[...A House Built On Sand

That the results of the present method of treating defects of vision
are far from satisfactory is something which no one would attempt to
deny. It is well known that many patients wander from one specialist
to another, seeking vainly for relief, while others give up in despair
and either bear their visual ills as best they may without assistance,
or else resort to Christian Science, mental science, osteopathy,
physical culture, or some of the other healing cults to which the
incompetence of orthodox medicine has given birth. The specialists
themselves, having daily to handle each other's failures, are scarcely
better satisfied. Privately they criticize each other with great
asperity and freedom, and publicly they indulge in much speculation as
to the underlying causes of this deplorable state of affairs.

At the recent meeting of the Ophthalmological Section of the American
Medical Association, Dr. E. J. Gardiner, of Chicago, in a paper on The
Present Status of Refraction Work, [1] finds that ignorance is
responsible for the largest quota of failure to get satisfactory
results from what he calls the "rich heritage" of ophthalmic science,
but that a considerable percentage must be attributed to other causes.
Among these causes he enumerates a too great dependence on measuring
devices, the delegation of refraction work to assistants, and the
tendency to eliminate cycloplegics, in deference to the prejudices of
patients who have a natural objection to being incapacitated by
"drops."

On the same occasion, Dr. Samuel Theobald, of Johns Hopkins
University, noted a tendency to "minimize the importance of muscular
anomalies" as an important cause of many failures to give relief to
eye patients. Among cases that have come into his hands after glasses
had been prescribed by other ophthalmologists he has often found that
"though great pains had been taken to correct even minor faults of
refraction, grave muscular errors had been entirely overlooked." From
this fact and from the small number of latent muscular defects noted
in the hospital reports which he has examined, the conclusion seems to
him inevitable that such faults are in large measure ignored.

Dr. Walter Pyle, of Philadelphia, laid stress on "necessary but often
neglected refinements in examination of ocular refraction." "Long
practice, infinite care and attention to finer details," he said, "are
imperative requisites, since a slight fault in the correction of a
refractive error aggravates rather than relieves the accompanying
asthenopic symptoms." This care, he says, must be exercised not only
by the oculist but by the optician, and to the end that the latter may
be inspired to do his part, he suggests that the oculist provide
himself with the means for keeping tabs on him in the form of a
mechanical lens measure, axis finder and centering machine.

Dr. Charles Emerson, of the Indiana University School of Medicine,
suggested a closer co-operation between the ophthalmologist and the
physician, as there were many patients who could not be helped by the
ophthalmologist alone.

The fitting of glasses by opticians is usually condemned without
qualification, but in the discussion which followed these papers, Dr.
Dunbar Roy, of Atlanta, said that the optician, just because he does
not use cycloplegics, frequently fits patients with comfortable
glasses where the ophthalmologist has failed. When a patient needs
glasses, said Dr. Roy, he needs them when his eyes are in their
natural or normal condition and not when the muscle of accommodation
is partially paralyzed. Even the heavy frames used in the adjustment
of trial lenses were not forgotten in the search for possible causes
of failure, Dr. Roy believing that the patient is often so annoyed by
these contrivances that he does not know which is causing him the
roost discomfort, the frames or the glasses.

Nowhere in the whole discussion was there any suggestion that this
great mass of acknowledged failure could possibly be due to any defect
in fundamental principles. These are a "rich heritage," the usefulness
of which is not to be questioned. If they do not produce satisfactory
results, it must be due to their faulty application, and it is taken
for granted that there are a select few who understand and are willing
to take the trouble to use them properly.

The simple fact, however, is that the fitting of glasses can never be
satisfactory. The refraction of the eye is continually changing [2].
Myopia, hypermetropia and astigmatism come and go, diminish and
increase, and the same adjustment of glasses cannot suit the affected
eyes at all times. One may be able, in many cases, to make the patient
comfortable, to improve his sight, or to relieve nervous symptoms; but
there will always be a considerable number of persons who get little
or no help from glasses, while practically everyone who wears them is
more or less dissatisfied. The optician may succeed in making what is
considered to be a satisfactory adjustment, and the most eminent
ophthalmologist may fail. I personally know of one specialist, a man
of international reputation, who fitted a patient sixty times with
glasses without affording him the slightest relief.

And even when the glasses do what is expected of them they do very
little. Considering the nature of the superstructure built on the
foundation of Donders. and the excellent work being done by leading
men, Dr. Gardiner thinks the present status of refraction work might
be deemed eminently satisfactory if it were not for the great amount
of bad and careless work being done; but I do not consider it
satisfactory when all we can do for people with imperfect sight is to
give them eye crutches that do not even check the progress of the
trouble, when the only help we can offer to the millions of myopic and
hypermetropic and astigmatic and squinting children in our schools is
to put spectacles on them. If this is the best that ophthalmology can
do after building for three-quarters of a century upon the foundation
of Donders, is it not time that we began to examine that foundation of
which Dr. Gardiner boasts that "not one stone has been removed"?
Instead of seeking the cause of our failure to accomplish even the
little we claim to be able to do in the ignorance and carelessness of
the average practitioner, great as that ignorance and carelessness
often are; in the neglect of cycloplegics and the refinements of lens
adjustment: in the failure to detect latent muscular anomalies; in the
absence of co-operation between specialist and general practitioner:
would it not be wiser to examine the foundation of our superstructure
and see whether it is of stone or of sand?

--------------------------------

[1] For reports of all the papers quoted, see Jour. Am. Med. Assn,
June 21, 1919.
[2] Bates: The Imperfect Sight of the Normal Eye, N. Y. Med. Jour.,
Sept. 8, 1917...]

- "Better Eyesight", Dr.W.H. Bates, August 1920