THE theory that errors of refraction are due to permanent deformations of the eyeball leads naturally to the conclusion, not only that errors of refraction are permanent states, but that normal refraction is also a continuous condition. As this theory is almost universally accepted as a fact, therefore, it is not surprising to find that the normal eye is generally regarded as a perfect machine which is always in good working order. No matter whether the object regarded is strange or familiar, whether the light is good or imperfect, whether the surroundings are pleasant or disagreeable, even under conditions of nerve strain or bodily disease, the normal eye is expected to have normal refraction and normal sight all the time. It is true that the facts do not harmonize with this view, but they are conveniently attributed to the perversity of the ciliary muscle, or if that explanation will not work, ignored altogether.
When we understand, however, how the shape of the eyeball is controlled by the external muscles, and how it responds instantaneously to their action, it is easy to see that no refractive state, whether it is normal or abnormal, can be permanent. This conclusion is confirmed by the retinoscope, and I had observed the facts long before the experiments described in the preceding chapters had offered a satisfactory explanation for it. During thirty years devoted to the study of refraction, I have found few people who could maintain perfect sight for more than a few minutes at a time, even under the most favorable conditions; and often I have seen the refraction change half a dozen times or more in a second, the variations ranging all the way from twenty diopters of myopia to normal. Similarly I have found no eyes with continuous or unchanging errors of refraction, all persons with errors of refraction having, at frequent intervals during the day and night, moments of normal vision, when their myopia, hypermetropia, or astigmatism, wholly disappears. The form of the error also changes, myopia even changing into hypermetropia, and one form of astigmatism into another.
Of twenty thousand school children examined in one year, more than half had normal eyes, with sight which was perfect at times; but not one of them had perfect sight in each eye at all times of the day. Their sight might be good in the morning and imperfect in the afternoon, or imperfect in the morning and perfect in the afternoon. Many children could read one Snellen test card: with perfect sight, while unable to see a different one perfectly. Many could also read some letters of the alphabet perfectly, while unable to distinguish other letters of the same size under similar conditions. The degree of this imperfect sight varied within wide limits, from one-third to one-tenth, or less. Its duration was also variable. Under some conditions it might continue for only a few minutes, or less; under others it might prevent the subject from seeing the blackboard for days, weeks, or even longer. Frequently all the pupils in a classroom were affected to this extent.
Among babies a similar condition was noted. Most investigators have found babies hypermetropic. A few have found them myopic. My own observations indicate that the refraction of infants is continually changing. One child was examined under atropine on four successive days, beginning two hours after birth. A three per cent solution of atropine was instilled into both eyes, the pupil was dilated to the maximum, and other physiological symptoms of the use of atropine were noted. The first examination showed a condition of mixed astigmatism. On the second day there was compound hypermetropic astigmatism, and on the third compound myopic astigmatism. On the fourth one eye was normal and the other showed simple myopia. Similar variations were noted in many other cases.
What is true of children and infants is equally true of adults of all ages. Persons over seventy years of age have suffered losses of vision of variable degree and intensity, and in such cases the retinoscope always indicated an error of refraction. A man eighty years old, with normal eyes and ordinarily normal sight, had periods of imperfect sight which would last from a few minutes to half an hour or longer. Retinoscopy at such times always indicated myopia of four diopters or more.
During sleep the refractive condition of the eye is rarely, if ever, normal. Persons whose refraction is normal when they are awake will produce myopia, hypermetropia and astigmatism when they are asleep, or, if they have errors of refraction when they are awake, they will be increased during sleep. This is why people waken in the morning with eyes more tired than at any other time, or even with severe headaches. When the subject is under ether or chloroform, or unconscious from any other cause, errors of refraction are also produced or increased.
When the eye regards an unfamiliar object an error of refraction is always produced. Hence the proverbial fatigue caused by viewing pictures, or other objects, in a museum. Children with normal eyes who can read perfectly small letters a quarter of an inch high at ten feet always have trouble in reading strange writing on the blackboard, although the letters may be two inches high. A strange map, or any map, has the same effect. I have never seen a child, or a teacher, who could look at a map at the distance without becoming nearsighted. German type has been accused of being responsible for much of the poor sight once supposed to be peculiarly a German malady; but if a German child attempts to read Roman print, it will at once become temporarily hypermetropic. German print, or Greek or Chinese characters, will have the same effect on a child, or other person, accustomed to Roman letters. Cohn repudiated the idea that German lettering was trying to the eyes (see note 1). On the contrary, he always found it “pleasant, after a long reading of the monotonous Roman print, to return ‘to our beloved German.”‘ Because the German characters were more familiar to him than any others he found them restful to his eyes. “Use,” as he truly observed, “has much to do with the matter.” Children learning to read, write, draw, or sew, always suffer from defective vision, because of the unfamiliarity of the lines or objects with which they are working.
A sudden exposure to strong light, or rapid or sudden changes of light, are likely to produce imperfect sight in the normal eye, continuing in some cases for weeks and months (see Chapter XVII).
Noise is also a frequent cause of defective vision in the normal eye. All persons see imperfectly when they hear an unexpected loud noise. Familiar sounds do not lower the vision, but unfamiliar ones always do. Country children from quiet schools may suffer from defective vision for a long time after moving to a noisy city. In school they cannot do well with their work, because their sight is impaired. It is, of course, a gross injustice for teachers and others to scold, punish, or humiliate such children.
Under conditions of mental or physical discomfort, such as pain, cough, fever, discomfort from heat or cold, depression, anger, or anxiety, errors of refraction are always produced in the normal eye, or increased in the eye in which they already exist.
The variability of the refraction of the eye is responsible for many otherwise unaccountable accidents. When people are struck down in the street by automobiles, or trolley cars, it is often due to the fact that they were suffering from temporary loss of sight. Collisions on railroads or at sea, disasters in military operations, aviation accidents, etc., often occur because some responsible person suffered temporary loss of sight.
To this cause must also be ascribed, in a large degree, the confusion which every student of the subject has noted in the statistics which have been collected regarding the occurrence of errors of refraction. So far as I am aware it has never been taken into account by any investigator of the subject; yet the result in any such investigation must be largely determined by the conditions under which it is made. It is possible to take the best eyes in the world and test them so that the subject will not be able to get into the Army. Again, the test may be so made that eyes which are apparently much below normal at the beginning, may in the few minutes required for the test, acquire normal vision and become able to read the test card perfectly.