A few years ago an attack was made on an Oklahoma statute regulating the practice of our profession and the dispensing of corrective eyewear. This law as attacked on the ground that it violated the Federal Constitution, and certain sections of it were held unconstitutional by a three-judge Federal court.

However, the U.S. Supreme Court on the appeal, in a unanimous opinion by Justice Douglas, sustained the Oklahoma law in its entirety.

The optometry statutes of Illinois, Wisconsin, and Oregon have also been before the courts and when sustained in their respective jurisdictions, the U.S. Supreme Court has in each instance allowed the decision of the State court to stand.

There are those in every profession who reflect discredit on their fellow colleagues, and optometry is no exception. However, by means of legislation, court proceedings and post graduate education, we are endeavoring to correct this situation.

In this we are constantly opposed, as might be expected, by the commercial interests, but what may seem more strange is that we are also opposed by the medical profession, particularly the AMA and its satellites.

For my part, I shall base my presentation on what optometrists have actually accomplished in detecting pathology and making referrals. The figures I shall present are based upon two surveys, the first of which was reported in an article that appeared in the American Journal of Public Health, volume 51, No. 11, November 1961. The survey represented a random sampling of 1,350 optometrists. The results when applied to the entire optometric profession indicated that on an annual basis something over 700,000 patients are referred by optometrists, of which over 400,000 were to ophthalmologists, an additional 270,000 to general practitioners, some 27,000 to dentists, and 41,000 to other optometrists.

The other is a survey just completed by our association which involved replies from 2,645 of our members. Using the same factor as was used in the other survey, it would show a total referral of over 900,000 patients during the past year.

Next, I would like to call your attention to what some physicians. including ophthalmologists, and other individuals have said about our ability to detect glaucoma. Before doing so, however, I would like to point out that there are two distinct kinds of blindness. One is referred to as "totally blind." This means that the sight is totally destroyed, and in many cases the eyeballs have been removed, or if not, the optic nerves have been so destroyed by injury or disease that there is no sight remaining. In these cases there can be no question but that the optometrist is as well qualified as anyone to certify blind

ness.

The other cases are those where there is some residual vision but where it is so limited that the individual is classified as "legally blind." This is usually defined by a limitation of visual acuity or a limitation of the visual fields, or both. Certainly optometrists are well trained and qualified to give an accurate report concerning these criteria.

The objection of those who would relegate our profession to the status of mechanics or laboratory technicians is that in the course of the examination necessary to certify blindness the optometrist fails to detect signs of pathology, with resulting injury to the patient. Right here I want to suggest that the judgment of an individual is not infallible, regardless of his education and the field of his activity. Optometrists are no exception to this rule.

But we have an abundance of examples, with which I do not propose to burden the committee, to prove that the oversight of ophthalmologists, as well as general practitioners, has resulted in errors which, fortunately for the patient, were detected by optometrists who had made the original referrals and upon subsequent referrals the judgment of the optometrist was confirmed.

Recently E. H. Spitzka, M.D., professor of anatomy at Jefferson Medical College, a recognized author and authority on anatomy, neurology, and brain diseases, said:

When an individual's vision becomes impaired I would rather have him go to an optometrist. As an active specialist in his field, he acquires a special aptitude for the recognition of every abnormality which only a few medical practitioners can enjoy. In the majority of cases only correcting lenses are needed. In a small minority of cases in which a diseased condition exists, the optometrist can be relied upon to recognize the pathological state and send the patient to a suitable practitioner.

Another enlightening quotation is to be found in the editorial by Walter C. Alvarez, M.D., editor emeritus of Modern Medicine. It appeared in the April 2, 1962, issue, as follows, and I quote:

Saddening to me is the fact that when I see one of these patients, suffering from ptosis of a lid or a diplopia, he tells me he has been going around to one ophthalmologist after another for a year or two, and no one of them either made the correct diagnosis or referred him to a neurologist. Something would seem to be lacking in the present-day training of some of our ophthalmologists. As far back as 1950, Peter C. Kronfeld, M.D., professor of ophthalmology, Illinois Eye and Ear Infirmary, University of Illinois College of Medicine, wrote an article from which I quote:

It is fully realized that in actual figures the optometrist makes a greater contribution to the early recognition of glaucoma than does the ophthalmologist. Undoubtedly optometrists in the United States are in contact with a much larger section of the population of the United States than is the body of ophthalmologists.

It was not until the Dougton amendments to section X of the social security law were passed that ophthalmologists worked together with optometrists in aid-to-the-blind programs. One of these examples was the cooperative program between optometrists and ophthalmologists in the Industrial Home for the Blind in Brooklyn, N.Y. In September 1957, the home published an "Optical Aid Survey" covering the first 500 cases. These cases were handled during the period, March 1953 to December 1955. Permit me to quote from the commentary of Leo Esbin, staff ophthalmologist:

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.

Only this week the Professional Services Committee of Group Health Association of America, Inc., at its annual meeting submitted a report from which I quote:

4. The formulation of a program aimed at utilizing to best advantage the talents of physicians, nurses, optometrists, and other skilled persons who are involved in the health services field. The storage of professional personnel and the increasing demand for health services will call for a drastic reevaluation on the part each of these persons can play, both in regard to quality and cost of care.

I would also like to quote from a letter dated April 10, 1962, written by the director, public welfare, for Coffee County, Ga. :

This is to certify that examinations made by local optometrists are acceptable by the State department of public welfare for aid to the blind.

It is our belief that the State department feels as we do that Coffee County is most fortunate in having well-qualified optometrists to serve its people.

At the hearings before the House Interstate and Foreign Commerce Committee in January of this year, Dr. Gerald O. Dorman, M.D., one of the trustees of the American Medical Association, in response to a question from one of the committee members stated:

Optometry plays an important part in the vision of the American people.

Because we believe that it is in the public interest to make certain that optometric services will be available to the beneficiaries, both old and young, who desire to utilize them, I would like to suggest that the following amendments be incorporated in the bill now being considered by you gentlemen:

Page 18, line 25, after the word "services" insert the following: "including optometric services when desired by the applicant."

Page 30, lines 22 and 25, after the word "medical" insert "and optometric".

Page 76, after line 15, insert "(9) Optometric services" and renumber items in lines 16 to 21, both inclusive, on page 76.

Page 76, line 17, after "drugs" insert "lenses and" before "eyeglasses".

Among the declared purposes of the legislation is to provide services that will help families become self-supporting and independent and to provide services to rehabilitate recipients of public assistance programs. Certainly, good vision for schoolchildren, adult workers, and especially for the aged, will contribute immeasurably to reducing the financial burdens of our public assistance programs and at the same time instill in the beneficiaries of these programs self-reliance, a sense of achievement, and the ability to become self-supporting, or at least more nearly so.

Mr. Chairman, I tried diligently to condense this into a period of 10 minutes that you kindly allotted.

I would like to make just this closing statement, that it is with a very deep desire that I suggest to this committee that we are keenly interested in cooperation between our profession and that of the medical practitioner, particularly the ophthalmologist, and that is what we are going to attempt to work for.

I would also like to be extended the privilege of making an additional statement if it should become necessary to do so.

The CHAIRMAN. Without objection, if you decide to submit an additional statement it will be inserted in the record.

(Dr. Chapman did not submit a supplemental statement.) Dr. CHAPMAN. I thank you, sir.

The CHAIRMAN. Thank you very much, Dr. Chapman.

The next witness is Dr. J. Spencer Dryden, of the American Medical Association.

Dr. Dryden, take a seat, sir, and proceed.

STATEMENT OF DR. J. SPENCER DRYDEN, PRESIDENT, MEDICAL SOCIETY OF THE DISTRICT OF COLUMBIA, REPRESENTING THE AMERICAN MEDICAL ASSOCIATION

Dr. DRYDEN. Thank you, Senator Byrd.

Mr. Chairman and members of the committee, I am Dr. J. Spencer Dryden of Washington, D.C. I am appearing here today on behalf of the American Medical Association to comment on certain provisions of H.R. 10606, 87th Congress, the Public Welfare Amendments of 1962.

I am a practicing ophthalmologist in the District of Columbia. In addition, I am president of the Medical Society of the District of Columbia. With me is Mr. Paul R. M. Donelan, legislative attorney in the Washington office of the American Medical Association.

The proposed addition of a new title XVI to the Social Security Act would permit States to formulate single unified plans combining public assistance programs for the aged, blind, and disabled and medical assistance for the aged. This proposal is wholeheartedly endorsed by the American Medical Association as being consistent with the policy of this association that there are no reasonable grounds for arbitrarily dividing the needy into categories.

At the most recent meeting of the American Medical Association, which was held in Denver during November of last year, our house of delegates adopted a recommendation that all "categories" in FederalState programs of assistance to the needy should be eliminated. The house of delegates further stated that:

"Eligibility should be based on a comparison of the individual's or family's resources and a reasonable estimate of the amount necessary for adequate maintenance of the necessities of life, including necessary medical care, with due regard to enabling the individual family to regain self-supporting status, so far as possible. Assistance should be based on need, rather than attained age or physical disabilities." It would appear that the proposed addition of title XVI to the Social Security Act would be in furtherance of this policy.

The American Medical Association has no established position with respect to the other provisions of H.R. 10606, 87th Congress, with the exception of that portion of section 1602 (a) (12) which authorizes the determination of blindness of an individual by an optometrist.

It has long been the position of the medical profession that the appropriate responsibility of the optometrist is in the measurement of ocular refractive errors and their correction by glasses. The structure, function, and diseases of the eye and of the visual system is a part of the science of medicine. A physician who specializes in the diagnosis and treatment of ocular diseases, in the application of physiological and optical principles to the prescription of glasses and the correction of aberration of ocular function, and in the surgery of

the eye and its related structures, is known as an ophthalmologist. In addition to his acquired general medical knowledge, he has special education and training in these matters.

The determination of blindness is a diagnostic procedure. Diagnosis, as much as medical therapy, requires medical training. Medical training is not necessary to qualify one to perform refractive tests, nor is it always necessary to qualify one to prescribe satisfactory glasses.

However, complete medical training is required to qualify one to determine the need for medical treatment, to diagnose, and to assume the responsibility for detecting or determining the presence of or absence of diseases.

That portion of section 1602 (a) (12) of H.R. 10606, 87th Congress, which would authorize an optometrist to determine whether or not an individual is blind, is not, in our opinion, in the public interest in that it grants medical responsibilities to nonphysicians, and implies that one other than a physician is competent to discharge them. The effect of this provision is to establish a double standard for the practice of medicine which is neither in the interest of the public nor the recipients of public assistance.

It is our understanding, based on the debate when this legislation was before the House of Representatives for consideration, that the Department of Health, Education, and Welfare has, since 1950, been in accord with the position of the American Medical Association that only medical doctors are qualified to determine whether an individual is blind.

Accordingly, I would suggest that section 1602 (a) (12) of H.R. 10606 be amended in such a manner so as to provide that in determining whether an individual is blind there shall be an examination by a doctor of medicine.

I thank you on behalf of the American Medical Association for giving me the opportunity to express the views of the physicians of America on this important legislation.

We will be pleased to attempt to answer any questions that the committee may have.

Thank you very much.

The CHAIRMAN. Thank you very much, Dr. Dryden.

Dr. DRYDEN. Thank you, sir.

The CHAIRMAN. The next witness is Dr. Ralph W. Ryan of the National Medical Foundation for Eye Care.

Dr. Ryan, take a seat, sir, and proceed.

STATEMENT OF DR. RALPH W. RYAN, ON BEHALF OF THE NATIONAL MEDICAL FOUNDATION FOR EYE CARE

Dr. RYAN. Mr. Chairman and members of the committee: My name is Ralph W. Ryan. I am a physician engaged in the private practice of ophthalmology in Morgantown, W. Va., where I also serve as chief of staff of the Vincent Pallotti Hospital.

I have earned a master of science degree in ophthalmology from the University of Michigan, and am qualified as a diplomate of the American Board of Ophthalmology. I have engaged in research in the fields of industrial eye safety and care at the University of Mich