ua Lite dat^s^ows when this volume was taken. To relfewiSteSfeoMbMmr Jhe call No. and give to HOME USE RULES. All Books subJeU to Re All books must be re- turned at end of college year for inspection and repairs. Students must re- turn all books' before leaviiK town, 0£5cers should arrange for the return of books wanted during their absence from town. Books-' needed by more than one person are held on the reserve list. Volumes of periodi- cals and of pamphlets, — ^^^^ are held in the hbrary ^MUvtAi 5? ""'^ ^ possible, (ibUiUCI ^o"" special purposes they are given out for a limited time. Borrowers should „ iiot use their library 'j' privileges for the bene- fit of other persons. Books of kjeda value, afld gift book when the giver wish It, are not allowed circulate. a . Readers are aska A.'L'l &3 FQ '"^°'"* ^ '^ases of h< ' ' — ^^ . marked or m utilaU "^ °»t deface books by marks and writing. " \'> /^Vcfft ^le S^uM&A ^im^Umek EXAMINATIONS OF THE EYES OF COLLEGE STUDENTS. M. DRESBACH, M.D., ^THAcX, N. Y. From the Department of Physical Culture, Cornell University. -• REPKINTBD FKOM THB MEDICAL RECORD August 3, 1912 WILLIAM WOOD & COMPANY NEW YOKK \ Cornell University Library LB3498.C81 D77 Examinations of the eyes of college stud olin 3 1924 030 605 178 fe % 3J^ A ■^l "53 5 EXAMINATIONS OF THE EYES OF COL- LEGE STUDENTS. By M. PRESBACH, M.D., ITHACA, N. Y. FROM THE DEPARTMENT OF PHYSICAL CULTURE, CORNELL UNIVERSITY. It has become an almost universal practice in the colleges and universities of this country to require a physical examination of entering students, and many institutions require a prescribed course in physical culture extending over one or more years. In making such requirements the schools assume the function of guarding the health of the young men and women during a part or the whole of their study years. In this respect our educatipnal sys- tem is unique; but, as might be supposed, the atti- tude taken towards this subject is by no means the sarne in all institutions. This fact is showii by the varying extent to which emphasis is laid upon ath- letic sports at different schools, and by the ex- tremes in the methods employed in examining the students for physical defects. An inquiry into these methods shows that they range from superficial in- spections, by untrained persons in charge, to rigid tests and thorough examinjitions by specialists with a medical training. Until very recently but little careful attention has been given to ocular defects (and still less heed has been paid to ^r, nose, throat, and kidney conditions), it having been deemed sjiffi- Copyright, William Wood & Company. cient to know whether or not the student was sound in heart and lungs, or whether or not he met cer- tain so-called standard tests of measurement and strength. In other words, the physical examina- tions have often been far from complete, some very important organs having been omitted. It is one of these neglected organs that I wish to consider in this paper, which is based upon facts revealed by the examination of the eyes of a large and repre- sentative body of students. The problem of how to inspect a large body of entering students in the shortest time compatible with efficiency is a difficult one. For the good of the students it is desirable that they should have the complete examination as soon after entrance as possible, preferably within three months after en- rollment. Where a thousand or more individuals must be examined, it means, of course, that either a few examiners will work many hours a day for several weeks or months, or that a larger examining force must be secured to complete the work within the desired length of time. At this institution it has been necessary during the past two years to examine from 1400 to 1600 men students and from 200 to 300 women students on entrance. This work has been done by two examiners for the men and one for the women, but during the present year a third physician has been secured for the men in order that certain features of the work might be extended and improved. The object of the examination. — While my prin- cipal duty was to make the eye, ear, nose, and throat examinations, the general object of the en- tire physical ii^pection, as conducted at this insti- tution, may be stated as follows: (i) To detect those students who have physical defects or states of health of such a nature that immediate medical attention is advisable, as, for example, in the case of those with cardiac and pulmonary lesions, ocular troubles, infectious diseases, etc. (2) To pick out those with minor defects and faulty development, in order that corrective exercises may be begun. (3) To determine the fitness of candidates for spe- cial athletics to go into contests, and to advise such candidates about their physical condition from time to time. (4) To tabulate vital statistics which may be of value. Objects, methods, cmd limitation of the examina- tions for visual defects. — ^As stated above, it is de- sirable to have these examinations made as Soon as possible after the student enters college, in Order that he may have the benefit of the information ob- tained. The practice here is to require the student to report at once to the physical director after regis- tration in order to make'i,n appointment for the complete physical examination. In this inspection approximately one-half the time is devoted to the eye, ear, nose, and throat tests. The eye-tests have included the following steps, each eye being taken separately: (i) Inspection for external signs of inflammation or other evidence of disease. (2) De- termination of visual acuity by means of test let- ters. (3) Examination for . refractive errors, myopia, hyperopia, and astigmatism. (4) Exam- ination for muscular imbalance. (5) Testing of the power of accommodation. (6) felicitation of symptoms of eyestrain. In steps 3, 4, 5, and 6, we made use of the trial lenses,* and took into account errors of 0.25 D. or more. Heterpphoria of less than 5 degrees was not *The trial frame used was devised by Dr. George M. Gould. It is accurate and permits one to work rapidly. k'ecorded. By means of well directed questions the history of each student was obtained and noted, and if there were objective or subjective signs of eye- strain; if glasses worn were poorly adjusted or without correction for astigmatism; if the last ex- amination had been made without a cycloplegic or "drops," or if it had been made more than two yfears before the student registered for examina- tion at this institution; if lenses worn had been or- dered by some optician, optometrist, or "eyesight specialist;" in short, if any suspicion arose that ex- amination by a competent physicain was advisable, the student was so informed. He was also re- (|uested to report later as to what he had done about the matter. In carrying on these tests there have been certain limitations which should be mentioned. First, no cycloplegic was used (a§ is done at the University 01 I'ennsyhania). While this restriction made it impossible to diagnose accurately the nature, amount, etc., of the refractive error in some cases, it was always f^ossible to decide whether or not a more thorough examination was needed. All cases of doubtful diagnosis were appropriately marked and most of such students were sent to an oculist at once. These cases are included among the "un- classified" in the table below. Secondly, there was the time-limit. The average time igiven to each stu- dent was frdm lo to 15 minutes. In some instances this was increased and in particular cases a special appointment was made for more extended testing. Thirdly, the ophthalmoscope was not often used. However, all cases in which inspection of the fundus was ifldicated were sent to the oculist. In spite of these limitations, the results have been very encouraging and have shown that it is possible for one or two men to examine rapidly a large number of students with a degree of success that justifies the time, labor, and expense devoted to the work. In the tables below are collected certain data which have been accumulated during the past three years. Many points of clinical and scientific inter- est have been observed but they could not be brought within the scope, of this paper. Thus, to mention only one, the subject of muscular imbalance has not been discussed in any way though it is impor- tant. The data given are not presented because they offer anything new, but because they help to emphasize the too greatly neglected factor of eye- strain in its relation to health and happiness, and therefore to efficiency of work. The statistics have been classified in a way that is purely personal with the writer. An attempt has been made to present them in a form which is clear and which will make them available for comparison with others of the kind. The separation of the students into two groups — those wearing glasses and those not wear- ing them — has no special significance. It simply serves to indicate the number who, for one reason 'or another, have found it necessary to pay some attention to their eyes. How well this duty has been performed is another matter which must be determined in each separate case. The data are given as percentages, and a word of explanation as to how the percentages are calculated is neces- sary. The table is divided into sixteen subdivisions in which will be found the numerical values upon which the calculations are based. Thus, for exam- ple, the table shows (in division 3) that there were 2 16 1 students who had hyperopic astigmatism, com- pound or simple, and who did not wear glasses. Of these 2161, 89 per cent, had normal visual acuity. Division 6 shows that 320 (wearing glasses) had myopic astigmatism, compound or simple, and that 50 per cent, of these had a reduction of acuity to between 20/40 and 20/100 (that is, to between 1/2 and 1/5 normal), etc. Another point that will 'be noted is that the classi- fication of refractive errors is limited practically to a division into hyperopic and myopic types, though a few figures are given relating to asym- metric and mixed astigmatism, to unequal visual acuity of the two eyes, and to some other matters. This arrangement has been unavoidable for the rea- TABLE OF ST.ATISTICS. From Examination of 3326 Regularly Enrolled Men. The asterisk printed after the numbers in the right hand column indicates that glasses were worn. Astigmatism — simple and compound. ^ (1) 2484 (2) 842* / Per cent. with hyperopic Per cent. with hyperopic type 87 type 50 Per cent, with myopic type. . 8 Per cent, with myopic type. .39 Unclassified (including Unclassified cases 8 mixed astig., doubtful (as in division 1) diagnoses) 3.0 Astigmatism (hyperopic type). (3) 2161 (4) 427* \y Per cent, with acuity normal Acuity normal in both eyes, in both eyes 89 60 per cent. Acuity subnormal in both Acuity subnormal in both eyes, eyes 5 32 percent. Acuity in left eye normal but Acuity normal in one eye, sub- subnormal in right 4 normal in other.. 8 per cent. Vice versa 2 Acuity reduced to 20/40 or Acuity reduced to 20/40 or less in one or both eyes... 19 less in one or both eyes...l0t Astigmatism (myopic type). (S) 222 "(6) 320" Acuity 20/40-20/100 both eyes. Acuity 20/40-20/100 bgth eyes, 34 per cent. 50 per cent. Acuity 20/40 or less one eye, Acuity 20/40 or less in one eye, 13 percent. „ 6 percent. Acuity 20/100 or less in one or Acuity 20/100 or less in one or both eyes 4 per cent. lioth eves 2-3 per cent. (7) Asymmetric and mixed. (8) Anisometropia. tPercentage calculated from those with subnormal acuity. 6 Percentage asymmetric axes in hyperopic eyes (yr. 1910) with normal vision 40 Percentage of, axes at or near 180° in asymmetric class... SO Mixed' astigmatism, with v. — 20/40 or less — approximately 2 per cent of those with sub- normal vision. Total percentage with unequal visual acuity in the two eyes due to errors of refraction, in- cluding both myopic and hy- peropic types, amounting to 0.25 D. or more (.no .glasses worn) 10 per cent. Emmetropia. Total number in whom no re- fractive error below 0.25 ■ D could be demonstrated 18 or 20 (10) Simple hyperopia and my- opia (glasses not worn), 2.0 per cent. Myopia of 5 D or more — a half- dozen cases. Proportion of hyperopes to my- opes among those who have subnormal vision : Hyperopes slightly in excess. Hyperopia and Myopia. (11) Simple hyperopia and my- tJpia (glasses worn) 3 per cent. Myopia of low degree, 88 per cent. Myopia of medium degree, 6 per cent. Myopia of high degree, 12 per cent. Cases with one eye myopic and one. hyperopic 30 Miscellaneous Data. ^ (12) Percentage of 3326 students wearing glasses 27 Percentage wearing glasses constantly 3 or 4 Percentage of 842 wearing glasses needing change of lenses 40 Number blind or practically so in one eye 15 Number totally blind in both eyes (year 1911-12) 6 Percentage with weak accom- modation (no glasses worn) 4 Total per cent, with subnormal acuity 30 Percentage of students who have never consulted a specialist 40 *'^ Percentage with symptoms of eye strain (no glasses worn), approximately 25 ty^ Showing symptoms and glasses worn 22 Muscular imbalance of 5 de- grees or more (no glasses worn) 2 per cent Nystagmus 1 case Diplopia Several (13) 205 Vision normal both eyes, 70 per cent. Z' Hyperopic astigmatism, 88 per cent. Myopic astigmatism. . 7 per cent. Unclassified astigmatism Women Students (360 examinations). (14) 1S5* 43 per cent. Hyperopic astigmatism, 40 per cent. Myopic astigmatism . . 50 per cent. Unclassified 10 per cent 3 per cent. Miscellaneous Data. (15) Percentage of those not wearmg glasses who showed symptoms of eye strain 36 per cent. Showing symptoms and glasses worn 26 per cent Women who had never consulted a specialist 40 per cent. Asymmetric astigmatism, vision normal (no glasses), 42 per cent. Anisometropia (no glasses), 12 per cent. Number of serious cases of Simple hyperopia and myopia eyestrain 28 (no glasses) 2 per cent. (16) Short Course Students (agricultural). t Total 1091. Hyperopic astigmatism, Wearing glasses 12 per cent. 77 per cent. Glasses wrong 40 per cent. Myopic astigmatism. .17 per cent. Showing symptoms (no glasses Unclassihed astigmatism, worn) .13 per cent. 6 per cent. Marked anisometropia but no Never examined by oculist, symptoms 7 per cent. 50 per cent. fMainly from rural districts, and attending courses for 12 weeks only. son that, under the restrictions mentioned above, refraction work must necessarily be only qualita- tive. An attempt has been made in each case to determine the manifest myopia or hyperopia, and to locate as closely as possible the axes of astig- matism. The data given on this last point are pre- sented as approximate figures only. Discussion of some phases of the subject of eye- strain suggested by the above statistics. — The im- portance of visual defects in school life is now pretty generally recognized, though there is still a woeful lack of intelligent cooperation among par- ents, teachers, and physicians in dealing with chil- dren handicapped by malfunctioning eyes. This condition of affairs exists in spite of the fact that attention was long ago called to the prevalence of eye defects in school children by the papers of Erismann^ and Conrad^ (1874) in Europe, and by Vance= and Loring* (1877), Risley= (1878, 1881), and RandalP (1882) in this country. The results of these earlier writers have been abundantly con- firmed by many ophthalmologists, both in America and abroad. That many children do not have their eyes examined at the critical time is well known.', *, °, " This neglect has been strikingly shown by our statistics, too, from which it appears that from 30 to 40 per cent, of the students have 8 never consulted an oculist.* Among these young people have been found many with deplorable con- ditions of the eyes, conditions which are frequently due entirely to neglect or to ignorant treatment. This point will be considered later. There are many phases of the subject of eyestrain suggested by the above tables, but only a few can be considered here. In the first 'place it should be stated that we have used the generally accepted standard of visual acuity, viz., the Snellen test let- ters at a distance of twenty feet. Those who could read the letters subtending an angle of 5 minutes were set down as having an angle of normal acuity, expressed as 20/20. If we had held the men up to the higher standard of 20/15, ^^ some of the best oculists are now doing, there would have been found a much larger number with subnormal eyesight. With the standard used here 30 per cent, of all stu- dents had subnormal acuity in one or both eyes. The next fact to be noted is the high percentage of hyperopic errors. The figures given are in fair accord with those of Posey and McKenzie" and with those of Zimmermann,^^ which, excepting the work of Derby^' and Randall,'^* are about the only published statistics relating to eye defects among college students. The fact that the majority of eyes are hyperopic would seem to be too well known to deserve mention, but it is a fact which, after all, cannot be overemphasized, particularly in explain- ing to students and non-medical people generally the causes of eyestrain. When we consider that ♦GuHck, in the Medical Record, Vol. 70, page 12, says: "Not less than 30 per cent, of all children in our (New York City) elementary schools are suffering from ocular defects demanding correction, and not less than 17 per cent, have ocular defects so severe as to be a se- rious menace to their progress." the hyperopic eye is relieved of work only a moment at a time during the whole of the waking period, and that when focussed upon near objects, as in reading or doing any close work, the strain put upon such an eye is tremendously increased, the wonder is that poor vision and resultant ill health are not more prevalent. It may be stated that in a large body of individuals as strong and healthy as the majority of American college students are, at least ID per cent, will have subnormal sharpness of vision as a result of the strain. induced by hyperopia and particularly by hyperopic astigmatism. The importance of astigmatism was first clearly demonstrated by the epoch-making work of Bon- ders/* and since his time volumes have been written upon the subject. It has been shown that the ma- jority of eyes are astigmatic to a greater or less degree. Gould, basing his statement on the exam- ination of 15,000 or more pairs of eyes, says that lit- tle or much of this form of ametropia is present in 99 per cent, of eyes. There is no doubt that astig- matism holds a commanding place as a pathogenetic factor.^*' ^^' ^^' ^®' ^'^- ^1 It is not the purpose of this paper to discuss this subject, however. It is permissible, though, to plead for a recognition of the importance of astigmatism as a cause of eyestrain and many forms of ill health, and to call attention to the fact that it is a condition which is often overlooked, because with the ordinary trial frame and lenses, and with some of the methods general employed, it is impossible to measure low refractive errors with any degree of accuracy. It should be appreciated, too, that often in normal visual acuteness, astigmatism, pernicious in almost every case, cannot be found, much less measured, without the use of drops or, in technical language. without cycloplegia. The inaccurate work done in ignorance of, and in open defiance of, such well- established facts is accountable for many failures to relieve distress caused by eyes laboring under the handicap of refractive errors. In this connection may be mentioned other im- portant facts. It is well to remember that hyperopic eyes, which are known to be so prone to set up dis- turbances of one sort and another, may, in the be- ginning at least, cause no other result than gradu- ally failing vision. In many instances we have noted marked reduction in acuity without the individual having suspected it. The explanation seems to be that the brain in such cases early fails to secure binocular vision, in that it neglects the impressions from one eye. In this way the individual may es- cape the sufferings of eyestrain, because of mon- ocular vision, which, in the course of time, may result in permanent and severe injury to the ne- glected eye as a consequence of disuse. This means, of course, a great handicap; and there is the added danger of total blindness, or near approach to it, in case the better eye be injured by accident, of which there is no small risk among those students who work in chemical laboratories, machine shops, and the like. Generally, these eyes which are going out of function by reason of the disuse which the re- fractive error entails may be saved in these young people by proper glasses. Another phase of the results of hyperopia, and of the astis'matism nearly always associated with it, is the matter of reflex disturbances met with in so called nervous individuals. These are persons with nervous systems of such a nature that persistent strain of any kind easily disturbs the equilibrium of the nervous organization, with the result that symp- toms of the disturbance develop in one direction or another. Often these patients either fall into the hands of unscrupulous quacks who style themselves ■'specialists," or else wander into some sort of a sanatorium where a vague diagnosis is made and some such loosely used term as "neurasthenia" set, down as the difficulty. They may be then treated by every therapeutic measure except accurately fit- ted gjasses. In many instances a pair of scientific spectacles, properly worn, is all that is needed to restore the individual to health. We do not often meet with such cases in a body of college students, but we do encounter not a few students who have constitutions which can but poorly stand the pres- sure of a four-year course of study plus the extra strain which even a low grade of refractive error necessitates. Allusion to this type usually calls to mind the poorly nourished, anemic person, more frequently a woman, who has difficulty in doing mental work and who often complains of being nervous. But these are not the only sufferers from eyestrain. There is another type altogether different, but not so frequently met with, represented by the big, healthy boy, whose strength and virility enable him to take part in such vigorous sports as football, hockey, etc., but whose life is often made miserable by severe headaches, and occasionally by insomnia, photophobia (hypersensitiveness to light), or indi- gestion. Most frequently the trouble first mani- fests itself as sleepiness on attempting to study, or as conjunctivitis or inflammation of the eyelids, etc. The symptoms are relieved to a large extent by strenuous exercise but often this fails to mitigate the discomfort which follows close work with the eyes. On examination, hyperopic astigmatism is usually found to be the cause of the difficulty, which disappears under proper treatment with glasses. Myopia is also such a cpmmon defect, and people generally are so familiar with the prevalence of "near sight," that an additional word on the subject would seem quite unnecessary. The intention here is not to discuss myopia but to speak of the way in which it is, unfortunately, so" frequently treated. Myopia may or may not be a very dangerous dis- ease. Some oculists would say that it is always serious, inasmuch as it distinctly limits the field of vision. Certainly in progressive myopia we have a dangerous condition of the eye, and one which de- mands the most careful treatment. It is pitiftil to see how some cases of near sight are handled, or even allowed to go unattended altogether. I re- member one poor boy who came for examination about a month after entering college. He could . not see a single letter on the test chart. It was quickly discovered that he had a myopia of about 2.50 D, with oblique axes of astigmatism. He had never had his eyes examined and was not aware that his vision was poor. He only knew that he did not see as well as some people. As the examination proceeded he became ill at ease, and when asked if the tests bothered him, he said that they made him feel "sick." The next moment he fell over in a faint. He was placed under the care of a good oculist, who had considerable trouble in carrying his examinations of the boy to completion at first, because of the nervous condition of the patient. Eventually the young man was eflabled to continue his four-year course. How he could have done this without glasses is difficult to imagine. Many other instances of the neglect of eyes could be given, as could also many examples of the bungling attempts 13 to relieve near sight. Many times have students come up for examination, which revealed that they had well advanced compound myopic astigmatism that had been entirely overlooked, or, what is worse, disregarded, by some one who had simply given plain concave lenses to improve vision. At this point it should be stated that a fearful amount of botch work is done, both in the refraction of eyes and in the supplying and adjusting of glasses, with the result that there is almost as much glass strain as eyestrain." We find refraction being done without cycloplegia when "drops" are absolute- ly essential for de.termining the true statical errors ; patients are not required to return for confirmatory examinations and inspection of their glasses; they are not told the importance of keeping their glasses properly adjusted and cleaned ; their eye- lashes are allowed to rub against the lenses, and foolish notions about spectacles are permitted to_ in- terfere with the oculist's work. The most astonish- ing thing is the employment of incorrect test lenses, of'^ which there must be an amazing number in the land, because it has been found that even the best op- tical firms have put out test cases, pronounced per- fect, which in some instances have proved to contain manv wrongly marked lenses, particularly among the cylinders. One such "perfect" set contained nearly 17 per cent, of incorrect cylinders.^' In addition, the opticians who grind the lenses for the patient fre- quently do miserable work. They interchange the lenses, or reverse them, center them improperly, lo- cate the axes wrongly, and adjust the frames badly. It is no wonder that people often fail to obtain relief, become discouraged, and eventually resort to almost anything in their despair. Here a word may be said about the unfortunate M and vicious legislative errors which have been made in this country. Our laws have made it possible for people to do refraction work without having any knowledge of the eye and its diseases, and par- ticularly without the slightest idea of the close re- lation of ocular conditions to pathological states of other organs,^* and thus it comes about 'that many persons, ignorant of the complexity of the eye, and of the skill and knowledge required to treat its dis- eases, generally due to refractive errors, place them- selves in the hands of "eyesight specialists" and persons who make a great point about testing the eyes without the use of "poison drops." The re- sult is that miserable refraction work is done and serious lesions of the eye are overlooked. Not in- frequently these ocular disturbances are due to dis- ease processes located primarily in other organs, and thus the diagnosis of dangerous maladies is delayed. Twenty-six states in this country encourage work to be done in this way by licensing people to prac- tise "optometry"^' '^ without a medical education and with no more experience than a few weeks' or months' training in elementary optics. And what is more to our shame, we are not yet rid of quacks who do not refract but who prey upon ignorant peo- ple by offering to cure for stated sums all sorts of serious ocular diseases by "magic eye treatment" of one kind and another. These are conditions which seem impossible when we think of how we pride ourselves on our twentieth century methods of education. They are serious matters which call for intelligent and careful consideration. Allusion has already been made to the import- ance of astigmatism and of unequal visual acuity of the two eyes, or anisometropia, as this condition is technically called. The two subjects may well 15 be given brief consideration together because the latter condition, which is much more common than usually supposed, is so frequently caused by the former. It is important to note that the percent- age of eyes having unlike axes of corneal curvature is high. (We should remember that it is such eyes that most frequently cause trouble.) Further, it is interesting to observe that quite a number wrill have the axes exactly reversed in the two eyes, that is, the planes of abnormal curvature will be at 90 and 180 degrees respectively, for example. All pos- sible deviations from the vertical axis, 90, are found, and the percentage of odd axes is large. When we remember that, in addition to this, the amount of curvature defect in the two eyes may differ greatly, thus producing the condition called anisometropia, we can easily see how difficult it is, in many cases, to obtain binocular vision, and how great the corresponding strain upon the nervous and visual mechanisms may be. Dr. George M. Gould has emphasized the fact that an ametropic de- fect which throws the focus only 1/300 of an inch away from the point where it ought to be may inter- fere distinctly with the sharpness of vision. In the majority of ametropic eyes the misplacing of the im- age is more than 1/300 of an inch. Furthermore, be- cause of the fact that the refractive power of the two eyes is generally not the same, the size, shape, and position of the two images are such that it is diffi- cult, or impossible, to fuse the two impressions into one mental picture. It comes about that with this effort the coincident strain aggravates the defect, and sooner or later reflex? functional disturbances arise, such as headache, nervousness, indigestion, and many other symptoms which presage the ap- proach of ill health. 16 The author^^ just quoted, who has done so much in this country to emphasize the importance of ex- act correction of astigmatism and anisometropia, is of the opinion that these two conditions are the great causes of eyestrain, and secondarily of a large number of systemic diseases. The beginning of ill health is certainly often to be traced to reflex disturbances of ocular origin. One of the most in- teresting and valuable things that this writer has pointed out is the connection between right and lef t- handedness and right and left-eyedness, and the important practical bearing this relation may have in the treatment of visual defects.^*, ^° It is a sub- ject incompletely investigated as yet, but it is doubt- less of great significance. We have not appreciated fully the harm done to left-handed children in at- lemptmg to make, them right handed, nor the dam- age that may follow when a left-eyed individual is compelled by an ocular defect to be right-eyed, or a right-eyed one to be left-eyed. In this connec- tion it is important to recall that not every person with bad eyes has general symptoms. We have found many instances of astonishing degrees of ametropia, both of hyperopic and myopic varieties, with absolutely no symptoms of eyestrain. It may be said that it sometimes happens that no symptoms develop in these subjects until some unskilled per- son attempts to render the eyes emmetropic by glasses. It is clear that the danger of badly im- paired vision in these insidious cases is great. In completing this division of the subject brief allusion will be made to the relation of college work to increase of eye defects. We have not had oppor- tunity here to follow up this subject, but we have undoubted proof that many eyes fail during the college course. It seems to be most noticeable here 17 among architectural and engineering students, and is doubtless due to the great amount of drawing required of these men. One important factor in the production of failing eyes is poor artificial light and poor distribution of such light. There are thousands of students working many hours at night, and even many hours in daytime, with glar- ing electric hghts shining directly into their faces. Lights are generally arranged in libraries, reading rooms, and laboratories without much reference to the comfort of those who must use thern. There are great public and university libraries where hun- di-eds of eyes are treated daily to the most un- hvgienic distribution of light imaginable. When shall we learn the injustice of this sort of thing? Another cause of failing students' eyes is the use of skull caps, which furnish no protection from bright sunlight. 'J"o compel boys, especially those with sensitive retinas, to wear these caps in obedi- ence ^G college customs is a vicious practice. More sensible caps could just as well serve to distinguish freshmen and sophomores, etc., and a vast amount of eye trouble would be prevented. Eye-tests at various colleges and universities. — In the introduction it was stated that the thorough- ne-a of the physical examinations at various institu- tions varies greatly. Bearing upon this point, I have collected statistics by sending a questionaire, with especial reference to eye examinations, to about 150 institutions of .learning in this country. Replies were received from 105, and to those who were kind enough to answer the questions mv thanks are due. Twenty-two of the institutions from which replies were received do not require eye examinations. Some of these institutions do not consider such work practical, others are in- different, while a few have a genuine interest and enthusiasm in the work. Among those which do not require these examinations were three promi- nent schools of technology, two well known schools for women, and one great university, all having a large number of students. In most instances where the tests are made they are made by the physical director in charge, who is often not a physician, in only about a dozen institutions is an eye spe- cialist engaged. Eighteen replies indicated that this sort of work was done with care and interest, to a degree that an effort had been made to get at im- portant facts regarding the influence of eyestrain upon the college work and the health of the stu- dents. From the replies of these few schools it could be seen that the tests were being made care- fully and that results were being recorded and studied. The writer was interested to know what estimate had been made elsewhere of the number of students needing glasses. In seventeen col- leges and universities the estimates ranged from 10 to nearly loo per cent., the latter figure being that from a government institution, where, it is stated, practically every student wears glasses be- fore he finishes his course. The average of the percentages quoted is 34, which is probably not far from the truth. Taking the regularly enrolled men at this institution, the lowest estimate I can put upon the proportion whose eyes' are defective enough to justify the wearing of glasses is 40 per cent. Among the women it will be higher by at least 5 per cent. In one well known college for women where careful examinations of the eyes are made, the physician in charge estimates that from 50 to 60 per cent, of the students wear glasses or heed them. 10 From the facts given in this paper it may be seen that ocular defects must be an important factor in determining the efHciency of the work done by college students (witness the case cited). It is also apparent that we are sorely in need of means for examining more thoroughly the eyes of the public school children. Rough tests for myopia alone are all that are usually attempted, so that many cases of astigmatism and hyperopia are over- looked. These are often the most serious cases. In spite of the agitation which has been made, eye strain is a matter which has been too greatly neg- lected. There is no doubt that many a worthy student has been dropped in disgrace from his col- lege when he might have completed his course with credit had his eyes permitted him to study as he desired to do. It is important to recognize, there- fore, that eyestrain is not a fad and not simply a pet subject for eye specialists to harp about. Defective vision is a real condition afflicting most seriously the lives and careers of great numbers of people, and among our college students it is one of the most important factors which have to do with progress and success. I wish to acknowledge mv indebtedness to Drs. L. Coville, A. C. Durand, George M. Gould, J. S. Kirkendall, S. A. Mumford, and R. C. Wilson of Ithaca for assistance in collecting data for this paper. By the help of these gentlement the labor connected with the work has been made a pleasure. REFERENCES. I. Erismann : "Ein Beitrag zur Entwicklungsgeschichte der . Myopie," Archiv. fur Ophthalmologie, 1874, XVII, i. page I. 2. Conrad, M. : "Die Refraktion von 3036 augen -von Schulkindern," Inaugural Dissertation, Konigsberg, 1874. 2C 3. Vance, R. A.: "The Development of Myopia Among the School Children of America," Detroit Medical Journal, 1&77, page 561. 4. Loring: "Is the Human Eye Changing Its Form and Becoming Nearsighted under the Influence of Modern Edu- cation?" Medical Society, County of New York, November, 1877. 5. Risley, S. D. : "Weak Eyes in the PubUc Schools of Philadelphia," Transactions of the Medical Society of Pennsylvania, 1881. "Good Vision an Important Factor in the Educational Process," Bulletin of the American Acad- emy of Medicine, Vol. VI, No. 4. 6. Randall : "Hypermftropia in Public School Children," Medical News, 1882, XL, page 141. 7. Brav, A.: "Eye Strain Among School Children," In- ternational Clinics. Philadelphia, 20, S. I., page 149, 1910. 8. Claiborne, J. H. : "The Nervous Symptoms Produced in Children by Uncorrected Refractive and Muscular Errors," Journal of the American Medical Association, 1904, XLIII, 1754. 9. Adams, A. L. : "Subjective Symptoms of Eyestrain and Theil" Effects upon Pupils' Work," Illinois Medical Journal, 1906, X, page 581. 10. Cornell, W. S. : "Eyestrain in School Children," New York Medical Journal, 1907, LXXXIII, page ioz2. "Health and Medical Inspection of School Children," Philadelphia, 1912, page 201. 11. Journal of the American Medical Association, Vol. XLVIII, page loio, 1907. 12. Annals of Ophthalmology, October, 1905. 13. Boston Medical and Surgical Journal, XCVI, 1877. 14. Transactions of the Medical Society of Pennsylvania, Philadelphia, XVII, 1883. 15. "Astigmatismus und cylinjlrische Glaser," Berlin, 1862. 16. Pyle, W. L. : "Asthenopic Reflexes," Cohn's System of Physiologic Therapeutics, Vol. VII, page 367. 1904- 17. Dixon, L. S. : "Eyestrain," Journal of the American Medical Association, 44, II, page 1256, 1905. 18. Reber, W. : "Some Unusual Effects of Eyestrain," Opthalmoscope, London, VIII, page 880, 1910. 19. Alger, E. M. : "Reflex Disturbances Depending upon Eyestrain," Boston Medical and Surgical Journal, CLXIV, page 142, 1911- 20. Hunter, D. W. : "Some Phases of Asthenopia — A Study of Eyestrain,'' New York Medical Journal, XCIII, page 122, 191 1. 21. Pohlman, A. G. : "The Etiology of Eyestrain from a Phylogenetic and Ontogenetic Standpoint," Journal of the American Medical Association, 44, II, page 1434, ipoS- 22. Gould, G. M. : "Sixty-eight Reasons Why Glasses Did Not Give Relief," Biographic Clinics, Vol. 11 ; Ameri- can Medicine, July 4, 1903. 23. Hartshorne, Isaac : "Accurate Optics," Boston Med- ical and Surgical Journal, CLXIV, 12, page 786, 191 1. 24. Thorington, J. : "Refracting Opticians," Pennsylvania Medical Journal, 1909, XIII, page 369; Journal of the Medical Society of New Jersey, 1910-11, VII, page 403. 25. Jackson, Edward: "The Optometry Question and the Larger Issue Behind It," Journal of the American Medical Association, 1911, LVII, page 265. 26. Hall, G. C. : "The Optometry Question ; Its Relation to the General Profession and Public Health," American Practitioner and News, Louisville, XIV, page 567. 27. Gould, G. M. : Biographic Clinics, 1903-1909. "The Cause, Nature, ahd Consequences of Eyestrain," Popular Science Monthly, November, 1905. Borderland Studies, 1896, 1908. 28. "Right-eyedness and Left-eyedness," Science, New Series, XIX, page 591, 1904. 29. "Right-handedness and Left-handedness," 8vo, 1910. For more extended references and discussions bearing upon this subject and others considered in this paper see the excellent work of Professor C. Hess : "Die Anomalien der Refraktion des Auges." Graefe-Saemisch Handbuch der Gesamten Augenheilkunde, 1910. 22 A Mupokitt riejiMiLi MEDICAL RECORD A Weekly Journal of Medicine and Surgery wiuuH WOOD AHo oeuPAHr, r SSJX) Pcf Annum. PimLiBHBD AT New York Every Saturday SMeCoplnw IScw ORiaiNAL ARTICLKa. bttum lor iBi Traalmant of Cancar SfS, SR^'tolS """■" ''™* CDUntoui Tubtmilln Vacrfuttoa m ■hi Dlicntali at TutKccutoiU. Br WUIluti T BuUir. M D , ChJciio Vt*v*nilao Df Dikih OUrlni AnatliHU br Chlororonn and Eitwr By Rolxil RiyBuni, A.H.. H.D^ WBilitiicUi& ■tfJkllQD Implii. ,. \t ifi* Ultnii. Bkiud M«1MU- . ._ .1*cumni CarolnomB. Br Omx KuR, 1I,D, Bailon, Uin ccMtQU (0 Puncllonal an til* Berdnrlsnil Iniithq SurB'iT Sid IniirnBl MrdlPlnk By fohn C. ■iTiTTitKr, U.D- Pb-D., lLi>„ Baia- msrti UdL ■ . Th* Orainle Parlor In Hlah Blood Prouuri BvAlHandar Hal*. U.A^ PrImHn' M#lanp>l> ct (ria'palaio: '!>*■ aobucnl Flilulu or Rtrani tsarsoma- «iiua Ortrs- By i. N. Ho)-, M.Oi. tlonlraal, Canada ■DITOniAL*. Ceniraaictorr 'Advin* to CoupniDtlTn. 'Th* Arrtir Conttsn ........ * Tha Dani(rou> Ellwti bI Blhtr and tDITORlAb NOTIB. TIM CanMIlon or APPandlellM n To Aci-flimt (fi( Coiicaa of Labor.. ■> TM Parioa of InlKllon In TypboM Trwimini of OonMlpUlsn tar AlwU- BiDva from Ural 7'. H» N«w Tubrreulln lloaitlon* '^''^^.'.Tr'i^!?..?''** ""**"*"' ■VPhlllUe Ktrvoua Dlwaaii . ., NSWk OF THE WKCK. Acalnn Clganifoa lo HleUno— -Onu bait for tlia Blino'— TyphoU invaalN nilm ID TrtDlon — CodlBcatloD ol AmuuiIou or iw Chlcuo Holta Dcpartmcal— aiDdr of Spaaob 0*< («tP— VaMloHilan Sula Biuulnad la Chlcuo— ContadiralUm ot Hiudaotr Bacl*llH--Halia Do«Eiiri Hla VlB- llraa— PhnlrUna- Bullilinc far aavo- Und—Drunlii OoDVlawa^Tba Nloh* olaa BeniilEaiaM ....„ CO HR BSPONOENCB. Our Lotlar (rora CopanhMon >■' '•■ PHOOBEU OF MKDICAk MIKNCC. AcAonorla and Lapaniomr — Trrpilii Id iha Traatmanl at Hallnuint Tumora — VkrlEon Voliu, ThalrTraauntni Oy Uultlpla Shan InoWoBa — Artorlo- aclBrsslo— Upnr RMPIraiory OMtrue- llon and Oral Oalonnliy SuiiBcuia PoiymiviIilB—pamaaUa Pm- Uuiuai Relallan* at"6ppir^AlT\rrai3l^ - -* ■"*■- ™-«ioal» i3 of BacMrlal Dlaaoaa. BOOK REVtIWI. , Mmrtcan PraaUsa of Suratry A Com* pMta ayaiein at Iha BcTrncB and Art ol Sarnry. by nsprvunuillta Bur> ■BODi of Iha Hallwf Sul'bi and Can- uda Bdlion. joHpli l>, Drranlt U.n. and Atbart H Bmiu U.D, Com- Jnnm lluonn Fran Iicvlaad LMIilan. lib iiiuimiiBni. « UainK Full-pasa Plaiaa la TInia and UnBurl dt Orntvolbila pntliiua.' ' ' par Uaniul at Hyclana and Banliatlon. R> KMiMK RKTiirl. M.D. Pourlli B<1l- (fun. KnlarRfd and Thoroujflili !(■• virnl I'lualraird with Mngi>-ilin« EnmavlDKa. •001 KTV MEFOHTa. "■^eM •"'•tl' of !»»• lUto ol Haw Oanaral Haonna •otiwiarn Burgicai and Ognwoalagleal maoolofly a/id Tbarapautlei Amartcan Larynpol ' ' - Amtrtean Public M< I Oarmaloloalul Caiil ''(^^Jf•* Ataduny of' Madlcinai """ •MUenon Amfrlcin Tharapautlcal ■oclaty PblladalpMa County Madleal eocli^' . WIMiiUrn Surgical and aynaeolOBlcaJ Aa. *uon'"" **''^'"*™"^'"'' *ii»ii«- ' New VarMPaycniairlHiaoeiaiy":::;" eriilib MMIeai AaMciailcin; ^.:.^:" dactlon M Tropical OlHiiaa VTATE MCDICAL LICENBINQ BOAnOfc BiBta Board EuniinttlDn Quaailoo^ UbIvanlEi' or ihe Siaia ol Nn Yarii. Aniwara lo Slatt Board EiamlnailDn Quaiilona, VnlvanLiy of iha tlMM,or - SIMS Board" Eiianiiiuiian"liualtioiub ElJnaSsuta Board ot H*alih... .77. Anawrn lo SUia Doanl Biamlnallon fiu«"lon*. lllhiola OUta Board «t , Bullgtln of App'niachl'nr' Eianil'nattau' ■ - SUROICAL SUCaESTIONa. Clr^TiKlilan— Mtihoda Afalnai Pl«ai— Urcllirol Hamarrhaca— Straosulalad Homla— Haalili llvpan . 7 Oormalo-Vaneraul Don'i*— Bi DBrculoan Parllonltli—SKIn OraltV THERAPEUTIC HINTS. t Handa oi Phi— InHunk Alt'aalar AlW'au-l'WirlBMa— Pan in Oftiid- - - ■ - NEW INSTRUMENTS. ~' A Naw Blilhoaropt By Dunlas p. Panhanaw, M D., B>mnn Xtml!'' Bono Drill a By Ckrl Back. U.D., K*w rerk...i" ' HEOICAI. ITEMS. Cbniacloua nuain — Haalih IMp4na DIRECTORV OF NATIONAL AND STATE MEDICAL SOCIETIES...... JUST PUBLISHED TEXT-BOOK OF ANATOMY £y D. J. CUNXINGHAM, F:itS. TMIilD EDITION f'RorsI Octftvo, M6T pngiM: 036 Wind Engravings of which 406 are'lo two or more cotorv. Hii3Uii,$e.00iiBt; Ball Ho(occo,$T.SODet. ' URGENT SURGERY " tBy'pfiLIX LEJARS. Translated by WILLIAM S. DICKIE. PJLC.S.. FROM THK SIXTH fRENCH EDITION .TwovolnniM.Iaiieortiv^yoIjpne.'iJIpagM. iHurtTatcdby 4Jacii8ravinEa,lnblBcl