"This is Runnymede, where the famous Magna Carta was signed," said the English tour guide to the American tourists.

"When was that?" asked one of the tourists.

"1215," replied the guide.

"Geez, Myrtle," said the tourist to his wife as he glanced at his watch. "We only missed it by 45 minutes!"

I also was a tourist in Merry Olde England recently and learned an exception to a tenet I've always preached in these columns.

Where angels fear to tread

My wife and I were "elder hosteling" outside the small village of Wye in southeastern England. One day, we discovered that we needed something (I'll explain later) obtained only from a chemist (English for pharmacist).

In discussing this item with Wye's only chemist, I inadvertently ventured where customers weren't supposed to tread. Looking down his nose and with a nasty tone, the chemist said:

"This is what you do in the United States? Barge right into a chemist's private area?"

Exception to my rule

His snide comment wasn't the best way to build good patient rapport, which I've always maintained is even more important to a successful practice than technical skill. But then it dawned on me: This case was probably the one exception to the rule.

If you have a patient who:

a.      lives 4,000 miles away and will never be back again, and

b.      you have the only badly needed service available within 10 miles, and

c.      the patient has no transportation to go elsewhere, then

d.      You don't have to pay attention to building patient rapport. In all other cases, it's still important.

A special diet

So what was this much-needed item? My wife has Sj�gren's syndrome, which has caused her immune system to destroy her salivary glands, in addition to producing dry eye problems. She can't eat solid food and exists almost entirely on Ensure liquids. This is what we found we could obtain only from Wye's "friendly" chemist.

I've learned a great deal about Sj�gren's in the 6 years she's had it. First of all, it's a difficult disease to diagnose, and many M.D.s have never even heard of it. Conversely, I've never known an O.D. who wasn't aware of Sj�gren's as part of our work with dry eyes. This makes our role in diagnosing it vital.

Sj�gren's "is so hard to diagnose that patients spend years hunting a medical Sherlock Holmes to solve the puzzling symptoms," according to an Associated Press news release of Sept. 19, 2000. The release continued, "frustrated by the ignorance, the National Institutes of Health this week holds an unprecedented meeting to teach health workers how to spot Sj�gren's and ease symptoms."

Moisture seekers

One way to learn more is to contact the Sj�gren's Syndrome Foundation (1-800-475-6473), or at www.sjogrens.org, to request that they send you their monthly newsletter, The Moisture Seekers.

"I went from doctor to doctor trying to find out what was wrong," read typical letters I've seen there. "Many told me it was all in my mind and that there was nothing wrong.

"It was such a relief to finally, after many years, find a doctor who was aware of Sj�gren's and could diagnose my problem!"

Become a hero

According to a Sj�gren's Syndrome Foundation estimate, up to 4 million Americans are affected by this disease -- many remain undiagnosed. How can you help?

�         Question female dry eye patients (90% of Sj�gren's sufferers are women) as to whether they also have dry mouth or spells of fatigue to determine whether to refer them to an immunologist for a definitive diagnosis.

�         Polish up on the subject. Know what to look for, and you could become a hero to some of the undiagnosed Sj�gren's patients who're frantically visiting multiple doctors trying to find out what's wrong.

Jack Runninger, our consulting editor, lives in Rome, Ga. He's a past editor of Optometric Management.