THE WHOLE TRUTH
It would not surprise me at all, if some of our readers
noticed that there was something different about the last
issue of the Glaucoma Letter. More repetitive than usual,
and with an illustration whose legend did not quite match
the drawing, it hardly measured up to the usual standards.
For these various deficiencies, I offer no excuse, but I do
have an explanation. Let me tell a story.
You may remember, it is now almost a year and a half
ago, that I mentioned in these pages my penchant for
traveling, a propensity which brought about, now almost two
years ago, my meeting with Professor K. I have described
the idyllic university town, where half-timbered houses
cluster around the medieval marketplace, and ancient linden
trees shade the sightseer from the glare of the noontime
sun. It was there, in the stuccoed office building of the
local university, that I had met Professor K., who regaled
me, as you may remember, with an account of his mathematical
model of progressive excavation of the optic disc. I did
not understand it then, and I do not understand it now, and
I returned on this occasion, not so much for continuing
education, although I believe that, far from being a
dangerous thing, a little knowledge is better than none at
all, but because I find this world to be a kind of museum,
or, with a view to its inhabitants, "ein zoologischer
Garten", as the Germans would say, and I make it a point,
whenever I go, to be sure to remember to take a look
especially at the rarest of creatures. In short, I
considered Professor K. an unusual and somewhat exotic bird
in this human aviary, and a chance to have another look at
him seemed to me well worth the trouble of a tax-deductible
flight on the Lufthansa 747 with two or three glasses of
Piesporter Spa#tlese, poured by an attractive and attentive
young hostess.
Nothing had changed. It was as if time had stood
still. The door to the waiting room stood open. The
maroon-covered chairs were empty, as I had always found
them. I don't believe he ever saw any patients. It was the
same secretary, the tall lady with the greying hair and the
pleasantly modulated voice, who turned at her desk to
welcome me.
"It is good to see you again," she said. "How have you
been, and how fares your Cambridge Glaucoma Foundation?" I
assured her that all was well. "We received your letter.
Professor K. is waiting for you."
"I hope I do not interrupt him."
"No, not at all," she replied and added confidingly, "It is
not every day that we have a visitor from Cambridge."
It was the same office, and Professor K. was sitting in
the same chair from which he had tried to enlighten me about
his mathematical model. But the computer terminal was gone.
The walls of the room, which seemed not have been painted
since I had last been there, were grayer than I remembered
them. He smiled when he saw me, but he looked tired, and
there were wrinkles in his face that I had not seen there
before.
"You look great," I said, "Not a bit different from the last
time." No sooner had I spoken than I was embarrassed by my
so obviously transparent flattery.
"You Americans always look at the bright side of things."
"Have you been ill?"
"No, I have not been sick, at least not literally, only
tired. Nothing is wrong which a good night's sleep and a
leisurely walk to the Ko#nigswarte will not undo."
"I saw your article about the venous drainage of the optic
disc," I began. I was only trying to make conversation, but
I realized that what I was saying was flattery again, albeit
true.
"Do you agree?"
"I am not sure I understood it completely."
"But surely you examine your patients with an
ophthalmoscope."
"Of course."
"And you look at the disc."
"Every time that I am able to see it."
"Then surely you will have noted that whenever veins from
the upper and lower poles of the disc can be recognized,
they will be seen entering the retinal vein upstream nearer
to the disc margin, while veins from the temporal and nasal
sectors of the disc course across its surface to enter the
retinal vein just as it is about to penetrate the lamina
cribrosa."
"I guess I don't look at the disc that closely."
Professor K. was silent, and I thought I saw the reflection
of critical disapproval in his eyes. Then he collected
himself and continued: "Curiously, I inadvertently neglected
to describe one of the most interesting inferences from my
observations. The veins receiving blood from the upper and
lower poles of the disc contain blood at pressures that
equal the intraocular tension. The veins receiving blood
from the temporal and nasal sectors drain into vessels are
collapsed and therefore their contents are at much less than
intraocular pressure. As the excavation of the optic nerve
deepens, the segment of collapsed vein is displaced
downstream. Admittedly the range of this displacement is
small, no greater than the distance that the lamina cribrosa
is displaced posteriorly. Yet undoubtedly it suffices to
bring into the field of increased intravascular pressure at
least some of the disc drainage that had previously been
protected from it. That provides a tentative explanation
why the excavated disc is relatively more vulnerable to
ocular hypertension."
"I am not sure I understand your theory," I said with some
hesitation.
Professor K. appeared irritated. "Please don't call it a
theory. All that I have to contribute is a set of
observations which if they are correct are accessible even
to the casual ophthalmoscopist." Then he added with some
emphasis: "If you don't understand, perhaps you should go
back and read the paper."
It was obvious that he was in no mood to tutor me.
Perhaps it is best for me to go back to the hotel, I
thought, just possibly to come back in a day or two.
Professor K. must have read my thoughts. He was not ready
to have me go. He changed the topic, and began in a much
more relaxed tone of voice. "If I seem tired that may be
because I have been in court."
"I am sorry to hear that," I said.
"It is not so serious as it sounds. I was not the
defendant. I was not even the plaintiff. I was summoned
only as a witness, and even then I was never called to
testify. But nonetheless, it was a tiring experience."
I said nothing. I did not know what to say. It is not my
custom to inquire into the private affairs of my
acquaintances, but if Professor K. wanted to tell me about
his, that was his prerogative. As I mentioned, I found the
man a little bit out of the ordinary; I was curious, and I
was certainly willing to listen.
"I feel a little bit sheepish," he began, "to have spent so
much time and energy on what is essentially such an
unimportant and trivial matter. But then again I am always
reluctant to circumvent any of the problems that present
themselves to me. Life is so short, that we learn the most,
if we learn from whatever presents itself to us, and we
accomplish the most if we devote ourselves, not to some
remote selected enterprise, but to the task at hand."
He paused, but I had nothing to reply. There is nothing
that one can add to such lofty sentiments.
"A patient of mine with glaucoma was involved in a serious
automobile accident. He was being sued for damages in the
amount of one million marks.
It was not, I should quickly add, that clarion call for
professional accountability from the disgruntled patient who
blames me for an uncomplicated intracapsular cataract
extraction because I did not inform her of the Chimpanzee
Suspensionless Autofocus Intraocular Lens, which, according
to her nextdoor neighbor is so perfect that it improves the
vision even before the patient gets to the operating room.
It was an ordinary accident case, one car hits another
car, and I, as chance would have it, happened to be the
ophthalmologist to the driver.
* * * * *
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Copyright 2006, Ernst Jochen Meyer