Deterioration of Vision 
IN 
SCHOOL CHILDREN. DETERIORATION 
OF 
VISION IN SCHOOL CHILDREN. 
BY 
V" 
S. O. RICHEY, M. D., 
WASHINGTON, D. C. 
REPRINTED FROM VOL. X—REPORTS OF AMERICAN 
PUBLIC HEALTH ASSOCIATION. 
Conairir, f1. ||.: 
Republican Press Association, 22 North Main Street. 
i885. DETERIORATION OF VISION IN SCHOOL CHILDREN. 
Wherever “ two or three are gathered together ” a legitimate field is. 
created for investigation by those interested in the moral and physical 
welfare of their race,—because one may be in health and another diseased, 
the former, in time, being “ made black by handling pitch.” If the 
hygienic arrangements of private houses, barracks, ships, and hospitals 
are studied, so should be those of theatres, churches, and schools. 
Schools are to a great degree protected-from the more pronounced con- 
tagious diseases, but are they guarded so well as they might be from those 
that are obscure and less easily detected ? Should not each school be 
ensured all possible safety by a preliminary physical examination in 
every respect of each child entering it? A certificate of vaccination is 
demanded of each new comer in many schools. When any of the erup- 
tive fevers are known to exist in a household, no child from that house 
is allowed to attend until all danger of contagion is believed to be past \ 
but how many there are, especially among the poorer classes, who have 
some conjunctival affection, and yet attend the schools, associate inti- 
mately with those who have not, use the same wash-basin and towel, the 
same books and pencils ! The extent of exposure is not justifiable, and 
a certificate of health in this particular is as important as in any other. 
1 Reich had an experience due, probably, to exceptional circumstances, 
but among three hundred and seventy school children in Armenia he 
found trachoma to exist to the extent of thirty per cent, of the males and 
twenty per cent, of the females ; and there was conjunctival trouble of 
some character in sixty per cent, of the males and seventy-three per cent, 
of the females. 
Weber suggests that a special physician be appointed with executive 
authority. This would meet the difficulty at the outset, but it would add 
to safety to banish wash-basins and towels from the school-room unless 
each pupil could have his own towel. This last recommendation will 
not seem uncalled for by those who have seen instances in which the dif- 
ferent members of the same family have suffered in a like manner, the 
source being a single individual and the medium of communication the 
articles in common use. A low form of granular conjunctivitis, with 
its train of consequences, trachoma, distortion of the lids, and paunus, is 
1 C. f. A. Oct., 1878, p. 228. 4 
DETERIORATION OF VISION IN SCHOOL CHILDREN 
much to be feared. I have never seen it happen in a very young child 
but once: it is not infrequent after eight years of age. Landesberg 
states (Archiv. Oph. vol. vj, p. 487) that he has “ seldom seen children 
under five years suffering with granular conjunctivitis.” An affection of 
the eye due to contagion is an accident not attributable to the work of 
the school-room ; but there is another form of trouble which cannot justly 
be characterized as accidental, because of the constancy with which it 
prevails among all schools ; a shifting or varying in the power of refrac- 
tion of the eyes, the refraction increasing as the eyes are kept at close work 
for a long time. This condition of near-sight will in time be as much a 
curse to civilized people as tuberculosis, uniting as it does the influences 
of inheritance and acquisition. Germany to-day probably heads the. list 
in the per-centage of myopia to its population, especially among its edu- 
cated people. That country has also been among the first to appreciate 
the greatness of the evil, in that it disqualifies in a great measure those 
who have it for military duty, and therefore for good and efficient citizen- 
ship. We, in our neglect or in the inadequacy of the measures adopted, 
are xdvalling her in our results. 
Hygiene will be the medicine of the future, and Prophylaxis the pa- 
tron saint of physician and layman alike. More is to be gained for our 
race by avoiding now, when it is possible, the sins which will be sure to 
curse our children, than by all the measures of relief they can reach. 
The sage contemplates the probabilities of the future, and endeavors to 
prepare for them. The fool lives in the present, with a selfish regard for 
himself alone : he drinks his wine to excess, regardless that his offspring 
must pay to Nature his debts in pain, blindness, general infirmity, and 
shortened life. A debauch is such, whatever form it may take. No one 
disputes that excessive guzzling is dissipation. Over-sleep, over-exer- 
cise, anything which exceeds the limits nature has fixed, and which does 
not give to employment the variety that charms and rests, is debilitating, 
and in so far adds a burden to those who come after us. The overtaxing 
of any organ makes it tired—a street synonym for drunk. Our moralists 
inveigh against intoxication by drugs, and yet often encourage that of 
exhaustion, probably not realizing one to be as bad in its effects as the 
other. How often does one see this individual at his work, giving testi- 
mony against excesses, while himself exhibits the pallor and exhaustion 
of late hours, hard work, and mental anxiety, the result of which is felt 
by the child born of his wearied body. He forgets this possibility, and 
that the Book from which he often gets his inspiration says, “ The sins 
of the fathers shall be visited upon the children, even unto the third and 
fourth generations.” Others, with this example, are inclined to act in 
the same manner. The children of these individuals begin the work of 
life handicapped, and their school life at a very early age. They must 
contend with the offspring of more vigorous parents, and to keep abreast 
must make greater effort. The working organs are forced to labor beyond 
that which allows of health, and structure change follows. The bow 
is never unbent, and it breaks. With longer persistence come greater DETERIORATION OF VISION IN SCHOOL CHILDREN. 
5 
changes and increased disqualification, which in turn are handed down 
to their own children, who then have the burdens transmitted by the 
father and the grandfather. As living means struggling, there is rarely 
an opportunity to retrace our footsteps ; therefore we must go on, and, 
moving on, struggle at a greater disadvantage with each succeeding gen- 
eration, so the end of such a family can be easily predicted, because the 
evil influence accumulates by geometrical progression. 
What is said of a family is true also of a race, except that the causes 
are in greater variety and intensity, and require a longer time, though the 
ultimate conclusion must be the same. Let the organ of the body which 
shows this tendency to depreciation be what it may, the best method of 
procedure is that of prevention. The ills which our bodies sutler were 
probably not existent at first, but are the outcome of a long series of in- 
dulgences by our fathers. We should hold them responsible for them, 
and ourselves accountable for any addition to them which may be man- 
ifested in our children. We should not be profligate in study, more than 
in other things. It is selfish to ourselves to enjoy our patrimony, to spend 
it all, and then to propagate children who will inherit from us nothing 
but ills. 
Though myopia may not exist in a given instance, the tendency may be 
inherited ; and if any ancestor has had near vision, the precautions against 
it should be increased. We have here to discuss school work as a prob- 
able cause in the production and increase of myopia, and the best means 
to prevent or lessen it, if possible. 
A small proportion of very young children in this country have a high 
degree of myopia, which is inherited, and these must be excluded from 
the discussion. 
It is not infrequent that the individual begins as a hvperope, the refrac- 
tion increasing to emmetropia (or normal refraction), and myopia, pro- 
gressive myopia. The statistics, which are large enough for conclusions, 
show, in our own and in foreign schools, a gradual increase in the per- 
centage of myopia from the lowest to the highest classes. The persistent 
use of the eyes at short range upon objects improperly illuminated, or for 
other reason insufficiently distinct, are believed to be the prominent fac- 
tors in its production. 
Dobrolowsky, in examining the children of the Ural high school, finds 
myopia infrequent—12 per cent, of the whole. These children live 
much out of doors, and their high animal spirits no doubt so much 
diminish their taste for mental work, that they do less of it than many 
others. 
Compare the above with what follows : Durr reports, that among the 
scholars of the II Lyceum, Hanover, in the lowest class, there are 15 per 
cent, near sight, and 94 per cent, in the highest, with a mean of 37.7 per 
cent. In the lowest class there was 81 per cent, of hyperopia, allowing 
only four per cent, for normal refraction. 
Reich found, in a girls’ school, 12 per cent, myopia in the lowest class 
and 53 per cent, in the highest, with an average of 33 per cent. 6 
DETERIORA TION OF VISION IN SCHOOL CHILDREN. 
Dunnert examined 1,133 pupils of Hyde Park schools: 76 per cent, 
were normal; 12 per cent, of the rest were hyperopic, 8 per cent, my- 
opic, and four per cent, miscellaneous. Only 18 per cent, under ten 
years had eye-trouble. Among those over fifteen years emmetropia was 
exceptional. Myopia increased from J per cent, between 5 and 10 
years, to JO per cent, between 15 and 20 years,—ten times. 
1Zehender, in his examinations, found nearly 11 per cent, myopic in 
the sixth or youngest class; in the fifth class, 16 per cent. ; fourth, 
per cent. ; third, per cent. ; in the second, 33J/3 per cent. ; and in 
the first, 41.38 per cent. ;—making an average of about 28.6 per cent. 
2Agnew examined 1,479 students. The ratio of myopia increased with 
the grade of the school, as in the previous statements reaching an aver- 
age of 28.8 per cent., nearly corresponding with the report of Zehender. 
In the district schools 10 per cent, were myopic ; in the normal high 
schools it reached 16 per cent. ; in the intermediate school, 14 per cent. 
In the New York college, Introductory class, the myopia was 29 per 
cent. ; in the Freshman class, 40 per cent. ; in the Junior, 56 per cent. ; 
and in the Senior, 37 per cent. At the Polytechnic Institute, Brooklyn, 
the myopia was 10 per cent, in the academic and 28 per cent, in the col- 
legiate departments. 
1Cohn, among 9,344 pupils, found the ratio of near vision to increase 
from the lowest to the highest class. In the sixth class the per-centage 
was 22 ; in the fifth, 27 ; fourth, 36 ; third, 46 ; second, 55 ; and in the 
first, 58 ;—making an average of the whole nearly 39 per cent. Among 
1,004 myopes, only 28, or 2.7 per cent., had a myopic father or mother. 
These figures are not all, but they are sufficient to show the tendency 
of the eyes doing the necessary work at school to be in the direction of 
increased refraction. 
A variety of measures, somewhat conflicting in certain respects, have 
been suggested for the purpose of preventing or limiting as much as 
possible the changes in refractive power. 3 Von Reuss claims that in 
early life the curvature of the cornea is greater, and that it lessens until 
the seventh year; that after the twelfth year the curvature again in- 
creases. The child is sent to school at a very early age (sometimes at 
four years in Germany, and at five or six years in America), when the 
tissues are forming, and are more susceptible, because of their pliability, 
to outside influences than they would be a few years later. His school 
days cover the period of second dentition, at which time the nutrition of 
the region of the trigeminus is much disturbed. His eyes are not yet 
accustomed to forced labor, and every deleterious circumstance makes 
the most of its opportunity. Constant labor, for from four to six hours a 
day, at close objects, often in themselves indistinct, with poor or badly 
regulated illumination and ventilation, enforced tiresome position, an 
existing slight error of refraction uncorrected, are some of the deleterious 
circumstances. 
1 Rostock Gazette, February, 1880. 
2 New York Med. Record, 1877, x'j, P- 34. 
3 A. f. O. Bd. xxvij. DETERIORATION OF VISION IN SCHOOL CHILDREN 
7 
Weber, in his report on the higher schools of Darmstadt, recommends 
that the light should come from a point as high as the heads of the pupils 
standing up ; that the benches should vary in size with that of the pupil ; 
that the work should not be continued for more than forty-five minutes 
at a time, fifteen minutes being given to exercise ; that the teachers be 
required to see that the work he held fifteen inches from the face ; that a 
special physician be appointed, with authority to enforce these require- 
ments. 
1 Derby suggests that each pupil be tested every six months by the 
teacher, that a very early knowledge may be had of the condition, in 
order that he may be treated, and progressive myopia avoided. In my 
opinion, it will be better if children are not permitted to attend the pub- 
lic schools until the age of second dentition is past, as the rapid progress 
their more matured minds will make will compensate for the time appar- 
ently lost, while they will gain in bodily vigor, and the eyes will be in a 
more settled condition, structurally and functionally. Objection is made 
by good2 authority to all work requiring close vision for young children, 
giving as a reason that they often leave the kindergartens myopic. 
Hasket Derby’s views, with regard to the examination of the eyes 
every six months, are good. The teacher might easily test the distant 
vision when the child enters the school ; then once in six months, and 
the record would be useful to the child and to school statistics. Becom- 
ing a part of the school history, it would show the progress of each indi- 
vidual, as well as the changes from class to class. 
The character of the materials used in the school-room has been dis- 
cussed with some freedom, and with varying conclusions. Malarewsky 
commended to the Russian Society of Hygiene white letters upon a black 
background. Cobn prefers the use of white slates, as they do not reflect, 
and the characters made upon them can be seen farther. Horner advises 
that ink and paper be substituted for slate and pencil. 
The effect of the various methods of writing has been studied, and 
with not greater unanimity of opinion as to what is important, or the 
kind of characters and the background which are most conservative. 
‘Berlin thinks slanting penmanship is the best method, the angle of the 
down-stroke with the perpendicular line being about 350 to 40° ; that the 
vertical system requires more muscular exertion of the arm, and forces 
an oblique position upon the child. Schubert opposes the slanting sys- 
tem of penmanship in schools, because he thinks the difference in dis- 
tance of the point of fixation of the two eyes might produce anisometropia, 
squint, loss of binocular vision, and loss of visual power, by causing un- 
equal accommodation. 
Manz, of Freiburg, objects to inclined writing, for the reason that it 
may assist in the causation of myopia by the unnatural attitude of the 
head. Ellinger thinks the inclined method favors myopia. Konigshofer 
iBoston Med. & Surg. Journal, June, 1880. 
‘Berlin and Rembold,—“ The influence of writing on the eyes, and the attitude of children.” 
*Archiv. fur Ophth., vol. xxvij, p. 259, and Ref. to Heidelburg Ophth. Soc., 1882. 8 
DETERIORATION OF VISION IN SCHOOL CHILDREN. 
does not agree with Berlin. He thinks the direction of the writing is. 
not important; that the laws of the movements of the eyes act very 
slightly during writing; that the attitude is controlled by the desire for 
ease of the hand. 
It occurs to me that the greatest danger is not to be found in the origi- 
nal work done by the pupil, as in writing on a slate or blackboard, but 
it exists in the effort he makes to get at the thoughts of others as expressed 
in print, keeping his eyes fixed upon the same character of type for a 
long time without relaxation. Much more, in my judgment, is to be 
feared from the glazed paper, the type, unvarying in size and color, of 
the school text-books, read by bad light, with the body wearied by the 
overtaxing incident to our hot-house method of education, which so often 
unfits its victims for success in anything in after life, than from any 
method of penmanship whatever. Less mental work, more mental and 
physical recreation, with some variety in the images upon which the 
eyes are fixed, and in the distance of such images from the eyes, will do 
much to obstruct the progress of the affection under discussion. 
I would suggest, in conclusion, that in the arrangement of our school- 
books we should endeavor to follow the teachings of Nature, who offers 
us, instead of plain surfaces and flat objects, broken surfaces and objects 
differing in color, giving change in form, distance, and color. Instead of 
a white surface with black letters, or white letters upon a black back- 
ground, it would save effort on the part of the eye if the school-books 
were made with raised or embossed letters, varying in color, printed 
upon an unglazed neutral surface. Thus direction of light would have 
less importance. 
With even surfaces, and single colored flat objects, the ciliary muscle 
is kept in tonic spasm instead of in healthful play, and, like any other 
muscle when compelled to move in a fixed direction with measured 
force and regularity, it becomes less fitted for other efforts, like the man 
who has been walking over plowed ground for a whole day, who will 
lift his feet unnecessarily high when walking upon a pavement immedi- 
ately afterwards. Thus we have myopia acquisita from setting the ciliary 
muscle for objects at a given near point for a long time, and the recti 
muscles, being required to maintain great convergence, press upon the 
bulb and lengthen its antero-posterior diameter. A plain surface gives 
the idea of fixed distance, and a great extent of snow or sand gives in 
nature the persistent color, unchanging light—intensity, and unbroken 
surface, the effects of which are so familiar to us.