Card C.

Card "C" is printed on a light weight Bristol board (about a library bureau "1" card) 10 X 15 cm., and perforated for filing in a card catalogue case, with the following arrangement :

This card is for permanent record, and must follow the child in case of promotion or transfer. (To be placed in card index in care of principal.)

Card D.

(To be sent to parent or guardian of any child whose vision is found to be defective.)

Dear.......

.The examination of the eyes of..

progress

....shows defective sight which may hinder.. in the school work or lead to permanent injury to the eyes. It is therefore recommended that an eye physician be promptly consulted.

....Teacher.

School (name and location).

The cards were distributed to the schools in January, 1902, with a general letter of instruction to the principals and the examinations begun. Before many days, children bearing the card of advice presented themselves at the various clinics and consulting rooms in the city. A number of these fell into my own hands at my Wills' hospital clinic so that I had an opportunity to verify the practicability of the plan. Without exception every child presenting these cards was unquestionably in need of professional advice. By far the larger number needed glasses for the correction of some form of anomaly of refraction,

and were already suffering injury from the strain of school work. The great value accruing both to the individual and to the community from the correction of the congenital anomalies of refraction by glasses I have been able to demonstrate; consult "A System of Diseases of the Eye" Vol. II, J. B. Lippincott & Co., edited by Drs. Norris and Oliver, "School Hygiene;" also Achives of Ophthalmology for July, 1894, p. 247. It is there shown that in twenty years, during which ophthalmic surgeons in Philadelphia and vicinity had sedulously corrected the eyes of all persons with asthenopia, applying for relief, that the percentage of near-sighted eyes had fallen from 28.43 per cent. in the first period to 16 per cent. in the last period, a fall of approximately 50 per cent. There was also a corresponding diminution in the degree of myopia. To those who are familiar with the hampering influence of myopia over the career of the individual, or with the serious consequences of the disease in causing partial or complete blindness from choriodal atrophies, detachment of the retina, etc., these figures are of great significance. In addition to these considerations the permanent records of these examinations preserved in the school archives will, after a few years have passed, prove a source of valuable information to scientific ophthalmology in its efforts to meet the baneful influences of modern life over the integrity of the visual organs of the race.

DISCUSSION.

[The chair invited Drs. Frank Allport, of Chicago, and John E. Weeks, of New York City, to participitate in the discussion.] Dr. Frank Allport, Chicago:

Mr. Chairman: Not being a member of this distinguished body, I had no notion whatever of taking part in any of the discussions. Inasmuch, however, as your chairman has so courteously offered me the privileges of the floor, I cannot do otherwise than accept his kind invitation and participitate somewhat in the discussion of the valuable paper which we have just heard.

Perhaps no one has done more than my friend, Dr. Risley, in advocating and successfully working for the proper examination of school children's eyes, and whatever he may have to say upon this subject must be listened to by everybody with interest and respect. The examination of

school children's eyes by physicians, while ideal in its conception, is unfeasible in its practical workings. It involves too much time, trouble, expense and ill feeling, and those of us who have had something to do with such examinations in American schools within the past few years have become pretty well convinced that the only kind of an examination which stands a chance of being generally adopted, is that which is accomplished roughly, but still quite satisfactorily, by the school-teachers themselves. This method of examination is being adopted quite generally throughout the United States, and has become incorporated as a law in the state of Connecticut. It is also being used quite frequently throughout European countries, and a recent letter from India informs me that it is being used in some of the government schools in that far-off country. The methods of making these tests by school-teachers differ somewhat in different localities, but the underlying principle is always there, namely, the systematic examination of school children's eyes by school-teachers. The method used by Dr. Risley is without doubt superior, if it can be accomplished, to the one used in Chicago, Minneapolis, Milwaukee, and many other cities. It is more complete, and therefore better, but I shall be interested to learn of the ultimate history of this plan and of whether it is adopted in other cities. If it can, I shall be rejoiced, but I doubt it. It involves more labor than teachers are willing to devote to the subject, and the equipment of the different rooms in the schools with records, apparatus, etc., advocated by Dr. Risley, will, I fear, make the expense so burdensome that the average board of education will seek for cheaper means to the same end. I believe that the chief end to be accomplished in these tests is not the accumulation of statistics, however valuable they may be, but the benefit to the children, the coming generation, the hope and promise of our great Republic. If this aim is the true one, then the result can be accomplished by the asking of the simple questions, and the distribution of the warning cards to the parents of defective children, with a little moral suasion thrown in to induce such parents to accept the advice of the school authorities. This plan is perfectly simple, easily accomplished, and so cheap that 500,000 school children can be properly examined at an expense that will not exceed $150. The expansiveness of this work is colossal. I am informed that there are between 7,000,000 and 8,000,000 children attending the public schools of this country. If this is true, 5,000,000 or 6,000,000 of them have defective eyes, ears, noses and throats, which impair their health and usefulness, and impede them in the acquirement of an education, which is perhaps the most potential and influential factor in the dissipation of anarchy and crime. These facts are enormous, and face the school authorities of this country annually. They can be grappled with and conquered successfully, and a benefit accomplished that will hardly be secondary to that of vaccination, if physicians, boards of health, and boards of education, and law makers, will deter

mine that such a desirable result shall be accomplished. This subject is, therefore, of great interest to this Academy, and to all medical organizations, and we all thank Dr. Risley for once more bringing it to our attention. I would suggest that other tests be incorporated with the visual tests. I refer to tests for hearing and for tests of the nose and throat. These matters are also of great importance, and inasmuch as they can be easily accomplished, there is no reason for omitting them.

The objections to these tests are trifling, and need hardly be dwelt upon. For instance, teachers often enter the objection that they are not competent to make tests of this nature. This is nonsense. Any teacher can ascertain how far down upon a Snellen card a pupil can read. Any teacher can ascertain whether the child habitually suffers from headache, eye tire, red eyes, crossed eyes, discharging ears, deafness, mouthbreathing, etc., and as Dr. Risley says, any one who is competent to be a teacher at all, is competent to make these simple tests. Some objectors dwell upon the fact that many parents pay no attention to the cards of warning that are sent to them by the teachers. This is doubtless true. Out of a hundred parents thus warned, a certain percentage of them will neglect the cards, but what of it? the balance do pay attention to them, and this balance I firmly believe constitutes a majority of the whole. We, therefore, are able to accomplish an enormous good to a great number of children, and should we falter or hesitate because a few foolish parents neglect the warning? Emphatically no. Therefore, let the good work go on. Some also see an objection in the fact that many parents send their children to department stores, jewelers, opticians, etc. This is also undoubtedly true, but it must not blind us to the fact that such a result does not occur as a rule, and that the majority of children find their way into the offices and dispensaries of reputable ophthalmologists, and many of those who at first seek unprofessional advice, once their attention has been aroused to the fact of existing trouble, frequently seek safer and wiser counsel in the end. But these and many other objections are trifling. They are mere incidents along the pathway of progress,—incidents to be overcome, and conquered, and should not deter us in advancing along those lines, which will lead us to the highest victory in the end. Dr. J. E. Weeks, of New York:

I thank you very much for the privilege that has been accorded me. I am sorry to say that in New York the system of testing the eyes of school children has not advanced to the degree that it has reached in Philadelphia. This is largely because the ophthalmologists in New York have not been as fully alive to the desirability of such a system. The question is certainly one of great importance; the solution of the question has been reached by the labors of Dr. Risley, and his associates and by the labors of Dr. Allport, of Chicago, and his associates. I believe with Dr. Allport that school boards and boards of health should insist that tests of this

nature should be made, and that the teachers should be instructed so that they could conduct the tests in a satisfactory manner. Even though the parent pay no attention to the first recommendation, repeated admonitions will convince them of the importance to the child of the examination advised.

Dr. Leartus Connor, of Detroit:

There is another phase in which vision is a factor in educational progress and that is in the fact that the teacher has good vision. I do not believe that any individual should be placed in charge of the young whose vision is not normal or as near normal as science can make it. The irritability of the nervous system from defective refraction or muscular balance, and its resulting effects upon the children, all will agree is a very important factor.

It has been proved beyond a doubt that the reason the world does not advance more is because the medical profession does not fully appreciate the importance of the definite scientific knowledge of growing children right and keeping them right in every important direction. There is nothing in medicine so magnificent as the work spread before us to-day. It is a misfortune that it takes so long to have educated doctors appreciate these magnificent things. It is difficult to teach school boards and the people, but if we could only have our brethren know and carry out this work the results would be gratifying.

Dr. Risley closes :

I have nothing special to add. I would like to say to my friend Dr. Allport that the tests for hearing were included in the plan, but did not come under the title of my paper. As to the feasibility of the plan, I will say that it had not been in operation a week in Philadelphia before a number of these cases came to my own clinic and presented the cards of advice to parents. There was considerable discussion in the committee as to how the card of instruction should be worded, and we finally decided that the name, surgeon, should not be mentioned, but the parents advised to consult an eye physician. We thought that if we chose the word surgeon they would be afraid of possible surgical interference and so would fail to follow the advice.

Dr. J. H. McBride, of Pasadena, Cal.:

It has been stated in California that in certain of the Eastern states where these investigations are being made that the public is becoming tired of them because the method is complex and expensive. I would like to ask Dr. Risley whether that is so.

Dr. Risley :

I am glad that the question has been asked. There is only one portion of this plan which is complex, that is, the permanent record of the examinations. The examinations should cover ten years of the child's school life