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Is Sympathetic Ophthalmia Tuberculous?
AMERICAN JOURNAL OF OPHTHALMOLOGY PUBLISHED MONTHLY BY THE OPHTHALMIC PUBLISHING COMPANY EDITORIAL STAFF LAWRENCE T. POST, editor H. ROMMEL HILDRETH 524 Metropolitan building, Saint Louis 824 Metropolitan building, St. Louis WILLIAM H. CRISP, consulting editor PARK LEWIS 530 Metropolitan building, Denver 454 Franklin street, Buffalo EDWARD JACKSON, consulting editor M. URIBE TRONCOSO 1120 Republic building, Denver 3S0 West 85th street, New York HANS BARKAN M. F. WEYMANN Stanford University Hospital, San Fran 903 Westlake Professional building, Los cisco Angeles HARRY S. GRADLE JOHN M. WHEELER 58 East Washington street, Chicago 30 West Fifty-ninth street, New York Address original papers, other scientific communications including correspondence, also books for review and reports of society proceedings to Dr. Lawrence T. Post, 524 Metropolitan building, Saint Louis. Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan building, Denver. Subscriptions, applications for single copies, notices of change of address, and com munications with reference to advertising should be addressed to the manager of subscrip tions and advertising, 508 Metropolitan building, Saint Louis. Copy of advertisements must be sent to the manager by the fifteenth of the month preceding its appearance. Authors' proofs should be corrected and returned within forty-eight hours to the editor. Twenty-five reprints of each article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Com pany, 450-458 Ahnaip street, Menasha, Wisconsin, if ordered at the time proofs are re turned. But reprints to contain colored plates must be ordered when the article is accepted. IS SYMPATHETIC OPHTHALMIA TUBERCULOUS? The numerical incidence of sym pathetic ophthalmia is not so large as to constitute a community problem of ma jor importance. But, to the individual patient and his family, and to the oph thalmic physician concerned in the case, this malady presents one of the most tragic experiences possible in life or in the realm of medicine. The determina tion of its etiology has long been counted among the seeming impossi bilities of medical science. Few were satisfied by the theory that the virus of the disease passed by way of the optic nerves and the optic chiasm from one eye to the other. Some, like the elder Fuchs, were disposed to be lieve that whatever organism was to blame traveled through the blood stream and so lodged in the second eye. Some twenty-five years ago Elschnig put forward his anaphylactic theory, ac cording to which the disintegrated pig ment of the injured uveal tract acts as an antigen. Knapp and Woods, among others, supported this theory and used
uveal pigment therapeutically, with the object of diminishing the risk of sym pathetic ophthalmia after injury. The microscopic appearance of the granulomatous tissue in the primary and the secondary eye bears so close a resemblance to the tuberculous granu loma that a number of authors have tried to establish a relationship between sympathetic ophthalmia and tubercu losis. Several Japanese writers have written enthusiastically concerning the therapeutic value of "AO", a tubercu losis vaccine developed by Arima, Aoyama, and Ohnawa ; and one writer, Nakamura, last year published a paper (Klinische Monatsblätter für Augen heilkunde, volume 89, page 43) upon the successful treatment of exudative uveitis and also sympathetic ophthalmia by means of "AO". All of these uveal con ditions in which Nakamura has used the vaccine are regarded by him as having a very close etiologic connection with tuberculosis. Meiler, of Vienna, who has devoted a great deal of attention to tuberculosis in its relation to the eye, at last claims
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to have proved definitely that sym pathetic ophthalmia is tuberculosis lo cating in the uveal tract of the injured eye (Zeitschrift für Augenheilkunde, volume 79, page 95). The histologie and cultural bases of what may prove to be an epoch-making discovery are given in elaborate detail, with a beautiful series of illustrations. The patient was a cabinet maker of forty-two years whose left eye was penetrated by a splinter of steel. The steel was removed, but six weeks after the injury with the usual symptoms of persistent iridocyclitis in the injured eye, the second eye became involved. The pathologic changes in the injured eye were in every detail typical of sym pathetic uveitis. Those who desire to continue the investigation along the lines laid down by Meiler will be in terested in the technique employed by Meller's Viennese colleague, the path ologist Löwenstein, in the study of Meller's case. The intraocular tissue was carefully ground in a sterile mor tar for fifteen minutes or so until a black emulsion was formed; the emul sion shaken for five minutes with twice its volume of fifteen percent sulphuric acid; the mixture considerably diluted with sterile distilled water and vigor ously centrifuged ; the sediment washed with distilled water and again centri fuged ; and the final sediment carefully flowed on to three tubes of egg culture medium with a pipette. Distinct macroscopic growths of tu bercle bacilli were obtained on these culture tubes, and microscopic cultures of the bacilli were obtained on cultures inoculated with the blood of the pa tient, taken on the day of the enucleation. Animal experiments were positive for tuberculosis in the cultures from both sources. Examination of the blood ten days after operation was equally positive. Many medicinal remedies have been employed for sympathetic ophthalmia —Gifford's massive doses of sodium salicylate, antiluetics including ancient mercury and modern arsenicals, and tu berculin as recommended by some re cent writers including Meiler and Nakamura. Of interest in this connection
is a very recent report by Wachendorff on the successful treatment of three cases of sympathetic ophthalmia with intravenous injections of atophanyl, a solution of 0.5 gram of atophan with 0.5 gram of salicylic acid (Klinische Monatsblätter für Augenheilkunde, vol ume 90, page 81). With his injections of "AO", the Japanese tuberculin above referred to, Meiler combined the ener getic use of mercury. In another paper (Zeitschrift für Augenheilkunde, volume 79, page 110), Melier describes a previous case of se vere sympathetic ophthalmia in which he was able to demonstrate tubercle ba cilli in the blood stream ; and he quotes with approval Hippel's declaration that "the histologie picture of sympathetic ophthalmia contains nothing that is in any respect in opposition to the diag nosis of tuberculosis". Some may doubt the finality of Mel ler's triumphant conclusion that "a dis cussion which has lasted for decades on the question of the connection of sym pathetic ophthalmia with tuberculosis is thus decided beyond cavil". I t is often difficult or impossible to differentiate histologically between granulomatous conditions arising from separate causes ; and the ultimte judgment may be that tuberculosis is simply one of several exciting agents of sympathetic ophthal mia. But the technique employed and the results obtained by Löwenstein and Meiler should prove the starting point for much useful investigation. Meiler suggests that the abundance of intra ocular hemorrhage associated with per forating injury to the ciliary body may favor the lodgment of tubercle bacilli; but he at once proceeds to ask the ques tion why sympathetic ophthalmia does not follow non-penetrating contusions of the eyeball, which also are often ac companied by profuse intraocular bleeding. The invasion of the second eye may depend upon an increased outpour ing of tubercle bacilli into the blood stream and associated changes in the biologic qualities of the bacilli, adapt ing them for successful attack upon uveal tissue. Among other questions which Meiler propounds for investigation are the fol-
EDITORIALS lowing: (1) W h y were all previous in oculations of tissue from eyes enucle ated because of sympathetic ophthalmia into animals sensitive to tuberculosis negative, whereas the germs cultivated from the tissue upon laboratory medium showed typical development in these animals? (2) W h y is the proliferative form of uveitis especially apt to pro duce involvement of the uvea of the second eye? W . H. Crisp. DEFINITIONS OF B L I N D N E S S There is a popular impression that everyone knows what blindness means ; as Dogberry believed, "to write and read comes by nature". But those who deal with the blind know there are among those called blind amounts of vision that vary from absence of all light perception, up to a quite useful ability to recognize objects at some dis tance. In deciding whether a certain in dividual is blind enough to claim bene fits, accorded to the blind by charity, or legislature, it is often necessary to fall back on a legal interpretation ; and de cide that such a person is, or is not blind within the intention of the law. Total blindness, loss of all light per ception, is entirely different from eco nomic blindness—inability to perform any work for which sight is essential ; or from educational blindness—too blind to read the ordinary school books used by children. It has been attempted to fix the limit of blindness at a certain fraction of full visual acuity at a dis tance, at less than 6/60 or 1/10. But to ignore the field of vision and the light sense, admits grave confusion and in justice. In discussing the certification of blindness N. Bishop Harman, of Lon don (The Medical Officer, Dec. 24, 1932), who has done much to prevent blindness and assist the blind, mentions three cases that illustrate the practical difficulties encountered. A woman with chronic glaucoma, V. = 6/9 ; but with field limited to 5° from the fixation point, can read when she can find the place; but cannot walk without being led, and cannot see to shake hands with a visitor.
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A country parson, with central senile choroiditis, and V. = 0, but a good peripheral field, has complete freedom of movement, and knows his prayerbook ; and so goes about and performs all his parish duties. A volunteer officer with retinitis pigmentosa, had full vi sion and good fields, by daylight; but had to be led when marching at night. Organic blindness due to ocular le sions can be recognized or excluded with certainty. But psychic blindness, as il lustrated by "shell shock", and hysteria, may puzzle or defeat the most experi enced diagnosticians. Seeing is done, not with the eye but the brain. The great mass of cerebral convolutions, that have developed with accurate macular vision, explains the enormous influence of vision upon all our con sciousness; and suggests the possible influences of cerebral function upon vi sion. Perhaps the broad practical defini tion for blindness is important defi ciency of useful vision. In schools for the blind it is recognized that a large proportion of children have some sight. Harman says, "where there is no full provision for children with defective sight, and no choice between the ele mentary school and the blind school, it is inevitable that border-line cases will be drafted into the blind schools. The certification of blindness in children can rarely be final. It should always be recognized as provisional and subject to revision". No sharp and permanent line can be drawn between blind and seeing, either by a formal definition, or a scien tific test; and it is not desirable that there should be such a discrimination. The majority of those called blind can find satisfaction and usefulness, in the exercise of the remnant of vision they do possess. The most that can be done for them is to help them keep and use what sight they have. When it becomes necessary to discriminate between the seeing and the blind, for purposes of education or care, each case should be carefully studied for itself ; by a person trained and experienced for such exam inations, both as to ocular conditions present, and as to other abilities and surroundings. Each blind person pre-
uveal pigment therapeutically, with the object of diminishing the risk of sym pathetic ophthalmia after injury. The microscopic appearance of the granulomatous tissue in the primary and the secondary eye bears so close a resemblance to the tuberculous granu loma that a number of authors have tried to establish a relationship between sympathetic ophthalmia and tubercu losis. Several Japanese writers have written enthusiastically concerning the therapeutic value of "AO", a tubercu losis vaccine developed by Arima, Aoyama, and Ohnawa ; and one writer, Nakamura, last year published a paper (Klinische Monatsblätter für Augen heilkunde, volume 89, page 43) upon the successful treatment of exudative uveitis and also sympathetic ophthalmia by means of "AO". All of these uveal con ditions in which Nakamura has used the vaccine are regarded by him as having a very close etiologic connection with tuberculosis. Meiler, of Vienna, who has devoted a great deal of attention to tuberculosis in its relation to the eye, at last claims
247
248
EDITORIALS
to have proved definitely that sym pathetic ophthalmia is tuberculosis lo cating in the uveal tract of the injured eye (Zeitschrift für Augenheilkunde, volume 79, page 95). The histologie and cultural bases of what may prove to be an epoch-making discovery are given in elaborate detail, with a beautiful series of illustrations. The patient was a cabinet maker of forty-two years whose left eye was penetrated by a splinter of steel. The steel was removed, but six weeks after the injury with the usual symptoms of persistent iridocyclitis in the injured eye, the second eye became involved. The pathologic changes in the injured eye were in every detail typical of sym pathetic uveitis. Those who desire to continue the investigation along the lines laid down by Meiler will be in terested in the technique employed by Meller's Viennese colleague, the path ologist Löwenstein, in the study of Meller's case. The intraocular tissue was carefully ground in a sterile mor tar for fifteen minutes or so until a black emulsion was formed; the emul sion shaken for five minutes with twice its volume of fifteen percent sulphuric acid; the mixture considerably diluted with sterile distilled water and vigor ously centrifuged ; the sediment washed with distilled water and again centri fuged ; and the final sediment carefully flowed on to three tubes of egg culture medium with a pipette. Distinct macroscopic growths of tu bercle bacilli were obtained on these culture tubes, and microscopic cultures of the bacilli were obtained on cultures inoculated with the blood of the pa tient, taken on the day of the enucleation. Animal experiments were positive for tuberculosis in the cultures from both sources. Examination of the blood ten days after operation was equally positive. Many medicinal remedies have been employed for sympathetic ophthalmia —Gifford's massive doses of sodium salicylate, antiluetics including ancient mercury and modern arsenicals, and tu berculin as recommended by some re cent writers including Meiler and Nakamura. Of interest in this connection
is a very recent report by Wachendorff on the successful treatment of three cases of sympathetic ophthalmia with intravenous injections of atophanyl, a solution of 0.5 gram of atophan with 0.5 gram of salicylic acid (Klinische Monatsblätter für Augenheilkunde, vol ume 90, page 81). With his injections of "AO", the Japanese tuberculin above referred to, Meiler combined the ener getic use of mercury. In another paper (Zeitschrift für Augenheilkunde, volume 79, page 110), Melier describes a previous case of se vere sympathetic ophthalmia in which he was able to demonstrate tubercle ba cilli in the blood stream ; and he quotes with approval Hippel's declaration that "the histologie picture of sympathetic ophthalmia contains nothing that is in any respect in opposition to the diag nosis of tuberculosis". Some may doubt the finality of Mel ler's triumphant conclusion that "a dis cussion which has lasted for decades on the question of the connection of sym pathetic ophthalmia with tuberculosis is thus decided beyond cavil". I t is often difficult or impossible to differentiate histologically between granulomatous conditions arising from separate causes ; and the ultimte judgment may be that tuberculosis is simply one of several exciting agents of sympathetic ophthal mia. But the technique employed and the results obtained by Löwenstein and Meiler should prove the starting point for much useful investigation. Meiler suggests that the abundance of intra ocular hemorrhage associated with per forating injury to the ciliary body may favor the lodgment of tubercle bacilli; but he at once proceeds to ask the ques tion why sympathetic ophthalmia does not follow non-penetrating contusions of the eyeball, which also are often ac companied by profuse intraocular bleeding. The invasion of the second eye may depend upon an increased outpour ing of tubercle bacilli into the blood stream and associated changes in the biologic qualities of the bacilli, adapt ing them for successful attack upon uveal tissue. Among other questions which Meiler propounds for investigation are the fol-
EDITORIALS lowing: (1) W h y were all previous in oculations of tissue from eyes enucle ated because of sympathetic ophthalmia into animals sensitive to tuberculosis negative, whereas the germs cultivated from the tissue upon laboratory medium showed typical development in these animals? (2) W h y is the proliferative form of uveitis especially apt to pro duce involvement of the uvea of the second eye? W . H. Crisp. DEFINITIONS OF B L I N D N E S S There is a popular impression that everyone knows what blindness means ; as Dogberry believed, "to write and read comes by nature". But those who deal with the blind know there are among those called blind amounts of vision that vary from absence of all light perception, up to a quite useful ability to recognize objects at some dis tance. In deciding whether a certain in dividual is blind enough to claim bene fits, accorded to the blind by charity, or legislature, it is often necessary to fall back on a legal interpretation ; and de cide that such a person is, or is not blind within the intention of the law. Total blindness, loss of all light per ception, is entirely different from eco nomic blindness—inability to perform any work for which sight is essential ; or from educational blindness—too blind to read the ordinary school books used by children. It has been attempted to fix the limit of blindness at a certain fraction of full visual acuity at a dis tance, at less than 6/60 or 1/10. But to ignore the field of vision and the light sense, admits grave confusion and in justice. In discussing the certification of blindness N. Bishop Harman, of Lon don (The Medical Officer, Dec. 24, 1932), who has done much to prevent blindness and assist the blind, mentions three cases that illustrate the practical difficulties encountered. A woman with chronic glaucoma, V. = 6/9 ; but with field limited to 5° from the fixation point, can read when she can find the place; but cannot walk without being led, and cannot see to shake hands with a visitor.
249
A country parson, with central senile choroiditis, and V. = 0, but a good peripheral field, has complete freedom of movement, and knows his prayerbook ; and so goes about and performs all his parish duties. A volunteer officer with retinitis pigmentosa, had full vi sion and good fields, by daylight; but had to be led when marching at night. Organic blindness due to ocular le sions can be recognized or excluded with certainty. But psychic blindness, as il lustrated by "shell shock", and hysteria, may puzzle or defeat the most experi enced diagnosticians. Seeing is done, not with the eye but the brain. The great mass of cerebral convolutions, that have developed with accurate macular vision, explains the enormous influence of vision upon all our con sciousness; and suggests the possible influences of cerebral function upon vi sion. Perhaps the broad practical defini tion for blindness is important defi ciency of useful vision. In schools for the blind it is recognized that a large proportion of children have some sight. Harman says, "where there is no full provision for children with defective sight, and no choice between the ele mentary school and the blind school, it is inevitable that border-line cases will be drafted into the blind schools. The certification of blindness in children can rarely be final. It should always be recognized as provisional and subject to revision". No sharp and permanent line can be drawn between blind and seeing, either by a formal definition, or a scien tific test; and it is not desirable that there should be such a discrimination. The majority of those called blind can find satisfaction and usefulness, in the exercise of the remnant of vision they do possess. The most that can be done for them is to help them keep and use what sight they have. When it becomes necessary to discriminate between the seeing and the blind, for purposes of education or care, each case should be carefully studied for itself ; by a person trained and experienced for such exam inations, both as to ocular conditions present, and as to other abilities and surroundings. Each blind person pre-