“DAUGHTER” of TETRALOGIA – The Clinical Significance of Ocular Accommodation
Oculists find themselves in the same dilemma as doctors in general: when young they lack experience. Thus a doctor who has himself often been ill is generally a good doctor and best understands the perils of taking several drugs at the same time. A young oculist inevitably has little experience of the nuances involved in prescribing glasses and has even less experience of the burden of hypermetropic, knows nothing of the awkwardness of presbyopia with advancing years and cannot know how hard it is for those who suffer from both hypermetropic and presbyopia to do close work. Even a presbyotic oculist often rejects the use of glasses in the manner of a layman. How then can he help his tormented patient when diagnosis of his latent trouble requires at least that the oculist understand what is going on? Thus the oculist himself, often without intending it, makes light of hypermetropia.
Even today a great deal of “traditional knowledge” is picked up from one’s elders in the course of training – and it is hard to know whether this is good or bad – but one thing is certain, the really important things about refraction are sadly neglected. One sometimes wonders why capital so dearly bought should remain in pawn. One pre-supposes that a doctor who is specializing will already have a talent for unearthing such everyday things, but what I am trying to say is that there are a vast number of things which cannot be learnt from books and which require years of experience, even with the same patients, before they become clear. You cannot really follow how the refraction of a particular patient changes when working in an out-patients’ department and in any case three or four years’ specializing is only a drop in the ocean when it comes to learning how to prescribe glasses.
Those who have worked only a few months in a clinic easily think that they know more or less what is involved in this field, at least where something basic like refraction is concerned! One does not have to be a genius in order to prescribe spectacles for those who seem to need them. This is well illustrated by the remark of a young fellow who did not find the prescribing of glasses very interesting. “What the hell does it matter whether a patient’s glasses are half a diopter in one direction or another?” Why not indeed, provided that it does not bring further problems in its train and that incorrect spectacles do not lead to a lengthy history of suffering as has so often been the case.
Prudence and true learning only begin when one’s own mistakes begin to boomerang and no comfort can be had from the thought that lack of time was the cause, for hurriedness and prescribing of spectacles are unsatisfactory bed-fellows. One of my colleagues once observed that in prescribing glasses one must begin by assuming that everybody else, — often the previous oculist — has been an absolute idiot. The only trouble is, however, that one is often the idiot oneself. I confess that the most difficult thing of all is to face up to one’s own mistakes, but here too love of truth will help.
There is no need to worry about our mistakes if we have the strength to admit them (La Rochefoucauld).
Just as every man must go through a certain process of biological development, so must a man grow up to his profession thus one generation advances little upon the previous one, energy is squandered on the same old mistakes which could so easily be avoided. It is for this reason that I have here collected together the experiences gained during twenty years of practice. One may have to see a lot of life before one realizes how important a good basic training is. I cannot boast of my pre-medical learning, but I understand now how important each branch is, especially, I think, anatomy (that of nervous system), pharmacology and physiology. I am therefore all the more horrified by all kinds of crash courses and short-cuts in present-day medical training. One must have at least so much basic knowledge that one can make intelli¬gent use of books when dealing with problematic cases and in addition plenty of common sense if one is to go forward wisely. The most efficient brains are impotent if they are used for appropriating “accepted ideas” blindly and if they lack the true scientific spirit and more especially if they hold key positions.
At least in Finland, the fact is that most oculists are private practitioners and it has been estimated that the prescribing of spectacles comprises between 80% and 95% of their work. The present book is therefore based on refraction,which is intimately connected with diseases like migraine, increase of intraocular pressure,many troubles accepted as actual eye diseases, and probably other troubles like high blood-pressure. Simple though the theme may be, it is of such great importance that no (see also foot note l,p.344.) oculist can study It too much and one must pity the oculists In hospitals who either have not mastered refraction or underestimate Its seriousness. When the question I am dealing with Is taken Into account the oculists’ work that Is left over Is really very restricted, at least quantitatively, although of course It has Its problems.
Even the work of a run-of-the-mill oculist Is so heavy and time-consuming that he Is seldom able to view any patient’s troubles In perspective, but once the matter Is understood, It Is extraordinary to discover what a conspicuous part Is played by the eyes and especially accommodation stress In a whole group of different symptom-complexes and how crucial the decisions that have to be taken may be for the patient. I believe the practical applications of neuro-ophthalmology to be almost unlimited.
It may seem Incredible that such a wide medical field is covered by a simple-seeming thing like latent hypermetropia and spasm of accommodation. We shall
perhaps understand it better if we stand back a bit and look at it from a distance. It may then dawn on us that the workings of the human body have in recent times become subjected to many unwonted strains, affecting particularly the eyes. The eye, both because of its proximity to the brain and on account of its function as a transmitter of that indescribably important sensory stimulus – light – is neurologically at the centre of the stage.
For this reason, the thesis here propounded, if acted upon, will mean that patients with certain symptom-complexes are dealt with by other hands and given a different kind of basic examination.
I have tried to ignore the objections made to my work – we all come in for our share of obloquy – and to draw strength from those of my patients who have returned to give thanks for the inalterable advice which has enabled them to persist in wearing glasses when It seemed that all was lost and thus to succeed in overcoming their troubles In the only way possible. We have all met patients who have traipsed from doctor to doctor over the years on account of severe headaches and have been overjoyed to hear that after wearing the glasses we have prescribed they “never ‘ad a day’s illness since”. And how such experiences comfort one and confirm one in one’s convictions !
“Put your glasses on the bedside-table when going to bed and put them on as soon as you get up in the morning”^ I should like this sentence to ring in the ears of head¬ache sufferers ! “You must come back again and again if the trouble goes on; your glasses may have to be modified. Headaches are not normal, as some people seem to think ! Your head shouldn’t be aching!” Ethically I cannot allow my patients’ heads to ache and especially I can’t bear the thought that they may be taking headache pills.
A patient taking pills for headaches is the oculist’s nightmare and no oculist should be content with a 25 % recovery rate (Sandoz Report 3/1972). If there is no brain tumour or other proven organic defect an oculist should have no peace of soul until every headache has been cured. As I often say to patients I am ashamed to see them wearing nothing but dark glasses – the sign of a bad oculist. Tinted glasses merely cover up mistakes and enable them to endure the wrong spectacles.
As I have said,it is all the same to me, but not to society as a whole, whether people can cope with their lives or not, provided they are happy and fit to work, their heads are not aching and their eyes are not troubling them. It is all the same to me if they do not mind looking strained and old, if they do not mind having high blood pressure and high intra-ocular pressure, both of which endanger vision and can in extreme cases lead to blindness. However, as soon as somebody comes to me for help, I feel my responsibility and am in no way ashamed of my over-enthusiasm in the attempt to reach the goal. I always say to any patient I catch being disobedient that I will not see him again because he is just wasting my time. There are plenty who can be helped and who wish to be helped. Patients who will not wear the glasses prescribed for them, run incurable, from doctor to doctor, giving a totally misleading picture of the matter.
My book is intended to demonstrate how essential the prescribing of proper glasses can be and how important their use is for almost everything, and not just for the eyes.
In writing the book I have tried to shut out Mark Twain’s aphorism from my mind: ” The less I know about a subject, the more confident I feel and the more I illustrate it.”
I am under no illusion that in this world of “received ideas”, where thought is paralyzed, any great change will be wrought at a single blow. I remain optimistic, however, for I have seen the fruit of much more modest labour after a lapse of only six or seven years. The one thing that is certain is that if one does not
even try to change opinion there is no hope that it will change on its own and the written word has the advantage over the spoken that it can bide its time !
I am fully aware that many and even contemptuous criticisms have been raised, that there are some who see only fourth-rate didactic fiction in everything, but even if the seed never grows I have been able to write and express myself.
Tetralogian “tytär” – The Clinical Significance of Ocular Accommodation