see what is written upon it. These young people also complain that they cannot see faces across the street, and that they cannot recognize their own parents at that distance. Now that the child has called attention to some growing defect in the eyes, it is noticed that in studying at home the book is held much nearer to the face than formerly. If the parents are themselves near-sighted, they recognize the trouble in their child from their own familiar foggy outlines of distant objects. They first test them with the glasses which the pa- rent wears, and if distant objects come out boldly a similar pair of concave glasses are given to the child. By this course the parent may possibly be acting in a ju- dicious manner towards his child. In by far the major- ity of instances, however, the supplying of concave glasses to the child without a careful and thorough examination of the eyes by some one skilled in this work, would en- tail permanent injury. The myopia in this case need not be a congenital acquisition, and the over-work to which the young eyes have been subjected may not yet have caused organic changes in the walls of the eye. The child may be strictly one of that very large class of young persons who are only acquiring myopia through permanent spasm of the ciliary muscle, and the case is not so far pro- gressed but that it can be promptly and permanently cured. Such a child may exhibit most of the signs of near-sighted- ness, but they may all be fictitious. She may have very defective distant vision, and yet not be a confirmed myope. The carefully prepared test types, which should be readily made out by a perfect eye at twenty feet, may not be read by her at the distance of ten feet, or even of five feet. The op- tometer for measuring the range of accommodation, may 18 MYOPIA IN ITS VARIOUS PHASES. show clear vision for only very near objects. Even the ophthal- moscopic examination may indicate myopic refraction. All of these evidences of myopia in children are not conclusive, and may be fallacious, unless the atropia test be also applied. If, when the eyes have been saturated with a solution of the sulphate of atropia, grs. iv, to 5j of rosewater, they yet show no change from the standard already elicited by the test types and the optometer, then the existence of myopia has been positively determined, and the correcting concave glasses for distances should be prescribed. The various mydriatics, of which atropia or duboisin are the best, are an essential ele- ment for determining the presence of permanent near-sight- edness in children. No eye-glass should be given to a child without testing the eyes with a strong atropia solution. Most near-sighted cases in children commence with ciliary mus- cular spasm, which resembles myopia so closely as to be readily mistaken for that form of defect which is caused by an elongated eye-ball. In all of these cases, and they are very numerous among school-children, the free local use of a strong solu- tion of atropine can alone solve the problem. In no case can this eye-drop do harm. By expanding the pupil and paralyzing temporarily the ciliary muscle, it will put a stop to all reading, and will compel the little patient to take the so much needed eye rest. In a few days, the effects will al- together pass off, and the eye will resume its former activity and acuteness of vision. The following case will illustrate this defective condition of eyes among man}7 school-children, and is given as a typical instance of how fictitious near-sightedness is brought about by ciliary spasm. This muscular spasm is a way station in the development of permanent myopia, to which organic change it will surely lead if not recognized in time, and the proper remedy used for its arrest: Sarah M., aged 13, a girl in good health, has complained for the last three months of pain in the eyes, and not being able to see the blackboard from her seat in school. Last year she had no such difficulty, and she could detect any dis- tant object that any other schoolmate could see. The eyes of the children in her class at the public school had been ex- amined last season by a specialist in eye diseases, and she MYOPIA IN ITS VARIOUS PHASES. 19 was put among those who had good eye-sight, both for dis- tance and for near objects. She was not aware of any eye defect until she was moved up to a higher class. From the beginning of the present session, she has been applying her- self much more closely to her studies. Besides the school hours for recitations, she devotes to study all of the afternoon, and often evening hours until bedtime, at 10 o’clock. The print in some of her books is very fine, and the paper of which the book is made is so thin that the type shows through the page. Her map questions annoy her much. She had been at this hard work for six months when she no- ticed that her eye-sight was becoming defective, and that dis- tant objects were as if in a fog. In blackboard recitations, she had been compelled to ask the teacher to allow her to sit nearer to the board. At first this change of place answered very well, but now, even at the nearer seat, the figures are as indistinct as they had been two months ago from the more distant bench. She thinks that resting her eyes makes her see a little clearer, and that on one occasion recently, when she had to be absent from school for one week, she could see much better the blackboard figures upon returning to school. A very few days’ study brought back the cloud, and also the pain in her eyes, which she had not felt during her short absence from school. It seems to her that the sight is getting worse every day. She is complained of at home for inattention, when she really cannot see the expres- sion of one’s features across the table. She has tried a pair of near-sighted glasses belonging to one of the school- girls, and sees beautifully with them. Her father, not wish- ing to purchase a pair of eye-glasses for her without knowing the exact number which her eyes require, preferred first to consult a specialist. I examined each eye for distant vision, and found that letters which a good eye should readily read at one hundred feet, could only be seen by her at eight feet— a reduction of her distant vision to T$0 of the normal, and what hers ought to be. She reads fine print readily at the usual distance of one foot. Looking through a ten-inch lens at some fine print, she could only read it when it was ap- proached to within six inches of the eye. From the six inch point to four inches she could read readily, but not beyond these limits. Two inches through a ten-inch magnifying glass measured the extent of her accommodation. The careless observer would say at once that here we had a case of progressive myopia requiring a fifteen-inch concave 20 MYOPIA IN ITS VARIOUS PHASES. glass for its correction, and would, therefore, prescribe this number of spectacle through which she can see letters marked for 20 feet at 20 feet, and, therefore, by aid of which she had distant vision perfectly restored. Before doing this, however, a careful doctor would prefer making an ophthal- moscopic inspection to see whether the interior of the eye exhibits any evidences of a posterior yielding. The lengthening of the antero-posterior diameter of an eye usually shows itself by an irregular, whitish mottling on the temporal side of the optic nerve entrance—a commencing atrophy of the choroidal boundary of the disc, called a cres- cent. In incipient myopia, there is no sharply-defined outline to this crescent, and the whitish mottling is restricted to a narrow half zone. In the course of time, the outline of this half moon sharpens, and by extending in area, indicates that the near-sightedness is decided and permanent. In the case of Miss M., the optic nerve entrance was sharply defined and uniformly round, showing that the oph- thalmoscope revealed no cause for her short sight. The rap- idly-increasing near-sightedness, and the usual additional application since the new school term, based upon a good eye of six months back, leads me to suspect that the apparent myopia is of that fictitious kind induced through spasm of the ciliary muscle. If not recognized and judiciously treated, this leads to organic changes in the eye-ball, and becomes a case of confirmed myopia. To determine this most important point, I instilled into each eye a four-grain solution of the sulphate of atropia—the patient lying upon a lounge, so as to allow the drops to remain for a few minutes in contact with the cornea for absorption, and to produce their full action. At the end of an hour, the pupils were found much enlarged, and distant test types could then be much more readily seen. She now read No. 30 at 20 feet, and by the aid of the optometer, with a ten-inch lens, the near point had receded to 8 inches, she reading from 8 to 9 inches. The degree of visual range, which could still be ex- ercised, showed that the ciliary muscle had not yet been alto- gether relaxed, and that by its action the too great convexity of the crystaline lens was still kept up. The patient was given a small quantity of the four-grain atropia solution, with instruc- tion to drop it in the eyes three times a day, and to return on the morrow for inspection. At the next examination, MYOPIA IN ITS VARIOUS PHASES. 21 after four more instillations of atropia, she complained that her vision had again become misty, and that nothing was clearly seen. She could not make out any kind of print, and standing at 20 feet from the test types, she can only see letters which should be read at 70 feet. She was now tested with the ten-inch optometer, and her nearest and only point for reading was at 15 inches from the lens. The atropia action in her case had solved the problem, and had dissipated the fictitious myopia. By this valuable test the patient was proved to be not near- sighted at all. She was, on the contrary, over-sighted—a condition known as hyperopia—-just the antipode of myopia. Nature had made her with an eye too short in its diameter behind the pupil, necessitating some effort to focus even dis- tant light, which is just the opposite of the long eye of my- opia. As long as the eyes were not called upon for much work, this defect in the construction of the eye was not felt. When greater demands were made by more studious habits, and the ciliary muscles were inordinately taxed to make the lens very convex to cover the defect of shape in the eye-ball, then muscular irritability ensued, and finally the muscles became spasmodically contracted, as a permanent state. They would not relax during the short interval of rest from study, and hence the lens kept too convex—lost all of its abil- ity to condense distant light. In its fixed, abnormal condition of excessive convexity, it could only focus light from near objects, and became, on this account, practically a near-sighted eye. When the ciliary muscle had been temporarily paralyzed by the atropia, we could examine the eye in its normal state, and find that, instead of re- quiring a concave lens, as heretofore believed, the very pair of friend’s spectacles, which yesterday helped her so much in seeing distant objects, now blurs them the mors. A thirty-inch convex glass was the one which, in the dilated condition of the pupil, cleared up distant objects, and re- stored her to vision. The course to pursue with this young lady, to prevent her from becoming near-sighted, was very clear. Re- move some of the strain from the eye muscles by do- ing some of the condensation of light for them. The magnifying glass, with which she can see most distinctly distant objects when the eye is fully under the effects of atropia, is the glass which she should wear at all times, both for walking and reading, and they should be put on at once. Gradually the effect of the atropia will pass off*, and in ten 22 MYOPIA IN ITS VARIOUS PHASES. days she will be able to read again and resume her school work with her spectacles. The ten days’ rest has done her eyes immense good. It has enabled the long-continued con- gestion to pass off, and has put the eyes in a much more healthy condition for work. After wearing the magnifying spectacles for some weeks, she can discard them for walking, provided she never studies without them. At the end of school life, she will be able to discard glasses altogether, and will find her eyes strong for all ordinary uses, without the help of spectacles. Suppose, under bad advice, or by her own selection, the myopic glasses, which seemed to her so useful, had been adopted. The true condition of over-strain would not have been discovered. The momentary clear vision, produced by concave spectacles, would have become so dim in a few days or weeks as to necessitate the use of stronger lenses. The eyes, constantly under congestion, and with increased straining on the part of the ciliary muscles, would have be- come painful, and would finally have given way by the yield- ing of the protective coats. The result would have been a progressive myopia, organic and not functional in character, and therefore a permanent eye defect. The ease of Miss M. is the history of thousands of indus- trious school-children, anxious to excel in their recitations, and daily stimulated by ambitious teachers, thoughtless of what injury they inflict upon their scholars, provided long lessons can be accurately committed to memory. Should Miss M. be allowed to follow the course which her teacher would map out for her, and had neglected profes- sional treatment for her eyes, it would be a very easy matter to foreshadow her future, for we are frequently called upon to examine just such neglected cases. She perhaps would have had the one great transient satisfaction of receiving on graduation day the highest award of the school. She would have entered the world very wise as to school-book learning, but with poor health, a pale face, and with the knowledge that she has a pair of eyes which resent, with pain, any long- continued use. Without concave glasses, the outside world is a blank. Without them, her friends are not recognized as they pass her on the sidewalk. A few years may have MYOPIA IN ITS VARIOUS PHASES. 23 elapsed since school days closed, and much of book- learning has been forgotten, because not wanted in the prac- tical affairs of every-day life. But the eye discomfort, ac- quired in the ardent desire to have perfect lessons, is ever present, and pregnant with anxieties for the future. When- ever impaired digestion, the sequel of sedentary habits, makes her nervous, spectra of losing vision haunts her. The in- ducements held out to her of being the prize scholar has turned out an empty honor, which has embittered her life. When the attention of the medical friend of the family is called to the growing near-sightedness of children, instead of suggesting near-sighted glasses, it would be well for them, in every instance, to see the effect of a strong atropia solution on the eyes. This atropia drop will never do injury in such cases. The rest from study, which the belladonna alkaloid will ensure, will be in itself a great comfort to the over-taxed organ. If distant vision improves when the pupil becomes thoroughly expanded, showing conclusively that the near- sightedness was of that delusive, fictitious kind induced bv the over-straining and long-continued spasm of the ciliary muscle, then a weak magnifying glass, to be used for all near work, will prevent a return of the annoyance, especially if there be some relaxation from and diminution of too much study. This simple treatment of belladonna application, with the rest it gives to the fatigued organ, and with the valuable in- formation which it elicits, can never do harm. It alone will be the means of preventing in children thousands of cases of ap- parent myopia from becoming permanent, life-long defects. Among patients which a specialist is daily examining, he very often finds cases which the following description will fully cover: James II., aged 16, recently promoted to a collegiate institu- tion, has been a special favorite with his teachers on account of very studious habits. For some time he has been aware that his eyes were weak, as he often has headache and pain in the eyes from study, also that his distant horizon had become much befogged. This was not the case three years since, when he often tested his eyes in detecting small, dis- tant objects during his many steamboat excursions. For the 24 MYOPIA IN ITS VARIOUS PHASES. past two years he has been nmcli of a hook-worm, and has been encouraged to use all his time not absorbed by his lessons in desultory reading. His greatest annoyance at present is dur- ing blackboard recitations, especially in algebra. Unless standing near the blackboard, he cannot detect a single char- acter, and is often placed at disadvantage before his class- mates on account of his defective vision. In reading, he has no trouble, and does not hold the book nearer than the usual distance of twrelve inches. Near-sightedness is not a family defect. He is one, the eldest, of four children; all the others with good eye-sight. His parents have no eye defects. Exam- ined by the test types, he has only one-sixth of the normal dis- tant vision. Figures to be seen at 100 feet by good eyes, he approached within 15 feet before detecting them. In drawing his eye-lids closely together, so as to convert the palpebral tissure into a linear split, he sees distant objects much better. Under the local use of atropia, no material im- provement is made in his distant vision; and although the newspaper print is somewhat blurred, he can still make it out. Concave glasses clear up his distant horizon. The ophthalmoscopic examination indicates a myopic rctlex of the retinal vessels, and shows that an irregular, whitish, mottled area of choroidal absorption extends for some distance on the temporal side of the optic nerve entrance. This choroidal atrophy has already been referred to as a crescent, and de- notes the fact of an established myopia by the posterior bulg- ing of the eye-shell. It also indicates that the near-sighted- ness has been acquired by the over-use of the young, soft, yielding, growing organ. As the mottling is not sharply limited by healthy red choroidal tissue, but is irregularly scattered for some distance around the optic disc, it is also an indication that the case is one of progressive myopia, and that close application will increase the troubles. The con- cave eye-glass becomes an essential to Master II., and has already established itself as a life-long appendage, never to be discarded if clear, distant vision is to be desired. The eyes of Master II. have been already seriously and per- manently damaged by too close application to books, and if, under bad advice, his ambition to continue over- study is stimulated, it can only be at the expense of this most valuable organ, which must hereafter be called a diseased eye. lie is now laying the foundation for future trouble, and possibly, in the end, loss of useful vision. His best course, for the safety of his eye-sight, would be to give up study for the present, and take up some out-door MYOPIA IN ITS VARIOUS PHASER. 25 occupation until such a time as the choroidal atrophy should become sharply defined, and the sclerotic coat relieved of constant congestion. When the coats of the eye, after one or two years of out-door life, become firm, he may resume study with much better prospect of keeping good eyes in his advanced age. These two reported cases, that of Miss M. and Master II., form the bulk of the material for acquired myopia among young scholars, the first preparing to become near-sighted and the second progressing rapidly in it; and it is between the ages of 8 and 18 that most cases of myopia acquire their near-sightedness. We have so far thrown out that small list of hereditary myopia where children are born with eyes already too long in their antero-posterior diameter. Such ejres, although weak in configuration, are not necessarily diseased; but, if pressed with head work while still young, they are predis- posed to give way with what would be called progres- sive myopia. These need concave glasses to see clearly dis- tant objects at even an early age. We find a fourth form of acquired myopia. This time it is with old persons, in good health. They cannot accuse their eyes of over-work. On the contrary, they have never overtaxed the eyes at anytime from childhood up. The following case will represent this very interesting form of the eye defect: Mr. S., aged 75, a case in point, has gone through life with no eye discomfort. lie found, at the age of 45, that he could not read fine print with his former facility. Marginal notes he had to abandon, even when he could enjoy the strong light of an open window. For evening reading the selection of a good, bold print was a matter of some importance, and news- paper reading at night had been discarded. lie was advised at that time to get the magnifying glasses which the begin- ning of old age requires. With the use of these he found much solace. By their instrumentality, he had been able to resume night-reading, which he has steadily kept up. From time to time, he has changed the spectacles for stronger ones. Commencing with No. 48 magnifying, he changed them every two or three years, using, respectively, those which focus at 36, 24, 18, 14, 12, 10, and finally at 8 inches. The last strong spectacles he has used since he was 68 years 26 MYOPIA IN ITS VARIOUS PHASES. of age. Two years since he discovered that in reading with his glasses he had to hold the book very near to his face, and one day, taking up the newspaper, he found, to his surprise,, that by holding the print at a distance he could decipher it without his glasses. For the past two years he has discarded spectacles for reading altogether, and has rejoiced in the restoration of a second sight. For the past twelve months he has become aware that the faces of friends across the street are not so easily detected as formerly, and he often passes persons unintentionally without recognition. It is this closing in of his area for distinct vision that has induced him to seek advice. I find that Mr. S. has suffered no eye pain at any time, and that this recently-acquired short sight is his chief discomfort, lie reads book print at the usual distance of 12 inches without much difficulty, and does much of it during the day. When tested by the larger type from the distance at which he is sit- ting, 18 feet, he could only read oft* specimens of type which can be readily seen by a good eye at 100 feet. His near, clear sight and distant, foggy vision establishes in his case myopia, and that evidently acquired within the last six months. I used atropia with him, and his distant vision did not clear up in the least, whilst his near vision dis- turbed. The ophthalmoscopic examination explained to us the cause of the error of refraction. In the retina and choroido-schlerotic coat, around the optic nerve entrance, we found no changes from the normal condition. It was in the lens substance that the alterations were found. Upon the very edges of the crystalline lens, in that portion of the periphery usually covered by the iris in the ordinary contracted state of the pupil, I saw one or more delicate black lines, resembling cracks in a pane of glass. They extended from the margin towards the centre of the lens, and in the direction of the pupil. These lines may streak but one side of the lens border, or they may be more or less disseminated around the entire outer margin of the lens. Sometimes there is but one single dark stripe, not more than one or two lines in extent, which mars the complete transparency of this brilliant body. That single flaw' is, how'ever, enough to ex- plain the near-sightedness, and will, wdth certainty, foretell that in time a cataract will develop in that eye, of which this line of fatty degeneration or organic change is the sure fore- runner. The privilege of second sight, unless it appears at a very old 27 MYOPIA IN ITS VARIOUS PHASES. age, is seldom an enjoyment of long continuance. Should tins privilege be secured before 70, it foreshadows cataract blindness not very many months or years ahead. When second sight appears in persons of 80 and upwards, although it is of the same pathological significance, the lens changes are so very slow that general senility may carry off the per- son before the opacity in the lens has made sufficient ad- vances to be annoying. In these cases of acquired myopia in old age, an explanation is found in the fact that the lens of a person growing old is condensing, dessicating, and therefore shrinking. It is this flattening which goes on perceptibly from 40 to 70 years of age, and which necessitates with us the supplementing of the lens by spectacles. These increase in strength with the lens shrinkage. Preparatory to the formation of cataract in some of these old persons, the lens commences to imbibe fluid, and becomes more juicy. The fibrous tubes, of which millions are found in the many laminae of the lens, suck up fluid from the aqueous liquid from which it draws its normal supply of nourishment. This imbibition of fluid swells the lens within its elastic capsule so as to make of it a strongly magnifying body, only capable of focusing at short distance. For many months, the lens, altered in shape and made very convex, may retain its perfect transparency. After a while, opaque streaks and spots make their appearance in it, and in time the whole lens loses its clearness. Concave glasses for a time will correct the excessive re- fraction for the acquired myopia of old age when the crystal- line lens, by recent swelling, is preparing to become opaque with cataract. In the progress of degeneration of the lens substance, when light becomes impeded in its passage to the retina, foggy sight comes on for all objects, both near and far. Of the five kinds of myopia which I have tried to de- scribe, the last—viz., that coming on in old age—is the most rapidly progressive, and is that form of myopia the most speedily converted into very defective vision by clouding of the lens substance. The near-sightedness which follows upon the acquisition of the second sight, is only temporarily 28 MYOPIA IN ITS VARIOUS PHASES. relieved by the use of concave glasses, but it will finally be removed altogether by a successful operation for cataract ex- traction. The second form of acquired fictitious myopia in young per- sons brought on b}r exciting the accommodating muscles with- in the eye into a more or less permanent spasmodic contrac- tion,is to be detected through the relaxing influence of a strong solution of atropia. The constant wearing of a suitable con- vex eye-glass for all near work will prevent a recurrence of the muscular spasm and cure the apparent myopia. The congenital myopia, which is a mis-shaped eye,inherited from near-sighted parents, also that more common form of eye bulging, the result of long-continued congestion kept up by too long neglected over-work of the eye muscles, can only be corrected by the judicious selection of concave spectacles. These are to be worn, in most cases, only for distant vision. If the case be one of excessive elongation of the eye diame- ter, requiring the book to be held within six inches of the face when reading, a weaker concave glass than the one used for distance will be necessary to enable the book to be held at from 12 to 14 inches. This weak spectacle may be con- stantly worn. There is no sanitary question at present exciting the atten- tion of the medical world of greater interest than the hy- giene of the eyes. How shall we take care of the eyes of the growing race so as to keep them in the good condition with which they start life? is the most absorbing subject. With very few exceptions, nature makes the eyes right. In- jury usually comes to them from abuse, especially during school life, in acquiring book lore, most of which is dis- carded as soon as the scholars control their own actions. Near-sightedness is the diseased condition which over-work at school engenders. By the judicious selection of school-rooms, books and studies, much can be done to prevent this disas- trous consequence to the growing race, and to the next gene- ration. That acquired myopia can be afterwards transmitted to offspring is too often seen to be doubted. A- case in support 29 MYOPIA IN ITS VARIOUS PHASES. of this statement has just consulted me, and her family his- tory is that of many others : Mrs. B., of Ohio, aged 57, has been near-sighted from childhood. Both of her parents had excellent sight. She was a precocious child, and when still very young became engrossed in books. At a comparatively early age she put on near-sighted glasses, and has worn them as her constant companion throughout her adult life. She now has on ex- cessively strong concave spectacles of two inches focus, and even these give her very little of distant vision. Her eyes are now so much affected that she can no longer read small print; and they have given her much pain of late. The right eye, which,for many years,has been her chief dependence, lias recently given out entirely. The left eye, for a long time con- sidered very weak, is now her only useful visual organ. An ophthalmoscopic examination explained her defective vision. Around each optic disc there was a large area of choroidal atrophy, which always means retinal destruction over such atrophic spaces. This condition of great stretching in the right eye had lead to detachment of the retina at the yellow spot for central sharp sight, and has made the eye perma- nently useless. In the left eye the choroidal atrophy was encroaching also upon the important retinal centre, so that this eye also is threatened with destruction at no distant pe- riod. All of this serious injury can be traced to the yielding of the eye-walls from over-work in childhood. She is the wife of a gentleman who has perfect eye-sight. By him she has three children, only one of whom has good eyes; the other two have been near-sighted from early life. In this instance, at least, the mother’s acquired eye defect has been directly transmitted to two out of three children. The hygiene of the eyes should be carefully studied by parents and by teachers. Children in early years should not have their eyes taxed to their life-long injury. If in many of our schools more time were given to physical culture, and less attempts be made to force intellectual development, there would be less eye tax, and consequently fewer eye defects. In most cases it would be far better to restrict study hours rigidly to school hours, and leave the books in school, to be resumed on the following morning. The amount of indif- ferent and often useless knowledge, acquired by the over- work of the eyes of school children, is a very miserable re- 30 MYOPIA IN ITS VARIOUS PHASES. turn for the life-long annoyance of weak eyes and acquired near-sightedness. These remarks are especially applicable to the education of girls. Very few ladies who receive the so- called higher education ever make it available for teaching. Many of the studies in the female high schools are of a thoroughly useless, as well as often of an annoying descrip- tion. Algebra, geometry, the higher mathematics, and other studies equally useless to the majority of ladies, absorb many months of close and injurious application. After the final ex- amination, these studies are most gladly dismissed, never to be resumed, and are very soon forgotten. Would that the effects upon the eyes, induced by their study with the dis- eased condition of acquired myopia, could be as readily thrown aside. The uselessness of many of these studies was forcibly brought to my notice a few months since : Mrs. W., a former patient, brought her daughter, 13 years of age, to me for treatment. The child had been advanced to classes beyond her age, and could be, with difficulty, re- strained from reading, to the exclusion of all other domestic duties. Myopia had already become positive, and a concave glass was necessary for seeing at even short distances. While referring to the over-taxing at school, compelling night as well as day study, the mother had taken no steps to restrain this young child from so much eje work. She happened to remark that her eldest daughter, aged 18, was just about graduating at the Female College, and that she had come out among the first in her class of over 200 girls. She was glad that her daughter was about finishing her school education, as she had become very near-sighted, and often complained of pain in her eyes with head- ache. The lady referred with pride to the high grade which her daughter had taken in geometry and algebra. I suggested the remark that these higher mathematical stu- dies were utterly useless to young ladies, as they were to most male collegiate graduates, and thdt they did not take the place of the simple mental arithmetic so valuable for every day use. I asked this simple question, Whether this educated mathematician knew if her change was cor- rect in shopping? The mother had to confess that this part of her mathematical studies had been sadly neglected. It was expected that this young lady would in time have a MYOPIA IN ITS VARIOUS PHASES. 31 house of lier own to manage, and not a class of pupils, and most of these two hundred young ladies who had gone through the same course of study expected to be similarly engaged in domestic work. If a pupil, restrained when young, shows in maturing years any desire to study, one year’s close application at the age of from 18 to 20 will advance an education more than several years of work in early life. At the age of 20, the eye-walls have hardened so that no amount of eye work is likely to make them yield. Our present system of forced early education for both sexes offers some points for thoughtful consideration. Girls up to 15 years of age are, as a rule, brighter than boys, and can under similar circumstances, be further advanced in ed- ucation. Of a more domestic turn, they take readily to books, and can be the more easily induced to study. At the age of 16 or 17 most of the female world is supposed to be suffi- ciently educated to fit them for society; hence, the last two or three years has been a cramming one at the schools, ne- cessitating the use of all day light hours to secure good re- citation marks. While the girls are at their studies, boys are on the play-ground developing their physical frames and laying up a store of vital force which will enable them to work harder during college life. Close mental and eye work with the youth usually commences at a period of life when the young lady leaves off. The maturing condition of the eye will explain why the education task of the girl from 13 to 16 is so much a greater strain on the eyes than that of the youth between 16 and 20, which are the years of college life. With the older persons, the eyes are becoming daily more firm and strong to stand work without detriment. The younger the eye is forced, the more readily it gives way. In Germany, where the forced education in very early years is the law of the land, myopia, or weak eyes, abound. In England, where the school life is of a more advanced age, near-sightedness is the exception. It is easy to draw a valu- able moral from these data. Fortunately, all children who study hard do not become victims to myopia. Would that none should become so. 32 MYOPIA IN ITS VARIOUS PHASES. Family medical advisers would act most wisely if they recommend that all annoying and useless lessons be stopped as soon as they find the eyes of children taxed to injury by their acquisition. When a young lady, who does not expect to be a teacher, finds her eyes painful and misty after some hours’ application upon the closely and badly-printed school- book, better cast such a book aside, and devote that time to recreation in taking out-door exercise. A stock of general health is worth much more in the family circle than a knowl- edge of many useless books. It is far better that some should take book knowledge, which is not the most useful knowl- edge, in moderation, rather than obtain a large degree of brain development without a healthy body to sustain it.