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Percutaneous Tuberculin
564
EDITORIALS
shelter in caves. The need for the rapid adaptation of the eye has become enor mously greater since the adoption of electric lighting within the memory of men now living. The quick adaptation of the eye comes through contraction and dilata tion of the pupil. W i t h a sudden flash of light the pupil contracts almost instant ly. By repeated flashes of lightning the swift ■ pupillary contractions preserve enough of dark adaptation to be quite serviceable in the intervals between the flashes. When the pupil is contracted by such a flash, the contraction is immedi ately followed by a dilatation, and there is a series of contractions and dilatations that follows a decided change of illumi nation. These have been studied by various observers. It is generally agreed that these decreasing oscillations of the pupil, under laboratory conditions, may continue gradually for ten or fifteen minutes. The writer has experienced at times, when going out from a dark room into strong mid-day sunshine, a sharp pain in the eye, which lasted for several minutes and gradually declined. This seemed to be due to the spasmodic contraction of the pupillary sphincter. There are some people who have as a congenital anomaly a pupil that will not dilate to more than two or three millimeters in diameter. Such eyes can read newspaper print, even when the ciliary muscle is fully paralyzed by atropine. But they are practically blind for many minutes after going into dark ness. A mining engineer who had such pupils had noticed for years that when he went down into a mine with a group of men, the others could see immedi ately. But it took him ten or twenty minutes before he regained equally good vision. For most people who have an abnormal fear of light, the going into strong light is most disagreeable. Their unpleasant sensations are in creased by fatigue, or nervous excite ment. Such photophobia is not generally due to permanent unfitness for strong light, but to the sudden exposure to it. Care to prepare for the change, by look ing out of a window, or standing in the shade two or three minutes on going out, will very often give relief from or
prevent this annoying symptom. There is need that ophthalmologists study the facts of light-dark adaptation, both from the side of personal experi ence and through the observations of intelligent patients. It is not likely that adaptation is so rigidly defined and limited by evolution that the experi ences of one or a few observers could furnish adequate information for a full understanding of the subject. Even to determine what features of adaptation are general and important will require more wide and general acquaintance with the facts than can be acquired by a few investigators working in special ized laboratories. Some things which investigators have observed may have unsuspected significance; other things may be merely accidental and mislead ing. The wider observations are needed to discriminate which characters are general and important. Especially we need to know more about the slow, primitive, retinal adaptation to dawn and twilight, and the adaptation of eyes that present different forms of congen ital, or acquired, amblyopia. The sub ject of afterimages is closely related to retinal adaptation, but that is another story. Edward Jackson PERCUTANEOUS TUBERCULIN Skin reactions play an extremely im portant part in the process of immuni zation. Among the infectious diseases, the most likely to be followed by satis factory immunity against further at tacks are those producing an exanthem, such as smallpox or measles. The skin is thus to be regarded as the chief source of immunity. Lowenstein (Zeitschrift fur Augenheilkunde, 1935, volume 85, page 191) insists that the best results in specific treatment of chronic tuberculous dis eases of the eye are obtained in cases which give a sharp reaction at the site of inoculation. For this reason, many of those ophthalmologists who use tu berculin have substituted the intracutaneous for the subcutaneous method of administration. Unfortunately, with the utmost care as to dosage, even the intracutaneous
EDITORIALS method frequently produces very dis agreeable general and local disturb ances, although superior in this respect to the subcutaneous method. The dan ger is particularly present in cases of recurrent hemorrhage into the vitreous. For these reasons Lowenstein has for some time resorted to what he calls the percutaneous mode of inoculation. An area as large as the palm of the hand is abraded with a square of sandpaper, to the extent of removing epithelium, but without producing even minimal amounts of bleeding. On to the abraded area is dropped old tuberculin in a dos age beginning with one drop and in creasing to eight drops, and the vaccine is rubbed in vigorously with a glass rod. It is possible to use this method even in cases of extreme hypersensitivity to tu berculin, for the skin reaction is accom panied by little or no local reaction. The cutaneous reaction consists of diffuse reddening of the inoculated area, usually appearing after twentyfour hours, and sometimes associated with formation of minute blebs. A fur ther application should not be under taken until five days have elapsed after complete disappearance of the skin re action. In the course of three years of steady use of this method, Lowenstein has never seen an incidental rise of tem perature. A few patients had headache at the height of the reaction. A striking accompaniment of the skin reaction was a decided paling of the affected eye. In illustration, Lowenstein cites the case of a physician of fifty-five years who had had many recurrences of iridocyclitis in each eye. H e also suffered from severe painful curvature of the cervical and upper thoracic spine. The percutaneous method gave a very marked skin reaction, with bleb forma tion. All the iritic symptoms disap peared much more rapidly than in pre vious relapses, and there was also a surprising cessation of the supposedly rheumatic pains in the vertebral col umn, which hitherto had been constant ly present. T h e patient continued his own treatment for eight months with out ocular recurrence and with great improvement in the spinal condition. William H. Crisp.
S6S
L E N S SEGMENTS FOR DIVERS PURPOSES Among the many advances in the science of optics, one of the most useful has been the notable improvement in bifocal lenses since their introduction. Admitting that some of the refinements may be "ultra," exceeding the necessity or even the appreciation of many to whom they are sold at an increased cost over the standard models, no one can question the tremendous advantage of fused forms over "pasters" or of the possibility of using segments of a size and shape suited to the vocation or avo cation of the wearer. It is only the inexperienced ophthal mologist who overlooks the importance of giving careful thought to prescribing the most acceptable bifocal for his pa tient. Many a patient has been rendered unhappy and dissatisfied with his eye physician because an unfortunate choice was made in this part of the pre scription. That one type of segment is not ideal for every kind of work is ob vious; that for certain vocations the best that is possible in shape, size, and position is far from satisfactory is equally apparent, but much may be done to select the most useful form for the individual need. I t is well to allow ample time for this phase of the consultation. Too often, after a very careful refraction and gen eral study of the ocular condition, only a very brief time is taken to consider the exact use which the patient wishes to make of his glasses. Probably most oculists inquire concerning the patient's occupation and have recognized the special needs of workers engaged in certain activities, such as stenography, music, machine-shop work, card play ing, and so forth, and have come to conclusions as to what focal distances are required and what sized segments for each of these, but this is by no means the whole problem even if the general principles have been well con sidered because individual differences exist in the work in all of these voca tions and in the preferences of the pa tient. By the time the age of bifocals is
EDITORIALS
shelter in caves. The need for the rapid adaptation of the eye has become enor mously greater since the adoption of electric lighting within the memory of men now living. The quick adaptation of the eye comes through contraction and dilata tion of the pupil. W i t h a sudden flash of light the pupil contracts almost instant ly. By repeated flashes of lightning the swift ■ pupillary contractions preserve enough of dark adaptation to be quite serviceable in the intervals between the flashes. When the pupil is contracted by such a flash, the contraction is immedi ately followed by a dilatation, and there is a series of contractions and dilatations that follows a decided change of illumi nation. These have been studied by various observers. It is generally agreed that these decreasing oscillations of the pupil, under laboratory conditions, may continue gradually for ten or fifteen minutes. The writer has experienced at times, when going out from a dark room into strong mid-day sunshine, a sharp pain in the eye, which lasted for several minutes and gradually declined. This seemed to be due to the spasmodic contraction of the pupillary sphincter. There are some people who have as a congenital anomaly a pupil that will not dilate to more than two or three millimeters in diameter. Such eyes can read newspaper print, even when the ciliary muscle is fully paralyzed by atropine. But they are practically blind for many minutes after going into dark ness. A mining engineer who had such pupils had noticed for years that when he went down into a mine with a group of men, the others could see immedi ately. But it took him ten or twenty minutes before he regained equally good vision. For most people who have an abnormal fear of light, the going into strong light is most disagreeable. Their unpleasant sensations are in creased by fatigue, or nervous excite ment. Such photophobia is not generally due to permanent unfitness for strong light, but to the sudden exposure to it. Care to prepare for the change, by look ing out of a window, or standing in the shade two or three minutes on going out, will very often give relief from or
prevent this annoying symptom. There is need that ophthalmologists study the facts of light-dark adaptation, both from the side of personal experi ence and through the observations of intelligent patients. It is not likely that adaptation is so rigidly defined and limited by evolution that the experi ences of one or a few observers could furnish adequate information for a full understanding of the subject. Even to determine what features of adaptation are general and important will require more wide and general acquaintance with the facts than can be acquired by a few investigators working in special ized laboratories. Some things which investigators have observed may have unsuspected significance; other things may be merely accidental and mislead ing. The wider observations are needed to discriminate which characters are general and important. Especially we need to know more about the slow, primitive, retinal adaptation to dawn and twilight, and the adaptation of eyes that present different forms of congen ital, or acquired, amblyopia. The sub ject of afterimages is closely related to retinal adaptation, but that is another story. Edward Jackson PERCUTANEOUS TUBERCULIN Skin reactions play an extremely im portant part in the process of immuni zation. Among the infectious diseases, the most likely to be followed by satis factory immunity against further at tacks are those producing an exanthem, such as smallpox or measles. The skin is thus to be regarded as the chief source of immunity. Lowenstein (Zeitschrift fur Augenheilkunde, 1935, volume 85, page 191) insists that the best results in specific treatment of chronic tuberculous dis eases of the eye are obtained in cases which give a sharp reaction at the site of inoculation. For this reason, many of those ophthalmologists who use tu berculin have substituted the intracutaneous for the subcutaneous method of administration. Unfortunately, with the utmost care as to dosage, even the intracutaneous
EDITORIALS method frequently produces very dis agreeable general and local disturb ances, although superior in this respect to the subcutaneous method. The dan ger is particularly present in cases of recurrent hemorrhage into the vitreous. For these reasons Lowenstein has for some time resorted to what he calls the percutaneous mode of inoculation. An area as large as the palm of the hand is abraded with a square of sandpaper, to the extent of removing epithelium, but without producing even minimal amounts of bleeding. On to the abraded area is dropped old tuberculin in a dos age beginning with one drop and in creasing to eight drops, and the vaccine is rubbed in vigorously with a glass rod. It is possible to use this method even in cases of extreme hypersensitivity to tu berculin, for the skin reaction is accom panied by little or no local reaction. The cutaneous reaction consists of diffuse reddening of the inoculated area, usually appearing after twentyfour hours, and sometimes associated with formation of minute blebs. A fur ther application should not be under taken until five days have elapsed after complete disappearance of the skin re action. In the course of three years of steady use of this method, Lowenstein has never seen an incidental rise of tem perature. A few patients had headache at the height of the reaction. A striking accompaniment of the skin reaction was a decided paling of the affected eye. In illustration, Lowenstein cites the case of a physician of fifty-five years who had had many recurrences of iridocyclitis in each eye. H e also suffered from severe painful curvature of the cervical and upper thoracic spine. The percutaneous method gave a very marked skin reaction, with bleb forma tion. All the iritic symptoms disap peared much more rapidly than in pre vious relapses, and there was also a surprising cessation of the supposedly rheumatic pains in the vertebral col umn, which hitherto had been constant ly present. T h e patient continued his own treatment for eight months with out ocular recurrence and with great improvement in the spinal condition. William H. Crisp.
S6S
L E N S SEGMENTS FOR DIVERS PURPOSES Among the many advances in the science of optics, one of the most useful has been the notable improvement in bifocal lenses since their introduction. Admitting that some of the refinements may be "ultra," exceeding the necessity or even the appreciation of many to whom they are sold at an increased cost over the standard models, no one can question the tremendous advantage of fused forms over "pasters" or of the possibility of using segments of a size and shape suited to the vocation or avo cation of the wearer. It is only the inexperienced ophthal mologist who overlooks the importance of giving careful thought to prescribing the most acceptable bifocal for his pa tient. Many a patient has been rendered unhappy and dissatisfied with his eye physician because an unfortunate choice was made in this part of the pre scription. That one type of segment is not ideal for every kind of work is ob vious; that for certain vocations the best that is possible in shape, size, and position is far from satisfactory is equally apparent, but much may be done to select the most useful form for the individual need. I t is well to allow ample time for this phase of the consultation. Too often, after a very careful refraction and gen eral study of the ocular condition, only a very brief time is taken to consider the exact use which the patient wishes to make of his glasses. Probably most oculists inquire concerning the patient's occupation and have recognized the special needs of workers engaged in certain activities, such as stenography, music, machine-shop work, card play ing, and so forth, and have come to conclusions as to what focal distances are required and what sized segments for each of these, but this is by no means the whole problem even if the general principles have been well con sidered because individual differences exist in the work in all of these voca tions and in the preferences of the pa tient. By the time the age of bifocals is