Compliments of the Author. 
SCHOOL HYGIENE IN RELATION TO ITS INFLUENCE 
UPON THE VISION OF CHILDREN, OR 
SCHOOL SANITATION. 
AN ADDRESS DELIVERED BEFORE THE MEDICAL 
ASSOCIATION OF GEORGIA, 1884. 
vX BY 
A. W. CALHOUN, M.D., PRESIDENT, 
-STEaNTA, GA. 
ATLANTA, GA. : 
JAS. P. HARRISON & CO., PRINTERS. 
1884. 
Reprint from the Transactions of the Medical Association of Georgia. President’s Address. 
DELIVERED BEFORE THE MEDICAL ASSOCIATION OF GEORGIA. 
A. W. CALHOUN, M. D., Atlanta. 
Gentlemen of The Medical Association of Georgia—Ladies and 
Gentlemen : 
It will perhaps surprise some of you that I have depart- 
ed from the usual order of addresses before this Association, 
and to some degree have been actuated by rather a selfish 
motive in the selection of a subject, for I have fallen upon 
one not only in accord with my own tastes, but one which I 
feel assured will impress each individual of this intelligent 
audience with its appropriateness, with its practical facts, 
and with its notes of timely warning. 
My subject-School Hygiene in Relation to its influence 
upon the Vision of Children, or School Sanitation—does 
not express the full scope of this discourse, but is a faint 
outline of what I shall have to say to you in the time 
allotted to me. 
Education is the preparation for the work of life, not a 
thing that is good in itself. If it has helped life to be 
healthy, happy, successful and long, then it has been good; 
if in any degree it has caused disease., unhappiness, non- 
success, then it has been bad. The medical aspects of school 
life are deservedly attracting more and more the attention of 2 
doctors in every land where education and civilization have 
made much progress. The researches of one investigator 
developed the fact that out of more than 2,300 infants ex- 
amined by him, only 122 possessed abnormal peculiarities 
of any kind, and from this fact drew the conclusion that 
children, as a rule, are physically sound when they start to 
school. That deformities of one organ or another, simple or 
serious, do exist among school children, admits of no argu- 
ment, and many of these may be reasonably attributed to 
the influences surrounding a child during its life in the 
school-room. The various parts of the organism of youth 
are easily disarranged, and if the cause operates continuous- 
ly the disarrangement is liable to become permanent. 
Before the child ever sees the inside of a school-room he 
learns many useful things—and yet this learning does not 
injure his eyes. It is a fact that children at the time of 
entering school are free from that common affection, near- 
sightedness, but almost immediately thereafter the disease 
begins to show itself. This is conclusive evidence that the 
fault to a great degree, at least, lies in the school. 
Before his school days begin, and while the child is learn- 
ing, and that too very rapidly, all the knowledge that he 
gains is real knowledge of concrete things, gained through 
the use of all his senses and all his activities by being 
brought into contact with the things about which he learns. 
He is free to sit still or to move; to fix his attention upon 
a thing as long as it interests him, and then to leave it for 
something else. But at school nearly everything is unnat- 
ural. Very often the child is seated on a hard bench, so 
high that his feet cannot touch the floor, with the back, if 
it have any, so straight that a comfortable position is im- 
possible, and the desk, if there be any, so far in front of 
him that he cannot use it without leaning forward much 3 
further than is good for either his back or his eves; and 
there with foul air to breathe, with windows improperly 
shaded, or not at all, with light coming from the front as 
often as otherwise, and with little or nothing to make the 
place look cheerful or homelike, he is confined for six hours 
a day, five days in the week, from twenty-eight to forty-five 
weeks in the year, and for as many years as his constitu- 
tion can stand such abuse, or his parents afford to send him. 
In this room he seldom comes in contact with natural 
things, or even with representations of them, excepting his 
teacher and fellow students, and they, too, are made as un- 
natural as possible. Seated on his high, hard bench, pro- 
hibited from looking to the right or left, book in hand, he 
is committing to memory the words of the author, and this 
they call getting an education. “ What’s in a name.” 
It has been truthfully said that sight is the noblest ave- 
nue of the mind, and its impairment or loss is a greater 
evil than would be that of any other bodily sense. For 
many years deterioration of the eye among pupils in public 
and private schools has been a subject of complaint and in- 
vestigation both in this country and the older portions of 
the world. This impairment of sight, this deterioration of 
the eye, is principally the immediate result of myopia, or 
near-sightedness which, in its turn, is caused by defective 
modes of education and their hurtful surroundings. 
Myopia is a disease. A near-sighted eye is not a normal 
eye. Children born in the normal state do not have near- 
sighted eyes. But what is myopia? Anatomically the dif- 
ference between a normal eye and one that is myopic, or 
near-sighted, is practically a difference in the length of the 
eye-ball. The slightest fractional increase in the length of 
the ball beyond its normal length is an increase of myopia. 
As the eye becomes elongated the retina, which receives 4 
impressions, and upon which images are formed, is thrown 
beyond the focus of the rays of light coming from a dis- 
tance. 
Very rarely before the fifth or sixth year of life does myo- 
pia make its appearance, about which time children usual- 
ly begin their attendance upon school, but from this time on, 
under certain unfavorable circumstances, the eye gradually 
elongates, reaching and remaining, perhaps, at a certain 
point of elongation, a slight or high degree, or constantly 
increasing through all the years of school life, even to the 
twenty-fifth year, and indeed in some instances, continuing 
slowly to lengthen through almost the whole of life. 
Myopia is essentially a disease of childhood, beginning 
from the sikth to the fifteenth year, just at a time when 
the body as a whole is developing most rapidly. Rarely 
does it originate after the twentieth year. When once in 
existence in a child, it is usually progressive, and therein 
lies the danger; and this fact, coupled with the fact that it 
is an incurable disease, makes it an important subject in 
connection with education, for the causes that produce the 
disease at this period of life also operate to increase it. The 
eye of a child is a plastic organ, easily changed in its shape, 
and its tissues are in a condition to be readily modified by 
the use which is made of the organ. The child goes on to 
the eighth or tenth year, perhaps a little longer, when it is 
observed that it has to hold whatever it is looking at a lit- 
tle nearer to the eye than previously, and then upon ex- 
amination, the fact is revealed that the eye is myopic or 
near-sighted. If you follow such a child up to the age of 
twenty five or thirty years, it will be found that the myopia 
has doubled, and perhaps quadrupled. 
I cannot here refrain from quoting a well known author, 
who thus writes: 5 
“ Predisposition to myopia is almost always inherited by 
at least some of the children where one parent is myopic. 
In these children myopia may often be detected, if sought 
for, at.a very early age, and is generally evident at from 
eight to twelve years of age. Once present, it tends to in- 
crease, and should be watched with care. If not existing 
at least in some degree before sixteen years of age, it is 
never developed, even by excessive use of the eyes. 
“ During the period of youth, which is usually also the 
time of closest application to study, there is a disposition 
to gradual development of the inherited myopic tendency ; 
but this may be kept in abeyance if the eyes are used prin- 
cipally for large objects; and if, during this period, the 
myopia does not become very considerable, it may remain 
stationary during the rest of life. Temporary increase of 
myopia may take place during these years of growth and 
of study, from too close application ; but, provided its degree 
is still moderate, its further progress may be arrested at or 
after maturity if the individual grows more prudent. But, 
and this constitutes the gravest feature of the disease, if 
the myopia has, during this period, already reached a high 
degree, the tendency to continued progress frequently can- 
not be arrested, notwithstanding the exercise, too late, of 
the greatest care; and degenerative changes go on in the 
tissues and media of the eye, with the sad prospect of par- 
tial or even total blindness at or before middle age. 
“ Since it has been shown that it is especially by con- 
tinued tension of the muscle of accommodation in study 
that myopia with its attendant dangers is generated and 
increased, and as it is well known to be only preventable 
and not curable, it follows that a change in our methods of 
education is an absolute necessity, or else this which might 6 
be termed self-imposed disease, will impose a more and more 
grievous burden on the community. 
“ A child having an hereditary leaning towards myopia 
is expected to give a large portion of time every day to 
study of oftentimes badly printed books, perhaps in a dim 
light, and sometimes with the requirement from his teacher 
that he shall not take his eyes from his lesson. Myopia is 
thus begun. As this augments, the child who does not see 
things about him clearly, has less pleasure in the usual 
sports of his age, and finds more enjoyment in books. His 
close application to reading, writing, drawing, etc., keeps 
up convergence of the eyes and pressure upon them of the 
recti muscles, which tends little by little to increase the ellip- 
soid change of form and elongate‘the antero-posterior axis. 
These alterations go on during the period of- growth and of 
most continuous study, because at this time the tissues of 
the globe are softer and more extensible than after maturi- 
ty. If on reaching this latter term the structural changes 
are still only moderate in degree, the myopia may continue 
stationary during life. But if at this time great deviations 
from the normal condition have already been produced, the 
affected parts are less capable of resisting further yielding, 
and progressive myopia is thenceforward an ever present 
source of danger. 
uPrevention is the sole resource at our command; resto- 
ration is impossible. And in order that preventive meas- 
ures may be seasonably adopted, it is first necessary that 
the profession and the public should become alive to the 
fact that in a large number of cases myopia is one of the 
gravest affections of the eye, capable of limitation by con- 
stant care during childhood and youth ; but, if not thus 
limited, likely to be a source of future disability and mise- 
ry, and to be handed down as an onerous inheritance to 7 
children. At present the warnings inspired by frequent 
sad experience in the practice of every skilled observer are 
almost unheeded, and it is but too common to see the 
chances of retaining even moderately useful vision in fu- 
ture years recklessly sacrificed to a vain ambition for acqui- 
ring mere book knowledge, which, when gained, is often 
valueless to its possessor, or if otherwise it could be usefully 
applied, cannot be made serviceable because of the imper- 
fection of sight which has been created in obtaining it. 
“ Very high degrees of myopia should also be recognized 
as an infirmity deserving careful consideration before as- 
suming the obligations of marriage; for those in moderate 
circumstances may well hesitate to choose partners whot 
though highly cultivated, ma}r probably at middle life be- 
come unable to provide for their households or their chil- 
dren.” 
That the eye grows weaker as the term of study grows 
longer, is clearly proven by actual investigation. Careful 
tests have been made of the eyes of many thousand school 
children in America, Germany, Austria, Russia, Switzer- 
land and other countries, and invariably with similar re- 
sults, viz: that the proportion of normal-sighted children 
generally lessens as the age of the subjects advance, and as 
they reach the higher grades of study. The statistics thus 
gathered show that while in children at common village 
schools there is but one-fourth of one per cent, of myopia, 
it rises to 21 per cent, in city schools of high grade, and in 
some high schools and universities it has reached 60 to 70 
per cent. The examination of six hundred students of 
theology at the University of Tubingen found 79 percent, 
suffering from myopia. Other statistics have shown that in 
those who studied two hours out of school, the proportion of 
myopic students was 17 per cent.; in those studying six 8 
hours 40 per cent. Germany furnishes more myopic, or 
nearsighted subjects than any other country in the world, 
her schools showing at least 62 per cent., while in America, 
so far as examinations extend, the rate is about 27 per cent. 
So it would seem that even in our own land the school- 
room is a factor most directly influential in the gradual and 
increasing development of a race of spectacle-using people. 
The ratio has been found to be smaller in America than in 
Europe, because, probably, of the greater activity and vari- 
ety of life and the less degree, as yet, of hereditary tenden- 
cy. A curious fact made known by these investigations is, 
that colored school children suffer so slightly from myopia 
as to be practically free from it. 
These facts deserve serious attention, especially in con- 
nection with our undoubted power of modifying or arrest- 
ing the progress of myopia by proper management and 
by self-denial during the years of growth and of education. 
Myopia, says one, is especially prevalent among the so- 
called cultivated classes, and the more time people spend in 
intellectual pursuits the more myopia do we find. Yet 
students do not use their eyes for more hours a day, or on 
finer objects than jewelers, engravers, draftsmen, seam- 
stresses, type-setters, and many others who engage in long 
continued work on small objects. These occupations do not 
show any tendency to myopia, while the piofessional and 
literary callings do. The particular reason why members 
of mechanical arts show less myopia than those of studious 
and literary occupations, is not because they use their eyes 
less, but that the application of their eyes occurs at a dif- 
ferent time of life and under entifely different conditions. 
Germany is confessedly one of the most studious nations in 
the world, and she certainly is the most near sighted. 
Many of her school houses are very old structures, original- 9 
ly built for convents, and poorly lighted; moreover, the 
German text itself is obscure compared with the clear Ro- 
man letters. 
In writing and study, it is easier to sit bending over an 
ordinarily located desk, in the stooping position, than in an 
erect posture. This position prevents by compression the 
free return of blood from the head. The posture of the head 
favors its detention in the eyes, while the working of the 
brain itself demands more blood, and hence we easily have 
a congestion of the eye-ball, and especially of those parts 
that are most active, viz: the retina and optic nerve. 
With this congestion there occurs softening of the sclerotic 
or outer coat and increase of the fluid contents of the eye- 
ball, increasing the pressure from within. At the same 
time, the muscles on the sides of the ball produce pressure 
from without, in their effort at converging for near vision. 
This condition of things causes a bulging of the posterior 
wall of the eye, and in this way myopia, or near-sightedness 
begins and increases, for the same causes continue to act with 
greater force as the trouble progresses. In children the 
tissues of the eye-ball are much softer than in the adult, 
and this is one of the principal reasons why these causes 
are more active in producing the disease between the ages 
of six and twenty. Undoubtedly the disease is often hered- 
itary, but the predisposition to it may be largely counter- 
acted by proper care. The absence of myopia among sava- 
ges is attributable to absence of hereditary tendency togeth- 
er with absence of undue tension of the eyes for near objects. 
British surgeons tell us out of many thousands of the na- 
tives of British India examined by them, not a single near 
sighted one was found. Who of you can call to mind one 
near-sighted negro who lived in antebellum days? Educa- 10 
tion has put its mark upon them now, however, and won- 
derful to relate, they are proud of their infirmity. 
The examination of several hundred negro school chil- 
dren in New York found only per cent, myopic. In 
many negro schools in the South, examinations discover 
less than 1 p6r cent. Absence of hereditary predisposition 
largely explains this difference, but a few generations hence, 
with increased educational facilities, and with the heredi- 
tary tendency steadily increasing, near-sightedness will be- 
come not an uncommon disease among negro students. 
Bad air and defective light play an important role in the 
production of myopia. Says a distinguished author : ‘‘ Air 
and light are the first and last and best messengers of life — 
the first breath and the last breath—the first glance and 
the last glance ; how wonderful! ” 
Bad air alone, in a school-room, acting as primary cause, 
may set in train a series of morbid processes, which may, 
and often do, affect not only the working capacity and in- 
tegrity of the organ of vision, but which may lead even 
to its total destruction. One of the professors in the law 
school at Cambridge, in commenting upon the frequency of 
eye diseases in that institution, says, it must not be sup- 
posed that young men injure their eyes by excessive appli- 
cation. “ Bad ventilation and the gas-heated air of the lec- 
ture room cause the trouble.” 
But light, plenty of good light, is one of the chief needs 
of the scholar. Too much light can never be thrown into 
the school-room, especially when we have at our command 
the means of regulating the excess of glare. A room is not 
sufficiently lighted when a child cannot easily read fine 
print, on a moderately clear day, at a distance of twelve to 
fifteen inches. The less the light, the nearer the object 
must he brought to the eye, and the greater the strain in 11 
the act of vision ; for reduction in illumination is, as a rule, 
precisely equivalent to a reduction in the size of the ob- 
ject. A model school-room would be one in which there was 
not only an abundance of good light and of good quality, 
but in which the eyes both of pupils and teachers were 
alike shaded from the painful glare. In all cases the light 
should come from the left and at a distance of four to five 
feet from the floor. Next to this a rear light is permissible, 
but light from the right should, if possible, never be used. 
Windows should never be placed in front of the pupil. 
Light from such a direction is positively injurious. They 
should always be placed on the left side; the next best place 
is the rear, and after this the right side, which position 
should only be occupied when no other can be obtained. 
But the true light should come from over the left shoulder. 
It does not harm the eye, does not cast a shadow on the pu- 
pil’s work and is not reflected directly into the eye. A Ger- 
man writer thus sums up the results of his investigations: 
“ The narrower the street in which the school-house was 
built, the higher the opposite buildings, and the lower the 
story occupied by the class, the greater the number of near- 
sighted scholars.” 
A recent investigator writes: “ Among the causes of vis- 
ual weakness among American youths may be named a 
stooping posture, which cramps the chest and brings the 
eye too near the book or paper; reading at twilight and 
late at night, and studying by lamp light in the early 
morning, reading in the cars, using kerosene lamps without 
shade, reading while facing a window or any light natural 
or artificial, and still more while facing the bright sunshine, 
reading dime novels or other books printed in too fine type, 
reading while lying in bed, wearing a veil; and neglecting 
to cultivate far-sightedness by carefully examining dis- 12 
tant objects. Hence myopia is more common in cities than 
in the country, more among those working on near and 
minute objects than those laboring in the fields with a 
wider range of vision and more objects to invite habits of 
observation.” 
Tension of the accommodation, that is, long continued 
use of the eye upon objects brought close to it, is consid- 
ered by all authorities one of the most (if not the most) 
fertile causes of progressive near-sightedness. The act of 
reading involves very considerable physical labor. It is 
said a book of 600 pages, 40 lines to the page and 50 letters 
to the line, contains 1,000,000 letters, all of which the eye 
has to take in, identify, and combine each with its neigh- 
bor. Yet many readers will go through such a book in a 
day. The task is one he would shrink from if he should 
stop to measure it beforehand. 
It is well known to every investigator that imperfect type 
is influential in the production of eye diseases. “ Bright 
white paper, particularly if its surface is glazed, is dazzling 
or irritating. It is on account of the quality, rather than 
the size of English print, that it is usually so much pleas- 
anter to read than American. “Some cheap publications 
manage to combine all of the defects referred to, in such a 
degree that a more paternal government than ours might 
well suppress them as enemies of society. Fortunately, 
such publications do not contain intellectual treasures that 
it need tempt one to risk his eyes to reach.” While too 
fine print is regarded as a factor in bringing about eye dis- 
ease, it must not be forgotten that too coarse print is weari- 
some to the eye, for it requires more exertion of the mus- 
cles governing the movements of the ball. Especially is 
this the case if the breadth of the page is too great. It is 
for this reason that the narrow form of the English blank 13 
verse is so little fatiguing to the eye. A double column page 
which is well printed and properly divided, is certainly 
preferable to the same amount of matter extending in a 
single line across the entire page. 
An enthusiastic and ingenious writer asserts that “nature 
and science declare” that the color of the paper of all books 
should be green. “Green grass covers the ground and green 
leaves are our canopy, and no other color is so grateful to 
the eye. Let our books be printed on green paper, and let 
our printers use red, yellow or white ink for the noxious 
black.” When this has been done, he says, “everybody will 
rejoice except the spectacle-makers. The eyes of the schol- 
ar and of the student will no longer be wearied with the 
myopian contrast of black and white, but strengthened and 
refreshed by congenial colors; and to pore over the pages 
of a book would be no more fatiguing to the eyes than 
gazing on a verdant prairie decorated with variously tint- 
ed flowers.” We must agree with him in this, that the re- 
form would be revolutionary, and that the interest of the 
trade would be hostile to the change. 
The best safeguards against harm are afforded by the best 
positions and best light, clear type, plain inks, with the 
best paper of yellowish tints and abundant space between 
the lines. 
“The increased demand that the exigencies of the fash- 
ion of the times make upon the eyes as well as upon the 
brains of the children, and the increased numbers that are 
yearly brought within the influence of school life by the 
compulsory laws of governments or of public opinion, 
should be accompanied by a corresponding increase in the 
use of all the alleviations and precautions that science and 
humanity can suggest. School training is necessarily an 
artificial process, and unless it is conducted under rational 14 
and favorable conditions, universal education can never be 
an unmixed universal blessing.” Much of the injury to 
body and mind as well as sight is traceable to causes which 
goad the children on to tasks that the brightest and strong- 
est of them are scarcely equal to, and the “higher educa- 
tion” that is now so earnestly demanded for the gentler 
sex, is too often dearly bought at the expense of shattered 
constitutions and unstrung nerves. But if these things 
must be, in the name of humanity and justice, let them be 
surrounded by all the checks that can lessen their power 
for evil. 
After a diligent study upon the question of construction 
of school houses and the construction and arrangement of 
desks and seats, a distinguished surgeon has stated, that 
90 per cent of curvature and other diseases of the spine are 
developed during and largely attributable to school life. It 
should not be forgotten that “there is an architecture for 
schools as well as an architecture for palaces. One is not 
less worthy of study than the other, and we are at fault in 
taste as well as in hygiene if we forget that here real beau- 
ty consists, above all things, in the perfect adaptation of a 
building to its uses.” An abundance of properly regulated 
light, good ventilation and plenty of room, are the essentials 
of a perfect school house. 
A certain school committee, after thorough investigation, 
reports that it is “of the opinion that the practice of requir- 
ing pupils to commit their lessons from books, is not only 
the cause of much of this near-sightedness, but that it is a 
most pernicious practice from every point of view, and more 
especially so when much of the so-called studying must be 
done at home evenings. Children under fourteen or fifteen 
years of age, should never be required to get regular lessons 15 
out of school hours. This is not to say they must spend 
those hours out of school in idleness or play.” 
Fewer hours of study and more rational methods of teach- 
ing, less cramming of mere memory and more healthy de- 
velopment of the intellect, will make brighter, healthier 
and more intelligent students, who will develop into 
stronger, happier, more energetic men and women. For 
such as these the practical affairs of life offer many and 
varied fields of usefulness, while for the sallow-faced, nar- 
row-chested, weak-eyed, book worm, there is no room in a 
busy world.