MYOPIA PREVENTION BY TEACHERS.
By W. H. BATES, M.D.,
Myopia with elongation of the eyeball is incurable. It is usually acquired during school life. Acute myopia, spasm of the accommodation, or functional myopia is an early stage of incurable myopia. The cause of myopia is an effort to see distant objects.
Corroboration: 1. Myopic refraction has always been produced in man and the lower animal when regarding unfamiliar distant objects which required an effort. 2. Myopia was prevented in the public schools of Grand Forks, N. D., for eight years by methods which prevented an effort to see distant objects. 3. Myopia was always benefited by treatment suggested by the cause. 4. The cause suggested a method for the experimental production of myopia in rabbits, dogs, and cats. 5. Physicians, teachers, and others interested have investigated and confirmed these facts. 6. It should be emphasized that there is but one cause of myopia, an effort to see distant objects. There is no other cause.
Near use of the eyes is not a cause of myopia. By the aid of simultaneous retinoscopy, it was always demonstrated that an effort to see near objects lessened myopic refraction or produced hypermetropic refraction.
Prevention of diseases is usually suggested by the cause. When the cause is known, prevention may be successful, but when the cause is not known prevention is uncertain. For example: Yellow fever, twenty five years ago, was not prevented by quarantine, disinfection, or other methods until the cause was discovered, the infected mosquito. By removing the cause, yellow fever has been eliminated form Havana and Panama.
Likewise, previous efforts to prevent myopia have failed because the cause was not known. It was erroneously believed that when school children regarded, or made an effort to see, distant objects, that the eyes were at rest or that accommodation or myopic refraction did not occur. Simultaneous retinoscopy disproved this assumption. It has been repeatedly demonstrated with the aid of the retinoscope that all school children with normal eyes when regarding unfamiliar writing or figures on the blackboard, distant maps, diagrams, or pictures had myopic refraction. It was quite otherwise when they regarded a familiar distant object. The retinoscope used at the same time indicated no myopic refraction.
The Snellen test card, while being of use for testing the acuity of vision, was found also during the past ten years to be the best distant object for exercises in distant vision. It should be memorized and thus made a familiar distant object. After its daily use for half a minute or longer myopia was prevented; and, in addition the vision of many pupils with defective sight was improved for an unfamiliar Snellen card, for writing and figures on the blackboard, and for other distant objects. Furthermore, near vision was benefited by the use of the Snellen card. Many pupils stated that they could study their lessons with less or no discomfort.
Myopia prevention was introduced in Public Schools Nos. 6, 183, and 186 of New York city January, 1912; later, Public Schools Nos. 46 and 43 tested the method.
A Snellen test card was placed permanently where all the pupils could see it from their seats. Daily the teachers recommended all the children to silently read the card with each eye separately, covering the other eye with the palm of the hand in such a way as to avoid pressure on the eyeball.
Records were made with the same card or with an unfamiliar card for testing the vision. This matter is discussed below. Each line of the Snellen card is designated by a number which indicates the feet that the line should be read by the normal eye. Records of the vision are written in the form of a fraction: The numerator of the fraction represents the distance in feet of the pupil from the card while the denominator denotes the number which designates the lowest line read. Records were usually submitted as follows:
|Public School No. 46, W. A. Boylan, principal.|
|E. 6A., J. Hiesel. T., 27|
|February, 1913.||April, 1913.||June, 1913.|
|John D. ......||20/100||20/50||20/50||20/40||20/20||20/20|
|Sanford G. ...||20/50||27/70||20/30||20/40||20/15||20/20|
Public School No. 6.
The first school authorized to try the method was Public School No. 6. Miss K. D. Blake, principal. In November, 1911, she permitted me to test and record the vision of 115 pupils. Later, she informed me that a medical inspector examined the same children and found my record correct.
In one class room she observed me relieve the defective vision of five pupils in fifteen minutes with the aid of the Snellen card. She was told that the teachers were able to improve the vision of all pupils in the same simple way and thus, logically, prevent myopia.
The memorized Snellen test card aroused much scepticism. Its value for testing the vision was questioned by most teachers. To settle the matter, Miss Blake had the vision of 1.500 pupils tested, January, 1912, with a memorized Snellen card by the teachers. Soon afterward, the vision of the same 1.500 pupils was tested with an unfamiliar Snellen card. The tabulated records of both tests were sent at his request to Gustave Straubemüller, associate superintendent, with the following conclusion: "The figures submitted are interesting and it would seem as though Doctor Bates had, to a certain extent, proved his point." The test was repeated in June, 1913, and the memorized Snellen card was again found satisfactory for testing the vision. Objective tests were conclusive, and demonstrated the interesting fact that school children did not deceive themselves or others, when their vision was tested with a memorized Snellen card. When a pupil said he was reading the memorized Snellen card with normal vision, the retinoscope used at the same time, indicated no manifest error of refraction; the eye was adjusted for normal vision.
The reliability of the teachers' records of the vision was investigated by Miss Blake. At her request the health department sent a medical inspector who also tested the vision of the pupils and told Miss Blake that the records of the teachers were reliable and correct.
One teacher taught her pupils to test and record the vision of their own eyes daily. They convinced me that they did both correctly.
The pupils learned the value of the Snellen card for improving the sight; and many obtained by their own efforts normal vision without glasses. This fact was observed also in other schools. One teacher asked me to investigate a boy who said his vision had improved from 20/200 to 20/30. I found the boy had normal vision, but I had trouble to convince a sceptical teacher that the pupil was able to see perfectly.
It is suggested that a monitor be appointed in each class to improve the vision of all pupils with defective sight.
Miss Blake deserves much credit for her intelligent methods of investigation of myopia prevention by teachers. When Dr. C. Ward Crampton, the director of physical training, investigated the method and visited her school early in 1913, he told her to remove the Snellen cards and discontinue her efforts to prevent myopia. This command was so manifestly unfair to the method at the time that she refused to comply without an order from her superiors. I cannot express in words my gratitude to her for her championship of the method. The records she submitted in June, 1913, of pupils also tested in October, 1912, were the best of all. She desires to continue the method and is now willing for me to use the ophthalmoscope to obtain more scientific facts for the benefit of school children.
Finally, when the question was asked her, "Do you believe that the Snellen card was a benefit?" she replied: "Yes, I do; but I do not understand it."
Public School No. 183.
In the Fall of 1911, Miss A. J. Farley, principal Public School No. 183, became interested in myopia prevention and consented to try the methods in her school. In the beginning most of the teachers neglected to use the method. This was true of other schools.
Miss C. V. Dillon, ungraded class, was the first New York city teacher to submit accurate records of the vision of school children before and after the use of the method of myopia prevention. She recorded the vision of all her pupils, October, 1911, and again, December, 1911. During this time the Snellen card was not used and the vision of no child improved. After the Snellen card was placed permanently in the class room, January, 1912, she gave her pupils daily exercises in distant vision with its aid. She noted a prompt improvement in the sight. The vision of the same children was recorded, March, 1912, and June, 1912, using an unfamiliar Snellen card for testing the sight. The records indicated that the vision of all was improved. She continued the use of the Snellen card, daily, during the school years, 1912-1913.
June 27, 1913, Miss Dillon was asked her opinion of the method. She answered that he results continued good, and offered her recent records as additional evidence in favor of the method. At one time during the year the health department prescribed glasses for all her pupils. As long as a child wore glasses she refrained from giving it exercises in distant vision with the memorized Snellen card, by order from the principal; but, after a child appeared in school without glasses she believed she was privileged to benefit it with the Snellen card. She described in detail the results obtained. Some pupils, even with glasses, were unable to see the writing on the blackboard from their seats. In a short time their vision improved without glasses, so that they had no further difficulty with their sight. Others complained of eye pain or had trouble in seeing to read. They held their books close, about six inches from the face. The use of the distant Snellen card gave them relief and they later read without effort or discomfort at a comfortable distance, about twelve inches. She discarded glasses and relieved her own eyes by the use of the Snellen card. I believe that if all teachers were as enthusiastic or as conscientious as Miss Dillon, no child would acquire myopia while attending school.
The success of Miss Dillon with the method encouraged Miss Farley, the principal, to persuade other teachers to try it.
October, 1912, Miss Knauff, 2A, reported the vision of six pupils with defective sight did not improve after one week when the Snellen card was not used. After the method was employed daily for one week, all had improved, and five of the six defectives obtained normal vision without glasses. Similar results were obtained by four other teachers. Miss Farley asked the health department for an investigation to determine the reliability of the teacher's records. The medical inspector sent tested the vision of the same pupils and told Miss Farley that the teachers tested and recorded the vision correctly. Relapses occurred after the use of the Snellen card was stopped.
In January, 1913, Miss Farley had the vision of all the pupils recorded on the school card which each child receives on entering school, a method of keeping records which I recommend. All the teachers began the use of the method and their records were tabulated in June 1913.
Miss Farley is to be commended for her thorough investigation of the method. She told me that she was convinced of its value and was willing to continue. She will permit the use of the ophthalmoscope.
Public School No. 186.
J. T. Nicholson, principal, Public School No. 186, had defective vision without his glasses. With the aid of a memorized Snellen card his vision became normal in a few minutes. In this way he learned something of the value of the Snellen card. After his personal experience with its benefits he more readily believed in the probability that the teachers by improving the vision of school children would prevent myopia. His teachers did not all record the vision until October, 1912.
On April 14, 1913, all the Snellen cards were removed and not replaced until June 16, 1913. The records of his teachers indicated a less number benefited than in Public Schools Nos. 6 and 183, where the Snellen card were in use for a longer time.
Miss Marry E. Sinnott, assistant principal, called my attention to the fact that the more experienced or better teachers benefited the vision of a larger number of children than did the teachers of less ability. Mr. Nicholson believed that the vision of the pupils in his school was benefited by the Snellen card. He is now willing that I use the ophthalmoscope for more accurate investigation.
C. B. Jameson, principal, Public School No. 43, in March, 1913, introduced the method in his school on the recommendation of J. T. Nicholson, principal, Public School No. 186. Four teachers tested the vision, made the records, and used the Snellen card for myopia prevention without my supervision. It was only through the courtesy of J. T. Nicholson that I learned the facts. In June, 1913, Dr, John P. Conroy, district superintendent, kindly loaned me the records of the vision of the pupils tested, in March and again in June, 1913, by the teachers of Public School No. 43. The results were good. It seems probable that the method could be introduced successfully in other schools without my supervision.
W. A. Boylan, principal, Public School No. 46, introduced the Snellen cards in 1912. He has incurable myopia acquired in school. With the aid of the Snellen card, I improved his vision, without his glasses, fivefold in ten minutes. He has cooperated with me as much as he could, but only two teachers submitted records, June, 1913.
Miss J. Hiesel, E6A, submitted the best records which I have seen in ten years. Of twenty-seven defectives all were improved and twenty-five obtained normal vision in both eyes. She described how one incorrigible, and one truant, became good students after their eyes were relieved of pain and discomfort by the use of the Snellen card. I attended one of her daily exercises in distant vision with the aid of the Snellen card, witnessed the enthusiasm of all the pupils in the game, and learned much of the possibilities of the method for improving defective vision and preventing myopia.
Table 1.— Summary of the records of the vision of the pupils made by the teachers of five New York city schools.
Note that in Public School No. 186 the Snellen cards were removed from all the class rooms April 14, 1913, and replaced June 16, 1913,
|T., Pupils tested twice .........................................||5700|
|D., Pupils with defective sight at the first examination ........||3299||58|
|I., Defectives improved in one or both eyes .....................||2026||61|
|N., Both eyes of defectives found normal at the second test .....||1023||31|
|W., One or both eyes of T. found worse at the second test .......||359||6|
|R., Dates when the two tests of the vision were recorded.|
|Table No. 1.|
|P. S.||Number.||Number.||Per cent.||Number.||Per cent.||Number.||Per cent.||Number.||Per cent.||Dates of tests.||Number.|
|6||925||474||51||390||82||303||64||83||9||October, 1912, June, 1913||37|
|183||635||333||52||250||75||168||50||38||6||January, 1913, June, 1913||21|
|186||1.939||1.223||63||669||55||220||18||69||4||October, 1912, January, 1913||49|
|186||2.007||1.139||57||620||54||276||24||164||8||February, 1913, June, 1913||57|
|43||131||85||65||61||72||30||30||5||4||March, 1913, June, 1913||4|
|45||63||45||71||36||80||26||58||0||0||March, 1913, June, 1913||2|
|Totals||5.700||3.299||Av. 58||2.026||Av. 61||1.023||Av. 31||359||Av. 6||121|
Table 2.—Summary of the records of the vision of the pupils made by those teachers of five New York city schools who recorded that the vision of no pupil became worse.
In Public School No. 186.
28 teachers recorded no pupils worse in January, 1913; 13 teachers recorded none worse in June, 1913; and 10 teachers recorded no pupils with vision worse both in January and June, 1913.
|T., Pupils tested twice .........................................||1351|
|D., Pupils with defective sight at the first examination ........||845||62|
|I., Defectives improved in one or both eyes .....................||605||71|
|N., Both eyes of defectives found normal at the second test .....||334||40|
|W., One or both eyes of T. found worse at the second test .......||0|
|R., Dates when the two tests of the vision were recorded.|
|Table No. 2.|
|P. S.||Number.||Number.||Per cent.||Number.||Per cent.||Number.||Per cent.||W.||Dates of tests.||Number.|
|6||244||135||55||129||95||111||82||0||October, 1912, June, 1913||11|
|183||198||85||43||81||95||62||73||0||January, 1913, June, 1913||7|
|186||414||318||77||170||53||52||16||0||October, 1912, January, 1913||10|
|186||365||213||58||152||71||64||30||0||February, 1913, June, 1913||10|
|43||67||49||73||37||75||19||39||0||Marsh, 1913, June, 1913||2|
|46||63||45||71||36||80||26||58||0||March, 1913, June, 1913||2|
|Totals||1.351||845||Av. 62||605||Av. 71||334||Av. 40||0||32|
All the principals and all the teachers, in the beginning, were sceptical. After they used the method and investigated the results in the class rooms, they became convinced that the use of the memorized Snellen card improved the vision of the school children. They do not understand it.
1. All investigators, I believe, have published that previous efforts to lessen defective vision or prevent myopia in schools have failed.
2. One hundred and twenty one teachers in the schools of New York city have lessened appreciably the number of pupils with defective vision. Note in the accompanying records that over 1000 pupils with defective sight obtained normal vision in both eyes.
3. Thirty-two teachers prevented the vision of all their pupils from becoming worse.
4. Myopia was prevented by teachers.
938 St Nicholas Avenue.