Ch 1: Introductory

Most writers on ophthalmology appear to believe that the last word about problems of refraction has been spoken, and from their viewpoint the last word is a very depressing one. Practically everyone in these days suffers from some form of refractive error. Yet we are told that for these ills, which are not only so inconvenient, but often so distressing and dangerous, there is not only no cure, and no palliatives save those optic crutches known as eyeglasses, but, under modern conditions of life, practically no prevention.

It is a well known fact that the human body is not a perfect mechanism. Nature, in the evolution of the human tenement, has been guilty of some maladjustments. She has left, for instance, some troublesome bits of scaffolding, like the vermiform appendix, behind. But nowhere is she supposed to have blundered so badly as in the construction of the eye. With one accord ophthalmologists tell us that the visual organ of man was never intended for the uses to which it is now put. Eons before there were any schools or printing presses, electric lights or moving pictures, its evolution was complete. In those days it served the needs of the human animal perfectly. Man was a hunter, a herdsman, a farmer, a fighter. He needed, we are told, mainly distant vision; and since the eye at rest is adjusted for distant vision, sight is supposed to have been ordinarily as passive as the perception of sound, requiring no muscular action whatever. Near vision, it is assumed, was the exception, necessitating a muscular adjustment of such short duration that it was accomplished without placing any appreciable burden upon the mechanism of accommodation. The fact that primitive woman was a seamstress, an embroiderer, a weaver, an artist in all sorts of fine and beautiful work, appears to have been generally forgotten. Yet women living under primitive conditions have just as good eyesight as the men.

When man learned how to communicate his thoughts to others by means of written and printed forms, there came some undeniably new demands upon the eye, affecting at first only a few people, but gradually including more and more, until now, in the more advanced countries, the great mass of the population is subjected to their influence. A few hundred years ago even princes were not taught to read and write. Now we compel everyone to go to school, whether he wishes to or not, even the babies being sent to kindergarten. A generation or so ago books were scarce and expensive. To-day, by means of libraries of all sorts, stationary and traveling, they have been brought within the reach of practically everyone. The modern newspaper, with its endless columns of badly printed reading matter, was made possible only by the discovery of the art of manufacturing paper from wood, which is a-thing of yesterday. The tallow candle has been but lately displaced by the various forms of artificial lighting, which tempt most of us to prolong our vocations and avocations into hours when primitive man was forced to rest, and within the last couple of decades has come the moving picture to complete the supposedly destructive process.

Was it reasonable to expect that Nature should have provided for all these developments, and produced an organ that could respond to the new demands? It is the accepted belief of ophthalmology to-day that she could not and did not,(1) and that, while the processes of civilization depend upon the sense of sight more than upon any other, the visual organ is but imperfectly fitted for its tasks.

There are a great number of facts which seem to justify this conclusion. While primitive man appears to have suffered little from defects of vision, it is safe to say that of persons over twenty-one living under civilized conditions nine out of every ten have imperfect sight, and as the age increases the proportion increases, until at forty it is almost impossible to find a person free from visual defects. Voluminous statistics are available to prove these assertions, but the visual standards of the modern army (2) are all the evidence that is required.

In Germany, Austria, France and Italy the- vision with glasses determines acceptance or rejection for military service, and in all these countries more than six diopters (3) of myopia are allowed, although a person so handicapped cannot, without glasses, see anything clearly at more than six inches from his eyes. In the German Army a recruit for general service is required – or was required under the former government – to have a corrected vision of 6/12 in one eye. That is, he must be able to read with this eye at six metres the line normally read at twelve metres. In other words, he is considered fit for military service if the vision of one eye can be brought up to one-half normal with glasses. The vision in the other eye may be minimal, end in the Landsturm one eye may be blind. Incongruous as the eyeglass seems upon the soldier, military authorities upon the European continent have come to the conclusion that a man with 6/12 vision wearing glasses is more serviceable than a man with 6/24 vision (one-quarter normal) without them.

In Great Britain it was formerly uncorrected vision that determined acceptance or rejection for military service. This was probably due to the fact that previous to the recent war the British Army was used chiefly for foreign service, at such distances from its base that there might have been difficulty in providing glasses. The standard at the beginning of the war was 6/24 (uncorrected) for the better eye and 6/60 (uncorrected) for the poorer, which was required to be the left. Later, owing to the difficulty of securing enough men with even this moderate degree of visual acuity, recruits were accepted whose vision in the right eye could be brought up to 6/12 by correction, provided the vision of one eye was 6/24 without correction.(4)

Up to 1908 the United States required normal vision in recruits for its military service. In that year Bannister and Shaw made some experiments from which they concluded that a perfectly sharp image of the target was not necessary for good shooting, and that, therefore, a visual acuity of 20/40 (the equivalent in feet of 6/12 in metres), or even 20/70, in the aiming eye only, was sufficient to make an efficient soldier. This conclusion was not accepted without protest, but normal vision had become so rare that it probably seemed to those in authority that there was no use insisting upon it; and the visual standard for admission to the Army was accordingly lowered to 20/40 for the better eye and 20/100 for the poorer, while it was further provided that a recruit might be accepted when unable with the better eye to read all the letters on the 20/40 line, provided he could read some of the letters on the 20/30 line.(5)

In the first enrollment of troops for the European war it is a matter of common knowledge that these very low standards were found to be too high and were interpreted with great liberality. Later they were lowered so that men might be “unconditionally accepted for general military service” with a vision of 20/100 in each eye without glasses, provided that the sight of one eye could be brought up to 20/40 with glasses, while for limited service 20/200 in each eye was sufficient, provided the vision of one eye might be brought up to 20/40 with glasses.(6) Yet 21.68 per cent of all rejections in the first draft, 13 per cent more than for any other single cause, were for eye defects,<(7) while under the revised standards these defects still constituted one of three leading causes of rejection. They were responsible for 10.65 per cent of the rejections, while defects of the bones and joints and of the heart and bloodvessels ran, respectively, about two and two and a half per cent higher.(8)

For more than a hundred years the medical profession has been seeking for some method of checking the ravages of civilization upon the human eye. The Germans, to whom the matter was one of vital military importance, have spent millions of dollars in carrying out the suggestions of experts, but without avail; and it is now admitted by most students of the subject that the methods which were once confidently advocated as reliable safeguards for the eyesight of our children – have accomplished little or nothing. Some take a more cheerful view of the matter, but their conclusions are hardly borne out by the army standards just quoted.

For the prevailing method of treatment, by means of compensating lenses, very little was ever claimed except that these contrivances neutralized the effects of the various conditions for which they were prescribed, as a crutch enables a lame man to walk. It has also been believed that they sometimes checked the progress of these conditions; but every ophthalmologist now knows that their usefulness for this purpose, if any, is very limited. In the case of myopia(9) (shortsight), Dr. Sidler-Huguenin of Zurich, in a striking paper recently published,(10) expresses the opinion that glasses and all methods now at our command are “of but little avail” in preventing either the progress of the error of refraction, or the development of the very serious complications with which it is often associated.

These conclusions are based on the study of thousands of cases in Dr. Huguenin’s private practice and in the clinic of the University of Zurich, and regarding one group of patients, persons connected with the local educational institutions, he states that the failure took place in spite of the fact that they followed his instructions for years “with the greatest energy and pertinacity,” sometimes even changing their professions.

I have been studying the refraction of the human eye for more than thirty years, and my observations fully confirm the foregoing conclusions as to the uselessness of all the methods heretofore employed for the prevention and treatment of errors of refraction. I was very early led to suspect, however, that the problem was by no means an unsolvable one

Every ophthalmologist of any experience knows that the theory of the incurability of errors of refraction does not fit the observed facts. Not infrequently such cases recover spontaneously, or change from one form to another. It has long been the custom either to ignore these troublesome facts, or to explain them away, and fortunately for those who consider it necessary to bolster up the old theories at all costs, the role attributed to the lens in accommodation offers, in the majority of cases, a plausible method of explanation. According to this theory, which most of us learned at school, the eye changes its focus for vision at different distances by altering the curvature of the lens; and in seeking for an explanation for the inconstancy of the theoretically constant error of refraction the theorists hit upon the very ingenious idea of attributing to the lens a capacity for changing its curvature, not only for the purpose of normal accommodation, but to cover up or to produce accommodative errors. In hypermetropia1(11) – commonly but improperly called farsight, although the patient with such a defect can see clearly neither at the distance nor the nearpoint – the eyeball is too short from the front backward, and all rays of light, both the convergent ones coming from near objects, and the parallel ones coming from distant objects, are focussed behind the retina, instead of upon it. In myopia it is too long, and while the divergent rays from near objects come to a point upon the retina, the parallel ones from distant objects do not reach it. Both these conditions are supposed to be permanent, the one congenital, the other acquired. When, therefore, persons who at one time appear to have hypermetropia, or myopia, appear at other times not to have them, or to have them in lesser degrees, it is not permissible to suppose that there has been a change in the shape of the eyeball. Therefore, in the case of the disappearance or lessening of hypermetropia, we are asked to believe that the eye, in the act of vision, both at the near-point and at the distance, increases the curvature of the lens sufficiently to compensate, in whole or in part, for the flatness of the eyeball. In myopia, on the contrary, we are told that the eye actually goes out of its way to produce the condition, or to make an existing condition worse. In other words, the so-called “ciliary muscle,” believed to control the shape of the lens, is credited with a capacity for getting into a more or less continuous state of contraction, thus keeping the lens continuously in a state of convexity which, according to the theory, it ought to assume only for vision at the nearpoint. These curious performances may seem unnatural to the lay mind; but ophthalmologists believe the tendency to indulge in them to be so ingrained in the constitution of the organ of vision that, in the fitting of glasses, it is customary to instill atropine – the “drops” with which everyone who has ever visited an oculist is familiar – into the eye, for the purpose of paralyzing the ciliary muscle and thus, by preventing any change of curvature in the lens, bringing out “latent hypermetropia” and getting rid of “apparent myopia.”

The interference of the lens, however, is believed to account for only moderate degrees of variation in errors of refraction, and that only during the earlier years of life. For the higher ones, or those that occur after fortyfive years of age, when the lens is supposed to have lost its elasticity to a greater or less degree, no plausible explanation has ever been devised. The disappearance of astigmatism,(12) or changes in its character, present an even more baffling problem. Due in most cases to an unsymmetrical change in the curvature of the cornea, and resulting in failure to bring the light rays to a focus at any point, the eye is supposed to possess only a limited power of overcoming this condition; and yet astigmatism comes and goes with as much facility as do other errors of refraction. It is well known, too, that it can be produced voluntarily. Some persons can produce as much as three diopters. I myself can produce one and a half.

Examining 30,000 pairs of eyes a year at the New York Eye and Ear Infirmary and other institutions, I observed many cases in which errors of refraction either recovered spontaneously, or changed their form, and I was unable either to ignore them, or to satisfy myself with the orthodox explanations, even where such explanations were available. It seemed to me that if a statement is a truth it must always be a truth. There can be no exceptions. If errors of refraction are incurable, they should not recover, or change their form, spontaneously.

In the course of time I discovered that myopia and hypermetropia, like astigmatism, could be produced at will; that myopia was not, as we have so long believed, associated with the use of the eyes at the near-point, but with a strain to see distant objects, strain at the near-point being associated with hypermetropia; that no error of refraction was ever a constant condition; and that the lower degrees of refractive error were curable, while higher degrees could be improved.

In seeking for light upon these problems I examined tens of thousands of eyes, and the more facts I accumulated the more difficult it became to reconcile them with the accepted views. Finally, about half a dozen years ago, I undertook a series of observations upon the eyes of human beings and the lower animals the results of which convinced both myself and others that the lens is not a factor in accommodation, and that the adjustment necessary for vision at different distances is affected in the eye, precisely as it is in the camera, by a change in the length of the organ, this alteration being brought about by the action of the muscles on the outside of the globe. Equally convincing was the demonstration that errors of refraction, including presbyopia, are due, not to an organic change in the shape of the eyeball, or in the constitution of the lens, but to a functional and therefore curable derangement in the action of the extrinsic muscles.

In making these statements I am well aware that I am controverting the practically undisputed teaching of ophthalmological science for the better part of a century; but I have been driven to the conclusions which they embody by the facts, and that so slowly that I am now surprised at my own blindness. At the time I was improving high degrees of myopia; but I wanted to be conservative, and I differentiated between functional myopia, which I was able to cure, or improve, and organic myopia, which, in deference to the orthodox tradition, I accepted as incurable.

CITATIONS

1. The unnatural strain of accommodating the eyes to close work (for which they were not intended) leads to myopia in a large proportion of growing children – Rosenau Preventive Medicine and Hygiene, third edition, 1917, p. 1093.

The compulsion of fate as well as an error of evolution has brought it about that the unaided eye must persistently struggle against the astonishing difficulties and errors inevitable in its structure function and circumstance – Gould The Cause, Nature and Consequences of Eyestrain, Pop Sci Monthly, Dec., 1905.

With the invention of writing and then with the invention of the printing-press a new element was introduced, and one evidently not provided for by the process of evolution The human eye which had been evolved for distant vision is being forced to perform a new part, one for which it had not been evolved, and for which it is poorly adapted The difficulty is being daily augmented – Scott The Sacrifice of the Eyes of School Children, Pop Sci Monthly, Oct., 1907

2. Ford Details of Military Medical Administration published with the approval of the Surgeon General, U.S. Army, second revised edition, 1918, pp. 498-499.

3. A diopter is the focussing power necessary to bring parallel rays to a focus at one metre.

4. Tr. Ophth. Soc. U. Kingdom, vol. xxxviii, 1918, pp. 130-131.

5. Harvard Manual of Military Hygiene for the Military Services of the United States, published under the authority and with the approval of the Surgeon General, U. S. Army third revised edition, 1917, p. 195.

6. Standards of Physical Examination for the Use of Local Boards, District Boards, and Medical Advisory Boards under the Selective Service Regulations, issued through the office of the Provost Marshal General, 1918.

7. Report of the Provost Marshal General to the Secretary of War on the First Draft under the Selective Service Act, 1917.

8. Second Report of the Provost Marshal General to the Secretary of War on the Operations of the Selective Service System to December 20, 1918.

9. From the Greek myein, to close, and ops, the eye, literally a condition in which the subject closes the eye, or blinks.

10. Archiv f Augenh, vol. lxxix, 1915, translated in Arch. Ophth., vol. xlv, No. 6, Nov., 1916.

11. From the Greek hyper, over, rnetrors, measure, and ops, the eye.

12. From the Greek a, without, and stigma, a point