for about 20 years. I know something of the battles that they have had in order to make their services available. They don't try to force themselves on anybody.

Congressman Alger, if he wants to go to an ophthalmologist, he is perfectly free to do so. So is everybody else. But we do believe that the American people ought to have a free choice of practitioners, not only among the individuals but among the disciplines. Optometry is an independent discipline in the eye field.

Mr. ÅLGER. I notice on page 53 of this bill the optometrist is mentioned.

Mr. MACCRACKEN. That is right.

Mr. ALGER. Why is it necessary to further amend the bill by inserting the optometrist in several other instances, would you say?

Mr. MACCRACKEN. I think Dr. Exford mentioned that, Congressman Alger, in his statement, that there are other places in the bill where, because it deals with different titles, we thought it ought to be in because if Congress does not put it in expressly, then they will have to come back and get an amendment.

Mr. ALGER. It is expressly in here, though.

Mr. MACCRACKEN. That is only in title XVI.

Mr. ALGER. You want it repeated in each one of the sections?

Mr. MACCRACKEN. In certain places. It is not in each one but there are a half dozen places where we felt that the wording should be clarified. No place does it make it complusory. It is merely clarification.

Mr. ALGER. You want it in several times and the ophthalmologist wants it deleted.

Mr. MACCRACKEN. They want it deleted from the bill and deleted from title X of the law as it has been in the past 12 years.

Mr. ALGER. No hope of getting you two together?

Mr. MACCRACKEN. I think the effort has been on our part and none on theirs.

Dr. EXFORD. We would like very much to have 100 percent cooperation for the benefit of the American people.

Mr. ALGER. Provided they agree with you.

Dr. EXFORD. The people of America are the ones that are suffering because of this.

Mr. MACCRACKEN. I don't know whether Congressman Alger knows this or not but the American Medical Association has a resolution which makes it unethical for an ophthalmologist to cooperate with an optometrist on a professional basis. Of course, that is something like our old prohibition law. It is violated more than it is observed but there are those who do observe it in the medical profession. They have in many instances kept medical professors off the faculties of optometry schools although they have not been completely successful. They have tried to do it.

Mr. ALGER. I think the physicians are very sincere in thinking that the optometrists do not have the level of training. I think there is a very definite clash between the two of you. I was kidding when I thought you would get together. From what I have seen this after

noon this is not so.

Mr. MACCRACKEN. What I was trying to point out is this. I think if they were sincere they would cooperate to the extent of at least let

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ting their men teach our students, the optometry students. Yet they won't do it without violating their canons of ethics. There are some of them that defy it. Of course, as you know probably, a good many of the faculty members in our optometry schools are imported from foreign countries. They are not as amenable to the dictates of the American Medical Association.

Mr. ALGER. I suspect that the medical association probably thinks you should have a number of other courses, too, rather than just teachers of the courses you have. I don't know unless we get them up here and have a little debate between the two of you.

Dr. EXFORD. The AMA recognizes the need for optometry. It is a human impossibility to care for all the human beings. They would like to exterminate optometry, to reduce it to a field of technicians. under medicine. We don't want to do that.

Mr. ALGER. You can't cooperate and exterminate at the same time. (Additional report referred to above is as follows:)

SUPPLEMENTARY STATEMENT SUBMITTED BY HAROLD W. OYSTER, O.D., DIRECTOR, DEPARTMENT OF NATIONAL AFFAIRS OF THE AMERICAN OPTOMETRIC ASSOCIATION (Pertaining to H.R. 10032, and the statements of Charles E. Jaeckle, M.D. of the National Medical Foundation for Eye Care and letter of F. J. L. Blasingame, M.D., executive vice president of the American Medical Association) One of the causes of confusion in dealing with the subject of blindness is that there are varying degrees of this affliction. Any person whose vision cannot be corrected to better than 20/200 is usually regarded as legally blind and yet these individuals, with the aid of telescopic lenses and other prosthetic devices, coupled with training, can actually see and even read.

The report submitted to the White House Conference on the Aging states: "Only 25 percent of the 'total blind' people have no perception to light, while the remaining 75 percent have varying degrees of useful vision, from the bare minimum capable only of giving guidance, to sufficient amounts to allow reading. Many of the senior individuals heretofore classified as 'blind' have found that what vision they do have can often be mobilized and made more efficient through the use of various optical aids developed by research in optometry.” Blindness is not a disease, but it may be caused by disease. There is no question but that where disease is a contributing factor to loss of vision which may ultimately result in blindness, the interest of the patient and of the taxpayer, who bears much of the financial burden, requires that the optometrist and the ophthalmologist should work together as a team. Optometry recognizes this fact and is ready, willing, and able to cooperate. However, there is a recalcitrant group of ophthamologists, represented by the American Medical Association and the National Medical Foundation for Eye Care, which refuses to cooperate with optometrists unless compelled to do so by law. It should be pointed out that in many places at the grassroot levels there is good teamwork, as evidenced in studies of referrals, between the two professions.

An innuendo pertained to the failure of optometrists to make proper referrals. The 1961 public health reports of the U.S. Department of Health, Education, and Welfare referred to a study of referrals by optometrists to members of other health specialties. It was based on a random sampling of 1,350 of the estimated 18,500 optometrists in active practice in the United States and indicated that more than 800,000 patients are referred by optometrists annually. Substantially over half of this number are referred to ophthalmologists, approximately one-third to general practitioners, and of the remainder only 5 percent were referred to other optometrists.

The 1950 amendments to title X of the social security law made the services of optometrists available to the beneficiaries of that act. The results have been satisfactory in all of the States of the Union. A few years ago, a questionnaire was sent to the welfare departments of the various States. Not a single one reported unsatisfactory results from the operation of the aid to the blind pro

gram as a result of the 1950 amendments to title X. One of the outstanding responses came from California from which the following excerpt is taken:

"It has now been almost 6 years since the law became effective authorizing county welfare departments in California to use the services of optometrists in determining degree of blindness in connection with eligibility of aid to the blind. At present there are more than 215 optometric examiners rendering this service. During the past year more than 1,200 optometric eye examinations were completed to determine eligibility for aid to the blind.

"The services of optometrists have proved over the years to be a valuable addition to the social welfare programs for the blind in determining eligibility as to degree of blindness. This is particularly true for the less populated communities where there is scarcity of examiners. The availability of optometric examiners has meant that the State could take action with respect to eligibility to aid to the blind without the cost to county of transporting the applicants to a neighboring community to secure the required eye examination; and, of course, without resultant inconvenience to the client."

This clearly indicates what it means to the partially sighted who live in small towns, villages, or rural communities, not to mention the saving to the taxpayers who bear the travel expenses of the indigent. Even in the larger metropolitan areas, the patient load of the ophthalmologist is so great that the elimination of the services of optometrists from the aid to the blind program would work considerable hardship on the beneficiaries.

In such well-known clinics as the Illinois Lighthouse for the Blind and the Industrial Home for the Blind in Brooklyn, N.Y., the cooperation of the optometrist and the ophthalmologist has brought almost unbelievable benefits to their patients. In the commentary to a survey published by the Industrial Home for the Blind, "Optical Aids Survey," covering the first 500 cases, Richard E. Hoover, M.D., ophthalmological consultant, stated:

"This program could not have attained the popularity which it enjoys and the success indicated in this report without the support, sincere interest, and capabilities of the director, the ophthalmologist, the optometrist, and the service and administrative personnel who gave encouragement, instruction, and help in the use of the aids. A much-needed service has been rendered."

Dr. G. Ottenheimer Hellinger, O.D.S., in his commentary said:

"The success of the first program established anywhere for the rehabilitation of the near blind by means of optical aids is due mainly to the courage and foresight of IHB's executive director, Peter J. Scanlon. It is largely owing to his efforts that the virtual elimination of the differences between optometrists and ophthalmologists concerning the use of telescopes and microscopes has been accomplished. *** The gratifying results achieved here with the complete cooperation of the other professions involved, indicate the tremendously valuable aid that is possible to the near blind."

Of particular interest is the commentary of Leo Esbin, M.D., staff ophthalmologist, as follows:

"As an ophthalmologist I have watched with keenest interest the development of the optical aids service at the Industrial Home for the Blind, the more so that the 500 clients served were persons who, on the basis of an ophthalmological examination were found to come within the legal definition of blindness. All of them had had ophthalmological service-some of them very extensive service over a period of years-and most of them had been told that nothing more could be done to improve their vision. Against this background, it was surprising to find that 68 percent of the group had obtained a useful increase in visual acuity through the use of optical aids." [Italic supplied.]

The quotations are from the publication of the home in September 1957, and the first 500 cases were handled during the period March 1953 to December 1955, all of which was subsequent to the passage of the Doughton amendment to title X in 1950 which medicine opposed and now seeks to have repealed.

The Optometric Center of New York City is another example of outstanding service by members of the optometric profession to the needy with impaired vision. This statement is borne out by two letters of recent date, one written by Maj. E. C. Hinkle, manager of the Social Service Center for Men of the Salvation Army in New York City. In writing to Dr. Alden N. Haffner, the optometrist who is executive director of the Optometric Center, Major Hinkle said:

"The many times we have contacted you on behalf of unfortunate and handicapped men for eye treatment and glasses is truly appreciated."

The Reverend Robert J. Fox of the Catholic Charities of the Archdiocese of New York, in a letter to Dr. Haffner said:

"Repeatedly our workers here in the family service division have spoken of the outstanding service accorded to clients referred to your center.

"In expressing the respect and gratitude of the agency, I should like to indicate that this service has greatly helped us in our work of helping families and individuals regain or develop their sense of dignity and their adjustment to society. The significant aspect of your service has been your sensitivity to the person's need not only for visual care but also for acceptance and considerate attention. This is a truly professional service."

The insinuation that optometrists are not well educated is utterly unfounded. Approximately 30 percent of the students entering optometry schools already have a bachelor's degree and those who do not must successfully complete a minimum of 2 to 3 years of college training before enrolling in the optometry courses. Optometry performs a unique and distinct vision care service. Its uniqueness stems from its extensive education not only in the sciences of physiology, anatomy, and pathology, in the training offered of the health care professions but in addition, the exclusively formal education in physiological optics. The only courses in graduate studies leading to the Ph. D. degree in physiological optics are found on campuses where schools of optometry exist. The hard core of their faculty teaching this subject is composed almost exclusively of optometrists.

In Maryland, the provisions of section 43, title "Health," subtitle "Optometry," section 259, reads as follows:

"Diseased conditions ***. It shall be unlawful for any person to knowingly sell or prescribe glasses for persons with diseased eyes except it be with their knowledge and consent or on an order or advice from a registered physician." This law was passed in 1914 and there has never been an optometrist who lost his license for failure to comply with this provision of the law.

The medical witness sought to confuse the words "diagnosis" and "detection." Webster defined detection as "the act of detecting, discovering," and the word "diagnosis" as "scientific determination; critical scrutiny or its resulting judgment."

Optometry's premise, published by the American Optometric Association

states:

"The treatment of pathological conditions and eye surgery is acknowledged by optometry to be in the field of medicine. However, for the protection of the public and in order to make proper referrals to other practicioners and specialists, optometrists must continue to be well trained in the detection and recognition of ocular signs of pathology." [Italic supplied.]

The medical diagnosis and treatment of eye diseases is clearly a function of the physician. We trust that the committee will not fall prey to the misleading argument that when an optometrist searches a patient's eyes to detect signs of pathology that he is thereby indulging in medical diagnosis which is the exclusive province of the physician.

In 1954 a book was published entitled "The Optometrist's Handbook of Eye Diseases" by Joseph I. Pascal, M.D., and Harold G. Noyes, M.D. The following quotation is taken from the preface of that book:

"The purpose of this book is to bring to the optometrist, student, and practitioner the salient facts regarding dieases of the eye, including congenital and acquired deformities. The authors have been teaching diseases of the eye to optometrists for a great many years and have incorporated here the results of their experiences in this field.

"The importance of the subject can be appreciated from the fact that the optometrist in the course of his professional work is bound to come in contact with eyes which may be diseased. In fact, he may be the first to come across diseases of the eye which, because of their unobtrusive nature, that is, lack of startling objective or subjective symptoms, may send the patient to the optometrist first, e.g., glaucoma simplex, diabetic retinopathy. Sometimes the eyes he sees may be in a stage of active inflammation, or they may present the sequelae of some previous disease which has already run its course.

"Thus the optometrist is sometimes the most important member of the healing profession with regard to the patient getting the quickest medical or surgical service. To perform this service successfully he need only know, sometimes merely suspect, pathological deviations from the normal. This is his principal concern. Of course he must also be sufficiently familiar with the physiological

deviations from the normal so as to know when a referral to the medical practitioner is necessary and when it is not. Differential (pathological) diagnosis is only of secondary interest to him.

"Differential diagnosis is a large and difficult field. A medical specialist, with all his training in this direction, with many facilities for making all kinds of auxiliary tests, is sometimes unable to make a differential diagnosis. What good is it for the optometrist to involve himself in such work?

"The various State and local standards of blindness, the courses and facilities for rehabilitation of the blind in the various institutes, the special visual aids available for the blind and near blind are all matters of concern to the optometrist and are therefore included."

The following quotations are taken from pages 19 and 20 of the same book: "In any survey of the care of the eyes in civilized communities it will be found that the great majority of citizens depend for the relief of their common visual disturbances on refracting opticians, ophthalmic opticians, and, in America, optometrists. This means that the first line in detecting early disease processes and frequently in preventing blindness is held by these practioners. Hence, the great importance of learning to detect signs which point to derangements of the eyes or to the body in general. The following is a brief outline of what is required. Emphasis is placed on the borderline cases so that the optometrist can distinguish between those lying within his province and those lying within the province of other practitioners; e.g., family physicians, and specialists (including ophthalmologists, neurologists, pediatricians, dentists, etc.).

"The signs and symptoms of disease are phenomena which are deviations from the normal. But the normal is not an absolutely fixed entity. There are many deviations from the normal which are physiological variations and fall into the realm of normalcy. It is important for the optometrists to learn to recognize these physiological variations."

Attached as an exhibit is a copy of the topical outline of the National Board of Examiners in Optometry dealing with the subject of diseases of the eye.

In the light of what Dr. Jaeckle said about the education of all medical students in ophthalmology, it seems appropriate to call to the attention of the committee a statement by the late Dr. E. F. Tait, M.D., an ophthalmologist active in the affairs of the National Medical Foundation for Eye Care, as it appears on page 824 of the "Transactions of the American Academy of Ophthalmology and Otolaryngology," November-December 1955.

"We have occasion, Mr. President, to discuss at times the undergraduate training of our medical students in ophthalmology, and we had last Sunday a very excellent presentation which I enjoyed very much. However, there is one factor which embarrasses a great deal those of us who have to do, unfortunately, with the legislative aspects of these things.

"We have thrust under our noses continually statements by physicians that the medical school training in ophthalmology is limited to anywhere between 26 and 60 hours. That may be true as far as the courses which are labeled ophthalmology in the medical school catalog are concerned. But, Mr. President, it is not true if we take into consideration the fact that these courses in the third and fourth years of medical school would be incomprehensive if it were not for the preceding work, some of it specifically in anatomy and physiology and pathology of the eye, and also in general anatomy, physiology, pathology, biochemistry, and other subjects which are included.

"So I would like at this time to present a motion which does not constrict the council in any way and should not in any way be construed as an attempt to dictate in this matter. It is just simply so that we who have to deal, as I say unfortunately, with these legislative situations may be aided; that is, that when these matters are discussed before the council or before this body we may be honest about them and say that the 26 to 60 hours in the medical school catalog does not mean that is all of the instruction a physician gets in opthalmology.

"So I move you, sir, that it is the sense of the academy that it is inadvisable that any paper or other communication be published in the transactions of this organization (that does not mean that the academy cannot publish, but it does mean that we feel that care should be exercised in this regard) that would describe the training of medical students in ophthalmologic subjects in terms of courses specifically labeled “ophthalmology" in medical school catalogs, without adequate reference relating that training to the specific eye instruction in preclinical subjects, as well as to the general instruction given in anatomic,