The Visual Inch as an Index to Systemic Conditions—Errors of Diagnosis.

W. W. WALKER, A.M., M.D., MARQUETTE, KANSAS

Among the five special senses, unqualified importance has always been conceded to the organs of vision, and any deviation from the normal in this special sense has evoked the most intense interest. As we approach this mystic temple of sight and investigate its divine secrets, let us walk lightly, for we are treading on holy ground. Blot out the light of the eye and we close the window of the soul and the blackness of despair that follows may pluck forever all hope and ambition from the stoutest heart.

It is said of Shakespeare that when he wrote he dipped his pen in his heart; and this is the secret of our success in choosing any subject whereby we may convey to others the earnest interest we feel in that special question.

In championing this subject I approach it not from the narrow field of the optician, but claim the broader cosmopolitanism of the oculist and physician. There probably does not exist in the world today, a man so wise as to know all that pertains to that one inch of the anatomy, combined with the physics of optics, embracing the organs of vision; and if this be true what shall be said or thought of those, who for the sake of money to be made therefrom, herald themselves as doctors of optics, claiming to the ignorant, a knowledge of all that pertains to this precious gift of sight?

Let us consider some of the functional and pathological diseases that manifest themselves in the visual organs and to which we look for pathognomonic manifestations.

Hysteria (if we exclude age) might be mistaken for apoplexy. "Muscae Volitantes," these floating objects may be of significance as determining whether we have a brain lesion or the cerebral disturbances are associated with anemia, cardiac maladies or narcotic amaurosis.

The appearance of the eyes themselves point significantly to systemic disturbances other than altered vision and refractive anomalies; the fixed stare, the oscillating globes, the glassy pupil, may indicate chorea, hysteria, approaching spasm, clonic and tonic, as well as insanity. Who of us has not observed the brilliancy of the eye in meningitis, and dreaded the onset of opisthotonos ?

Diseases that at first thought may appear to be remote, may have their affinity for and therefore manifest their expressions relatively by the visual organs. A patient may come to us complaining of some of the various expressions of ametropia, and after a more or less objective and subjective examination we have already in our minds assigned an amblyopic cause for their visual infirmity. To illustrate: A lady has been in the habit for several months of going to the jeweler across the way, until finally he becomes satisfied by her frequent visits and change of glasses, that her condition is beyond the ken of his limited knowledge. He refers her to us.

We have met this lady often, on the street, and have already made our mental diagnosis of glaucoma with its associate unfavorable prognosis, so that only a few questions and slight palpations are necessary, and we unhesitatingly tell her that her case is hopeless. (We cannot help volunteering the consoling remark for the benefit of her friends and the jeweler across the way, that had she come a few months earlier we could have afforded her the only chance of relief, viz.: an iridectomy.) Then our unfortunate patient starts out to ring the changes on all the oculists and opticians in the country, until a hopeless blindness checks her fruitless quest and she settles down to a life of gloom.

How often, think you, have jewelers, jeweler's clerks and itinerant spectacle peddlers mistaken staphyloma posterior, tumors of the orbit, Bright's disease, optic neuritis, choked disk and detachment of the retina for old sight, long sight, and short sight, until it is too late to remedy the existing evil. Then the doctor is consulted and perhaps censured because relief did not speedily follow.

Irritative cerebral lesions produce contraction of the pupils whilst lesions which destroy cerebral function produce dilatation. Does the vender of spectacles in his perambulations over the country know this? Slight hemorrhages or effusions into the pons, or lateral ventricles, by their irritation produce contraction, while an increase of effusion or hemorrhage produces dilatation of the pupil. Does the jeweler's clerk comprehend this? Chlorosis produces dilatation of both pupils, and after ascertaining that atropine, cocaine, or any other mydriatic has not been used shall we refer our patient to the watch repairer or to the tinker of clocks for a remedy?

The more serious of these lesions can only be demonstrated by the ophthalmoscope. Shall we ask the peddler of spectacles to stop his horse long enough to step in and demonstrate this fact to us?

"Arcus senilis" is a characteristic gray circle about the corneal limbus, an unfailing premonition of athromatous degeneration of arterial or cardiac origin. When we encounter this condition shall we refer our patient to the realm of mechanics, or render such relief as is known to medicine, conjoined with our advice to arrange his earthly affairs?

We would not detract a modicum of credit from the educated optician. Fortunately there are such, but they are the exceptions that we must consider. As such they observe their limitations and do not hesitate to refer questionable cases to the physician.

Our knowledge as regards the optical schools of the country convinces us that they do not desire matriculates who have already obtained their degrees from medical colleges, but they cater instead to jewelers and their clerks, or, in fact, to any one that can pay twenty-five or fifty dollars for tuition, and can spend from two to four weeks in attendance. These are then turned out with a showy diploma as full-fledged doctors of optics.

Were it not a most fortunate fact that the more frequent eye complaints for which patients consult us are errors of the refractive media, the physician would be consulted before the uneducated optician or jeweler, for barring astigmatism and aniso-metropia, they often render relief in simple hyperopia, presbyopia, and myopia.

We cannot expect to deprive people of their constitutional rights to buy their spectacles of jewelers, or patent medicine from druggists, but unitedly as the body of an educated profession we can demand that an ignorant class of men shall not monopolize this important branch of medicine.

Is it fair to the profession to allow this vital branch to rest in the hands of him whose knowledge of the eye does not comprise that limited portion anterior to the crystalline lens, and who can at best correct but a few of the simplest refractory errors, not knowing that even these may be but the expression of remote functional or organic changes in the economy?

Gentlemen, are your eyes of as much value as your teeth? Do the dental nerves take precedence of those of sight? You are supposed to be familiar with the functions of the twelve pairs of cranial nerves while the dentist in his treatment does not stop to even consider the functions of the glossopharyngeal alone.

And yet the law governs the dentists. Why, I ask you in common justice to both the doctor and his friends, cannot a clause be inserted into the statutes governing the practice of medicine demanding an examination in all the branches of ophthalmology before allowing a man to hold himself out to the people as a doctor of optics, doctor of refraction, or graduate optician?

Well, you might ask, what are you going to do about it? And I might answer by asking, what is your state board of examination and registration organized for? Is it to protect the doctors alone? If that were true, then, indeed, we would be a protected medical trust that some have accused us of being. No; these boards are organized not only to protect legitimate physicians against charlatanism, but to protect the people against themselves. If this were not so, how long, I ask you, would it be before a saturnalia of disease would sweep the earth? No restraints; no quarantine; no safeguards thrown about those we love. A devils' dance of suffering and death that would stagger the lay world, did not the honest, educated physician stand between the people and their enemies, whether these be the demon of disease or the soullessness of quackery.

It might be inferred by my choice of this subject that I am an eye specialist and take this method of bringing myself before you as such. Allow me to disclaim any such attribute or desire. In making this choice I only attest my love for this field of energy and only lay claim to the prerogative of "The General Practitioner as a Specialist."

"The greater a man is in power above others, the more he ought to excel them in virtue. None ought to govern who is not better than the governed."—Publius Syrus.

Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.