Contents:
Review of Tetralogia by Aune Adel, 1974
Suomen Kuvalehti magazine article 'Onko pluslaseista apua', 25th of April, 1974
Turun Sanomat article 'Jokainen tarvitsee laseja jonakin aikana elämässään' , June 13th 1973
Excerpts from correspondence with my colleague Aune Adel
After looking at my website, patient NN wrote to me (an excerpt)
Review of Tetralogia by Ophthalmologist Aune Adel:
Translated from Suomen Lääkärilehti (Finn Med J)6/74, Tetralogia -nakemys oftalmologiasta - Lataa suomenkielinen pdf
Tetralogy -A view on ophthalmology
This book is intended to ophthalmologists, the author herself being an ophthalmologist. It should, however, interest specialists in other fields since an enterily new approach to ophthalmolgy is
presented. This study breaks the traditional narrow boundaries of ophthalmolgy penetrating into the most central fields of medicine as a whole.
This book is not a doctrinal! work based on theoretical speculation nor is it a product of an unusual imaginative power. On the contrary, it is the anatomy of the work at a private practice during a period of years. The results of this work, however, did not fully satisfy the practitioner. Instead they seemed continuously to leave the door open to criticism leading to the search for new ways and methods. The ideas of the book, it seems to me, started with an intense questioning. Why does this particular patient show this kind of a refrative error, an anisometropia, a heterophoria, an increased intraocular tension etc. When the answer finally emerged the symptomatic treatment was resolutely given up. Thus "the exact correction" of a refractive error, the operative measure, the hastily written prescription for lowering the tension were abandoned. With the etiological factor found, the recognized academic measures no longer proved rational. Logical thinking combined with longterm clinical observation led to new methods and to therapy in conditions which, until now, have been considered beyond treatment.
The central theme of "Tetralogy" is the refraction of the eye, its determination, variations and its effect on the organism as a whole. Contrary to the textbooks, which divide refractive errors into three groups, the author believes that there is only one refractive error, hyperopia, together with its various grades. Thus myopia and astigmatism are distortions, artefacts, due to the corrective mechanisms of the eye, the accommodation performed by the ciliary muscle with its autonomous innervation. Under continuous strain and a presumable overexitability the result may end not only in pseudo-myopia and pseudo-astigmatism but at same time in overactivation, a possible sensitization of the entire autonomous nervous system. This is manifested in clinical symptoms as headaches, migraine, epilepic attacks, attacks of pseudo-angina pectoris, intestinal spasms, to mention only a few. Ocular symptoms include accommodative spasm, often combined with pseudo-myopia and pseudo-astigmatism, anisometropia, nystagmus, conjunctival irritations, photophobia, even detachments and degenerative conditions of the retina. Treatment is always solved once the etiology is found. Thus refractive error should not necessarily be corrected by prescribing lenses giving the best visual acuity at distance but by correcting the latent hyperopia as thoroughly as possible. Seemingly paradoxically, plus lenses are prescribed for pseudo-myopia the idea being, of course, relaxation of the accommodative spasm. The hazards of minus lenses are clearly brought out in the clinical material of the book.
Further the book shows clearly that applying optics as such into a living organism, the eye, may have a clearly damaging effect. of the refractive error at the moment of an examination is a relatively simple procedure by present methods. Thus correction of a refractive error according to the retinoscopy or refractometer findings and prescription of lenses giving the best visual aquity at five to six meters is easily performed. In practice this has led to certain schematism and nonchalans. Prescrpition of lenses come easily (touring ophthalmolgists prescriptions by opticians). On the other hand, a procedure that consists in a nearly mechanical mesuring, may easily become tedious. Many ophthalmologists therefore consider refraction the least interesting part of their field. It has even become a negation, it may be omitted entirely or left in the hands of the least experinced practitioner or of an optician. The results may be disastrous.
Adoption of the ideas ov Tetrlogy may not come easily. For an ophthalmologist it means a change of attituide and abandoning hypothesis already crystallized to axioms. But once adopted they offer the possibility of really helping the patient. They not only give significans to determination of refraction so often considered trivial but at the same time open up new dimensions invisible to both the retinoscope and the ophthalmoscope -a fact for which an ophtalmologist cannot be but grateful. The author has not by customary scientific methods attempted to prove her achievements. Every practising ophthalmologist, however, will be able to find the observations true provided he has the desire to "see wood for trees". Tetralogy, in my opinion, is more than a more scientific work. It breaths the joy of a basic perception having its full applicability in practice. This joy the author wants to share with her colleagues. What importance Tetralogy will have on medicine as a whole can so far only be envisaged.
Aune Adel Ophthalmologist
Articles:
Suomen Kuvalehti 25th of April, 1974
When journalist Vieno Räty from Turun Sanomat interviewed me in May 1973 about Tetralogia, she said that reading the book all the time had made her think about Jonathan Livingston Seagull. I immediately got hold of this book, and I have collected here a number of thoughts that describe the struggle needed for my thoughts to break through, too.
Most gulls don't bother to learn more than the simplest facts of flight.
I don't mind being bone and feathers, Mum. … I just want to know.
Of course, it is impossible to love hatred and meanness.
You just have to go on looking for yourself.
I want to share with others what I have found out myself.
When they hear about it, Jonathan thought, my revolutionary achievement, they will be wild with joy. How much more there now is to living … there's reason to live.
Excerpts from correspondence with my colleague Aune Adel:
Helsinki, 26 November 1973
Dear Kaisu,
I have given a lot of thought to your book, and been amazed over how well your insights hit the mark. Finally I feel that my own jigsaw pieces of ophthalmologic problems are starting to fall into place. I just returned from Meltola (a sanatorium that she visited for consultations) feeling great, as I really felt that refraction had given me results that were satisfying, at least to myself. I was genuinely surprised to see that the pressures of a glaucoma congestivum subject had gone down by around ten mmHg after I had added the missing +1.50 to both lenses, at the same time ending up with two equal ones. You may guess that I will now address other glaucomas under pilocarpin treatment. It is indeed remarkable that no one has discovered the disadvantages of pilocarpin before… I am curious to find out what I can achieve with a couple of troublesome pairs of eyes…
But I am disgusted to see that our colleagues are so unwilling to give up their deep-rooted beliefs. I must admit that I have myself had my doubts and been happy with retinoscopy, although I have often seen that in another year, the cylinder can be quite the opposite, or gone altogether. Happy, however, is the wrong word. On the contrary, just as you said, I was not happy with the results, even if I did feel that the refractions were more or less correct, as I still believed in my retinoscopy. As you well know, your book has caused great irritation in many of our self-assured colleagues. They know that they are right. Time will tell that Kaisu beat us all to it by miles.
By the way, as far as my own '"myopea" is concerned, I used to think that with my visus of one, I was a regular myope. Only in the last few years (at the age of 50-53) have I noticed my eyes stringing in the evenings, and I have not been able to read. I get tired and have to put the book away before I've even started. Yesterday, Sunday, I wore +2 glasses around the house all day (even though I had go give up playing music, as I could not see the fingering numbers). In any case, today I have been quite energetic, although in the past, every time I left Meltola my eyes were closing half way home and I was nearly falling asleep; even now, in the evening, I am quite bright, and my usual tiredness that has afflicted me all my life (and which I have consequently thought pathological) is gone. If only I did not have to wear the minus glasses at work I would be feeling better still. I have not yet received my Executives.
By the way, I have recently not increased the minuses in the glasses of a single patient. By applying a few drops of Cyclogyl to finish with I have been able to demonstrate that the old glasses will give them at least as good a visus as those slightly stronger ones that they thought they needed. To my surprise, after "Cycloplegia" I have observed with all those I have examined so far that after a full dose of drops, they have no trouble reading text with their own glasses from a distance of 30-40 cm, corresponding to a visus of one. In other words, they all suffer from an accommodation spasm which only relaxes enough to give them the same distance visus with their own glasses as they would have with a slightly stronger pair. In my opinion, this is proof of pseudomyopia. But how can I explain to the patients that they should not wear minus glasses at all.
........
2 December
Yesterday at the company's Christmas party I got talking to a surgeon and happened to mention the ideas of Tetralogia. He had already heard about your book and wished to read it. … He showed more understanding than many of our ophthalmologist colleagues (and told me he had heard from a physiatrist how the wearers of minus glasses kept coming for headache treatments after getting stronger prescriptions). I, too, have always been irritated by myopes who complain about headaches. They should, logically speaking, be free of headaches, and hence the false conclusion: the eyes cannot be the cause of your headaches.)
Yes, Kaisu, we have a lot to thank you for. You have indeed achieved more than our whole science of ophthalmology all put together so far. From here, it will be good to carry on.
I would love to come and let you examine me some time. I would not like to take a lot of your time, but I believe a basic examination would be a good idea (with one eye, I can see "soot particles", so I started suspecting vitreous ablation – that could indeed be possible).
With love,
Aune
***
Christmas 1973
Dear Kaisu,
thank you for taking the time to write despite your pneumonia. I ran into Heta at Stockmann's last Saturday, and she was really surprised that you were able to come and spend that long evening with us. I am just as convinced as you are that you put your health at risk by writing Tetralogia and looking after your patients. I admire and marvel at your work, which has untold significance, not only to us ophthalmologists – I hardly dare honour myself with the title, as I have caused so much harm by my ignorance – but more than anything to the suffering mankind (this without any attempt at sounding pathetic).
After finally understanding the idea I have seen that all my patients really are variations of the same theme. It is heart-rendering to see in my chair a girl aged 15 or 16 who has worn minus ad 5.50 glasses since she was 9 and who already has irrevocable, irregularly shaped atrophic white areas in the eye fundus. And what is worse, she is so fixated to her glasses that she will not give them up, not even while she is waiting for cycloplegia. I only wish from the bottom of my heart that I can keep her until my other colleagues see the truth. I so enjoy my work when I know what I am doing, can get results and be certain about them. You were of course right in assuming that it was high time for Maadi (her daughter) to wear plus glasses (at 10 years of age). One of her eyes had already tightened to +0.5, the other remained at +1.50. I examined at the same time a couple of other girls in her class, and they all now wear +1.50 glasses to start with. Both had often complained of headaches. I should have picked up on it ages ago. In a manner of speaking, they read twice as much as the others, all subjects both in French and Finnish, write a lot and spend a lot of time on their homework. Maadi loves school and for her own pleasure does maths exercises far exceeding what her teacher asks her to do.
You may guess I have had many chats with my colleagues, but I cannot say I've made much progress. It appears very difficult for them to see the forest for the trees. By the way, I was going to mention that when I was teaching the last group of students, I managed to interest some of them. One of the students started carefully asking how you should go about prescribing those cylinders. I said you might as well forget everything about the cylinders, and told them why. I should also say that this started an exceptionally lively discussion, and they asked if I was now teaching them some completely new doctrine. I said, of course, that this idea has already been published, and I would like to think they went to the library to read Tetralogia. Sometimes I wonder about this carefully planned teaching of ours: fragmented details with no content or guidelines. They respectfully listen to the clear-cut and erudite lectures of such as Ahti (Professor Tarkkanen), and I am sure they are convinced that ophthalmology must be something extremely advanced and difficult to understand. I am only so disgusted to witness all the evil that senseless prescriptions have caused. In the US, optometrists – you know, that lower cast – tend to say that the greatest cause for sore eyes and headaches is the ophthalmologist. I only think about the mass examinations of schoolchildren – distance visus, retinoscopy under cycloplegia and a prescription for glasses, all on a single breath. Yesterday I saw a young man studying for the entrance exams of a techincal college who came to Helsinki to get reading glasses. At Lehtinen's he had got weak minus glasses with a prism, the next colleague said that he needed no glasses (by the way, that was K....o, so not even he has picked up on the basics yet!) and finally, he got plus glasses from me. However, he had already spent hundreds of Finnmarks. I can only say that the patients have more sense than highly educated doctors.
I myself now have my Executives: the top part is -1.75 and the line of the bottom part +1, so high up that when I am looking straight ahead I can immediately go back to the plus side in case I have been obliged to look through the minus section. To my own surprise, I really have in this short time gone down by almost one dioptre. In other words, I wear the plus glasses for using the microscope and ophthalmoscope, which has made the work immensely easier. But as you said, I was rapidly heading down the road of suffering. Unexplained heart cramps, peculiar periodic intestinal cramps (which even led into that gallstone operation) and now, this autumn, insomnia and feelings of anxiety and tiredness that were always with me. The only thing that kept me from relying on psychopharmacological medications was my fear of drugs only releaving symptoms.
It may be too early to say that I am now well, if a follow-up period is required, but in my own mind I am convinced that I have recovered completely, and what a relief it was to know the cause to my symptoms. You are certainly right in that refraction could solve many psychiatric and other inexplicable cases. I am so grateful for my own recovery that I can never find words to describe it. Oh yes, and migraines; I spotted another new medication(?)in Duodecim, with which they claimed they had achieved some kind of results. I myself only a couple of years ago suffered a typical severe attack after going to see a performance of Carmen at the ice hockey stadium. I felt slightly nauseous coming home, but early in the morning I woke up with a dreadful headache and started vomiting. I should have seen that it was caused by the oculovagal reflex, which may have been further provoked by the fact that I was sitting high up near the ceiling and had to strain to see anything on a stage that seemed unnaturally small over too long a distance.
I would suggest that you should write about these reflectory symptoms. It could help untold numbers of patients and doctors. A few days ago in the coffee room a young, athletic otologist colleague of mine mentioned something about having had a severe attack resembling a pyloric spasm and seemed to be very much puzzled by the fact that it had hit him like a bolt from the blue. I asked him straight away it he wore minus glasses. Yes, he did. I said this could even be the reason. He was clearly interested, but wondered when I urged him to do away with his glasses at least when they are not absolutely necessary. But the glasses feel so good, he replied. Well, that's the whole point. We unhappy pseudos don't even realize how we tightened ourselves and our autonomic nervous system to the limit. Every word in Tetralogia is so apt that now that I am really reading it I cannot but wonder. What clarity and accuracy of observations, what correct conclusions, and finally a therapy that we knew nothing about, only getting it right sometimes by accident. This is how it feels. Indeed, the share of clear diseases is insignificant both in our field but also in that of internal medicine. But we are content to treat our idiopathic ablations and high blood pressure once the harm has already been done and publish our completely useless scientific studies without even realizing that in actual fact, we have achieved very little. Round and round it goes, and we go along with it.
I am sure I'm exhausting you, but what is in my heart is in my mouth, and it's great to unburden myself when so far, I cannot get any response here. You may be sure that I will do everything in my power for this cause. It is a great joy and honour to me, with no intention of going all solemn on you.
Now you have to get yourself better, and if I could, I would order you to take a year off, and if I were able to, I would gladly take care of your patients in the meantime.
...Merry Christmas! Thank you for your promise to examine me, as I would be very interested in observing your system on the spot. If you have recovered, I will come to Turku for a study visit some time early next year. Now that I am fairly clear about the general principles, I don't think that learning would be wasted on me.
So long, Aune
***
On 20 January 1974, Aune ia. writes:
…and as I have said, I find Tetralogia the most valuable ophthalmologic work I ever read!
(By the way; this "overly smart" colleague of mine told me in some connection that they say in England Duke-Elder knows nothing about refraction!)
I also met (the above-mentioned surgeon) – recently (he had already referred another headache patient to me in the meantime) and said that he now fully understands the state of terrible parasympathetic irritation that asp (accommodation spasm) patients live in.
Only ophthalmologists refuse to understand.
Many thanks for your instructions and unbeatable comment "the cloudier your vision, the sooner you will be better". I could not put it better myself.
***
On 12 April 1974, Aune writes: :
I just took a glance at the textbook "Ophthalmology, Principles and Concepts" written by Newell that is very popular at the clinic. I was astounded to see that there wasn't so much as a chapter dedicated to refraction. Only the examination of visus was described shortly. Ophthalmologists don't realize they have turned their backs on the most essential thing!
I rechecked it: at the end of the thick book I found a small "chapter" that was not titled refraction but "Optical Defects of the Eye" – in other words, precisely what us ophthalmologist want to see in refraction – and again no clinical symptoms and nothing about the role of accommodation.
Further, on 21 April 1976
...what an experience the day before yesterday as I was watching a ballet performance filmed at the Bolshoi Theatre on TV : I tried my small opera glasses for a few seconds. While I could see the smallest details, I felt such a cramp in my chest that I told Norman about it straight away. He told me at once to put on my glasses, which where right there by my side.
After looking at my website, patient NN wrote to me (an excerpt):
I'm sure I wouldn't be sitting here writing at all without you. I will never forget the 20-kilometre bus journey home from your surgery.
I came to your office with glasses that were -2 Sf, -3 Cyl, and I thought I couldn't even read number plates, as I had such a bad case of astigmatism. Indeed, I could not see the whole plate to begin with. After rather a lot of itching, the persistent cramp relaxed, and to my surprise I was able to read the numbers. The doctor was not perfectly happy with me, as I mixed up the numbers 3 and 8. Apparently I was an interesting and open-minded patient, as I was made sit on the chair for two and a half hours.
My front was soaking wet from the water running down from my eyes. The doctor asked me to look at the glasses on my nose that had given me the visus of 1. They had +2 lenses.
On the way home I did not put the old glasses on my nose, as I understood my problem.
To my surprise, I could read the newspaper of the person sitting in front of me – without glasses. For a few days I felt wonderfully relaxed and happy. But the spasm gradually deteriorated. I found the new glasses satisfactory, however. Acquaintances travelling on the same bus said I looked more relaxed and no longer so tense.
This took place some 28 years ago, but these events were etched on my memory forever. I am now 72 and feel healthy and active. I still have small scars on my forehead as a souvenir of three careers.
But what indeed is the value of my real hyperopia?
She relates further:
My own optician – when I said that these glasses make my back sore - just laughed at the idea of the glasses affecting my back.
He did not get it.
