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Migraine Due to Allergy
AMERICAN JOURNAL OF OPHTHALMOLOGY P U B L I S H E D M O N T H L Y BY T H E O P H T H A L M I C P U B L I S H I N G COMPANY EDITORIAL STAFF L A W R E N C E T. P O S T editor 524 Metropolitan building, Saint Louis W I L L I A M H. CRISP, consulting editor 530 Metropolitan building, Denver EDWARD JACKSON, consulting editor 1120 Republic building, Denver HANS BARKAN Stanford University Hospital, San Fran cisco HARRY S. GRADLE 58 East Washington street, Chicago
H. R O M M E L H I L D R E T H 824 Metropolitan building, St. Louis PARK L E W I S 454 Franklin street, Buffalo M. U R I B E TRONCOSO 350 West 85th street, New York M. F. WEYMANN 418 Westlake Professional building, Los Angeles J O H N M. W H E E L E R 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.
MIGRAINE D U E TO ALLERGY In a great many cases migraine arises from extraocular sources, without ap parent relation to eyestrain. But the attempt to relieve the sufferer from this distressing malady should always include examination as to the existence of uncórrected refractive error, and for the good of his patient the ophthal mologist ought to know what condi tions outside his own limited field may be to blame. In spite of the significance now at tached to allergy in the whole field of medicine, DeGowin (The Journal of Allergy, 1932, volume 3, page 557) com plains that important recent essays on migraine not infrequently omit any mention of the part played by allergy in the production of that disorder. In 1923 Miller and Raulston reported treatment of twenty-five migrainous patients with intravenous injections of peptone, improvement resulting in eighty-four percent of the cases ; and in 1927 Vaughan related ten cases in which migraine was relieved by elimi 63
nation of specific foods. In Eyermann's series of cases the symptoms disap peared upon elimination of proteins to which the patients reacted, and reap peared upon renewed administration of such specific proteins. The hereditary character of migraine has been attrib uted to an allergic inheritance ; and it must be remembered that dietetic hab its are particularly apt to be handed down through successive generations. DeGowin, working in the Depart ment of Internal Medicine of the Uni versity of Michigan, has studied sixty patients, all of whom were given the same protein sensitivity tests. In the course of half a day it was possible, without considerable inconvenience to the patient, to test for thirty pollens by the scratch method, and for over one hundred foods, epidermals, and miscellaneous substances by the intra dermal method. Treatment consisted wholly of elimination of the foods to which the patient reacted, or, where these were too numerous, the use of selected diets.
64
EDITORIALS
All the patients gave some positive skin reactions. The only reactions to pollens were in patients who had hay fever. Eighteen percent of the patients had allergic symptoms other than mi graine. Seventy-one percent gave a history of migraine in blood relatives, and allergic manifestations other than migraine were recorded in the families of fifty-one percent. Of forty-two cases in which it was possible to obtain satisfactory data as to the results of treatment, DeGowin records complete relief in fourteen and partial relief in nineteen, or a total of thirty-three cases (seventy-eight per cent) in which there was some bene ficial result from treatment. The most striking results were obtained in nurses and other hospital employees who could be closely supervised. There were some cases in which psychic upset played an important part. The list of foods to which sensitive ness may be displayed is a formidable one, and one shudders to think of the treachery that may lurk concealed at the dining table. Experience with the use of selected diets showed that, in the production of migraine, some of the foods to which the patient was sen sitive often played a more important part than others to which he likewise reacted. Researches by Rinkel and Balyeat on cellular sensitization (The Journal of Allergy, 1932, volume 3, page 567) in dicate that different foods may be re sponsible for a variety of symptoms in the same patient. Thus one patient suf fered from severe headache after inges tion of even very small amounts of apple and pecan; from hives after eat ing grapes; from gastrointestinal symptoms after partaking of corn or cherries; and from vasomotor rhinitis after contact with orris root or goose feathers, or after an excess of wheat in his diet. The two authors last mentioned point out that a patient should not be tested by laboratory methods alone, but that clinical testing should always form a part of the diagnostic investi gation. Reports concerning allergic dis eases should indicate whether the sen-
sitizations are clinical or cutaneous, and the character of the tests employed, whether scratch, intradermal, or patch. Bloch's theory is that certain groups of cells become capable of reacting to a given product with the formation of cellular fixed antibodies. In harmony with this theory is the fact that some hay fever patients have itching of the eyes, others have itching of the nose, and still others have the characteristic discharge of fluid from the nose with out a feeling of local irritation. W. H. Crisp.
WISDOM I N REFRACTION W h a t factors are we to consider as components of the refraction problem ? How heavily do they weigh? How do they influence each other? W h a t is the relation of the pure mathematics ar rived at by means of refractive ma chinery to the final prescription? How shall we use this information? Are we in our refractions, doctors of medicine first, employing our energies for the time being on a refraction problem, or are we refractionists with an incidental M.D. tacked on to our name? If the former, we are doing good work—if the latter we may be giving accurate glasses on the basis of pure ocular measurement, and yet never quite able to understand why in spite of the ac curate check-up of a dozen tests, the final test—the patient's happiness with his result—does not check up in an equally satisfactory manner. If we are the former the axis may be five degrees off, the cylinder a bit weaker than mathematically called for, the minus sphere less than machinery indicates, the plus more or less than usually called for by the rule of failing accommoda tion, but, if we have paid attention to certain factors apart from the ma chinery of measurement, and evaluated them properly, the shock of having the patient return within two days or two weeks with uncomfortable—too strong —pulling—tearing—unable to keep on ■—painful—blurring don't feel right—■ not as good as my old pair—complaints, comes at very irregular and infrequent
H. R O M M E L H I L D R E T H 824 Metropolitan building, St. Louis PARK L E W I S 454 Franklin street, Buffalo M. U R I B E TRONCOSO 350 West 85th street, New York M. F. WEYMANN 418 Westlake Professional building, Los Angeles J O H N M. W H E E L E R 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.
MIGRAINE D U E TO ALLERGY In a great many cases migraine arises from extraocular sources, without ap parent relation to eyestrain. But the attempt to relieve the sufferer from this distressing malady should always include examination as to the existence of uncórrected refractive error, and for the good of his patient the ophthal mologist ought to know what condi tions outside his own limited field may be to blame. In spite of the significance now at tached to allergy in the whole field of medicine, DeGowin (The Journal of Allergy, 1932, volume 3, page 557) com plains that important recent essays on migraine not infrequently omit any mention of the part played by allergy in the production of that disorder. In 1923 Miller and Raulston reported treatment of twenty-five migrainous patients with intravenous injections of peptone, improvement resulting in eighty-four percent of the cases ; and in 1927 Vaughan related ten cases in which migraine was relieved by elimi 63
nation of specific foods. In Eyermann's series of cases the symptoms disap peared upon elimination of proteins to which the patients reacted, and reap peared upon renewed administration of such specific proteins. The hereditary character of migraine has been attrib uted to an allergic inheritance ; and it must be remembered that dietetic hab its are particularly apt to be handed down through successive generations. DeGowin, working in the Depart ment of Internal Medicine of the Uni versity of Michigan, has studied sixty patients, all of whom were given the same protein sensitivity tests. In the course of half a day it was possible, without considerable inconvenience to the patient, to test for thirty pollens by the scratch method, and for over one hundred foods, epidermals, and miscellaneous substances by the intra dermal method. Treatment consisted wholly of elimination of the foods to which the patient reacted, or, where these were too numerous, the use of selected diets.
64
EDITORIALS
All the patients gave some positive skin reactions. The only reactions to pollens were in patients who had hay fever. Eighteen percent of the patients had allergic symptoms other than mi graine. Seventy-one percent gave a history of migraine in blood relatives, and allergic manifestations other than migraine were recorded in the families of fifty-one percent. Of forty-two cases in which it was possible to obtain satisfactory data as to the results of treatment, DeGowin records complete relief in fourteen and partial relief in nineteen, or a total of thirty-three cases (seventy-eight per cent) in which there was some bene ficial result from treatment. The most striking results were obtained in nurses and other hospital employees who could be closely supervised. There were some cases in which psychic upset played an important part. The list of foods to which sensitive ness may be displayed is a formidable one, and one shudders to think of the treachery that may lurk concealed at the dining table. Experience with the use of selected diets showed that, in the production of migraine, some of the foods to which the patient was sen sitive often played a more important part than others to which he likewise reacted. Researches by Rinkel and Balyeat on cellular sensitization (The Journal of Allergy, 1932, volume 3, page 567) in dicate that different foods may be re sponsible for a variety of symptoms in the same patient. Thus one patient suf fered from severe headache after inges tion of even very small amounts of apple and pecan; from hives after eat ing grapes; from gastrointestinal symptoms after partaking of corn or cherries; and from vasomotor rhinitis after contact with orris root or goose feathers, or after an excess of wheat in his diet. The two authors last mentioned point out that a patient should not be tested by laboratory methods alone, but that clinical testing should always form a part of the diagnostic investi gation. Reports concerning allergic dis eases should indicate whether the sen-
sitizations are clinical or cutaneous, and the character of the tests employed, whether scratch, intradermal, or patch. Bloch's theory is that certain groups of cells become capable of reacting to a given product with the formation of cellular fixed antibodies. In harmony with this theory is the fact that some hay fever patients have itching of the eyes, others have itching of the nose, and still others have the characteristic discharge of fluid from the nose with out a feeling of local irritation. W. H. Crisp.
WISDOM I N REFRACTION W h a t factors are we to consider as components of the refraction problem ? How heavily do they weigh? How do they influence each other? W h a t is the relation of the pure mathematics ar rived at by means of refractive ma chinery to the final prescription? How shall we use this information? Are we in our refractions, doctors of medicine first, employing our energies for the time being on a refraction problem, or are we refractionists with an incidental M.D. tacked on to our name? If the former, we are doing good work—if the latter we may be giving accurate glasses on the basis of pure ocular measurement, and yet never quite able to understand why in spite of the ac curate check-up of a dozen tests, the final test—the patient's happiness with his result—does not check up in an equally satisfactory manner. If we are the former the axis may be five degrees off, the cylinder a bit weaker than mathematically called for, the minus sphere less than machinery indicates, the plus more or less than usually called for by the rule of failing accommoda tion, but, if we have paid attention to certain factors apart from the ma chinery of measurement, and evaluated them properly, the shock of having the patient return within two days or two weeks with uncomfortable—too strong —pulling—tearing—unable to keep on ■—painful—blurring don't feel right—■ not as good as my old pair—complaints, comes at very irregular and infrequent