·Scientific Honesty... A CONTROLLING FACTOR IN ALLERGENS For nearly forty years every bacteriologist, chemist, botanist, mycologist, pharmacist and clinician associated with the Hollister-Stier Laboratorics has been under continuous challenge to improve allergenic extracts, In this concentrated search for a better antigen, we frequently have joined with dedicated individual physicians, scientific research groups and world respected medical centers, The work is constantly accelerated as new pproaches are opened through the everwidening horizon of clinical knowledge. Today, experienced technicians and qualified personnel in our regional laboratories draw upon this background of scientific honesty and vigor to give you superior allergy service ... prompt... dependable... strictly controlled. Hollister Stier laboratories PENNSYLVAMIA: 550 Industrial Park Drive, Yexton ILLINOIS 137 Morth Degroom Street, Chicago z WASHINGTON South 107 Division Street, Spokia 3 Caurot ta 255 *. 'stire sur le 4*free 37 1810 Marria94 3:10et, Calla17 CEORGIA 17C De fosi Pse, NW, Atta1 11 ·,الدنلررة JAIPUR NEW..COMPREHENSIVE... for your ALLERGIC Patients More than an antihistaminic Three needed actions in one tablet ALGIC Antihistaminic/Tranquilizer/Decongestant Provides comprehensive control without drowsiness . f: "The anxiety underlying allergic conditions is allayed, and the needed antihistaminic and decongestant actions are provided. Drowsiness - īs prevented by specific CNS'anti-depressant 2n, action. "Algic is highly effective in the symptomatic therapy of perennial allergic coryza. 82% of fifty V patients experienced marked therapeutic effect. Side effects were few and only one patient required aulthdrawal of the drug because of "sleepiness." Swarts, K., Clomical Evolvokor ol. New Drug Algicin, the Symplomatic Therapy of Premal Allergic Caryla," Current Therapeutic' Lanarch, 2.1960 Fach wored tablet contataumg. Chlorpheniramine Maleate; Som Phenyltolosamine DHC. 25 mg. Racephedrine HCl. 20 Door Adults One or two tablets every four hours. Children to 13 years): One-half adult dose. Chil SPENCER comorficoltorio NOIEITOWN, RIW 1111 ·LITOP3 Turgical Instrumenti U M오 ✓ Hydraulic, Foot Operated OperatedA NEGO ✓ Adjustable Height ✓ Adjustable Back Rest Mit ✓ Maximum Alaneuverability ✓ Finished in Gleaming Chrome for Lasting Beauty SINGH COLLEGE NY EDICAL Acn. No.93.28 Date. 5:.4..6.?... PriceR1..3:25 SAWAT Mowing SURGICAL STOOL FUCHS E-7540 Stool, Surgical, FUCHS, a hydraulic, fool operated sloo) with coil tension spring mounted motorcycle type seal. Comfort assured by easily adjustable back rest. Stool can be elevated and lowered by surgeon while sealed. Height is adjustable from 24" to 33". Mounted on four 3" swivel costers, complete with foot operated broke. Adjustment, maneuverability and resulting comfort of this chair are of special value in delicate and prolonged work such as Stapesfootplate procedures, reconstructive and ophthalmic surgery. $275.00 . STORZ INSTRUMENT COMPANY 4570 Audubon Ave., St. Louis 10, Mo. Nrw York Show 137 Eust 64sh Salmone Ant ·TABLE OF CONTENTS V VII ..lol .. lo...... VIII XIX 1 .... *** pylor DEDICATION OFFICERS FOR 1960 AND 1961 THE AMERICAN SOCIETY OF OPHTHALMOLOGIC AND OTO. LARYNGOLOGIC ALLERGY; HISTORY AND PARADE OF PRESIDENTS IN MEMORIAM SCIENTIFIC PROGRAM: INSTRUCTIONAL COURSES 1-General Principles In The Diagnosis And Treatment of Inhalant Allergy Kenneth L. Craft. M.D., Indianapolis, Indiana 2-General Principles in the Diagnosis and Treatment of Fond Allergy Sylvester C. Missal, M.D., Cleveland, Ohio Round Table Conferences (Courses No. 3 through No. 14). Recorded Excerpts 3. Pollinosis. Atmospheric Molds Michael H. Barone, M.D., Buffalo, New York Bernard M. Barrett, M.D., Pensacola, Florida á 6-Optimal Dosage Therapy, Technic of Cytological Examination French K. Hansel, M.D., St. Louis, Missouri Linden J. Wallner, M.D., Chicago, Illinois 7-flistory Taking Lawrence S. Crispell, M.D., Joplin, Missouri 8. Value of X-ray in Diagnosis. Differential Diagnosis Sam H. Sanders, M.D., Memphis, Tennessee Richard II. Stahl, M.D., Cuyahoga Falls. Ohin 10-11 ------ 6 sada...rer. 10 12 14 .... 16 18 12- 1841...... 20 Il Dergy .... William H. Evans, M.D., Youngstown, Ohio Joseph W. Hampsey, J.D., Pittsburgh, Pennsylvania 13.Allergy of the Eye; Diagnosis and Treatment Robert S. Coles, M.D., New York City Leland I. Prewitt, M.D., Ottumwa, Iowa 1-Food Allergy William 11. Barry, M.D, Kansas City, Missouri Sylvester C. Missal, M.D., Cleveland, Ohio sastevesa 22 24

·*************
LECTURES
Repository Therapy in Allergy
26
Lawrence J. Halpin, M.D., Cedar Rapids, Iowa
Use of Fluorescent Antibody Method
40
Frank W. Fitch, M.D., Chicago, Illinois
The Use of Cortico-Steroids in Otolaryngologic Allergy
47
David A. Dolowitz, M.D., Salt Lake City, Utah
The Diagnosis and Management of Non-Granulomatous Uveitis...... 62
Robert S. Coles, M.D., New York City
PRESIDENT'S PAGE
G6
Leland H. Prewitt, M.D., Ottumwa, Iowa
EDITOR'S COLUMN
67
Kenneth L. Craft, M.D., Indianapolis, Indiana
BUSINESS SESSION
69
COMMITTEE APPOINTMENTS
71
REGISTRATION AT CHICAGO
72

·11 seenis fitting that this first official publication of the American Society
of Ophthalmologic and Otolaryngologic Allergy should be dedicated to the Founder
of the organization.
And so, this talunie is dedicated ly the Society to
TREXCH KELLER HANSEL
AUTHOR-EDUCATOR-PHYSICIAX-SCIENTIST
Acting for the Society, and as a token of their individual affection and esteem,
the Officers and Councl Members of the Society have caused their signatures to
tre inscribed hereupon.
Council
thuishael H. Barone
B.
Fr. Paust
I'resident
Menard & Yarnett
Kennette L. Craft
odensyoner.
President-Elect
It rencie
rencies a. o foole.
Lawinend Aufrece Walter E. Omen
Frederick Itslundene
Pemillest takafuliley,
Ham H. Sanders
Vice-President
Secretary-Treasutet
v

·FREYCH K.H.IXSEL, MI. 1)., J. S. St. Louis, Missouri MEDICIL BOXER IIY St. Louis L'niversity School of Medicine, JI, D., 1918. St. Louis City Hospital, Interne, February, 1918-February, 1919. Missouri Baptist Hospital, Resident, February, 1919-Nay, 1919. Vaso Foundation, Mayo Clinic, Fellow, Way, 1919-October, 1923. L'niversity of Minnesota and Jayo Foundation, J. S., in Otolaryngology. June, 1923: thesis on l'asoniotor Rhinitis: preparation began in 1921, Private practice in St. Louis from October, 1923. ffiliation with Department of Otolaryngology, Washington L'niversity, October, 1923, ter Dr Greenfield Slurer wità Department of Allergy and Internal Medicine. Organized Illery Clinic in Department of Otolaryngology wwer Dr. I.. W'. Dean in 1930. .Jasociate l'rofessor of Omaryngologs since 19.30 Co-author of Ilajek Diseases of the larani al Simuses, 2 101, 1026 Fellow. .Imerican Icademy of Opplethalnuology and Otolaryngology, 1926. Society of Sigma Si, 1928 Fellow: American laryngological, Runological and Otological Society, 1928 Fellow: Imerican Icadlem of Illergy. 1933. Chairman, Section on Merg). Southern Jelical Association, 1934 Jutitori cest on Iliergs of line and l'aradasal Sumse, 1936. Fellow: Imerican Laringological fasciation, 1940. Cas cllury Award for thouse on Cytotox of Secretions of lonc anil l'aranal Sucs, 1910 Founder and Charter Vemier of Imerican Sixiety of Ophthalmologie anul Otero laryngologie llicres, 1911. I'restekent. 1941-1916 Charter Member and Co-organizer of Imerican College of Vlereses, 1012. l'ress. (kent, 1944-45. Editor. Imals of Werks, 194,3-1953 lounier. Ilancel Foundation, 1947, Director from 1947 Inhor; text of Clinical Illergy, 1953 Chief of Illergy Staff, De l'aul flospal, luns, die Original articles and lwls through 140, alxit 125 11 ·OFFICERS FOR 1961 Leland I1, I'rewitt, President Udley 11 Jones, President-Elect Lawrence S Cr-pell, l'ice-l'resident thniel S De Stio, Secretary-Treasurer .Ottumwa, lowa l'icksburg, Mississippi Joplin, Missouri Pittsburgh, Pennsylvania MEMBERS OF COUNCIL Walter L Onetz Bernard M. Barrett...... William Barry.. Sanı Il Sandlers....... Francis I O'Tinle.. French k Hanscl.. I'rolerich II Thcolore.. Vishacl 1 tarone, henneth 1, Crait 1 den 5. Waliter. Peoria, Illinois Pensacola, Florida .... Kansas City, Missouri ...llemphis, Tennessee Clinton, Massachusetts ...... St. Louis, Missouri .... New York City ..Buffalo, New York .. Indianapolis, Indiana .Chicago, Illinois OFFICERS FOR 1960 Walter I. Owen, l'rcsdent. Learl Il f'renitt. President-Lloct. 1) Shinner, l'ice-President. Daniel De 10), Secretary-Treasurer Peoria, Illinois ....... Ottumiwa, Iowa Newark, Ohio Pittsburgh, l'ennsylvania MEMBERS OR COCXCIL ictor R Viare In Intersin Schnelli Barunc fichir Barrett William R Barry henneth 1. trait Traxch k flance! Iran I Tenda Sam 11 Sapelers I realerad 11 Theor ute Thereset . Washington, DC. New Orleans, Lousiana Buffalo, New York ..Pensacola, Florida Kansas City, Missouri Indianapolis, Indiana .....St Louis, Missouri Clinton, Massachusetts Vlemphis, Tennessee New York City YU ·(Re-print St Louis l'out-Dispatch, Satunlıy. Jinie 5, 1948) 55 Doctors Attend School to Learn Latest on Allergies - 1ły * l'oet tennich Piaff l'hutographs In sichnis sroying alleruics at the sherohen flotd consult teeth OR TRANH KILIYSIT. paduy at Intl. Others from left are PR GORDON (111701 Moull I'mirer sur. ontreal, Canada, DA DIVI11 1710), Pittsburgh. DRI. (1./16. Ilonon. llot and DR P11 V 11.11! Pushursh. sh.min. o hi Course Offered for First Time by Jansel Foundation-15 Instructors Demon. strate Methods, Give Talks ilty-inr car, 36 and that perral? * #rxh tableta sf ragweed curacy are not le going to schw all the wech at the The other is an instigation of Ifratmetit i raton Hotel, Icarning how to truende anx! certain types of sus headaches with hista i allergies The cur«c 15 lxing offeret for ins Both studies are shall in progress that first time try tlic newly estatal steel Hansel results w far ucre et toke Cin Miragt undation, name for Dr I retxchh llansel Il sectains of the limited States and catia: St Louis a1N! Hanail are represented by tiwients in the iftarti in trikinrt 1121 licen ** m* the first catre, *luch start. **TTheir < ami thuat specialists {» to make skin are aluwt NIU car, ryne an! that real for allergies anx! huic debuerat talk, on m the l'hotel Statet forlay, ile onlatot h subjects as bronchial author. rum dis jeffrl, "Put only about a harc amuar -. ftiicillin allergies, ha frier treatment kulelse 11 allergy as relafol to their fr Inrikation for surget) culty for tłuan Tou) chhren har Tarteral en l'ebrury 1917. the fulatuin toronchial audima, and a large pirmtacco undertaken tari clitical im*131*»] (ne them are tur I. orain et traitent, the n intry into a new luy fact treatment in frstrathin aucto! VIII ·THE AMERICAN SOCIETY OF OPHTHALMOLOGIC AND OTOLARYNGOLOGIC ALLERGY KESXETH L. CRAFT, W.D Indianapolis, Indiana Thic origin of this Society really dlates lach about 25 years in 1936 Dr french ki. Ilansel, of St. Louis, began to give private instruction in allergy to in lividuals who came to his office In Octoiser of that year Dr. Hansel conducted his first class course in Xaval Allergy. This group met at Washington University anul was composed of Ductors William Craddoch, Monty Meyer, Lyman Richards, Charles Savery, Kinsey Sinxonton and Roland Starr. Collewing this first group course, Dr. Hansel decided that it would be more satisfactors to conduct the instructional courses at lus own office and by the krar 1911 alxit forts otolaryngologists from all over the country had taken advantage of this opportunity to study Nasal Allergy under Dr. Hansel. This groitip fortrical the nucleus of the American Society of Ophthalmologic and Oro- Taryngologie .lllergy which was organized during the meeting of the American Icarlemy of Ophthalmology and Ozolaryngology at Chicago in October, 1941. The «ratoul purpose of this new organization was the "promotion of wide-spread interest in LEXT..lilergy and the dissenzination of knowledge already accumu- 111011 is 1.ss sulyject." The fort meeting of the new Society was held at St. Louis in 1942. No further meetings were hell during the course of World War 2 but the meetings were Truime in 1947 and have leta held annually since that year. The first printel program, palilished in 1947, carried a picture of Dr. Hansel and Statel. "Tls, annual meeting of 1947 is delicated to the Founder and First J'resudent of <*tst Society, f'rench K tansel In order to promote further interest assol pirupteus in allergy, 25 related to our specialties, we believe that there is a (lefonste nervt fur this organization il'e hope that others, qualified in this special farkl. wil joun us anul particip127e su tie activities of the Society" be 11 sofficers and continçil members were as follows. l'Italent reich K Hansel Vice-treulent... 11 m. II Craddock Secretary-Treasurer W Byton Mach Council Rea E Ishley L E. Darrough 3. IV. I{ampsey Francis L. VcGannon Walter 1. Owen Aubrey G. Rawlins George E Shanlauh 1r ·The first roster listesi 78 active meni Vicc-resident.......... Rea E. Ishley bers in 1947. The micetings have been held each October during the convention Secretary-Treasurer... Walter E. Owen of the .Imerican Acadeny of Ophthal. Trustees.......... .Rica E. Ishley mology and Otolaryngology, usually at W. liyon Klach, Gordon I. VcCurdy, Chucago. At the present time (1960) 1. Lambert Victannon, l'alier E. there are 278 .Ictive Members and 24 Honorary Members in the Society. Owen, .lubrey G. Rawlins, Ilowani l. Stitt. Since the affairs and interests of the Society have been so closely lmhed with Each spring since 1948 1 )-grado those of the lausel Foundation, we feci ate course in oplithalmologic and tothat any history of the Society would be laryngologic allergs las been presented! incomplete without some mention of the at St. Louis luy the Foundation finder thic Foundation, the lirain chuid or Dr. Wal direction of Dr. Hansel and his faculty, ter E Owen, of Peoria, a Charter Niem. composeri mostly of luis former sturlents. les of the Society. Dr. Owen had foug in athron to px'rsoni muruction of thes felt that there shoukl lic a definite, well-type, the foundation has conducted inorganizcil plan for the promotion of fur. tense insestigation and study in a m. ther cclucation and research in the fielel ber of rescarch projeces 7lus las reof E. E.X.T, .Illergy, and he suggested sulted in widespread dissemination of the establishment of a scientific foundamuch valuable information concerning tion for this purpose to a group of the the chiology. gathulogy, diagnosis and Society members at a meeting of the treatnient of allergic disease and otlar Inscrican Icademy at lucago 11 1940) The telea caught on quchis and this was prithologic conditions affecting the ye, lxurn the lanse! found.101011, with Dr car, nose and throat Horst of the mem. lirench K. Hansel as its Director funds hers of thic Imerican Sxrety of psywere raised by means of generents contra thalmologic and Olularyngologic Silergy, initions from Society memixrs and from though not all, are former students and various conuercial firms and other "Vesnis" sf the Ilanci Foundation. friends, and a feliruary, 1947, a charter l'erowie reports of the working and *3 kranter to the te's foundation by coveries of the foundation have in cui the statc of Missouri The Ilinci lioun m.de aulable to memiler of the Sky dation was incitrateel inder the last in fulletin pubih her under the alt of Vamour "for the dagnose, treatment rert101 of 1) llanıcl, and imance is anul cure of, and for helical research fronts from the Scicly and study into the cases, dagt, The rest of this ifrsture will be intreatment and cure wf, umholmologie fuleled log insting the l'ame t're-solenty of and otolaryngologic alleryte the Soviety in chronological unter and loy The first officers and trusters of the Tushy a brief rmmmz act of 15ksfoundatus were 14 folkes dieses of mteret ud afwirtance to the Director .. Firenci K. Harre? Svrict which incuirteij during racle $17ti's term of uffice. This reros! Ir. l'resident....... 11, bly out flach pins with the year 1917.

·Ingram-Eiser, of London, England, and the prezentation of an honorary key to Dr. W. Ryton Black. first president of the Hanse! Foundation. 1947 TREVI IT ISEL, W.D ST LOUIS The domici Bich accompanies the First 1948 1's sulency 1xclungs. 722turally, to the founder of the Society I brographical W. EYROX BLACK, V.D. accesint of some of the accomplishments KAYSAS CITY f () Flansei amears el-ewhere in this journal 144 p 11) On the day before this meeting was held, a refresher course in E.EX.T. Al- In 1947 the Society held the first of lerg) was presented by the faculty of the the regular anmul meetings which has Foundation, Girtinucl cach year lo the freschi teme The for printer program made its op The rapid growth of the Society was prarance as the needing the program indicated by the fact that the Crystal *Is prestits-hed in a -mall attractive book- Room of the Palmer House in Chicago, let hish ale Carne hinci kustories of where the meeting was held, was overturn the .nety and the foundation, croweled even though the Crystal Room listing of the officers and commitees ol was four times larger than the room used path orangzatxomin the newly adopted the star before. matius 19 anul tias oi the Society arvits current finder vi 78 metnicts in The 1943 meeting was highlighted by 101 car 1947 repers presented by three prominent Guest Speakers, Doxtors V Murray 1 catures of De nxetmg kare the it. Tetkin, Sen Yorh, Lyman D. Richcelleme: lotute en allergic disca4 giren ands, Brookline. Mans. und Fred kl. In the figure of Ilimit. dir. Reginald flittich, Vinneapolis X1 ·.Rea E. Ashley The first roster listed 78 active nicm Vice-President...... bers in 1947. The mectings have been hiell each October during the convention ... Walter E. Oncn Secretary-Treasurer. of the Imerican Academy of Ophthal- Trustees..... Roa E... Ishley mology anel Otolaryngology, usually at \\'. Byron Black, Gordon J. McCurdy, Chicago. At the present time (1960) F. Lambert McGannon, Walter F.. there are 278 Active Members and 24 Ilonorary Members in the Society. Owen, Aubrey G. Raulins, Iloward L. Since the affairs and interests of the Stitt. Society have been so closely linked with Each spring since 1948 a post-gradu those of the Ilansel Foundation, we feel ate course in ophthalmologic and otothat any history of the Society would lic laryngologic allergy has been presenter! incomplete without some mention of the at St. Louis ly the Foundation under the Foundation, the brain child of Dr Val direction of Dr. Hansel and his Faculty, ter E. Owen, of l’eoria, a Charter Meme composed mostly of his former students, ber of the Society. Dr. Owen had long In addition to personal instruction of this felt that there should be a definite, well type, the foundation has conducted inorganized plan for the promotion of fur tensive investigation and study in a sumther cclucation and research in the field ber of research projects. This lo- reof EE XT. Ilergy, and lie suggested sulted 11 widespread domination of the establishment of a scienufic foundamich valuable information concerning tion for this purpose to a group of the the cttuleny. pathology. diagnosis and Society members at a meeting of the treatment of allergic clisease and other American Academy at (lucago w 1946. pathologic conditions affecting the cyc, The ca caught on quichly and thus was car, nes and throat Most of the memn. born the Hansel Foundation, with Dr French K. Ilan cins its Director funds bers of the \merican Society of plawere ransce) ly means of generous cuntrsthalmologic and Otolaryngologic Illerky, initions from Society members and from theugle not all, are former students and various conuercial firms and other Vumi" of the land foundation. friends, and in Feliruary, 1947, a charter l'ortode rexists of the working and dis was growled to the new loundation bus coveries of the foundation las treen the state of Missouri The Flanel loun- made available to members of the Skislation was incurimated under the lasty m Bulletins published under the do of Jinscuri "for the diagnosis, treatment rex of Dr Ilanse, and formal by and care of, and for medical research hrants froin the Skiety and fly into the causea, diagnosis, The rest of thors Intry will l 1117- treatment and cure of. phthalmologic folder log insting the las! I'readcuts of and otolaryngologie allergies the Skiety in chronological opiles and los The first officers and trusties of the SISI a loirí rumun act of ines Foundation were as follows lents of tuterest id mistance to the acl: Dirextor.... . l'rench K. Llanse! Svrict: uch incurred during man's term of office. 11.) reteted le. 1resident... W. Byron Blach fint with the year 1917. X ·Ingram-Exer, of London, Englanıl, and the presentation of an honorary hey to Dr. II', Byron Black, first president of the lanel Foundation, 1947 FRENCH K HANSEL, VID ST LOUIS The honor which accompanies the First 1948 Presidency belongs, naturally, to the W. BYROX BLACK, 11. D. Founder of the Society A lographucal account of some of the accomplishments KANSAS CITY of Dr Hansel appears elsewhere in this Journal (see p. VI) On the day before this meeting was heid, a refresher course in LEXT. Al- In 1947. the Society held the first of lergy was presented hy the faculty of the the regular annual meetings which have Foundation continued each year to the present time The first printed program made its ap The rapid growth of the Society was pearance at this meeting The program indicated 19 the fact that the Crystal was published in a small attractive book- Room of the Palmer llouve in Chicago. let which also carried brief histories of where the meeting was held, was overboth the Society and the Foundation, a crowded even though the Crystal Room listing of the officers and committees of was four times larger than the room used both organizations, the newly adopted the year before. Constitution and By-Laws of the Society and its current roster of 78 members in The 1948 meeting was highlighted that year of 1947 papers presented by three prominent Guest Speakers, Doctors M. Murray Features of the meeting were the ex- Peshkin, New York; Lyman D. Richcellent lecture on allergic disease given ards, Brookline, Mass., and Fred W. by the Guest of Honor, Mr Reginald Wettich, Minneapolis. XI ·Tire first interim meeting of the Society was lield at St. Louis on June 1, during the annual Course given by the Ilansel Foundation, Vuch discussion, pro and con, was lield regarding the hits jusal of the Imerican Icademy of Oplethalmology and Otolaryngology that the Society lioll its meeting on Friday at the end of the annual Icademy woch, instead of prior to the ..cademy session. Py this more, the Iculorny hopxvl 81277 thic Society meeting would help maintain 1949 i full attendance of Icademy members REIE, ISHLEY, M. D). until the end of its own program..is SIX FRANCISCO an inclucenient to effect tliis change, the It various tinies, there had been Academy agreed to publisko in its Transproactions all of the scientific papers and posals and attempts to bring the Society discussions of the Society's programs. and the foundations together into one .Iction upon this matter was deferrel organization Dr Ishles carly saw the until the regular annual meeting of the inadvialulity of this we and was in- Society to be held on October, 1950, strumental m pomiting out the importance of preserving the lonomy of cach It was proposed tint the Society estalı. lish a memorial fund in honor of Dr. l. FTON The largest artendance to date enjoyal Hyron Black, a clarter member and lase an excellent cientific program headci I'resident of the Society and a founter lay a brilliant d-CU-480311 xxn ".Vleres of the Hanset Foundation. It the time in tulug" by the Coliest of Tutor, Iron of 1114 death on October 23, 1919. Dr. fe mor liste Dullman of the I'muotsi Hich was a member of the Council of of luni), at Lund, Sweden the Society and was l'rrssilent of tlic foundation This matter also was tablet until the Octulxer meeting of the Sauci. It this meeting a communutie op [*inted to consider the matter, recom muended that all funes contributed this (ar le transferred try the lansel Fatin vlation and administered try the rus tre of thic Pruncluttern Thus retom menclattın was actrice 10, at the fall nicebinkit was dc- Cafe: 1111t the entire Semioty tra! stre coming a multice to meet with the (uncil of the rulerican Iracklity 1950 just 1 sm of the leademy'. fifcig** GIORGI I.. SHAMBI.1. J*. JD il trailing the meeting title of the CHICTGO XI worul.

·Dr. Hausel was chosen to represent to the It. Byron Blach Memorial Fun. the Society at the international allergy This fund was to lie administral by the meeting to be held at Zurich, Switzer- Board of Trustees of the lanset lounland, in 1951 dation and was to be used to lielp defray thic expenses of Research Felloss in the The Society's Guest of Honor this Foundation, year (1950) was Herbert Rinkel, M. D., of Kansas City, who gave an excellent discussion upon "Food Allergy" Dr. Rinkel also gave a very interesting account of his recent trip to France during which he had revisited scenes of his World War I experiences. This talk: was illustrated with colored slides made by De Rikel and was presented at the annual banquet 1952 HUGI I KUIIX, M. 1). HAMMOXD, INDIAS Dr. llausel announced plans for the publication of a Bulletin dicsotel to) E.EXT Allergy, to be sent qkrivulically to each memlier of the Society. It was decided to finance this project toy aprpropriations from the treasury of the 1951 Society WILLIAM H. EVANS, NI D. The annual lanquet will long lere YOUNGSTOWN, OHIO membered for the uproarious per forni. Another interim meeting was held in ance of one of President Kuin's guests, 1951, this time at the Edgewater Beach a talented magician Among other hi- Hotel, Chicago, on February 11, 1951 larious stunts, he removed Bill Owen's It was decided to recommend that the shirt from beneaih his coat by a dex- Society change the time of its regular terous twist of the wrists, and then actuannual meeting to Friday of American ally cut Archie Cruthirds' necktie in half Academy week when the scissors "slipped" In demon- It the Society meeting held in Octo- strating this trick later with a knifc, Rusber, 1951, the above recomendation was sell Williams chopped up one of Rill adopted Owen's gorgeous red nechtics when the knie really slipped, to the delight of the It was also decided to donate the sum audience and the disconliture of both of $200000 from the Society's treasury Owen and Wiliams, XIII ·The first interim meeting of the Society was held at St. Louis on June 1, during the annual Course given by the Hansel Foundation. Much discussion, pro and con, was held regarding the proposal of the American Academy of Ophithalmology and Otolaryngology that the Society hold its meeting on Friday at the end of the annual Academy week, instead of prior to the Academy session. By this more, the Academy hoped that tlic Society meeting would lielp maintain 1949 a full attendance of Academy members REA E. ASHLEY, MD until the end of its own program As SAN FRANCISCO an inducement to effect this change, the At various times, there had been pro- Academy agreed to publish in its Transactions all of the scientific papers and posals and attempts to bring the Society discussions of the Society's programs. and the Foundation together into one Action upon this matter was deferred organization. Dr Ashley early saw the until the regular annual meeting of the inadvisability of this move and was instrumental in pomting out the importance Society to be held on October, 1950. of preserving the autonomy of each It was proposed that the Society establish a memorial fund in honor of Dr. W. group. The largest attendance to date enjoyed Byron Black, a charter member and Past an excellent scientific program headed President of the Society and a Founder by a brilliant discussion upon "Allergy of the Hansel Foundation At the time in Otology" by the Guest of Honor, Proof lus death on October 23, 1949, Dr. fessor Goste Dohlnian of the University Black was a member of the Council of of Lund, at Lund, Sweden the Society and was President of the Foundation This matter also was table until the October ineeting of the Society At this meeting, a commuttee appointed to consider the matter, recommended that all funds contributed thus far be transferred to the Hanscl Founclation and administered by the Trustees of the Foundation. This reconmendation was adopted Also, at the fall meeting, it was decided that the entire Society Council should compose a committee to meet with the Council of the American Academy 1950 for (liscussion of the Academy's propo- GEORGE E SHANBAUGH, JR J.D. sal regarding the meeting time of the CHICAGO Society. XII ·contribution from the Society of $500 00 was voted to help defray the crpense of the Internatinnal Corintent of Orolaryngology to be held at Waliing. ton, D. C., in 1957. Guests of llonur ti year were 7. %. Goullosshi, 11.1), of Northwesteru Lni. versity Schoul of Medicine, T, F. Dougherty, 1)., of the University of Lisak College of Medicine, and J. B. Miller, JD, of Mobile, Alalania, Dr. Wil let's talk upon "The Lise of Nucolytic 1955 Aero»nls in Respiratory Discases" was F LAMBERT MCGANXOX, NI, D. given upon the Americin .cademy js. LIKEVOOD, OHIO Fran under the sxnsorship of the So- The report of the Committee on Con- csety sistustson and By-Laws was accepted and revisions were adopted as recommended Is the Committee Under the sponsorship of the Society, Harry B Stauffer, 11 D., of Jefferson City, Missouri, gave a beautifully illustrated lecture at the American Academy meeting upon "Allergic Discases of the External Eye 1957 SAW H SANDERS, M. D. MENPIIIS, TENNESSEE popular improvenient was adled to the program booklet this year in the listing of the members gengraphically as well as alphabetically In further discussion regarding 3 1956 DEAN M LIERLE, N D change in the time of holding the Soci- IOWA CITY, IOWA cty meetings, it was brought out that a poll of the membership showed the ma- Some discussion was held regardirsg jority to be in favor of holding the meetthe feasibility of changing the time of ing on the Saturday or Sunday just prior Society meetings to an earlier day of the to the annual convention of the Ameri. American Academy week can Academy Xy ·Cleveland. This battle of words (though such words) ended in a draw between the two gladiators and a victory for the clelighted audience President and Mrs. Walter Theobaldi and other high officials of the American Icademy were guests of the Society at the banquet. 1953 KENNETH L. CRAFT, M. D INDIANAPOLIS I'lans were announced for a two-day postgraduate brush-up or refresher meeting on E.E.N.T. Allergy to be held during the annual Foundation Course at St Louis, in June, 1954. A “Hospitality Suite," to be itsed as a 1954 rendezvous for Society members and ILBERT D. RUEDEMANN, M. D. friends, was maintained at the Palmier DETROIT House, in Chicago, througliout the week in which the meeting was lield Tlus was The niceting this year was held late in to become a very popular amal feature September at the Waldorf-Astoria in of the Society. New York in order that our aplıthalmologic members could attend the Interna. The Society arranged and sponsored tional Congress of Ophthalmology which an excellent anel beautifully illustrated also met in New York at the same time. lecture upon "A Study of Living Cells Taken from the Human Eye, Nose and Another clonation to the W. Byron Throat," given as a special feature of Black Memorial Fund was approved at the American Academy program lvy the business session. This fund was set Charles M. Pomcrat, Ph. D., of the l'ni rip to provide a stipend of $200.00 per versity of Texas School of Medicine. month, for a period not to exceed three It was decided that all Guest Speakers months, to lielp defray the expenses of who were not Oplıthalmologists nor Oto-worthy E.EN T. specialists for training laryngologists should be made Slonorary and rescarch work at the lanset loma dation Members of the Society. At the annual banquet, the ruchtis be A committee was appointed to revise tween the North and the South was re the Constitution and By-Laws and to renewed by our story-telling Guest of Ilon port its recommendations to the Society or, Dr. Pomerat, and our own beloved membership in time for consideration at the 1955 meeting. raconteur, f. Lambert McGannon, of XIV ·man changing the meeting time of the Soci. These discussions were very interesting ety finally crystallized into a definite and instructive, plans of action Two important decisions Enjoyalıle clrtersions were polfing, or- Kere made, 1) to hold the 1900 meeting cellent trout fishing in a franch of the on Saturday, October 8, the day before Platte riser, scenic sitle trips and just the opening of the convention of the plain kafing American Academy of Ophthalmology Arrangements were in the capalie and Otolaryngology, and 2) to dietote hands of Dr, and Jrs, Russell I. \'ilthe morning hours to the presentation of Stanis, of Cheyenne, l'yoming. Instructional Courses in Ophthalmologie The fall meeting, at Chicago in Octoand Otolaryngologic Allergy. The overali commuttee consisted of Kenneth L. ber, kas one of the most interesting and Craít, Indianapolis, Daniel S De Stio, certainly the most unique in the listory Pittsburgh, French K Hansel, St. Louis, of the Society. The meeting was held at Leland II. Prewitt, Ottumwa, Iowa, Sam the Sherman Hotel on the Saturday just H Sanders, Mlenphis, and Walter E. preceding the annual convention of thic Owen, Peoria, Illinois, General Chair. American Academy of Ophthalmology and Otolaryngology The morning hours were given over to an Instructional Course presented in the form of cight Round Table Conferences tipon various subjects pertaining to Ophthalmologic and Otolaryngoingic Allergy: Each Round Table was mannesi ly two competent Instructors who conductail the Corferences and discussed the many questions propounded by the students" tipon various pliases of allergic practice, An equally interesting program of scientific papers was presented in the af. ternoon, as follows 1960 “Repository Therapy in Allergy" 'ILTER E OWEN, Y.D Lawrence j Ilalpin, 11 D. Cedar Rap PEORLI, ILLINOIS ids, Iowa three-day interim nieeting was held "C'se of the fluorescent Antibody t Saratoga, W'yonung, in July, the first Vethod"--Frank W Fitch, M D., Chiof such meetings to be held at a vacation Lago. About twenty members, with "The Use of Cortico-Steroids in Eye, wires and families, niade the trip to Sar- Far, Nose and Throat Allergy"-David atoga, mostly as a stop-over either while A. Dolowitz, MD, Salt Lake City. poing to, or returning from, vacations in "The Dragnosis and Nianagement of the great Northwest Round table dis Non-Granulomatous Uveitis"--Robert S cussions were held each morning under Coles, 11 D, New York City. the leadership of Dr Fresch Hansel, St Lous, and Dr Z. Z. Godlowski, Chicago, bers of the Society and Dr Fitch and Dr Coles and Dr. Dolowitz are meni. XVII resort ·l'ast President in a fitting ceremony at the annual banquet. In the future, this award is to be presented to cach Presi. dent upon his retirement from office. Inother feature of the banquet was a very interesting illustrated lecture by Dr. Musil, a guest of the Society, upon his recent travels in Russia. 1958 JOSEPH W. HAMPSEY, MI, D. PITTSBURGH, L'ENNSYLVANIA special feature of this year's meeting was the long planned and discussed Scientific Exhibit co-sponsoreel by the Society and the Ilansel Foundation and presented as one unit of the general sci- 1959 entific cxhibits of the American Icad UCHAEL I. BIRONE, JI. D. emy of Ophthalmology and Otolaryngol. BL'FFALO, NEW YORK ogy It was planned to show the Exhibit throughout the entire Icademy woch but As usual, the Society maintained its a disastrous fire broke out about me headquarters in the parlor of the Arizona 111glit on Thursday in the exhibit rooms Suite at the Palmer llouse, Chicago. and destroyed the Society Exhibit along Oser the years, this so-called "Hospitalwith several others. ity Suite" has proved to be just that and It was decided that all active members has been tlie nicauis of welding old friendof the Society to date shall be classified slips and of making new ones as the Som as "Fellows" and that hcrcafter all thew ciety mienilers, with common interests at members wlio are not Diplomates of licart, meet each other licre, year after either the Board of Oplithalmology or year. the Board of Otolaryngology shall be The annual program sponsored lry the classified as "Associate Members", ic, Society for presentation at the Amerithe difference between the two classes of can Academy "cssion consisted of a inembership shall depend upon certifica "Panel Discussion of Nasal Polyp." tion by either of the aliove two Roards Nemliers of the panel were Doctors Wil. Níore and more discussion was being Jiam II. Evans, Youngstown, Ohio, held concerning the Socicty's return to lirench k liansel, St. Lous, Sam 11. and Kenneth I. its original meeting time, ic., on the day Sanders, Memplus, or two inune liately preceding the Amer Craft, Indianapolis, Moderator. içan Acadcniy session. At a post-meeting session of the Com. Distinctive cuff liuks bearing the seal cil called by incoming President Walter of the Society were presented to eachi E.. Oweni, the long liscussed matter of XVI ·IN MEMORIAM Dicd ? ? Moore, Robert D., Little Rock, Arkansas Norwood, Eugene !! Waxaliachie, Texas James, Voyle, Los Angeles, California Black, W Byron. Kansas City, Missouri Fletcher, Harold A., San Rafael, California Mussum, William G., Cleveland, Ohio Gill, James P, San Antonio, Texas Donovan, J E, Erie, Pennsylvania Grimmett, Roger S, Vancouver, British Columbia Breakstone, Edgar 0, Chicago, Illinois Harshman, Martin L, Lafayette, Indiana Engler, Clarence W, Cleveland, Ohio Hamilton, Richard G, Pittsburgh, Pennsylvania Hurlbut. Jack A, Madison, Wisconsin Kuhn, Hugh A, Hammond, Indiana Lesson, Lavell H Vancouver, British Columbia Suitt, Howard L, Cincinnati, Ohio Strange, RH, Mt. Pleasant, Michigan McGannon, F Lambert, Lahcwood, Ohio Tippen, Ernest E. Wichita, Kansas Alvaro, Moacyr H. San Paulo, Brazıl Goodwin, Thomas NI, Elkins, West Virginia McCurdy, Gordon ), Phoerur, Arizona Skinner, DA, Newark, Ohio Jffiliated 1941 1941 1941 1941 19-48 1950 1941 1953 1941 1954 1951 1949 1941 1941 1941 1954 1941 1950 1941 1941 1952 1954 1941 1949 1919 1949 1952 1953 1954 1955 1955 1956 1956 1957 1958 1958 1958 1958 1958 1958 1959 1959 1960 1960 1960 1960 XIX ·Dr. Ilalpin were this year's Guests of hold tliis meeting on Saturday, October Honor, 7, again at the Sherman Hotel. Eighty-five members and guests at PLAN NOW TO ATTEND, tended the 1960 session and it was an (In order to avoid repetition, business nounced soon after the meeting was over matters discussed at the 1960 meeting that, due to the enthusiasm shown, and are not mentioned liere. They are, how- Buy popular request, the same type of ever, reported in the minutes of thie nieetmeeting would be held in 1961. Ar ing on another page in this volume. See rangements have already been made to page 69.) XVIII ·GENERAL PRINCIPLES IN THE DIAGNOSIS AND TREATMENT OF INHALANT ALLERGY KENNETH L. CRAFT, M, D. Indianapolis, Indiana SUBJECTIVE FIXDINGS The symptoms of allergic rhinitis or sinusitis include nasal blocking, spastriodic attacks of sneezing, watery or mittcold discharge, facrination and conjunctritis, itching of eyes and palate, and Enosmia, A good lustory is thic nost important smgle factor in the diagnostic procedure. 60% to 70% of all patients sulfering from nasal allergy will give a positive This paper will review, briefly, the family history of various allergic conditions if the luistory is thorough and propvarious features of the examination and erly developed The iustory, then, should management of the patient suffering include the patient's ancestors and other from the distressing symptoms of aller- relatives in a search for a possible heredigic disease of the nose and sinuses due tary allergic background of the patient's to allergens of the inhalant class. The complaint A negative family history, factors concerned in the diagnosis and however, does not rule out the possilsil. treatment will be amplified in the discus- rty of the presence of allergy in the pasrons to be held at the various Conier- trent, himself ence Tables following the fisst two pa The personal history of the patient pers upon this Instructional Course pro- should begin with his infancy Such algram lergic conditions as colic, indigestion, cy- The establsshment of a diagnosis of alclic vomiting, eczema, hives, etc., if preslergic disease of the nose or situses may ent in early use, often will disappear be simplified if the examining physician spontaneously, and may be forgotten, as will follow a definite pattern of procedthe child grows older. Frequently, how. ever, these conditions are the forerunure in his investigation Ders of other types of allergy appearing includes two main sources of informain later life. tion, 1) the subjective findings revealed by the patient, under the careful guid- should be made as to the effect upon the In taking the history, careful inquiry ance of the exammer, and 2) the objec- symptoms of any changes in the patient's tite findings discovered by various tests Has he changed his resi. and observations made by the physician dence or his occupation? Has he bought bimself, a new mattress or rug, has he changed This pattern environment 1

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·TREATMENT OF INHALANT ALLERGY increases in INFECTION but not tensive and chronic sinus infecin ALLERGY, tion, "3, The treatment of patients with 4. Leucopenic Indlerm(or digestive mucous polyps must include atten leukocyte response of Vaughan). In ALLERGY there is a decrease tion to the allergic factor; (the cause for the recurrence of polyps of leucocytes after the ingestion of after their removal)." allergenic food; (especially important in food allergy with nasal The presence of nasal polyps is so sigmanifestations), nificant and so pathognomone that every case of nasal pathology demonstrating The cytologie and hematologic examinamucous polyps should be considered as tion is extremely important in differenallergic in ongin until proven otherwise. tiating between ALLERGY and IN- FECTION as the causative factor in Cytologic examination of the nasal se diseases of the nose and sinuses. cretions is very important and, according to Hinnant, "is an accurate index of the Xray examination is of value in dirpathology in the tissues" An outstand- ferentiating between infection and aller- The typical ing feature in the diagnosis of nasal al- gic disease of the sintiscs. lergy is the demonstration of eosinophiles X-ray picture of allergic sinusitis will in stained smears of nasal secretions, show a thickened edematous lining ment- Eosinophiles are prevalent in the heavier, brane. This may vary from slight thick more mucosd secretions, and are especial ering of the mucosa to extreme polypoid ly numerous at the height of the allergic degeneration competely filling the cav. attack ity These changes are usually confin- A significant feature of these cells is ed to the antra and ethnoids. Retained their tendency to group together in rela secretions commonly revealed by the tively small numbers in various areas of X-ray in purulent sinusitis are seldom the ficld. This clumping feature is espeseen in allergic disease unless caused by cialy diagnostic, more so, even, than the secondary infection Allergic edema in presence of a larger nunster of scattered volving the mucosa of the sinuses is individual cells. Due to various factors, quite transitory and the lining memthese cells may not always appear at the brane may fluctuate considerably in size Eirst or even the second examination and and thickening as the allergic process im- It may be necessary to examine several proves or worsens This reversible reacstated specimens before their presence tion may be very nusleading in the intdesionstrated terpretation of x-ray films, unless follow- Reference to the following table should up films are made at various intervals. be of aid in the interpretation of the X-ray examination per se cannot alvarious cytologic and hematologic tests ways be relied upon in the diagnosis of veed in the diagnosis of rasal disease. sinus disease, either allergic or infectious. 1 Preponderance of EOSINO- All rhinologists, I am sure, have had PHILES indicates ALLERGY, many reports from roentgenologists of 2 freponderance of NEUTRO. positive x-ray findings in cases in which no clinical evidence of disease could be HUILES indicates INFECTION 3 Sedimentation rate of erythrocytes, of x-say evidence les in its correct infound. In allergic sunus disease the value ·2 KENNETH L CRAFT seen, his cliet; has a clog or other pet been in OBJECTIVE EXAMINATION troduced into the hotischiold? Has the In addition to the information receivpatient, if a woman, adopted a new finger nail polish, or changed her brand of ed from the symptomatology and history, further evidence of allergic disease may face powder or other cosnetics ? Debe revealed by the objective findings. tailed inforniation should be secured regarding the symptons complained of; if Examination of the nose in a case of they are constant or intermittent; if they allergic rhinitis or sinusitis reveals a picare influenced by any of the patient's ture in sharp contrast to that seen in indaily habits or by a vacation away froni fection. The mucosa overlying the sepfrome; the cffcct, if any, of weather contum and turbinates usually will be pale ditions and seasonal changes, or of exand grayish white in color. Often the posure to dusts, animals, foods or other logged in appearance, due to the presinlicosa appears to be boggy and water. common allergens. ence of edema, and may be covered withi Vany important clues leading not only a frothy mucoid secretion. Polyps and to the establıslıment of a general diagnopolypord degeneration are frequently sis of allergy but also to the liscovery of Olistruction to brcatling varies in the specific catuse, or allergen, responsdegree At times one side of the nose ible for the patient's complaint, may be may be completely blocked and the other uncovered by a good liistory. In history sal discharge is watery or mucoid and is sicle fairly clear, and vice versa. The na. taking, the doctor should follow the patusually profuse, demanding frequent use tern of a trial lawyer and cross-examine of the handkercluef. Acute infection his patient in great detail in order to complicating allergic sinusitis may, at bring out significant points and clues times, completely mash tlie allergic apwhich the patient may consider unm pearance of the nasal mucosa and render portant unless leading questions are put the diagnosis more difficult. to lum. Someone has said, very aptly, that the diagnosis of allergy is 25% sci- The presence of nasal polyps immediately suggests allergy. These growths ence and 75% good cletective work. Ocappear much more frequently in the pocasionally a case may be solveel by mtrent with chronic, perennial allergic disformation received in the history alone. case than in the individual with the spor- The classic symptonis of nasal allergy adic, or seasonal type. In an extcisive include paroxysmal attacks of sneezing, Stirley of the polyp situation Kern and Schenck made the following obscrvawatery or mucoid nasal and lacrima) disclarge, nasal obstruction, and itching of the nose, eyes and palate. Loss of taste "1. Mlucous polyps are extremely condand of the sense of smell occasionally mion in allergic conditions of the are present in tlie more chronic and pro respiratory tract. tracted type of case. The patient may "2. In patients with non-allergic discomplain of only one, or of all, of these ease of thic respiratory tract mu- Cous polyps are comparatively symptoms, or of any combination of rarc, even in the presence of cx. tien. tionis:

·5 TREATMENT OF INHALAXT ALLERGY should be kept as completely free from are effective in preventing the dispersion dust as possible of dyist iron articles thus treated. One Special attention should be given to of my patients, a small boy, is sensitive the toys of allergic children The fuzzy to dog dander. Efforts to get rid of teddy bear of the wooly dog which the the child's pet dog led to such violent child likes to cuddle and take to bed protest and emotional reaction that plans should be discarded and such toys re to banish the animal were given up. Inplaced by those made of wood, metal or stead, the mother periodically dunks the plastics It may be necessary to get rid dog in a bucket of the chemical menof pet animals or at least to deny them tioned, and reports that the poolsless has access to the house. "They shed their been solved. hair and dander on rigs, couches and The best treatnient by far, of course, Chairs and thus become a menace to for any allergic condition, is complete many allergie individuals It would be avoidance of contact with those allerwell if "no smoking" signs could be post- gens which are responsible for the paed and enforced in homes of snjoke sen tient's trouble. Ilowever, this cannot be sure patients accomplished with such allergens as Filter masks and inhalators afford house dust, pollens, molds, etc., which are much protection to farmers, miners, bak constant inhabitants of the air which the ers, housekeepers and others who are victim must breathe For these patients, freely exposed to irritating dusts, pow- much relief may be given by hyposensin ders, etc Air conditioners are helpful in tizing 191jections of an extract of the al. cleaning the air and keeping it free of lergen causing the symptoms The in- Tritating dusts Also of value are elec. jections are given either subcutaneously truc dehumidiers, electronic dust and or intradermally. After the maximum pollen precipitators, and filters placed in amnunt of relief has been obtained, the furnaces ard in hot and cold air ducts dosage is held at that optimum level and The tenperature of the patient's bed 15 contínuel as a maintenance clase at room should be kept above 65°, chilling the interval best suited to the patient's should be avoided needs. There is no universal pattern to Chemical compounds are available as cover all patients' requirements; the 2 spray for carpets, rugs, draperies, up treatment for each must be individualholstered furniture, bedding, etc, and ized ·+ KENNETH L. CRAFT terpretation and in its correlation with headings, 1) non-specific measures, and the clinical and laboratory findings. 3) specific therapy. If any one of these diagnostic factors, Local treatment as administered in the i, e., the listory, the clinical picture, the 110se in the usual slirinking measures, has general symptoms, the laboratory examlittle place in alicrgic disease. It best, ination or the x-ray findings, points to the effect is only a very temporary im. allergic involvement of the rose or ajo provenient in breathing. Recent reports nuses, niore specific etiological evidence from some investigators, however, indishould be sought by skin tests with the cate more prolonged and more satisfacvarious allergents which have been sugtory restilts from the use of steroids in. gested by the history and the clinical ccted into the turbinate bodies This findings. A good history, itself, often type of treatment has been advocated gives the clue as to whether the offend especially in the more temporary attacks ing allergen belongs in the food or in of allergic «liscanc, such as seasonal polthe inhalant group. mosis General systemic treatment is some. As a rule the intradermal method of tines helpful and the use of certain skin testing is preferred. It is more sensitive and exact and gives more informa- plicating symptonis. Such drugs as ephe drugs is valuable for the relief of comtion than the scratch method, which isticilme, aminophyllıu, adrenalin, iclades, ally is reserved for small children and for pollen cascs. calcium, atropine, endocrine gland extracts (especially thyroid), sedatives, The clinical and laboratory factors C'TH, cortisone, etc, are often of great concerned in making a differential diag- value when indicated Antihistaminics tosis between allergy and infection have are used extensively, prolaly such more already been mentioned. Iside from inthan is justified. In the phalant type fection, allergy also must be differentiat- of allergic disease, these drugs are of ed from certain other pathologic condi. more value in seasonal pollinosis ilian tions. Malnutrition, secondary anemia, in perennial conditions, Jypothyroidism, ctc., may produce the Specific trcatment includes, 1) prophysame color clianges in the nasal mucosis laxis, and 2) lyposensitization. membrane as thosc calised by alicrgy Nasal obstruction from other causes, and PROPIIYLAXIS certain plıysical agents such as gases, Juch can be done in a preventive way. smoke, fumes, and temperature and cli- The patient sluould avond contact as mich mate changes, often produce nasal smpas possible, with all allergens to which toms which may simulate an allergic at. he is sensitized Mattresses and pillows tack. Psychic and emotional factors and of clust sensitive patients should be coy. disorders of the endocrine glands may cred with just proof casings. Better cause nasal symptoms typical of an alstili, sponge rubber mattresses and joillergic condition, and also must be con lows should be substituted, if possibile. sidered in the differential diagnosis. Rugs, curtains, upholstered furniture The treatment of the inhalant form of and all such dust catchers and dispensers allergic diseases of the upper respiratory should be removed from the citroxing. tract may be considered under two main The house, and especially the bedroom, ·7 TREATMENT OF FOOD ALLERGY vary with the particular area where tionship between the ingestion of a spethe patient resides. cific food and the production and ac- Masking Rinkel (3) describes a centuation of allergic symptoms can be demonstrated. It does not imply posi phenomenon to which he applies the term "masking" in which ingestion tyve shin reactions, nor suspected foods of certain foods leads to diminution front the history. The main requirement of the definition is the demonstra or ablution of symptoms. The oftion of a cause and effect relationship fending foods, while symptoms from between the ingestion of a food and the previous ingestion are still present, production of symptoms. are not easily detected. This situa- The generally accepted classification tron particularly applies to foods eaten within an interval of three of food allergy is as follows: days or less. The phenomenon of Permanent Type In general the masking is the primary reason why omission of a food leads to tolerance it is so thfficult to detect offending while frequent ingestion causes a foods. breakdown of tolerance leading to We made an intensive study of 40 the production of symptoms Howcases with proven food allergy in our ever, some foods, fortunately a small percentage, always react to produce practice. Whereas in the literature it is symptoms regardless of how fre implied that food allergies are nost prevalent in the younger age group, we did quently or how infrequently they are not find this situation to prevail in our eaten This type of food sensitivseries All age groups were represented. ity is known as fixed or permanent. We are seeing more cases of food sensi- Cyclic Type To this group betivities in the older age group This may long patients who can tolerate foods be due to hormonal factors in addition to they are allergic to, provided they other changes in the aging individual, do not eat the foods at top frequent Sex incidence favored the female group, inter als Omission of the food but we feel that the variation is too slight leads to tolerance while ingestion to be of any significance tends to sensitize the patient The patient goes through a cycle from SIGNS AND SYMPTOMS the phase of tolerance to the acute Kasat obstruction with excessive secrephase, in which stage his symptoms are at their peak tion was present in all of the cases Itching of the nose and excoriation about the Conconuttant This is a form of food sensitization which manifests nares was a common finding The nasal mucous membrane appeared pale, boggy itself only when the patient is ex- and edematous posed to other allergenic agents to Dryness of the nose wluch he is sensitive, such as polwas a symptom frequenty complained of lens, dust and fungi. The oropharynx presented significant symptoms Cracking at the corners of Thermal In this type the food the lips was frequent The tongue was sensitivity becomes manifest only at times coated and reddened when the temperature attains a cri of the tongue and mouth was not un- Burning tical level. The temperature levels common The mucous membrane of the ·GENERAL PRINCIPLES IN THE DIAGNOSIS AND TREATMENT OF FOOD ALLERGY OF THE UPPER RESPIRATORY TRACT SYI.VESTER C. MISSAL, J. D. Cleveland, Ohio more acute because of tlic very nature of the type of allergy with which most of our patients are affected. The late Noah Fox of Chicago (1), a pioneer in Otolaryngologic allergy referred to these patients as liaving borderline allergies or sul clinical allergics. They are not so ill as tlic frank allergics who suffer from asthma, urticaria, or eczema. They come to tis with the chief complaint of sinus trouble because of postnasal drip due to allergy, or nasal blochage wluch they The significance of food allergy con hlame on a broken nosc, or irritation tinues to be one of the most controver and burning of the eyes which they blame sinl subjects w tlie field of allergy. Some on errors of rcfraction; whereas the truc allergists tend to ignore it entirely: while care is allergy. The problem becomes othiers, notably Rowe, Riuhcl, and Rana lual one-to lissuade them from their clolph attach considerable importance to preconccived notions as to what the cause the role food plays in the causation of of their trouble in, and to cclucate them as to the true nature of their ailment symptoms. The reasons for this situation are many, chicſ among which are. Our interest in food allergies stemned from the failures we encountered carly (1) that the cause and effect relationship IN our practice of allergy some twenty is obscure, (2) the offendimg food or years ago We concentrated all of our fools are difficult to identify, and (3) the patient's full cooperation in the chmattention on the inhalant factors and is ination of the harmful food from his flored the ingestant sensitivities Pecals We hrow so little about them We made (liet is not always casy. This applies a study of forty such patients in our particuarly to school age chukiren and the adult unmarried male One other practice (2). The observations we have male materially altercel our concept of important reason why the significance the role of food allergies in the causaof food as an allergenic agent is overtion of car, nose and throat ymptoms. looked, lies in the type of allergic in- Before going any further in our disclividuals who present themselves in our cussion, a few concepts and cfinitions offices. pertaining to food allergy are in order. \\'c who practice otolaryngologic al Food allergy can loc clefined as 11:2t conlerky find the problems of food allergy dition in which a cause and effect rela. 6 ·TREATMENT OF FOOD ALLERGY 9 1 en and utilize the tests as a starting point in tient oi today expects to lie cured by "miracle drugs" and resents laving to do the therapy. Hale (5) conceived the idea of testing something for himself rather than to with material extracted from the seeds have his physician prescribe a regime of of the fruits and vegetables for which medication which will assure a cure merethe patient was being tested He based ly by taking pills. Many want to know the rationale for the tests on the follow- why they can't go on eating the foods they the while receiving injections ing facts: The same substances are as com- against foods as they do for dust or polmon in the puip as in the seeds except len. Likewise the modern day housethat the coticentration is greater in the wife has forgotten how to cook and bake. seeds After one or two attempts at preparing 2 Experimental evidence shows that 3 Wheatless loaf of bread she gives up in there is a common antigen in the pulp despair and seeks a ready-made product and off the seed. at some health store where the food may 3 Extracts of seeds taken as foods be stale and unpalatable by the time it is such as nuts and cereal grams show a purchased. The clinician must see the relatively higher potency than do ex- patient's side of the story and assist and tracts of foods of which the pulp is eat- encourage him as much as possible. The author's point is well taken and SUMMARY his method may be of value in the skin testing The significance of food allergy in the Skin tests are then supplemented with practice of otolaryngology was emphaindividual food ingestion tests as adto- sized The symptomatology, diagnosis, cated by Rinkel The findings of sich and treatment of food allergy was distests are then utilized to establish a basic cussed The problems encountered in diet to which foods are gradually added the handling of a food allergic patient At times Derlacki's (6) basic diet is uti! were mentioned, ized if the patient does not do well on REFERENCES the original diet prescribed for him. It 1 Fox, N, Harned, I. W, and Peluse, S. is not enough to instruct a patient to stay Borderline allergy Arch of Oto.31.502, away front certain foods He must also March, 1940 be informed as to the sources of the 2 Massal, S C. Cluical evaluation of food harmful foods, how to avoid them and sensitization in perennial nasal allergy. what substitute foods he can use At- AMA Arch of Oto, 65 353, 1957. tention must also be taken to assure a 3 Rinket, H. ), Randolph, T G. and Zeller, NE Food allergy Charles C Thomas well balanced diet with proper vitamins Pullishers, Springfield, Illinois, 1951 and itinerals added. 4 Bryan, WTK, and Bryan, MP, The The fock allergie patients whom we application of in vitro cytotoxic reactions see in our practice are difficult to handle to clinical diagnosis of food allergy. The Stace ibeir symptoms are not as a rule 5 Hale, R Laryngoscope, LXX, No 6 810, June, 1960 Seeds as a source of food testsevere, many do not take the trouble to ing material And of Allergy, 18 270, embark on a rigorous regime of food March, 1960, elimination and substitution such as is 6 Lerlacki, E. L. Food sensitization as a frequently sejured. Then too, the pa. Cause of perennial pasal allergy Ann, of allergy, 13 682, 1955 ·8 SYLVESTER C. MISSAL mens. pharynx was often dull red in appear beliefs may lie an effect upon the diet. ance and had at times a glossy appear. A childhood history of colic, diarrheas, ance. A heavy tenacious mucous niem and food intolerance often point to food brane film often coated the oropharynx idiosyncrasies in later life. Likes and and the nasopharynx. Islands of eosino- dislikes to certain foods must be evaluphils could be found in stained specie ated with caution for, as a rule, they Sore throats were frequently bear little relation to the patient's tolercomplained of following ingestion of the ance or intolerance of foods incriminatoffending foods. These symptoms reacht ed by the patient. Eating habits of the ed their peak in 12 to 24 hours, then patient should be inquired about, for valgradually subsided Tenderness to pal- uable leads may be obtained from such pation along the carotid vessels could of information. As a rule, there is little ten be elicited. Aphthous ulcers were not scasonal variation to foods, except perincommon, especially in patients sensi- liaps in fall when an abundant barvest tive to cow's milk. These would dis may result in reduced prices which may appear spontancously when the offend- influence the thrifty housewife to preing foods were eliminated from the dict pare and serve such foods more often Lymphadenopatlıy was a significant than usual. finding in some cases Patches of lym I significant lead to the presence of phoid hyperplasia in the mucous mem food allergy in the patient under adebrane of the pharynx and hypopharynx quate inlialant therapy is farlure to rewas a more frequent funding with food spond to treatment. All inlialant cases sensitive cases than with inhalant aller which do not respond to adequate thergies The significance of lymphord hya apy shoud bc suspected of having a hidle perplasia remains obscure though many clen food allergy theories have been propounded to ex Bryan and Bryan (4) Irave applied the plain its significance in vitro cytotoxic reactions of leukocytes The larynx was the site of reactions in as an aid in the clinical diagnosis of food some cases. The vocal cords would be allergy We lave not utilized this methcome thickened and ecematouts and the od in our practice but intend to do so. voicc licconic lioarse after ingestion of .Is the authors stress, the success or noxious foods. We encountered 170 cases failure of the niethod is dependent upon of respiratory difficulty resulting from meticulous technic in carrying out the acute edema of the cords. DLAGNOSIS TREATMENT The patient's racial, cconomic and re Ile routinely employ shin tests by the ligious background liad some bearing on scratch method for all cases with food the history of food sensitivities, particu- allergy. We realize that such tests are arly in our practice for a large percent of limited valuc, but when properly cor. age of our patients came from immigrant related with a fool history they provide stock. Although the cating habits of the valuable information which renys for children are considerably altered from time and effort cxpended in performing that of their parents, certain nationality the losts. Ile use the results of the last dishes are retained. l'or some, religious as a guide as to what fixxls to climinate test.

·TREATMENT OF FOOD ALLERGY 9 1 . and utilize the tests as a starting point in tient of today expects to be cured by "miracle drugs" and resents having to do the therapy. Hale (5) conceived the idea of testing something for himself rather than to with material extracted from the seeds have his physician prescribe a regime of of the fruits and vegetables for which medication which will assure a cure mere the patient was being tested. He based ly by taking pills Jany want to know the rationale for the tests on the follow- why they can't go on eating the foods ing facts. they like while receiving injections The same substances are as com- against foods as they do for dust or pol- Likewise the modern day housemon in the pulp as in the seeds except len that the concentration is greater in the wife has forgotten how to cook and bahe Seeds After one or two attempts at preparing 2 Experimental evidence shows that a wheatless loaf of bread she gives up in there is a common antigen in the pulp despair and seeks a ready-made product and in the seed at some health store where the food may 3. Extracts of seeds taken as foods be stale and unpalatable by the time it is such as nuts and cereal grains show a purchased. The clinician must see the relatively higher potency than do ex- patient's side of the story and assist and tracts of foods of which the pulp is eat encourage hun as much as possible. en The author's point is well taken and SUMMARY his method may be of value in the skin testing The significance of food allergy in the Skin tests are then supplemented with practice of otolaryngology was emphaindividual food ingestion tests as adva sized. The symptomatology, diagnosis, cated hy Rinkel The findings of such and treatment of food allergy was distests are then utilized to establish a basic cussed The problems encountered in diet to which foods are gradually added the handling of a food allergic patient At times Derlacki's (6) basic diet is util were mentioned. ized of the patient does not do well on REFERENCES the original diet prescribed for him st is not enough to instruct a patient to stay I Fox, . Harned, I w, and Peluse, S Borderine allergy Arch of Oto, 31 502, away from certain foods. He must also March, 1940 be informed as to the sources of the 2. Myssal, S C. Cical evaluation of food harmful foods, how to avoid them and sensitization in perenmal sasa) allergy. what substitute foods he can use AMA Arch. of Oto, 65 153, 1957. At tention must also be taken to assure a 3 Rinkel, H, J, Randolph, T G and Zeller, M Food allergy Charles C. Thomas well balanced diet with proper vitamins Publishers, Springfield, Jinos, 1951 and minerals added 4 Bryant, W TK, and Eryan, M P. The The food allergic patients whom we application of in vitro cytotoxic reactions cee in our practice are difficult to handle to clinical diagrosas of food allergy The Laryngoscope, LXX, Xo 6 810, June, 1960. Since their symptoms are not as a rule 5 Hale, R Seeds as a source of food testsevere, many do not take the trouble to ing material Ann of Allergy, 18 270. embark on a rigorous regime of food March, 1960 clamabon and sulystitution such as 19 6 Derlachi, EL frequently required. Then too, the pacause of perennial nasal allergy Ann, of allergy, 13.682, 1955. Food sensitization as a ·POLLINOSIS AND ATMOSPHERIC NOLDS (Courses No. 3 and 4) MICHAEL, H. BARONE, M, D. Buffalo, New York BERNARD J. BARRETT, J. D. Pensacola, Floricla BG QUESTION What molls do you Thus un instances of positive reactions fcel one should shin test with to several genera of the Dematiaccae, uc DR. BARRETT In clinical practice, would include them all in a therapeutic the following molds are representative (lematiaceous mixture. Similarly, in defand practical and are the most common inite reactions to monilaccous molds, we offenders: Alternaria, Hormodendrum, would prepare all species of these molds lielmintlısporium, Pulluların, Aspergil 111 a monilaccous mixture Our experilus, Penicillium, Fusarium, Rhizopus and once has been that treatment miltures Mticor. containing all the reacting molds have Additional moll species, such as gram often afforded better ciuical results than rusts and smuts, may be important allerhave single species antigens. genic factors in certam arcas. Ilthough juathogenic fungi, espxecially QUESTION Wliat molls would you nionilia, may involve the respiratory employ in treatment? tract, they are most commonly encoun. DR. BARRETT It would be phys tered 11 «ermatologic conditions. The ically impossible to test with all moll types wluch come under consideration fungi or to combine all reacting species are, Tricliophyton, Alonilia and Epider. into treatment mixtures, even if the anti mophyton These commonly cause legeus were available. One can only hopxe Sons of the hands and feet and around that considerable cross sensitization ex thie eyes and cars. ists, Universal cross immunity cannot ll'e employ a mixture of trichopliz tili, lie anticipated among all the molds, and ordionycin (momlia) and cipdermoplyso expediency would clictate that treat tin. The stock solution, 1:1000 (3) ment mixtures be made as polyvalent as diluteel serially througlı Sos. 4, 5, (), 7. possible. 8, 9, and 10. We have found that the 10 ·POLLINOSIS AND ATMOSPHERIC MOLDS dilution most commonly effective is #7. ment is then continued coseasonally, (1-10 Alillion) For a nonspecific block using Hansel's optimum type of therapy. ing effect on the allergic process or for In order to institute thus forni of treatstaplıylaccus inimunization, staphylococ- ment, it is best to determine the degree cus toxoid may be added to the injection of reactivity of the skin, Ivy using serial of fungus extract The results obtained dilutions in skin titration. Start with a in the use of small optimum doses has dilution of me to ten million in allts been most dramatic (1-10,000,000) and one to one hundred great many cases of dermatitis are encountered in which it is a question of milion in children ,l-100,000,000): use only two difutions at the time of the first atopic dermatitis, contact dermatitis, or visit. If ng reaction occurs, the next a fungus (allergy or infection) and prompt initial improvement may be obtwo dilutions may be given, i e., 1-1,000,- 000 and 1-100,000 in 2-3 days and so on tained by the use of staphylococcus toxual, fungus extract, or a combination of until the end point is found, Loth Treatment is started with a dose of QUESTIOX: If a patient does not ten to fifteen times the end point, and obtain complete relief from preseasonal given every one to three days. If the pollen desentizatio, what can be done to patient responds well to a given dosage, help him get through the season with do not attempt to lengthen the period of less discomfort relief by increasing the dosage. In most DR BARONE li prescasosial ther cases, the coseasonal form of therapy is apy does not give adequate relief, treat my method of treatment.

·OPTIMAL DOSAGE THERAPY TECHNIC OF CYTOLOGICAL EXAMINATION (Courses No. 5 and 6) FRENCH K. HANSEL, M, D. St. Lous, Alissouri LINDEN J. WALLNER, J. D. Chicago, Illinois QUESTION Do you find nasal cy a long period of time we found in using tology of much practical value in private tood that from 1/10 of a unit up to practice? one it gives a stress or .ACTII effect. DR. WALLNER I certainly do It With a wcaker close, say to 1/100 or gives us a good objective method for tn 1/1000 of a unit, an inmmologic making a diagnosis of allergy. We may phase is reached with Immunity to stasuspect it from the symptoms or the ap- phylococcus Immunity to staplıylococpearance of the nose, but with an ob cuis is not produced with a stress coc of jective test we can be more stire Then staplı That was our first discovery. In we feel more justified in further work infantile eczema some years ago, I disup with skin tests, etc. covered that with this stress dose, re- QUESTION. Does your teclmcian markable results were obtained, then we do this examination for you? found that the immune doses were far DR. WALLXER: I pread the ma down the scale We hac reduced doses tcrial on the slide and she stais it and to as low as one millionth of a unit in it is ready in a few minutes, while the some cases of rheuniatoul arthritis. We patient is still in the office. But I ex clon't ordinarily treat patients of this amine the slide myself, as I find this of tyjxe but we liave experimented with it more benefit than a report. with excellent results. DR. BIAXSEL: (In answer to a QUESTIOX: Jlow long will the ciquestion apparently regarding dosage of feet last staplıylococcus toroid). ... the closage DR. 11.1XSEL. Tlie average close is based entirely upon clinical experi. will last about four days in the beginence. In a large number of cases over ning later the effect will last from 12 ·13 OPTIMAL DOSAGE 1 HERAPY CUT DR. WALLNER: I find that I use four or five days to one week. The treatment can be discontinued if there it almost routinely in children So often, If especially in children, the diagnosis is beare no symptoms after two weeks you are using a certain dose and getting tween obstruction due to aslenoid, inrecgood results you should automatically re tion, or allergy. This is especially truc duce the dose hecause there may be a where ne are attempting to find the All three loss of tolerance after a few doses, a cause of a setouis Otitis media half dozen or so, and a flare-up may oc- conditions may be present in the same The dosage can always be increas- patient The percentage of eosinophiles eil if it is too low but if a flareup of oiter determines whether we order an symptoms occurs, jou naay have difis- antihistamine or antibiotic, or both. culty in establishing an optimal dose. A QUESTION: Do you titrate with rest period of several wechs should be histamine? allowed before giymg further injections. DR. HANSEL: Some work las been clone on that. The average end point on QUESTION': in finding the optimal histamine is #5 or #6, that is, 1 to dosage do you use skin titration 100,000 or to 1,000,000 We haven't DR HAXSEL: This is a very good done too much with it but we recommend method in inding the end point in pol- utration to histaminc in headache cases len treatment but not so good with dustfor an optimal dose and to determine except Endo dust which trates ont very wliether a patient who titrates up to 1 to well Titration is not very adaptalle to 1,000,000 takes a different dose than one the establishment of toxoid dosage who fitrates to 1 to 100,000. The husta- QL'ESTION When do you use the mine reaction in the skin would depend stress dosage upon that patient's skin reactivity. A DR HANSEL patient with dermographia will react For urticaria, dermatitis around the ears or eyes, atopic or away up at #6 or #7 while a person whose skin is less sensitive will require contact dermatitis, for atij tlung in which you want an ICTH effect There are much stronger test extracts But if you KUNY ons vecaire remenes which do the titrate & patient with histamine, one on same thing, cells as pyromen of anergex whom you are gong to do skın tests, and We have preferred toxoid because the he gives a low point of 1 to 1,000 or 1 material is well standardized and we to 10,000, skin reactions are not likely Anow the ratige of dosage For a stress to le good! The histamine test is a good effect dosage we use less than one unit. indicator of how responsive the skin is We use 1/10 to 1/2 of a unit intradermgoing to be to other tests Wy, rarely more than 1/2 good positives may not be obtained, s0 in these patients, stronger extracts should QUESTIOX Just where do you be used The histamine titration would find cstuleys post helpful? indicate the ·OPTIMAL DOSAGE THERAPY TECHNIC OF CYTOLOGICAL EXAMINATION (Courses No. 5 and 6) FREYCH K HAXSEL, M, D. St. Louis, Missouri LIXDEN J. WALLNER, J. D. Chicago, Illinois QUESTION. Do you find nasal cy a long period of tinie we found in using tology of much practical value in private toxund that from 1/10 of a unit up to practice one unit gives a stress or ICTH effect. DR. WALLXER: I certainly do It With a weaker dose, say to 1/100 or gives us a good objective method for to 1/1000 of a unit, an inimumologic making a diagnosis of allergy. We may phase is reached with mmmunity to stasuspect it from the syniptoins or the ap- phylococcus. Immunity in staphylocncpearance of the nose, but with an ob cus is not produced with a stress dosc of jective test we can be more sure. Then staph That was our first discovery. In we feel more justified in further work infantile eczema some years ago, I disup with skin tests, etc covered that with this stress doce, re- QU'ESTIOX: Does your teclmician markable results were obtained, then we do this examination for you? found that the immune doncs were far DR. WALLVER: I spread the ma. down the scale We have reduced do-cs tcrial on the slide and she stains it and to as low as one mullionth of a unit in it is ready in a few minutes, while the Seime cases of theunatoid arthritis patient is still in the office. But I ex don't ordinarily treat patients of thus amine the slide myself, as I find this of type but we have experimented witli it more benefit than a report. with excellent results DR. HAXSEL: (In answer to a QUESTION llow long will the efquestion apparently regarding dosage of fect last? staphylococcus toroid). . the dosage DR 11.1.XSEL: The average love is based entirely upon clinical experi- will last about four days in the lugin. cnce. In a large number of cases over ning. Later the effect will last from 1.

·13 OPTIMAL DOSAGE. THERAPY cur The DR. WALLNER: I find that I use four or five days to one week treatment can be discontinued if there it almost routinely in children. So often, are 10 symptoms after two weeks If especially in children, the diagnosis is beyou are using a certain dose and getting tween obstruction due to adenoid, infecgood results you should automatically re tion, or allergy. This is especially true duce the dose hecause there may be a where we are attempting to find the loss of tolerance after a few doses, a cause of a serous otitis media. All three half dozen or so, and a flare-up may oc conditions may be present in the same The dosage can always be alicreas patient The percentage of eosinophiles ed if it is too low but it a flareup of often determines whether we order an symptoms occurs, you may have diffi- antihistamine or antıljatic, or both culty mi establishing an optimal dose A QUESTION: Do you titrate with rest pennor of several weeks should be histamine? allowed before giving further injections DR, HANSEL: Some work has been done on that. The average end point on QUESTIOX: In finding the optimal histamine is #5 or #6; that is, 1 to dosage do you use skin titration? 100,000 or to 1,000,000. We haven't DR HAXSEL This is a very good done too much with it but we recommend method in finding the end point in pal- titration to histamine in leadache cases Icn treatment but not so good woh dust, for an optimal dose and to determine except Endo dust which titrates out very whether a patient who titrates up to 1 to well. Titration is not sery adaptable to 1,000,000 takes a different dose than one the establishment of toxoid dosage wlio titrates tb 1 to 100,000 The hista- QL'ESTION. When do you use the mne reaction in the skin would depend site's dosage upon that patient's ski reactivity a DR FANSEL For Urticaria, serpatient with dermographia will react MAIS around the ears or eyes, atopic or away up at #6 or #7 while a person contact dermatitis, for anything in which much stronger test extracts whose skin is less sensitive will require you want an ACTH effect There are titrate a patient with histamine, one on any nonspecific remedies which do the Same thing, sucls as pyromen or anergex whom you are going to do shut tests, and We have preferred toxoid because the he gives a low point of 1 to 1,000 or i to 10,000, skin reactions are not likely terial is well standardized and we know the range of closage for a stress to be good the histatnine test is a good effect dosage we use less than one unut indicator of how responsive the skin is We use 1/10 to 1/2 of a unit intradermgoing to be to other tests ally, rarely more than 1/2 good positives may not be obtained, so in these patients, stronger extracts should QUESTION Just where do you be used The histamine titration would find cytology most helpiu' indicate this But if you In some, ·OPTIMAL DOSAGE THERAPY TECHNIC OF CYTOLOGICAL EXAMINATION (Courses No. 5 and 6) FRENCH K. HANSEL, V. D. St. Louis, Missouri LINDEN J. WALLNER, M, D. Chicago, Illinois ܕ find nasal cy- QUESTION Do you a long period of time we found in using tology of much practical value in private toxoid that from 1/10 of a unit up to practice one unit gives a stress or ACTH effect. DR. WALLNER I certainly do It With a weaker dose, say to 1/100 or gives us a good objective method for to 1/1000 of a unit, an immunologic making a diagnosis of allergy. We may phase is reached with immunity to stasuspect it from the symptoms or the ap- phylococcus Immunity to staphylococpearance of the nose, but with an obcuis is not produced with a stress dose of Jective test we can be more sure Then staph. That was our first discovery. In we feel more justified in further work infantile eczema sone years ago, I disup with skin tests, etc covered that with this stress dose, re- QUESTION. Does your technician markable results were obtained, then we do this examination for you? found that the immune doses were far DR IVALLNER I spread the ma down the scale. We have reduced doses terial on tlie slide and she stains it and to as low as one millionth of a uit in it is ready in a few minutes, while the some cases of rheumatoid arthritis. We patient is still in the office. But I ex don't ordinarily treat patients of this amine the slide myself, as I find this of type but we have experimented with it more benefit than a report. with excellent results. DR. HANSEL: (In answer to a QUESTION: How long will the efquestion apparently regarding dosage of fect last? staphylococcus toxoid). . the dosage DR HANSEL: The average dose is based entirely upon clinical experi- will last about four days in the begin- In a large number of cases over ning. Later the effect will last from 12 ence, ·15 HISTORY TAKIXG QUESTION. Do you use cortisone in QUESTION: Do you tahe your own histories? your allergy practice DR. CRISPELL: Yes, I sure do; I DR. CRISTELI. It depends entirely want to know the history; I prod the on who the patient is and what his prob mother. As soon as I decide that I am lemn is. You can't make anything stand- going to do an allergy examination I have ani This year I have used two things in the patient fill out this sheet regarding hay fever, ACTH and a cortisone used in his symptoms It helps me and it also corulnation with triaminic, the Smith- makes the patient think. Ily nurse starts Dorsey product which they put out in the skin tests and starts to talk with the combination with bydro-cortisone. There patient, going over and over the history were no youngsters in that group but with litt She wheedles things out of there were a few adults that I have had him and then instead of writing it down some trouble with in the past because of she will say to the patient or to the their tendency to develop asthma, and for mother, "Now, when the doctor comes that ten-day or two-week period during back to check these tests, you be sure to the peak time I have resorted this year tell that to him.' We use a sort of runto the use of triaminic with l»drocorti- ning history which works very nicely, sone It is not the type of therapy which So when I read the skin tests, that gives I like and I am against using it as a us & chance to coordinate the history routine measlise again.

·HISTORY TAKING (Course No. 7) LAVRENCE S. CRISPELL, MI. D. Joplin, Missouri COURSE 7 STOLT TAKING L 190L MD FOR MB QUESTION Wliat do you do in re again wliile I am reading the skin tests gard to taking an allergy lustory" On all subsequent visits we also press on DR. CRISCELL: An allergy history history and find that many times we can is actually, as far as I am concerned, a stinnılate the parents into thinking about rumming listory In working with a things that are very important that they youngster, I will start my pliysical exam, are not able to tell us on the first visit and wlule I am doing the physical exam because they simply do not tunk about I <liscuss the history with the mother I them. fund that if I heep prodeling the parent QUESTION Doctor, do you believe as I am doing the physical exam that I that a bustory form as produced by Dr get more out of it than if I just sit down Jack Anderson is lielpful? and start to take a history Ifter I harc DR CRISI'ELL Of course, there is fimshed my exan), we take our patient no question in anybody's mind that Dr. out into what we call our allergy room - Inderson's history is idlcal Ilowever, I and then give the mother a hustory sheet. feel that the sliort form that we use and which I have here and have shown you, the running type of verhal fustory that I and let her start filling in the answers am able to get from the parent are quite to this ablireviated history sheet, as we adequate in my hands, and in most cases, are doing the skin tests. The shin tests at least, answer the questions that I am in my office arc clone entirely by my interested m. To be quite frank with you, officc mursc-of course, I read them I do not feel that I fave extra time to sit but while my nurse is cloing the skin clown and go over the voluminous lustory testing, she also prods the mother regardlil suggested by Dr Anderson, i.c, rcading the history. If she can get anything ing it and cataloguing it, cte, which is out of tlic mother that she feels is imcertainly necessary if you are going to portant, slie tells the mother to be sure Disc such a form. Therefore, I and tell tlie doctor when lie returns, and to my shortened form as being most of course, go back over the history adequate for me. 14 go back I ·17 DIFFERENTIIL DIAGXOSIS her. This is not allergy I woului venture it outdoor activities with the other chil. to say no two men around this table dren he would take a cold. would suggest the same therapy. He had a dust sensitivity, a purulent Now, here is an X-ray of a child seven tischarge in his nose which contained an years old with nasal symptoms all of her occasional eosinophil and, as you see, the life As you see, the sinuses are clear X-ray showed a generalized density in in the X-ray. Tlis patient has an allergy, both maxillary sinuses. and not infection She was relieved of This patient was given large doses of lies nasal symptoms by allergie manage. antibiotics over a period of three weeks. ment The nasal symptoms cleared up in five QUESTIOX: What is your surgical days but returned soon after the antiapproacit to the antruin? biotics were discontinued. He was also DR. STAHL: I agree with Dr. Hensy being hyposensitized to house dust. Asti- Coolyear that a large percentage of botics were administered again for a antral infections can be surgically cured longer period-five weeks. The x-ray at ly the window approach It is important the end of the fne weeks still showed to create a large window anteriorly, and pathology and the symptoms returned as to pack the antrum for several days. before. However, after antral windows The Caldwell-Luc procedure is a fine were made, the child began to pick up operation and is reserved for those cases immediately in the past school term he that one wants to biopsy or explore for has missed only two days of school and idental causes that cannot be excluded has required antibiotics only on two ocpreoperatively. casions DR SANDERS, Here is an x-ray of This case shows the necessity of treatanother child seven years of age. He has ing both the allergy and the infection been sick practically all tres life. His when both are present in the same patient. tonsils and adenoids were removed at the Each condition requires its own especially age of three Hie missed over a month of indicated type of treatment, if the best school last year and every tune be joinesl results are to be obtained ·DIFFERENTIAL DIAGNOSIS X-RAY EXAMINATION AND INTERPRETATION (Courses No. 8 and 9) SAN II. SANDERS, M, D. Memphis, Tennessee RICIIARD H, STAHL, M. D, Cuyahoga Falls, Ohio Ruun * WHO mur QU'ESTION What is your opinion form «ensity which could be pathoconcerning the routine 11se of x-rays on logical. The nose chin position shows a new patients ? tluckening in tlic antral micosa and some DR STAHL: Generally speaking this generalized density which is cvidence of is a good idea, particularly if you take clironic infection the pictures in your office or at an adjac. It the age of four this child was seen ent center where they can be examined with bad tonsils and adenoids and a These pictures become more valuable of purulent sumisitis. She was scen later for we are able to examine them ourselves, car complications We could not persuade not necessarily taking the interpretation the parents to bring her un except during of the roentgenologist an acutc cxacerbation She was the micn- I feel that x-rays are indicated in most her of a large family living out of town cases, except those with trivial or muld and the parents said they could not recent complants. What do you think, afford the visit to town even thougli the Dr. Sanders? medical service was being given free of DR. SANDERS: Well, let's look at charge. this sinus x-ray of a tlurteen year old The chule was scen off and on at five, girl. In the nose forward position you six, and seien but not again for five can see much extra space in the lower years. Now she lias devcloped an atropluc lialf of the nose. This would suggest an rhinitis from a pansimusitis and has a atrophic condition. There is clensity in clironic bronchitis with an early bronclii. thie ethmoil, less density between the ectasis Farly treatment would have preseptum anel the midelle turbinate than icnteel this patient from becoming a would be expected, small frontals with respiratory cripple. What to lo witli 16 ·DIFFERENTIAL DIAGXOSIS her? This is not allergy I would venture in outdoor activities with the ottier children he would take a cold. to say 10 two men around this table would suggest the same therapy He had a dust sensitivity, a purulent Xow, here is an x-ray of a child seven discharge in lus nose which contained an years old with nasal symptoms all of her occasional eosinophil and, as you see, the life As you see, the sinuses are clear X-ray showed a generalized density in in the X-ray. This patient has an allergy, both maxillary sinuses. and not infection She was relieved of This patient was given large doses of hier nasal symptoms by allergic manage- antibiotics over a period of three weeks ment, The nasal symptoms cleared up in five QUESTIOX: What is your surgical days but returned soon after the antiapproach to the antrum biotics were discontinued He was also DR. STAIL. I agree with Dr. Henry being hyposensitized to house dust. Anti- (oodyear that a large percentage of biotics were administered again for a antral infections can be surgically cured longer period--five wecks. The x-ray at Wy the window approach. It is important the end of the five weeks still slowed to create a large window anteriorly, and pathology and the symptoms returned as ta pack the antrum for several days before However, after antrai windows The Caldwell-Luc procedure is a fue were made, the child began to pick up operation and is reserved for those cases immediately. In the past school term he chat one wants to biopsy or explore for has missed only two days of school and densal causes that cannot be excluded has required antibiotics only on two oca preoperatively. DR. SANDERS. Here is an x-ray of This case shows the necessity of treatanother child seven years of age He has ing both the allergy and the infection leen sıck practzcally all his life His when both are present in the sanic patient. tonsils and adenoids were removed at the Each condition requires its own especially age of three He missed over a month of indicated type of treatment, if the best school last year and every time he joined results are to be obtained ca s10n15 ·ARRANGEMENT OF OFFICE FOR THE PRACTICE OF ALLERGY PREPARATION OF DILUTIONS (Courses No. 10 and 11) EDLEY H JONES, M. D. Vichsburg, Mississippi DIVIGHT D. MOFFITT, I'h. D. Philadelphia, Pennsylvania How much equipment cessories. ? QUESTION vials, diluting fluues and all other acis necessary and how much time is required to make an adequate study of a patient with nasal allergy Scratch tests can be made with just about anythmg that will break the skin; DR. JONES: Since most of us have a hypodermc needle, a dull knife, the this work done by our office murse or l'on Pirquet chisel, or best of all, the laboratory technician, comparatively lit- Morrison Micro-scratcher. Intradermal tie of our own time is required Of tests are made with tuberculin syringes course, we must read and interpret the and small short needles, we use 25 gauge tests, make the diagnosis, outline and pre needles, %2 inch long, scribe the treatment, and give the patient You will need a separate sterilizer for full instructions. your allergy equpment, and sliould use You should have a full set of testing only distilled water in it Of course, an antigens-pollens, dust and molds, misautoclase is a satisfactory alternative. cellaneous, and food antigens Mr. You will need an adequate supply of tu- Dwight Moffitt, wlio is jointly conduct Iserculin syringes, a couple of 5 and 10 ing this Round-Table discussion with me, C.C. syringes, and plenty of small needles is connected with the Hollister-Stier Lab. QUESTION. In correlating dilutions oratories, generally recognized as a lead and pollen imits I'm never sure whetlier er in this field, and he can tell you ex the pollen units arc of cach item or actly what all the equipment costs, such wliether it is a combined total unitage of as testing antigens, sterile rubber-capped the pollens in a mixture. 18 ·19 PREPARATION OF DILUTIONS MR VOFFITT: The most concen when using S's you use 1 part of extract trated pollen extract we supply is a 1-20 to 4 parts of diluent to form another dilution which contains 50,000 pollen extract 1/5th as strong. For example, wsuits per culuc centimeter. If I c.c. of if you were diluting a 1°10 extract your 1-20 short ragweed, which is 50,000 pol- succeeding dilutions would be 1:50, Jen units, and I cc, of 1-20 timothy, 1:250, and so on. 50,000 pollen units, are combined, each QUESTION: Why do you always ce of the mixture will contain 25,000 advise testing with the individual polpollen units of short ragweed and 25,000 lens instead of using a mixed extract? pollen units of timothy, making a total MR MOFFITT. The mixing of exof 50,000 of the mixture in each cc tracts reduces the amount of each anti. This holds true with any number of gen, and the more pollens in the mixture, polleus in a mixture but there can never the less there is of each. If you are testle more than 50,000 pollen unsts per cc. ing a patient with a low skin reactivity in the combined mixture there will not be enough antigen to pro- QUESTION. How do you go about dure a diagnostic response to any indimahing up different dilutions? vidual pollen Thus, a false negative re- DR JONES. Some allergists dilute action is olstained. try 10's but I think most of us (lilute by Only in grasses is there a tanuly anti- 5's in prescribing an extract by 10's it gen Bermuda and Johnson grass are is necessary to give a dose of 1 full cc exceptions and do not share the same an. of a dilution before going to the dose of tigeris with each other or with timothy 10 cc of a dilution 10 times stronger, or Jure or the other common grasses. whereas by 5's you need to give a parent The weeds are the most specific, with a dose of only .50 cc before going to a very little cross reactions except in the dose of 10 cc of a dilution 5 times ragweed family stronger I prefer the smaller dose Testing individually and treating spe- The actual dilution is mere arithmetic, cifically will give the best results.

·TREATMENT OF INHALANT ALLERGY (Course No. 12) WILLIAM H. EVASS, M, D Youngstown, Ohio JOSEPII W. JAMPSEY, M, D. Pittsburgh, Pennsylvania ooh VER QU'ESTION Is treatment with in DR. EVANS: Yo. Frequently comhalants other than pollen often necessary plications requre the use of steroids, in food allergy? antihistaminics, ephedrin, adrenalin, scd- DR. HAMPSEY In my experience, atives, aminophyllin and other drugs for the majority of patients with food al their control. lergy also have some form of inlalant QU'ESTIOX How frequently dlo sensitivity as well. For this reason I you use antilistamines? usually titrate them to house clust at the DR EVANS. Since we are primarfirst visit, so that lyposensitization can ily interested in relieving the symptoms be under way while a scarch is being as rapidly as possible, we frequently premade for the offending foods, either by scribe antihistaminics immediately. Howskin test or dietary manipulation ever, as soon as possible, thic tise of the QUESTION What dosage of house drug is discontinued. dust is commonly used in these patients' QU'ESTION How do you usc staphy DR. HAMPSEY Idults are often lococcus toxoil in your allergy practice? started on the 1-100 million dilution, DR ILIMPSEY Well, I llare prwhile generally the 1-1 billion dilution is tients m whom I suspect food sensitivity uscsl for children After the inhalant at the scry first visit. I can't track it problem is controlled by the use of house down at the first visit but before they dust extract and the reduction of inhalleave I am apt to start them off with an ant contacts, it is easier to get satisſac- injection of staphylococcus toxoid and tory results from food tests and from occasionally they are benefited for a day the omission of offending foods. or two. They will mention it without QUESTION: Do you depend on ly being questioned And these are fool posensitization alone to control allergic cases. They get a non-specific response, I am sure, but staphylococcus to soil jirst 20 symptonis?

·21 TREATMENT OF INHALANT ALLERGY Traction? QUESTION, How many plants and happens to be one of the best purified weeds, etc, do you test with? vaccines that we have and one that we can rely upon in serial dilution When DR, HAAPSEY; I use about fif- Me are using it in 1-10.000 or 1-100,000 dlslutions we like to have a well purified teen weeds routinely. One of the most vaccine that we can rely 1pron. I usually myrortant ones in our area is Ålexican Tea, especially during the last five years. pre 1/100 of a unit as an initial dose It is air borne and usually precedes rage QU'ESTION. Da they get any local weed, coming at the end of July and during the early part of August. I've only OR HAMPSEY: No, not with 1/100 had two cases; I wasn't able to explain nt a unit. I usually rely upon what they their symptoms at the end of July until tell me when they come back. Now, as I learned about the importance of this you get into that case ritas be you can pollen and tested them out with it. jungout the food and remote it from the diet and then the patient won't need the QUESTION: From the standpoins toxoid But the little kick he gets from it generally of weeds such as dandelion, is helpful, although it may not work con- goldenrod, etc, with a heavy pollen; a tffittously if the patient continues to eat person issay be sensitive to them but do the foxx to which he is sensitive they really cause any symptoms? QUESTION. Do you use steroids DR ??: In sy part of the courroutinely in the treatment of inhalant try, in Idaho, we don't have ragweed, allergy but we have grass and other weeds, such DR EVANS: No, but we do use steras Russian thustle, sage brush, sugar beet, ords as an adjunct to other forms of treat- dandelion, etc, which cause trouble. ment in an attempt to control allergic QUESTIONER. They do simptomis L'sually this is cnly for a trouble; that's the point I was getting at. short period of time. We never disconfinne steroid treatment suddenly while that some of these heavy pollinating weeds Some doctors will dismiss entirely the fact the parent is taking a dose of maximum s not cause trouble because they are $Izc Insteasl, the dose 15 lowered grad not air borne, but some of thern do cause ually over a period of days or even weeks. trouble. QUESTION Are nasal applications of sterotis viseful in treating nasal al- QUESTION. Will the systemic use bergs of a steroid remove nasal polyps without OR $ 1.35. Yes floweser, they are sitgery? much more effectue when used as an aid DR. EVANS. You can shrink polyps In other forms of treatment, such is of allergic origin by administering a hyposensitization, anhistammes, steroid dy mouth, intravenously, or by l'uwdered hydrocortssone sprayed into the intramuscular soute, but you should the nose 18 very effecire si controlling caution the patient that if allergic sympacute sy niptoms toms, TECHI, the polyps also will return. cause etc ·ALLERGY OF THE EYE; DIAGNOSIS AND TREATMENT (Course No. 13) ROBERT S. COLES, M, D. New York, New York LELAND PREWITT, M. D. Ottumwa, Iowa AUTOMM • 02 #p RI QUESTION. Doctor, what percent tion, do you believe there is some other age of uveitis is due to allergy? factor which causes the pathology? DR. COLES Certainly there are DR. COLES: Well, I certainly feel many forms of uveitis in which I trunk that iveal sensitization plays the predominant role in the causation of symallergy plays an important role In addition to foods and inhalants, there are patletic ophthalmia. I believe that perhaps there is something necessary to trigo certain forms of bacterial uveitis in ger the reaction and this necessary facwhich bacteria or their products play an tor could be either a conjunctival saproimportant role--tuber osis, for ex- phyte of no pathogenic significance by ample. We now believe that toxoplas- itself, or a virus, or a bacteria \Vlicii mosis has a strong allergic component entering the eye, one of these may conic leading to a severe posterior uveitis, and in contact with tlic uvcal pigment of the allergy undoubtedly plays a predominant ucal tract, and then combine with it, part in the causation of sympathetic oph- forning an entirely new substance which thalmia I am afraid, however, when I acts as an antigen and then causes sensi. think of allergy as causing uveitis, I don't tization of the other eye, leading to syinthink of it in terms of everyday practice pathetic ophthalnna This is purely specwhere you can setermine tlus allergy via ulation, however. skin tests or patch tests or things of that QUESTION: Why doesn't antihis. nature. I think of it on a more intritamine therapy take care of the majority cate and a more complicated level of tisof allergic reactions > sie hypersensitivity DR. PREWITT. Antihistamine ther- QUESTION: In sympathetic oph- apy will help a great deal in the anaplıythalmia, besides uveal pigment sensitiza lactic and the acute reactions, but lista- 22 ·23 ALLERGY OF THE EYE nuine often is not the major factor in the ally use scopolamine, 002%, or homadelayed type of reaction. The toxic tropine, 5%, to dilate the pupil. I adproteolysis that takes place in allergic minister 242% solution of hydrocortisone of cortisone. I feel that the susreactions produces many various cher cals, each of which may produce a spe- pensions are better than the solutions in cific type of reaction in a specific flare the treatment of anterior uveitis, and I organ As a result we have a complex bave the patient take this every hour or series of chertical reactions taking place to In the evening I have him put in and, therefore, specific therapy for each a steroid type of ointment. 15 required Recently, we have begun to employ immunologie interaction of antigen Depo-lledrol in the treatment of anterior and antibodies, and biochemical altera uveitis This is a repository form of uns, take place in the cells of connec-methyl prednisolone which takes two to 1142 tissues, smooth muscle and nerve three weeks to be completely absorbed tissue These changes result in the lib. 12cc of this contains 20 mgs and by cration into the tissues not only of his giving one injection high in the superior tamine out of other potent biologie sub- temporal quadrant of the eye, we find stances, primarily serotonin, acetylcho that it is not necessary for the patient to Iine, fregarin and potassium This mul- tahe steroid drops We achieve a large tiplicity of factors explains why simple concentration in the anterior Ocular strucantihistamine treatment cannot entirely turcs rapidly, which is effective in curbcontrol the allergic reaction Considera ing the uveitis almost itrmediately. We un must be given to the use of anti find within 24 hours that any plastic cholinergic drugs and the discovery of changes that may have occurred in the antiserotonin substances. Physical con anterior chamber have subsided and that tacts, such as heat, light, cold and psy. the flareup itself is under control, and chogenic factors also play an important symptomatically the patient is infinitely part in the therapy allergic reactions more comfortable QU'ESTION Dr. Coles, would you I might adu that we have found that mind telling us how you would treat a Depo-Medrol is extremely effective in patient who came in with anterior alvei the treatment of any form of anterior 115 st attack ocular inflammation We use it with re. MI CUES I believe this patient markably good results in scleritis, in kershould have his mais dilated because, atstss and in patients who have developed uespite the administration of steroids, graft sickness following corneal trastsposterior synechiae terul to form I su- plantation.

·FOOD ALLERGY (Course No. 14) WILLIAM H, BARRY, M, D. Kansas City, Missouri SYLVESTER C. MISSAL, M, D. Cleveland, Ohio T KU VAN is QUESTION What effects do anti DR. JISSAL. Tlie escalator type histamines have upon food allergy the gradual step by step addition of DR. MISS IL In my experience, foods antifustaniinics do not excrt much effect QUESTION: Do you place much reupon alleviating the symptoms due to Irance on shin tests in food allergy? food allergy. DR. MISSAL. Yes. In the first QUESTION How soon after the in place I feel a large number of positive gestion of food can symptoms occur tests on the skin is not hyper-reaction in DR. MISSAL: The time interval the sense of giving false positives. I varies from an hour or two to 24 hours find that such an mdividual is likely to before symptoms occul In the case of be allergic to foods the ingestion test, you get more of an Of course, the most important tlung explosive immediate reaction whereas in when utilizing skin tests is to correlate the case of fool taken over a prolonged the patient's lustory with the tests. There period of time, you get a delayed cumuconcomitant interaction between lative reaction. foods and inhalants Certain inhalants, QUESTION: What is the shortest such as pollens, enhance and aggravate period of time required to develop toler. the reaction of the individual to food and ance to an omitted food ? he may give a hustory that lie is allergic DR. BARRY: It has been proven by to certam fools only during tlie pollen Rinhel and others that tolerance to an omitted food may occur in as short a QUESTION: Should you lise scratch time as 12 days. or intracutaneous testing for foods? QUESTION: What do you mean by DR BARRY: In the first place, as escalator type of addition to the diet? far as fools are concernci, neither is too 24 IS a Seson ·25 FOOD ALLERGY accurate, Ilowever, I do believe they ducts, such as ice cream, medicines, most are of smnie help and I prefer the scratch canned fruits, and juices. In fact, the tests for the following reasons: (1) list of corn-containing products is almost fantastic, They are much safer; a severe reaction In a rarity. (2) The average accuracy QUESTION: What are some of the of scratch tests is higher and they are commonest symptons to food allergy leys Brhely to give a high percent of false that you have noted in your practice? positives. QUESTION: Is condensed milk less DR, MISS IL. I feel that the throat likely to produce symptoms than raw manifestations are the most common and mith the most significant. It is satural that DR. MISSAL. Certain patients find this should be the case because ingested ut possible to the condensed milk but can food comes in contact with the mucous not take raw mulk. In the majority of membrane of both the oropharynx and instances, however, condensed milk has the hypopharynx on its way down to the alvout the same allergenic properties as esophagus, I have found that dull ach- Klocs raw milk. We advise our patients ing sore throats have frequently been to stay away from cow's milk entirely. 2$sociated with ingestion of noxious The same applies to powdered milk foods Also the appearance of the throat There are some patients who can utilize is rather characteristic. There are ispondered milk lut who are sensitive to lands of lymphoid hyperplasia. The mit whole mulk. cus membrane is dull red in character QU'ESTION Does food sensitivity and frequently resembles the smoker's miten cause ofitis externa? throat which you are all acquainted with DR MISSAL I would not say that I have frequently been amazed to get the often causes otros externa but cer- history out of such patients that they do tainly I have patients in whom food sen not smoke at al; yet their throats are Mitivity does manifest itself by a skin rask typical of that of a smoker. I feel it is 19 and around the external ears This irritative phenomenon where the undoubtedly is a form oi eczema wluch shock organ, or the shock tissue rather 15 related to foods. than a specific organ, is the mucous mem- QL ESTION What food do you feel bcane of the throat. Foad can, of COURSE 13 the hardest for the patient to eliminate produce generalızed allergic reactions completely from hy diet? just as inhalants do, but such reactions UIK BIRRY Corn is unquestionably 35 asthnia or severe rhinitis are far les the ment difficult because corn syrup common with foods than they are with and cum starch are in innumerable pro nhalauts 11 ·REPOSITORY THERAPY IN ALLERGY LAWRENCE J. HALPIN, M, D. Cedar Rapids, lowa answer to the complete treatinent of the allergic patient. Tlus is not the total answer to the treatment of the allergic patient; it is simply an easier and a better way to take care of the allergic patient. As an introduction, may I take the liberty of reading definitions of terms and plırases which will be using during the time that mulsions are discussed. In the first place, an emulsion may be defined as a suspension of an olcagenous I have been forewarued by your proor resinous material in an aqueous liquid; gram committee and by your Council or as an aqucous liquid in an oil with gum that you are a very attentive and critical or a similar agent; or as a dispersion of group. The evidence of your attentivefine particles or globules of a liquid in ness has been denionstrated this morning a liquid. There are two phases to an and before you become too critical of emulsion. One is the lispersed phase; me I will admit that I do not know all that phase of a substance in which the the answers in the use of emulsified exmaterial, in finely divided particles, is in tracts, I enjoyed your program this morning. I am sure you have enjoyed stance is called the continuous phase or a state of suspension in somie olier sul)- and benefited from the Round Tables the dispersion media. The continuous I have no slides and I have no aicis otlier than some pictures which I will pass to phase is that pliase of a substance in wluich other phases are dispersed. Synyou. eresis is the contraction in a gel on stand- In the past it has been recognized that ing, with or without exudation of the during every hay fever season something liquid; it is a drawing together, a con. 11cw comes up as the answer to the traction of a ciot. Tlie exudation of the treatment of the allergic patient By liquid constituent of a gel is irrespective "answer" I mean the answer to the prob- of the vapor pressure imposed on the lem of the allergic patient so that the system, and lowered vapor pressure aids specialty of allergy apparently would be the process of syneresis. Now, if I have doonicd. I think that was true with the you as mixed up as much as I am after introduction of antihistamines. The same reading this, you will see why I am going thing happened with the steroids. Now to talk to you on hote these emulsions with the use of mulsions in the treatbe used clinically, Icaving the ment of inlialant allergy, there is again reasoning for their use to those who a scare program that this might be the know more about emulsion chemistry, 26 ·27 REPOSITORY THERAPY IN ALLERGY The treatinent of inhaliant Sensitivity fever to realize the variables which nuust be considered in the treatment of that for pollens, molds, dust and other materials has been very satisfactory with patient. First of all, how sensitive is this contentional multisit therapy In the patient? He reacts to the material with past, the iniestigators have always been which he is tested or he reacts to the trying to find easier, better and safer material in his environment in a clinical Ways for the administration of these way because he is sensitive to it. extracts This work with emulsions has The metliod of administration of in been done over a period of the last fifteen or twenty years It is not new; this is jectable extracts is a matter of concern mot a new treatment, but a new applica- to the physician It is recognized that the trun of established principles The pro- order of safety in which any injectable cesses have been perfected to the point material (and particularly, allergenic exwhere they are safe, but they are not tracts) are given is intraspinously, intraavzdlable for general use. In the past, the muscularly, subcutaneously, intramucosemployment of extracts in the treatment aly and intravenously These emulsified of inhalant allergy has always been extracts are given subcutaneously. They pointed toward the prolongation of the can be given intramuscularly but by this effect or the use of the extract in a way route the material produces a greater flat will permit less visits and make it degree of local reaction and response easier for the doctor as well as for the When given subcutaneously, the local repatient Mary Loveless was the first one action, if any, is very minor The conto apply and extend the treatment of centration of pollen extract used in the pollinosis after the originał work of conventional multivisit type of treatment Freunit and McDermott with mineral 15 one variable which influences the pres- * Subscquent to dary Loveless, Ethan Van Brown and others have been using ence of constitutional reactions. The demulsions in the treatment of pollen sengree of activity of the material that is Aprivity and inhalant sensitivity being used is another. In other words, it 15 more satisfactory to treat a patient It is important to realize that oil and with grass pollen sensitivity than it is to water will not mu but for emulsion treat a patient with ragweed pollen sensiporefiaration an emulsifying agent is neces tiyity The grass palien extract has less 5271 Various oils and various emulssly "fire" if it than does the ragweed exing agents have been employed The ones tract The ragweed pollen stself is much that I have been using under the direc more active in the production of symtist of those who know much more about ptoms than is the grass pollen The this than I, are frlacel ... the enuulsiły. patient with ragweed pollen hay fever is ing agent, an Drakeol which is the much more uncomfortable than is tlie ittineral oil This is supplied as one part Irlacel and mine parts of Draheal aserage grass pollen sensitive patient with symptoms during tile grass season, And I have the material here and later I will then too, we must consider the amount try to demonstrate the preparation for of material that is given in treatment 11 ni that you an see the material and le fanuliar #ith st It is very important administration of the extract of these patients and the frequency of in treating any qoient with seasonal hay 13rables are considered in the itse of All these ·28 LAVRENCE ). HALPIN emulsions in the treatment of these in- tivity by their history but in summation, halant conditions. it is your own clinical judgment that There are other variables that must be cleterniines the dosage for these patients. considered from a clinical standpoint. The dosage schedule is based on how the It has been stated that children tolerate individual patient responds to treatment. increases in closage ljetter than o allults. In other words, you must individualize the amount of reaction is less, both con the treatment of your pollen sensitive stitutionally and locally. The material patient whether you are using conveninjected is important: ragweed is more tional inultivisit therapy or whether you likely to produce a constitutional reaction are using emulsified extracts There are than are other pollens, custs or moll ersonie variations in materials that are retracts. The time of treatment as far as quired. An emulsion requires the use of the season is concerned is important nonglycerinated extracts. There is 110 This so-called repository emulsion treattrue correlation, although this is delatment has also been termed opsiply lactic, able between the patient's clinical sensiwhich is a big word meaning "time" or tivity, lus ophthalnnc response to testing, "at the proper time." These emulsified hus skin test reaction size, the size of the extracts must be given at the best time close and finally, tlie degree of protection prior to the expected onset of the season, or anity that is produced. So again, as I will tell you later the most import- how do you judge the dosage for a given ant thing, however, if you are using mul- patient? How much do you think that tivisit therapy, is the response to the patient can stand within the limitations last previous dose. You juclge your dose «{ salety and protection for tim? today primarily upon the patient's re For demonstration of an emulsion, the sponse to the dosage he lead a week ago, casiest way would be for me to show the or four or five days ago, or two weeks material, let you see the manner in which ago, whichever is your schedule. Slow It is prepared, realizing of course that absorption is important. The work that there are variations to this, Experience has been done by various investigators has shown that emulsified extracts are using lanolin, mmeral oil, alnıond oil and safe. sound, and satisfactory. The physivarious forms of extraction and fractio11 cians having severc reactions or difficulty ation of pollen extracts, lias ucen pointed with emulsified extracts are those who toward slow absorption. Because it is have made variations upon their own slow, it is prolonged absorption without realizing wliat they were doing I know of no definite method that will or without knowing the reasons for the tell me or give me any real basic infor modifications. I think it is imperative to mation concerning how sensitive a patient have a defmite planned procedure in the is to the material that is being itsed. Be preparation of the emulsion. cause of the absence of any well based In the past month or so there have method by wliich the accurate degree of been publications stating that an emui. sensitivity can be established or deter- sion can be made in two minutes or tlirce mined, I know of no way to accurately minutes, or that you can tell" when an judge how much extract to give a patient. emulsion is good. If you do intend to 10 We can skiti test these patients, we can emulsions, you should set tip a definite determine their apparent degree of sensi schedule of preparation and not ry ·REPOSITORY THERAPY IN ALLERGY 29 method which has proven to be simple from it, bxit first become familiar with the technic. These emulsions are safe; and sound. An emulsion can be made ir it is a so-called "perfect" emulsion simply by sliaking oil and water, a temthere is small chance of harm that can porary emulsion that will settle out imive done as far as reaction is concerned. mediately, with the oil phase and the The reaction, or the percentage of reac. liquid phase being separated. This viał tions, is less with the use of good now contains a temporary emulsion made emulsions than it is with the use of the just by shaking it. But the reason that it conventional multivisit, aqueouis, glyceria is not satisfactory to use as it is, is benatel type of extract. cause it is not stable and it will immedi- Arlacel-Drakeol is supplied in a sterile ately break down. In other words, this sal so it is not necessary to Seitz filter is not a "good" emulsion. As soon as the it for sterilization you can, if you pre- oil-water mixture is placed into this larger fer, but it is prepared and available to syringe, we will put an emulsifying acceptable investigators in a vial, such as needle on it. The emulsifying needle is a this, conictaining 2 cc of ol To prepare double-headed needle of 18 gauge amenthe material for emulsion, the pollen ex sion. In other words, it is an 18 gauge tract can be added to the oil in this vial, needle with a head on each end. The For example, if we wish to have a final Ilsual technic is to run this all the machine strength of 2500 PNV,/m), such a for approximately forty-five to sixty strength of emulsified extract could be minutes, change to a smaller needle ben obtained as follows to the 2 ml of Arla cause of the turbulence and force that cel-Draheol there is added 1 ml of 10,000 will further emulsify it and finally to a PXC pollen extract and 1 ml of buffered twenty-two needle, if necessary to obtain saline as a diluentor originally 2 m a finer degree of droplet size. Ideally the of ragweed extract 5000 PNU/ml droplet size is zery, very small, one mistrength Thus in the 4 ml of material cron or less in diameter, so that the sothere are 10.000 PNL of pollen extract called liquid phase of this emulsion is giving a final ennulsified strength of 2500 practically non-existent The perfect I'St/ml It is necessary that all of the emulsion is one in wluch every droplet glassware used in the preparation of an of liquid, the ragweed extract so to speak, chuulsion Le cleansed with a detergent 15 coated with oil When this material There are several things that will destroy 15 gren subcutaneously it's set-for exthe emulsion. In other words, glyceri- ample, the material is given here (sec mateu extracts cannot be used because drawing) and it sets in these droplets, glycerine will destroy the emulsion Alco- The so, packed very, very tightly. What hod will do the same thing; detergent we want, and what eventually is going to »ill do the same thing, rubber will do happen is that the macrophages, etc., are the same thing The stopper on this sal is not ruller, therefore, but is neoprene going to rupture the oil overcoat and release the extract to be used by the patient. 11 24 caster to use a throw-away needle When these oil droplets have begun to than to have a reclinician clean & non rupture, from that moment the patient d1%walle nerelle is being treated every fraction of every Tliete art seseral ways of making an second whether he is asleep or awake, emulsion and I want to show you a because the rate of absorption is constant.

·30 LAIVRENCE J. HALPIN The more sinall droplets you liave, the and you can compare the difficulties of better is the emulsion, the better will be manual operation. the treatnient and the safer it is. In other It is necessary to remember that when words, it is very much as if you had a you are treating a patient who is scnsisilver dollar in one hand and one hundred tive, we will say, to both grass and racpennies in the other. If you are going weed, these two extracts can be given in to put a coin into a slot machine and get a single injection, if you are using contone play from each coin you could get ventional multivisit treatment. But if one lundred plays from the pennies while you are using emulsified extracts, it is you could only get one play from the necessary to give them as single injecdollar. If you have one hundred droplets tions of the individual antigen. In otlict you get one hundred so-called units workwords, the patient who is both grass and ing but if you have only one big droplet ragweed sensitive should reccive his grass you have only one uut The smaller the treatment at the proper time and also droplet size the better it is and the safer should receive his ragweed treatment at All of the syringes, vials and needles the proper time. As far as the schedule used in the preparation of emulsions are is concerned, the optimum time is four kept separate from the other material in to six weeks before the expected onset of the office. We want everything to be the particular scason. In other words, used only for this, so that anything that the treatment for trce pollen sensitivity is being used today with a glycerinated should be in February if the trec season extract, for exaniplc, will not be used to- begins in early or middle April. The morrow with the emulsion. grass patients are treated in April, with This is a double headed necdle, with the expected onset of the grass season onc head locked onto this syringe. We in Iowa, wliere I live, being perhaps in will lock another 10 c.c syringe on the the latter part of May. Ragweed is given other endl. Now we are ready to start our 11 June and July, mold in January and emulsion. It is done by pushing the ma February, and clust at any time, but preterial back and forth from syringe to ferably in the fall; in other words, about syringe. This can be done with the hands four to six wecks before the expected until the material becomes einulsified onsct of the scason. When the cımulsion Now it's more difficult. If we were to has been prepared and when the dosage inspect it now, microscopically and by lias been determined, tlic ennulsion is tahother test methods about whiclı I will tell en from this syringe and given to the you, we would see that the droplet size patient by subcutancous adninistration. is not uniform. If we work it for the Is I have stated, all of thic syringes are amount of time we hnow is necessary, first waslied in a detergent, cleaned, forty-five to sixty minutes on this gauge rinsed and autoclaved before they are necdle, and then change to a smaller fiscd with these cmulsified extracts. gauge needle, inspection would show that Clinical results with emulsifica extlic emulsion is more tiniform and of tracts, according to Jary Loveless, arc smaller droplet sizc. Now, pass tliis alrout the same as they are with convent. around and get the feel" as it is worked tional nuultivisit therapy. She states it is back and fortlı; then I will make another just an easier way to treat pollen scnsitivone and put on a smaller gauge needle ity; other investigators say it is not only ·31 REPOSITORY THERAPY IN ALLERGY a hot, muggy Saturday morning and casier but results are better, I think I will have to go along with the group that when he arrived home he had two cans says the results are better by this method of cold beer. He went out to the country club, had a scotch and seltzer, and went of treatment that they are by the convers out to watch a golf match. He followed tional multivisit type of treatment. During the pollest season of 1939, I treated the match for three holes, then came back 239 patients with emilsified ragweed ex and decided to play golf himself. He had tract All 239 of these patients were another scotch and seltzer and on the second hole of his own golf game lie had chnically sensitive to ragyeed. They were Ellen ragweed emulsions between July 7 an attack of generalized urticaria. In retand August 4, admittedly tate. Those rospect, I think the reason for his rewtu were treated after july 15 or in action was not the dose of ragweed Inguest were informed that they probably extract--and I can't tell you now what would have some trouble. It was hoped it was except that it was between 2500 that their season might be shortened The and 2500 units--but I believe the cause dosage was admittedly low because this of the reaction was the ingestion of alcowas "new territory" to me and I was hol These patients should not use alcautious. The season was late as far as coholic beverages on the day upon which the best time for the treatment was con they receive the emulsion However, cerned These 239 patients were all rag- enough inflammatory reaction is set up weed sensitive by scratch test and by by the second or third day to perniit the history, int there was no effort made ingestion of alcohol, and to protect the 10 consider other sensitivities. The pa- emulsion from destruction, fients may have been grass or mold os Two other patients had urticarial re- Just sensitive, lyst these extracts were not actions approximately three to four hours available to me for repository use at that after the administration of the emulsions time The dosage in these patyents varies For These two reactions, I have no expiafrom 1500 to 2500 protein nitrogen units sation. They were treated from the same fier ce of emulsion Other investigators supply of emulsion as had been those have used doses ranging from 7500 to patients who showed no reactions and 10,000 l'XT per c. Most of this work who were in the same so-called dosage has Ixeen done on the east coast and I classification These first three reactions think it is an entirely different problem there than in our middle west where the arterszed by generalized urticaria, itching were urticarial in type They were charwollen concentration is so much heavier and facial swelling, but these patients had In these 239 patients, there were sis te actions I am sure you have all been reaction picture no respiratory symptoms as part of the Concrete with the safety of this method of treatment and with the number of re- Three reactions were my fault. These actions that might be expected patients had their reactions approximately thirty to sixty niinutes after the admin- Let me sell you about these six reac istration of the emulsion The patients tions One young man was seen at mine were seen on a Saturday morning, they s'clock in the morning. was tested and were parents who never before had been was frien his injection of emulsified es. seen m my office and who never had 1ract, after which he went home it kis been treated for pollen sensitivity. They ·32 LAWRENCE J, HALPIN were tested by the scratch method, and expression of thic ilegree of relief will be were checked by intradermal tests to gain obtained, an estimation by titration, if possible, of Now, as to the results in these 239 their degree of sensitization. They were patients in 1959, fourteen of them must also tested for the ophthalmic response. be reported as total failures; they find no The patients, therefore, were tested by relief whatever from the dise of the exscratch, intradermally and by eye trops; tract in culsified formi. Let me esplai the ennuſsion was given, and within one of the failures. One patient was twenty to thirty minutes constitutional gives lier cnmulsified extract on a Monreactions were noted. I believe these were clay and on Friday or Saturday slie redue to the amount of work that was done appeared in the office with a lot, swollen rather than to the emulsion itself. I say arm. She returned a few days later after this because the reactions were not char- using ice applications. She still liad 2 acterized by urticaria These three pa- hot, swollen arm withi fluctuation in the tients had reactions that were respiratory center of the area. She had an abscess. in type. They had bronchial asthma and This could not be explained on the basis marhed symptoms of hay fever, even of the technic that had been 115cd. Other through their histories showed no sympa patients using that same source of enuittoms prior to ragweed exposure and sion had not reported abscesses. The this was about the middle of July. technic irad been sterile and I was greatly The results in 1959 are baserl upon relieved when the mother of this patient patient expression of relief at the time asked if I thought that the series of ſurof the season or inuncdiately after the uncles that slic lad been having had any. season This, admittedly, is not a realiabic thing to do with this. I believe that sonic method of measurement. Some investis of the surface staph were carried into gators say that the response to treatment the injection arca In draining the is a failure of the patient uses onc tablet abscess, the surgeon reported that the of antihistamine, or one tablet of a emulsifsed material drained out with the bronchodilator cirug. Other investigators purulent matter. She was unt protectedl, will accept the patient's expression of lus but I included her as a failure because degree of relief if that expression in she was given the caussion. 32, or 1376, given during or innediately after the of these patients liad results classified as season. The patient's judgement regards far 117, or 49%, had cxcellent results In sng the severity of his seasonal hay fever my estimation, a patient has an exccland seasonal astluna is influenced a great lent result if he takes less than 12 or 18 deal by the time at which he is questioned antihistamine tablets during the season In other words, the patient wlio is asked to assist in relicring his symptoms of Hay today, in October, how bad the 1960 icver. 76 of these patients reported perseason was, may say, "It wasn't bad": fect results; their seasons were completeabout like pregnancy or labor pains. Ou ly crasei, and they liad 10 symptons of the next day, or a week or so later, he any type forgets how uncomfortable he was duta Dr. Missal stated this morning that the ing the season. But if you ask a patient patient wlio has marked nasal congestion, kuring the season, or immediately after regardless of cause, is a toxic foching the scason, a more honest and accurate putient But, surprisingly, none of these ·33 REPOSITORY THERAPY IN ALLERGY patients, even the failures, looked toxic can be mixed, but if he has only oak poleven at the height of the season. They len sensitivity a mixture of tree pollen Emulsions should not be given. looked well, though their symptoms may The grass pollen sensitive patients have been present in the degree I have reported to you. 196 stated that they were easy to treat with emulsified extracts in comparison to the multivisit type were better with the use of the so-called single injection of emulsified extract of treatment. They were 100% relieved than they had been on whatever method I cannot recall a patient who admitted af treatment they had used in 1958 At having symptoins during the grass pal- These patients were both thus time I am unable to tell you how len scason many of those 239 patients had been clinically and skin test sensitive. The ragtrcated by conventional multivisit ther. Weed treatment results of 1960 are not in 1958 28 of these patients were available now but they should compare the same as they had been before treat- favorably to those received in 1959, and mene liut they were completely satisfied perhaps better, because of the more opbecause they had received their treatment timum time at which the extract was in a single injection and in a single visit given this year as compared to last year. to the office rather than coming in at un In using emulsified nold extracts it is tervals of every 3 or for 7 days 15 of necessary that the extract be aqueous these patients were worse than they had rather than glycerinated These extracts Iren in 1958 on whatever form of treat- in any form seem to be irritating. The ment they had receved In 1960, 233 of dose must be lower than might be exthese 239 patients returned for emulsion pected The results have not been 100%. treatment Of the 6 who did not ap as in grass and tree sensitizattart, but the reas, 3 were probably disgusted with the percentage of good results is extremely methoxl of treatinent and 3 had moved high in all of these patients at must be out of town remembered, as Doctors Missal and It can be stated that the patients who Craít pointed out this morning, that the were treated in 1960 for tree pollen sen patient must be treated totally Relief sitivity with free pollen emulsified ex cannot be expected by treating the patract, received 100% relief of symptoms tsent only for mold and ragweed senst- The free pollen season in my part of trity, if he has a complicating food allowa is short There are few tree sen. lergy, or if he is sensitive to other ensitive patients in comparison to the grass pronmental materials and ragweed population; there are few Dust treatment by emulsified extract patients who have tree symptoms of suf 15 definitely worthwhile. Some dust ex. ficient degree to warrant treatment tracts seem to be more irritating than Those who were treated, received 100% others when used as emulsions but the Complete and total relief of their hay results are exceptionally good. The na ferer symptoms from tree pollen sensitients and the doctor are well satisfied lity, fere again, the tree emulsion because of the case of treatment. must be individualized in other words, The use of emulsified itfluenza vacthe correct emulsion must be given as 19 cine in the patient with intrinsic asthma ccatal ins the patient's sensitivity. If or in the patient with symptoms froni a the patient is helm sensitive, the two viral source, is produtcire of excellent ·32 LAIVREXCE J. HALPIN were tested by the scratch method, and expression of tlie degree of relief will be were checked by intradermal tests to gain obtained. an estimation by titration, if possible, of Now, as to the results in these 239 their degree of sensitization. They were patients in 1959, fourteen of them riut also tested for the ophthalmic response. be reported as total failures; they lind no The patients, therefore, were tested by relief whatever from the use of the exscratch, intradermally and by eye drops; tract in eniulsified forni. Let me explain the emulsion was given, and within one of the failures. One patient was twenty to thirty minutes constitutional given her emulsificd extract on a Monreactions were noted. I believe these were day and on Friday or Saturday she redue to the amount of work that was done appeared in the office with a hot, swollen rather than to the emulsion itself. I say arm. She returned a few days later after this because the reactions were not char- using ice applications. She still liada acterized by urticaria These three pa- hot, swollen arm with fluctuation in the tients had reactions that were respiratory center of the area. She had an abscess. in type They had bronchial asthma and This could not be cxplained on the basis marked symptoms of hay fever, even of the technic that had been used. Other though their histories showed no symp- patients using that same source of emul toms prior to ragweed exposure and sion had not reported abscesses. The this was about the nuddle of July technic had been sterile and I was grcatly The results in 1959 are based upon relieved when the mother of this patient patient expression of relief at the time asked if I thought that the series of fura of the season or immediately after the uncles that she had been having liad any. season This, admittedly. is not a realiable thing to do with this. I believe that some method of measurement Some investi of the surface staph were carried into gators say that the response to treatment the injection area. In draining the is a failure if the patient uses one tablet abscess, the surgeon reported that the of antihistamine, or one tablet of a enjulsified material drained out with the bronchodilator drug Other investigators purulent matter. She was not protected, will accept the patient's expression of lus but I included her as a failure because degree of relief if that expression is she was given the emulsion. 32, or 13%. given during or inmediately after the of these patients had results classified as season. The patient's judgement regard fair 117, or 49%, had excellent results. ing the severity of his seasonal hay fever In my estimation, a patient has an exceland seasonal asthma is influenced a great lent result if he takes less than 12 or 18 deal by the time at wliich he is questioned antihistamine tablets during the season In other words, the patient who is asked to assist in relieving his symptoms of hay today, in October, how bad the 1960 fever. 76 of these patients reported perseason was, may say, "It wasn't bad"; fect results; their seasons were completeabout like pregnancy or labor pains On ly erased, and they had no symptoms of the next day, or a week or so later, he any type. forgets how uncomfortable he was dur Dr. Missal stated this morning that the ing the season. But if you ask a patient patient who has marked nasal congestion, during the season, or immediately after regardless of cause, is a toxic Inoking the season, a more honest and accurate patient But, surprisingly, none of these ·35 REPOSITORY THERAPY IN ALLERGY sions can be prepared so that the drop the dosage and compare the results at the let size is less than 2 micron in diame- end of this year. Now that comparison has not been made because this season ter a very small droplet, indeed, has not been over a sufficient length of DISCUSSION time to permit the work. QUESTION: What dose do you use QUESTION: Would you inercase the close on each patient the second year each year in pollen cases? DR HALPIN This is an individual or the third year? DR, HALPIN: I think this depends problem, there is no set dosage as far as the amount that can be used or is used upon what happens, what result is ob. on any particulat patient When you tamned, whetlier it would be decreased or see a patient to whom you are going to increased or whether it would remain the gule extract in any form, you individual same Thore mvestigators who have becit ize that problem and give him what you using envulsions--and I say thus as a bethink he needs or employ any method to lief and not as a confirmed statementcietermine what his dosage might be. have been using dosages as high as 7500 The sanie thing is true with emulsions or 10,000 protein nitrogen rits per cc In asing emulsified extract you are giva of emulsion. These men are lowering ing what is representative, we'll say, of the dosages in an effort to see whether the total dosage that will hold him for or not the tinsage level is really the facthe season, and the beneficial effect, ftor that matters in other words, if the any, 13 a result of prolonged slow ab. patent did well on 7500 units, this year sorption over a period of time the patient will get 6000 or 5000 and it QUESTION. What dosage do you he doesn't do as well on the decrease, the use? dosage will go back to 7500. DR HALPIN. The dose in 1959 As far as the dosage for dust is convaried from 2500 protein nitrogen units cerned, I don't belieye there is any methto 2500 ritrogen protein 1:31ts I had od of determining how Just sensitive a read somewhere that if the patient re patient may be. What irritating properacted to ragweed by scratch method of ties are in the dust extract that might testing, then that patient should not be give a false or a misleading local reacgiven more than 1500) protein nitrogen tion on skin testing? I know of no way limits of emulsion. That is incorrect but determune whether the patient's com- I lehened it, and I was not corrected in plaints today are due to his dust sensin my belief unt; after I had treated the trysty or to whether, as Dr. Missal and twenty-five or thirty patients last year De Craft mentioned this morning, they who received 1500 or thereabout protein are due to other things in the patient's nitrogen units of emulsired ragweed per environment and diet. Here is a patient The more you do of this the braver who shows a positive reaction to dust on you get so l increased the next few to skin testing; on allergy study he shows a 2000, and then to 2500 This year my positive reaction to dust; on scrarch test dusages have gone higher because I have he show's a positive reaction to dust on Telt that if the patient did well at 2500 high dilut:03 units In Guld mae him 2500 units, if he patient is serisitne to dust, but I know So you assure that the id not do so well at 2000 I would raise of no way to accurately determine this ·34 LAIVRENCE J. HALPIN results. Tlie closage is low. The maxi. tremely sensitive to pollen extract can muun dosage should be 125 CC A units not receive as much dosage as the pain / c.c. of emulsion. This, you will tient who, clinically and by tests, seenis realize, is alout 4 of the initial dosage to be somewhat less sensitive. A revior the single dosage that you may give sion of our line of thought regarding polwith the usual type of influenza vaccine. len treatment would suggest that may be The enhancing effect of the emulsion, the patient who is most sensitive requires because it does enhance the effect, inakes and can receive a ligler dose. With the it mandatory to use only 12 c.c., or less, use of enuulsified extract, and with the of the vaccinc. In other words, if we preparation of good emulsion, that dosare going to acld 2 c.c, of influenza vac age can be raisel safely and convenientcine to 2 cc. of oil, and are going to give ly Emulsified extracts may not be the cc. of this emulsion, this is actually 4 final answer to the trcatment of pollen of the sugg close that we are giving sensitivity, but I do think it is the better It has been stated that the full effect and easier way to treat the pollen sensiof the emulsified extract is not reached! tive patient. for approximately 2, 3 or 4 weeks after Regarding the economy of this, there the emulsion has been given. The time lias been some concern expressed in a interval is dependent upon the amount coninuunication that most of its receive of cmulsion that is given. The extract as to what is going to happen to the should be given in «oses of 1 cc In allergist as far as his cconomy is conother words, if a dosage of 3000 protein cerned. That is minor, I assure youi. nitrogen imits is to be given, it is better Tlus is a good way to treat the pollen to give 1 full c.c. containing 3000 tunits sensitive paticnt. It's an easy way to than to give %c.c. of a preparation con treat the pollen sensitive patient, but I taining 6000 units per cc would suggest that you become entirely With the use of ennulsions in the past, familiar and acquainted with thic prepathe patients were kept in the office for ration of emulsions, with the manner in period of 2 or 3 hours after their emul which these emulsions are tested, with sions had been given This was a source the use of emulsified extracts, and when of inconvenience both to the patient and they are indicated and when they are to me. This ycar, because it is recog not, and then wait until the bugs and nized that if a reaction is to occur, stumbling blocks have been removed. will not come for 3 to 4 hours after the Then you will will like administration of the material, the patients havc been excused as soon as they I liave some pictures here of good have received their emulsions. They are eniulsions and of bad emulsions. A good instructed to report any change or any eniulsion is one that is prepared with thic sign of reaction regardless of how in <lroplets being of uniforni, minute size. significant it may bc. If there is variation in them, the emul. It is aclvisable to remember that we sion should be further cmulsificil until may have to revise our line of thinking the droplets are of uniform size and as far as the treatment of the pollen Small, or the cmulsion should be cliscardsensitive patient is concerned. Tlie think el. The red blood cell, I believe, is 7 ing lias been that the patient who is ex inicrons in «liameter. I'resent day canal. accept it and yoli ·37 REPOSITORY THERAPY IN ALLERGY ?> any non-seasonal trouble. diy hay fever is determined entirely upon the sercugth of extract used in preparation, ends with frost; the end of the season QUESTION: Hosy olten do you 15 the end of my hay fever and I don't have any trouble until the following give dirst injections ? DR. JALPIN: I give them as often Year He is the patient, in niy mind, as it seeins necessary. When I give a who isn't quite as sensitive as the other dust injection, the patient is told to reexample So therefore, I am going to I( ise be a little nuore careful with the highly tum in six months, or sooner. comes inach in six months and he is all sensitive patient, the same as you would bie, than i am with the patient who is not nghi, I tell him to let me see him when necessary. He may come back in sin quite so highly sensitive. First of all, months, he may come back in it year, or I consider the history, Secondly, the size longer. of the skin test reaction, although it is ad- QUESTION. When to you ritest? nutted that the size of the skin test reaction DR. HALPX: 1 pe retesting as a cloes not tell you how sensitive the patient follow-up stuur. If I ani busy anul a is, whether the test is by the scratch or inpatient comes in, I may titrate him or tradermal method Nat it does give an check hin because this gives me some indication of the sensitivity this patient slight information and I find that he will has for that particular extract So the dosage, therefore, in determined by 195- want more patiently However, I sel. dom, if ever, "Re-study" a patient, if tory, by the size of the skin test reactions, scratch or intradermal, and by that is your question I believe there is a decrease in the size what I think fie needs, by what my clinof the skin reaction with emulsion therical judgment tells me this patient can I have never been able to see a safely tolerate The strength of the apy decrease in the size of the reaction from emulsion itself 18 determined by how much is put into it. In other words, if conventional multivisit therapy. QUESTION into 2 cc of oil, 1 put lcc of ragweed How often have you of 10,000 PN strength and 1 cc. of seen any constitutional reaction? DR. HALPIN diluting fluid, I'm going to end up with Vell, there were 6 4cc of 10,000 unit strength. The toreactions in 239 parents in 1959 and tal is 10,000 regardless of the volunte, I think that I can make So each cc of emulsion is going to be a better emulsion today than I could a 2500 P NU strength. year ago because I have had the year's experience I am more aware of leac- The same is true that if I want to tions and what to do to prevent them. mahe a 10,000 P N U per cc strength There have been more local reactions of enulsion, I will have to put in 40,000 from mold extracts because they are irtotal units into the total of 4 (Re sitating When the dosage was decreasmember, the volunje of emulsion to be ed to 1,000 protein nitrogen units or less, given should be lec If you wished to the local reactions were not masked The give, for example, 2500 P NU and gave most severe reaction I have had, if I may jat i ce of 10,000 P N L strength, take just a tinate, was in a patient who the volume would be considered inade was bee-wasp sensitive. There is no way quare So the strength of the emulsion I know to determine whether or not a fewer this year ·36 LAWRENCE J. HALPIN other than by the patient's statement standard has been 02 mgs. per c.c. of that: “When I clean house I am worse emulsion, or when I am exposed to dust I am QUESTION: How about ivy exworse." I know of to sure way of de tract in emulsion? termining whether that patient's symp DR. HALPIN: I don't know betoms today are clue to lus dust sensitivity cause that is an entirely different prob. other than by clinical experience. And fem-an inhalant allergy compared 10 : if you treat him for his dust sensitivity contact type of sensitivity. My only exand he doesn't show a good result, he is pression here is that I don't believe m included as a failure regardless of wheth the treatment of poison ivy sensitivity by er it is emulsion or multivisit type, when extract injection; perhaps for protecmaybe his symptoms weren't of dust tion, but certainly not in active treatment origin in the first place. of symptoms. Maybe I am wrong. QUESTION What close for cust QL'ESTION. How long are the reclic! use? sults from enuulsion therapy effective? yo11 DR. HALPIN. I can only say that DR HALPIN. I will have to do a the patients in my office are told that the little explaining for this reason. I have anticipated life of the protection that used a dust extract that has been sup- they are receiving is anywhere from 8 plied to me by a commercial laboratory to 12 months, I liope that tlic extract for an investigational study. This dust will carry tliem well througli the season. is standardized on a basis of protein nie If a patient had a good result in 1959 trogen units. I think talking about mea and a 100% result in 1960, I won't treat surements and standardization of ex lum in 1961-a trial without trcatment. tracts is pretty much like asking, "Ilow The patient who receives an injection of far is it from here to the door?" Some chiulsified cust extract may have relief one will say, "It's thirty-six feet," and for a year or longer. soncone else will say, "No, it's twelve QL'ESTION Please explain how yards," and someone else will say that it dosage and strength of comision is deis so many meters. We are all talking tcrmined about the same thung but with a differ DR, HALPIX: I wish I could exent method of expression. When I say plain how the dosage is determined. As I usecl 2500 protein nitrogen units of this I said today, you must consider the liscommercial dust, then my next statement tory of the patient. I think the patient is going to be misunderstood Two other is a little more sensitive who says, “I dust extracts which I use, from private have hay fever for about two weeks and laboratories, are both measured in mil then I have a horrible time with asthma. ligranis of dust per cubic centimeter lly symptoms contime into the winter. (weight by volunie). To be specific and I miss two wechs of work and 1 ani answer your question, my top (dosage of forced to sit up at night." In my mind commercial dust has been 2500 protein he is niore clinically sensitive than is thic per 1 c.c. of cmulsion and patient who comes in and says, "I am the dosage of tlie emulsion is always I having hay fever brut I get by; antilistac.c., so the patient receives 2500 units mines give me some relief and I have The top closage with weight volume never had any astma; I have never had nitrogen units ·39 REPOSITORY THERAPY IX ALLERGY next emulsion is 98% perfect ; that leases elder to bother that patient. There is 110 cochlebur; he shows reactions because 2% free This leaves only 1% difference But to the highly sensitive patient, they are in the same family. For the pait is 100% difference. The variables are tient sensitive to pak, elm and maple the patient and the purity of the emul- pollens, I would trcat liim for all three sron Wy statement implies that if the in one emulsion If we are going to give emulsion is a good one, it is safer than him 3,000 units, we will give him 1,000 units of each in eniulsion in the 1 cc. the average injection of any extract in any dilution and in any amount. But it would be unwise with a patient who reacts only to oak and whose kis- QUESTION. II a patient is sensitive to six weeds, do you give an emul- tory is compatible with the oak season to treat him for oak, elm, maple, sycasion for each separate weed or how many more, Wack imalnut, etc, etc, etc. You cik) you put together? You stated that might be sensitizing him to elm and we should avoid mixtures maple and the rest of them, when you DR. ALPIN. I don't believe I only want to treat him for onk. have ever seen a grass sensitive patient The same thing is true with mold exwho, when he was tested for timothy, tracts and it is a matter of great conorchard, June, redtop and other grasses, cern at the present time. Should you failed to show multiple grass reactions treat a patient with a hold mixture who In other words, if they are grass sensi- reacts only to Alternaria? I don't think tive, they are grass sensitive I would you should. The patient should be in treat me with a standard grass mixttire, dividualized. Therefore, you would make ie, standard for lowa or the middle one emulsion for Bill Owen who is senwest So I would treat him for timothy, sitive to three molds; a different one for orchard, june, redtop and what have you hest Craft who is sensitive to two other There is no Bermuda grass in Iowa so I malds, and yet another for French lanwouldn't put it in eien though he re- sel who is sensitive only to Alternaria. Rut here is a patient who is In other words, regardless of whether serisitive 10 ragweed, Russian thistle, you are treating these patients with emulmarsh elder and cochlebut. He begins sions of conventional multivisit type of to have his trouble on the minth day of treatment or with antihistamines or ster- August and it ends on the twenty-fourthods of what, you have to individualize of September I am going to treat him the patient you are treating. You can't for ragweed There is no Russiant thistie treat the disease; you have to treat the 11 Iowa There is not enough marsh patient acted to it ·38 LAWRENCE ). HALPIN patient is bçe-wasp sensitive other than Of the patients who have been sting to record the description of the attack in after receiving bee-wasp antigen, I can't the history. The history is all-important think of a one who had more than local for we cannot depend on the skin test reaction. None of them hall constituireaction to bee-wasp or yellow jacket ex. tional symptoms, at least none of those tracts, for diagnosis. If the patient frou vlom I llave heard. sliows a negative reaction, are you going QUESTION: You say that perfect to deny the fact that he is sensitive to emulsions are as safe as multiple cose the bee-wasp antigen? I'm not, I'm injections going to believe the liistory DR. HALPIN: So, therefore, I think a perfect when a patient appears in my office and emulsion is safer than the average aquesays he is sensitive to bec-wasp), I treat ous or glycerinated or multivisit type of him with a dosage which I think he can injection because, if it is a perfect emultolerate. sion, nothing can lappen. A patient on wechly injections lias 52 chances caçlı One patient came in with a history of year to liave a reaction; an emulsion pahaving been stung four times and on tient lras one. The emulsion cannot 110701 cach occasion lic thought he was dying. be totally absorbeel This droplet is I made up a bee-wasp emulsion 11 the broken up, that droplet is broken up and dosage that I thought would be satis another and another in turn. The outcr factory. The patient was given only 0 15 layer of droplets must be broken up bec.c. of this cmulsion because I didn't fore the next layer can be attached, and want to risk a constitutional reaction so on to the next layer and the next He sat in my office for 142 hours and layer, etc It is a slow prolonged type lie was fine, nothing happened Twenty of absorption and that is why in a good minutes later lus face was so swollen he emulsion there is little free antigen availcouldn't see. I thought he was dying able to react on that patient now That and so did he Emergency procedures answers the next part of the question of epinephrine, intravenous steroid soluwluch says, “What strength multiple tions, etc., were repeated for the next dose injection «lo you mean, 01 c.c. of a two hours until he was able to say. 1-1,000,000 strength or of 1-100,000 or "That's exactly what I do when I get 1-10,000 " I don't think it makes any stung Do you know what he said difference because if the patient is going then? He said: "When do I come back to react to 1-1,000,000 or 1-100,000, he for the next one? That was no worse is going to react only because of the imthan I have gone through with a sting mcdiate absorption of that extract which and I want no more stings." lle return was there for him to absorb and to wlich cd two weeks later and after preliminary he would react. protective cpinephrinc susphrine and If we lock the anigen inside a coating steroids, he was given 085 с.c. of the of oil, tlic antigen cannot be alysorbed or samc bee-wasp emulsion that had caused released for a period of two or three the reaction. Hc liad no reaction tliis wecks. This leaves little to which the time. He has since been stung, with patient can react. Let us say if an emmui. only a local reaction and this was no sion is 99% perfect, 1% is available to larger than the size of a lemon. produce a reaction. But suppose the ·FLUORESCENT ANTIBODY METHOD scopic equipment. Small, air-cooled, high mercially prepared antibatics are availintensity mercury arcs horised in standard able from several sources However, cach of these antilody solutions must be tested MIcroscope lamp housings are available from several sources. Microscopes have to evaluate the specificity of the atitilieen modified to permit easier observa. body. It is best to separate the antilly fraction from the rest of the serigro- 1101 as well as better photographic record mg of the results. The basic equipment teins. This can be accomplished cither is now readily obtainable from seseral by ammonium sulphate fractionation or sources and is only moderately expensive, by the samewhat more complicated alco Before considering some of the appli- hol fractionation methods (12). If this cations of fluorescent antibody technique, is not tione, there is greater likelslood of * 15 hetter to consider the method itself non-specific staining because of the gresm order that some of the potential pit-ence of labeled proteins which are not antibodies falis may be understood and possibly avouled Seseral recent articles deal with Once the antibody is obtaincu in a muxlvarious aspects of this technique (10, 11, erately pure forri, it is a simple matter 12, 13) No attempt will be made to re to conjugate it with the fluorescein iso. vew the vast literature that has now ac- thiocyanate Dry powder is nicely cumulated on fluorescence inmuno- sprinkled into the buffered antibody solul. histochemistry Rather, an attenipt will tron (9) After a period of time, the nonbe made co stress the general principles coupleci dye is removed by dialysis, Ilow. that are moved Reference will be maile ever, there are troublesome, non-specific to review articles which have adequate fluorescent produrts formed during the Inbliographies, conjugation which are not removed by METHOD tralysis Hente, a further purification of the conjugated antibody is necessary. imost any microscope is satisfactory Thus can be accomplished in a variety it should be equipped with a camera for of ways, including chemical precipitations permanently recording the results, and it of several sorts Most commonly, howsal have a dark field condenser It is ever, the labeled antibody solution is simpossible to olitain a black background ply absorbed with acetone-dried liver using a bright iield condenser with ultra- powder after passing the conjugated antirolet light However, the filter system body solution through a column of ion required to remove all the visible light exchange resin (11). This treatment causes marked reduction in intensity of usually removes the materials which the ultra, olet light Therefore, a darh cause nonspecific fluorescent staining. field condenser is usually more satisfacury The most convenient light source It is imperative to prepare the tissues or material wirelt one wishes to examine 15 an air-cooled, high pressure mercury are Larger, wates-cooled arcs give somein such a way that the immunological rewhat more intense llumination, but are activity of its components is not destroyed rathes cumletsoine to use. The treatment which tissues can Stand depends upon the materials for Since this method is an immunologic which one wishes to look Sonte subone, the results obtained depend largely as the quality of the antibody usedl. Cortsstances such as pneumococcal golysashade remain active even in fixed blocks ·USE OF FLUORESCENT ANTIBODY METHOD FRANK W. FITCH, M, D., Ph. D. Chicago, Illinois what more successful (5, 6). Small amounts of inimunologically active materials could be identifice but the ratlıcr low resolution of these radioautograplis did not permit precise localization of the sites of reaction. The fluorescent antibody technique was originally described in 1942 (1) but it did not attract much attention until 1950 (7) wlien it was again described in a somewhat simplificd form. However, even at that time, the method was so The application by Coons and co-work cumbersome that it was applied mainly ers of a method to couple a fluorescent in rescarch centers. A complex organic compound to antibody made it possible chemical synthesis was necessary to preto study histologically antigen-antibody parc tlie fluorescein isocyanate for coninteraction in tissues (1). Earlier at- jugation with the antibody In addition, tempts to do this, using antibody labeled this compound was very unstable. Carbon with visiblc dyes, were generally not arc lamps were generally used as light satisfactory lạecause antibodies labeled in sources. These were cxtrcnicly hot and this way dill not permit localization of gavc uneven, flickering light. Higli pressmall amounts of immunologically active sure, water-cooled mercury arc lamps materials (2, 3, 4). were also available, but these were usual- Fluorescent compounds have the prop- ly not supplied with suitable condensing erty of absorbing light energy of one lenses or housings. wave length and emitting light of another There have been two major teclmical wave lengtfi. By exciting fluorescent advances in recent ycars which lave made compounds with ultra-violet light it is it possible for an average laboratory to possible to visualize them as a result of litilize this technique with a minimum of their emitted visible light It is easier to difficulty. Riggs and co-worhers desee objects appearing as bright areas scribed the synthesis of fluorescein isoagainst a dark background than it is to thiocyanate, a chemical closely related to sce darkly colored objects against an fluorescein isocyanatc (8) This material illuminated background. Thiese are the is a stable compound which is now availreasons for the sensitivity of the method able comniercially from several sources tising antibodies labeled with fluorescent Conjugation with antibody is acconi. materials. plished by merely sprinhling the dry Later attempts to localize inmune re- powder into a buffered antibody solution actions in tissues using antibodies labeleil (9). The second important factor has with radioactive compounds were sone been the developnient of letter micro- 40 ·13 FLUORESCENT ANTIBODY METHOD Tessac antigens. Many studies have antibody technique will soon be an acbeen concerned with the location of anti- cepted method in the diagnostic laboragenic components in various tissties The tory: hutney, lung, and thyroid have been lllergic and lypersensitizily reactions: studied extensively Systemic lupus ery. Although allergic and hypersensitnity thematosus and the L E cell phenomenon reactions have an immunologic basis, they have recensed considerable attention. have been studied very little with the Other human diseases including amyloid- fluorescent antibody method much of 098 glasierulonephrits, and rheumatic the difficulty arises from the fact that feser have also been investigated, using many of the important hypersensitivity tlus method Erythrocyte and platelet reactions are of a delayed type and apantigens, skeletal muscle fibers, the exparently imole some sort of cellular ocrine and endocrine portions of the pan- antibody This type of antibody has not (reas, and the pituitary have also been leers tlenonstrated using the fluorescent studied. The results of these experiments antibody method. have been reviewed in detail elsewhere However, there are several types of (12) allergic reactions that have been exten- Microorganisins, Alost early studies of sively studied. Dixon and his co-workers viral diseases using this technique were hale examined experimental serum sickconcerned with the pathogenesis of vital ness in the rabbit (17, 18). They demoninfections in experimental animals. The strated that the specific antigen and host results of these studies have been thor- gamma globulin, presumably antibody, oughly reviewed (12) Recently, largely are localized in the lesions in the arterial through work at the Communicable Dis- wall. ease Center of the US Public Health The lesions develop at a time when Service, the fluorescent antibody method soluble antigen-antibody complexes are has been extended to use in diagnostic present in the circulation There is no trology, mycology. bacteriology, and detectable localization or fixation of antiparasstology The fluorescent antibody gen in those tissues which are predisposed test offers rapidity and considerable sen. to the levelopment of serum sickness sitivity in determining the presence of lesions before the lessons appear. The mcrostal agents in tissues and smears lesions regress after readily demonstrable It is possible to detect non-viable patho- antigen-antibody complexes disappear gens, and the presence of contaminating from the circulation The regression of viganisms does not interfere with the the lesions is associated with disappear test A major disadvantage of the test 15 ance of antigen from them. The demon tite possiility of non-specific reactions Stration of these events was dependent However, this is laterent in many situa- largely upon the use of the fluorescent con entional diagnostic antibody technique. methods Specific micro-organisms and The following sequence of events has cletails of the test used to identify each been postulated (18) As antibody begins of these are outlined in a recent Public to be formed, it conbines with the antigen Health Service publication (13) While in an antigeni excess environment. Sol. these tests hase not all been thoroughly ubie complexes are formed in the circulaevaluated, it seems that the fluorescent tion. These increase in amount until all totis lising ·42 FRANK IV. FITCH of tissues. In this case, paraffin sections tissuic section is first reacteel with specan be prepared. In most instances, low cific, ulabeled antibody solution. This ever, frozen sections of fresli tissues antibody, 11ow bound to its specific antimust be used. These are usually cut in a gen in the tissue, is visualized by reactcryostat. This is a refrigerated box ing tlie section with a labeled antibody cooled to about -20°C in which the micro-directed toward the imlabeled antibody. tome is located. The sections are cut, For example, it is possible to Incalize transferred to a slide, thawed, and then some viruses in human tissues by treatfixed, if possible ing tisstic sections with convalescent Tissues containing many protein anti serum followed by reaction with a labeled gens can be fixed in ethanol without anti-human gloluulin solution. This modliinactivating them. Most tissues infected fication permits onc labeled autibody sowitli viruses must be fixcel in acctone, lution to be used to demonstrate thic rcac- Occasional substances are inactivated by tions of scieral antigen-antibody systems any fixation and must be searched for It is frequently more sensitive. Also, in infixed tissues. Freeze-drying anul antibody can be demonstrated in tissue freeze-substitution have been used, but sections using the specific antigen as the these techniques still introduce many middle layer and the labelcl antibody as problems. the fmal layer. However, the "sandwich To produce the antigen-antibody reacteclinique" requires more controls to tion in tissuic sections, the slides are prove the specificity of the reaction. rcacted with the labeled antibody solution, Fluorescein is thic dye usually uscil for the excess unrcacted antibody washed conjugation. There are several reasons off, and the slicle examined under ultrafor this. It is a very efficient fluorescent violet liglit. Several controls are necesmaterial, concrting a large proportion of sary to establish the specificity of the the absorbed energy into vible light fluorescence which is scen. These include The yellow-green fluorescence is in the reaction of the section with unlabeled range of light to which the human cyc is nost sensitive antibody to saturate the reactive sites fol- Also, this color is lowed by reaction with the labeled antihellum seen in the autofluorescence of body. This should mish or nearly tistics. Occasionally, it is desirable to abolish staining Preadsorption of the label antibodly with a fluorescent dye of another color. Several are available; of fluorescent antibody solution with the specific antigen should precipitate the thiese, rhodamine, a red olyc, is most specific labeled antibody or form soluble frequently used (14, 15) antigen-antibody complexes wliich would APPLICATIONS not react with the antigen in the tissues. Most of the early applications of this This should abolish the fluorescence. A methodl were directed toward basic in. labeled, licterologous antiboly should not emmologic problems. The distribution of stain the section. An unrcacted section various antigens was determined (2. 10). should not fluoresce. Occasionally other The cellular changes occurring luring controls are used. antibody formation were studied (10. A valuable modification of this basic 16). As the potential of the technique method is sometimes called the "sandwich was recognizel, many other areas were technique." Using this modification, the explored, ·45 FLUORESCENT ANTIBODY METHOD of fluorescent antibody J. Immunol. 45: sponse of the host to this reaction 159-170, 1942 Answers to these questions should give 2. Coons, A H; Labeled Antigens and Antia better understanding of the pathogenesis bodies Ann. Rey Microbiol 8; 333-352 of these allergic conditions and may offer 1954 a clue to inore rational therapy. 3. Heidelberger, M, Kendall, F. E, and Soo Hoo, C. M.: Quantitative studies on the SURINARY precipitin reaction Antibody production in rabbits injected with an azo protein, The fluorescent antibody technique 5 Exp Med 38: 137-152. 1933 offers a sensitive method to study the 4 Sabiu, F.R Cellular reactions to a dye. precise focalization of antigen-antibody protein with a concept of the mechanism reactions in tissues The serological of antiboxy formacion. Exp red 70: pecificity of this method allows it to be 67-82, 1939 applied also to the rapid diagnosis of 5 Wormall, A Isotopes in the study of immunology Brit Med Bull 8 223-228, nucrobsal agents in biological materials 1952 The method is now sufficiently simple 6 Pressman, D.. Current status of the tisand good equipment has become $0 sue localization of 1-131-labcied antitis uc readily available that it is possible for antibodies Ann N Y. Acad Sci 70: 72. most laboratories to apply the technique 81, 1957 with minimal difficulty, 7 Coons, AH, and Kaplan, M. H.. Low calization of antigen in tissue tells 1 The pathogenesis of experimetital ser Improvements in a method for the detecum sickness, the Arthus reaction, and tion of antigen by means of fluorescent anaphylaxis in the rabbit have been parantibody. ) Exp. lied. o 1-13, 1950 8 Riggs, JL, Servold, RJ., Burchhalter, trally clarified through the application of H, Downs, CM, and Metcalf TG. this technique Studies have been per Isothocyanate compounds as forescent formed on the wheal reaction in human labeling agents for immune serum Agter. patients serisitive to egg white. Many J Path 3+ 1081-1097 1958. clinical and experimental allergic and hy- 9 Marshall, J. D. Eveland, W C, and persensitive conditions appear to have as Smith, CW, Superiority of fluorescein isothiocyanate (Riggs) for fluorescentthetr 13919 the reaction of humoral anti antibody technic with a modification of its body with antigen Study of these coul application Proc Soc. Ex Bol & ditions by the fluorescent antibody dled 03 808-900, 1958 method should furnish considerable basic 10 Caons, A FI Efistochemistry with lainformation about their pathogenesis and beled antibody Ist Rey Cytol 1-23, 1956 may suggest a basis for more rational Il Coons, A H Fluorescent antibody meththerapy ods to General Cytochemical Methods, Vol. The author is especially grateful to Dr. I. edited by J F Daniellt, New York, Academic Press, Inc, 1958, pp 399-422. Arthur 11 Silverstein, Dr Max D 12 Mellors, R. C. Fisorescent-antibody Voody, and Dr Dorothy flamre for the method in Analyt.cal Cytolugy edited by loan of slide material used to illustrate RC Mellors New York, McGraw-Hill portions of this talk Book Co, Inc, 1959, DP 1-67 13 Cherry, WV, B, Goldman, M Carski, T R. REFERENCES and Moody, MD Fluorescent Antibody { CX, AH, Creech, HJ, Jones, R, N. Techniques in the Dragstosis of Communic 210 Perlines, able Diseases Public Health Service Pub The demonstration of pretimycoccal antigen in tissues by the use lication No 729, Washington, DC VS. Government Printing Office, 1960, pp 73, ·FRANK W. FITCH of the antigen is eliminated. These Few studies have utilized hunian allersolule complexes circulate in the blood gic tissues. Pioneering work has been stream and by means not yet known, donc by Rappaport who has studied the initiate and are localized in allergic, in wheal reaction in human volunteers with flammatory lesions in certain arteries and! a clinical sensitivity to hen's egg albumin glomeruli. As the complexes are elimi (22) Biopsies were performed on innated from the circulation, the lesions challenged skin, on the whea? site after a of serum sickness promptly burn thiem scratch test with egg allumini, 3ul on the selves out and are repaired. whcal site after a screatch test with frista- The events taking place in the Arthus me. Sections of the skin were treated type of lypersensitivity lesion have been with fluorescein-lalveled globulin fracstudied by Cochrane and Weigle (19), tions obtained from serium of the patients and by Cochrane, Weigle and Dixon who had volunteered for the skin biop- (20). In both the active Arthus reaction sies The fluorescein conjugation had litand the reversc passive Arthus reaction, tle effect on the alulity of this serum to antigen and in all likelihood, antibody, confer passive sensitization to 1011-allerbccame localized beneath the endothelial gic individuals. cells to form 3 deposit within the vessel in the site challenged with eng alwail. if the experimental animal was bumin, the epithelial cells of the epidepleted of polymorphonuclear Icukocytes dermis, sweat glands, fair follicies and hefore the challenge injection, there was selvaccous glands gave specific stawing No vascular inflatination or necrosis in for the egg allum17. In addition, intense response to the antigen-antibody complex. staring was present in niacropliages and In normal animals. polymorphonuclear pericapillary cells. The endocliclium of Icukocytes accumulated and inflammation small blood vessels stared less intensely, was prominent. The mechanism by wluch but fibrous tissue bundles were specific. the polymorphonuclear leukocytes were alls stained. The lustamine whcal and instrumental in producing the inflanıma normal skin did not stain with the labeled tory angiitis in the presence of antigen antibody. and antibody is not clear It does appear. It is evicient that only a leginnmg has however, that the antigen-antibody com been made i the study of allergic reacplexes do not cause the inflammation tions by means of the fluorescent antiwithout the participation of other factors. body method. Many problems of allergy Large amounts of antigen and antiand hypersensitivity can be examinca body are requred to proluce anaphylactic profitally by tising this method. What is shock in the rabbit lickinnonct al the pattern of reaction of antigen and (21) using rabbits sensitized with borine antibudly in na al niucosa? What is the serum albumin demonstrated intravascii localization of soluble antigen-antiboly lar precipitation of antigen with antibody complexes injected liy various routes into in trito after injection of fluoresccin different species of aninnis? What is labeled antigen. They suggested that ols the role played by blocking antibody in struction of pulmonary capillaries allergic reactions? I\'lat are the effects mune precipitates was an important of anti-inflammatory steroids and antimechanism in the pathogenesis of ana listamines on the localization of the phylactic shock in the rabbit amigen-antibody reaction and the Tl- 101- ·THE USE OF CORTICOSTEROIDS IN ALLERGIC DISEASE OF THE EAR, NOSE AND THROAT DAVID A DOLOWITZ, M. D. Salt Lake City the surrounding ground substance. flis. tamıne slows their activity tremendously while heparin activates the engulfing of particles. Although polymorphonuclear cells are not present in connective tissue, inilamniation brings out all of the white blond cells The połystorphonuclcar leukocytes have an affmity for clearing away lacteris. The lymphocytes also help clear infection ly transformation to macrophages They also have the further func- Since basically discase is the result of tion of producing antibodies and perliaps reaction of the individual cells ta en other constituents of gammaglobulin. It vironmental afluences, it seems logical should be noted that corticosteroids deto review allergy, which is essentially a stroy lymphocytes, and suppress their enform of inflammation, in the light of trance into inflammed areas. Thus at connective tissue responses This is es times of stress, a change occurs in their pecially timely because of the progress cytoplasm, so that they may be easily made on the study of connective tissue recognized as stress lymphocytes The in the past decade role of the eosinophil is not known They Connective tissue consists of an aggre. have been thought to transport histamine, gation of cells and elastic and collagen but do not always contact this substance. & surrounding matrix, the One constituent is the basic protein moleground substance The commodest cell cule, spermine, but its function is unis the fibroblast, which constitutes about known There is evidence that the eosinninety percent of the connective tissue ophosis may and the phagocytosis of dead cells It produces mucopolysaccharides cells that macrophages are unable to fracwhich intersperse herneen the scaffold ture and engulf These cells are taning of connective tissure to form the gentially contacted by eosinophils which ground substance. produce some unknown alteration in The second cell is the lustrocyte or them The only mechanısın that can be macrophage, a primitive, reticulo-endo seen is a whirling motion of nucleoli, as thelial cell, which are the scavengers of of a bucket brigade. After some time, These cells wander through the eosinophils break contact with the out the ground substance, clearing de dead cells and wander off Macrophages 11s Their activity is markedly influ ther setan and are able to break down enced by the predominant material in the cells and ingest this cellular debris, 47 ssbers 153 thus a503 ·46 FRAYK WY. FITCH 19. Cochrane, C. G, and lleigle, W. O. The cutaneous reaction to soluble antigen-antibody complexes, à comparison with the Arthus phenomenon J. Exp Med. 10: 591-604, 1958. 14. Chadwick, C. S. McEntegart, N G, and Nairn, R. C.: Fluorescent protein tracers. A trial of new fluorochromes and the development of an alternative to fluorescein. Immunol. 1. 315-327, 1958 15. Hiramoto, R., Engel, K., and Pressman, D. Tetramethylrhodamine as immunohistochemical fluorescent label in the study of chronic thyroiditis. Proc. Soc. Exper Biol & Med 97 611-614, 1958. 16 Coons, A H.: Some reactions of lymphoid tissues to stimulation by antigens Harvey Lectures 53: 113-129, 1958 17 Dixon, FJ, Vazquez, J. J, Weigle, W O., and Cochrane, C G Pathogenesis of Serum Sickness A.M.A. Arch Path. 65 18-28, 1958 18. Dixon, F. J., Vazquez, J J., Weigle, W o, and Cochrane, C. G Immunology and pathogenesis of experimental serum sickness in Cellular and Humoral Aspects of the Hypersensitive States, edited by HS Lawrence, New York, Paul B Hoeber, Inc, 1959, pp 354-371. 20 Cochrane, C. G, Weigle, W.0, anxt Diron, F. J.: The role of polymorphonucicar leukocytes in the initiation and cessation of the Arthus vasculitis. J. Exp Med. 110 481-494, 1959. 21. NcKinnon, G E., Andrews, E C.. Jr, Heptinstall, RH, and Germuth, F. G, Jr.. An immunohistologic study on tlie occurrence of intravascular antigen-antibody precipitation and its role in anaphyla vis in the rabbit. Bull Johns Hopkins Hosp Tor. 258-280, 1957. 22 Rappaport, B Z.• Antigen-antibody reactions in allergic fuman tissues I. Preparation and use of fluorescein-conjugatel reagins for staining the reaction sites. J. Exp. Med 112 55-64, 1960.

·29 CORTICOSTEROIDS IN ALLERGIC DISEASE ment is not of great use in allergy, for molecule, it can enter the blood stream those studying otosclerosis it may be of only via the lymphatics; hence these extreme interest At present, our ens salts again form small granules which ergies are being expended to produce by- are picked up by fibroblasts, turning into pass mechanisms around the assicular mast cells. tumor Eventually, it will be necessary Before leaving connective tissue and to discover how the ground substance its functions, it may be ativantageous to calcifies the fibrous tissue, and why it stress that this is not a static area, but does this in otosclerosis; then we may One of constant motion. Gels are conbe able to eliminate the disease instead of tinuously turning 10 solds, and vice versa merely elimunating the deainess, tempo- as the ground substance changes. The rardly changes are local; they may be turning Intertwiex betueen the cellular ele to gel at one point, and a few centi. ments and the ground substance in con meters away may become trquid. The nective tissue, are elastic and collagen fi- local situation depends on the degree of ber's These fibers are created by the polymerization. Throughout this apparfibroblasts The collagen fibers particu- ent jungle of ground substance and interfariy, are extremely interesting in that twined collagen and elastic tissues, one they have a definite spatial relationship. finds cells wardering about. It is inter- If they are stretched until this spatial esting to speculate that each cell seerns arrangement is broken, disease is pro to have a specific function. If lacteria duced Progress is being made in study are present, polymorphonuclear cells will ing these linhages in the hope that their invade and engull thecer, The polychanges may give information of use in morphonuclear cells will not touch cel controlling the collagen diseases tular debris, which is picked up by the Finally connective tissue does a great macrophages. The fittle granules of de deal to maintain the mulieu internale by bsis are picked up by filoblasts and establishing ion exchange mechanisms is form mast cells, which disintegrate ag the ground substance. Through this mentioneul when damage is done to the mechanism, either acid or alhaine ma- The activity vanes with pH. 11 terial may be bound At present, it 15 fustamine is herated, the tissue swell: believed that inflammation occurs be- and cellular activity decreases, especially Quse of the presence of catechol amines scavenging The mast cells then degran liberated when any type of tissue dam ulate and decompose This arrests th age veurs These amines are detoxified swelling and reactivates the macrophages As noted earlier, It heparin is added, the activity is tre when histamine is liberated in the neigh- mendously enhanced and soon the area Lorlugod of a mast cell, us contained clean and normally active. granules explode, liberating mistamine It has been shown repeatedly that an The lustamine, being a type of injury (thermal, chemical, bac smalt nuolecule, enters the capillary best terial or physical, etc) causes the libera through the ground sulistance barrier and tion of histamine, or the H substance diffuses throughout the body, while the Lewis. His wisdom in calling the is heparin unites with the neighboring his flammatory agent "H" substance, thoug tarttine, neutralizing it. Being a larger he was quite sure it was histamine, zrea in connective tissue and heparin ·18 DIVIDI. DOLOWITZ The function of the plasma cell is also mal and yet, at the same time, allowing in doubl. Jíany claim it produces anti- eachi cell to selectively allow material to body protein, as gammaglobulin; others pass within the cell or to be excluded doubt this. Further stuciy will be neces Il'ere it not for this ground substance, sary to determine the correct answer. each cell would have to remain similar, last cells are also present in large num and development would have been rebers While it is classified as a distinct stricted to forms similar to the stronges. cell, it is our feeling that the mast cell It has further allowed us to develop spemost probably represents a fibroblast cificity in cells and yet exchange material wlich has picked up metaclıromatic gran- throughout all of them. ules, which are probably the salt formed As aninials developed phylogenetically by the union of histamine and lieparın. and locomotion increased, a circulatory This is thien metabolized and hista system developed which could carry meanine and heparin are held in readiness tabolites throughout the body. However, for extrusion from the cell. it must be noted that after leaving thic Thic primitive one-celled animal re- capillarics, the metabolites nrust traverse quired a senii-permeable menibrane that the ground substance in order to enter could contain the cell, allow it to extract the individual cell, where final metabolnourishment from the surrounding area 14011 occurs. The ground substance is the and to excrete waste products. This was final guardi, allowing the entrance or exthe beginning of the ground substance. it of any naterial into, or from, the cells. Phylogenetically, animals are not the As mentioned, ground substance cononly ones that have developed a ground wists of polymers of the two sugars. As substance. Plants have small hollows, the polynierization incrcases, the number called canaliculi, which ru the length of of free bonds decreases Thereforc, ani the plant. These canaliculi are filled with individual who is ciematous funds it polymers of the sugar, xylose. This su casier to exchange ions than one in whom gar enables the trec to extract water and polymerization has occurred until there various salts from tlie earth and trans are few free bonds Thic practical appli. port them to the ends of tle trec for cation of this is to point out that if too nourisluent. Waste products are climi miucli water is extracted, it becomes difnated in the opposite direction ficult for sons to reach the cells to bring In animals, instead of xylose, glucose tire materials needed for metabolism. and galactose serve as the basis of the This action of ground substance is enmucopolysaccharides that form their fianced by the action of hyaluronidase, ground substance. Without this ground which increases permeability of mern. substance, neither the trees nor tlie ani branes. This allows larger molecules to mals could have developed into a multi reach many cells inorc casily and cven cellular animal. I unicellular animal has to cross tfie capillary barrier. no difficulty in extracting nutrients from Another function of connective tissue the surrounding water, and excreting is to give rigidity and strength to the wastes. Multicellular animals, however, framework of the body. Bosses are acill- Iradd to develop sonic way of bindling thically a form of ground substance in which cells together. Tlie grou! sulistance the fibrous tissue has become calcified. lias scrved as a mortar, forming one ani. "While thic importance of this at the ·51 CORTICOSTEROIDS IN ALLERGIC DISEASE throughout the hody. Therefore, one capsular cataracts are produced by the must be certain which organism is in use of steroids These are so well known fecting the body and, further, certain that one need not discuss then. that one can control it with either a While the steroids are dangerous, if chemotherapeutic or antibiotic agent in used properly in small, non-continuous order to prevent the infection's spread. bursts they are of great help in hay fe- If one does not have such control of inver, urticaria, hives, sinusitis and polyn ſection, it is better not to use the adrenal. formation. By decreasing the ground extracts, substance they decrease the edema, and Thirdly, cortisone has been found ta hence the size of the turbinates and the decalcify bones through allowing the polyps Histamine spreads through the escape of calcrum li used too long, one body more slowly and the allergy is more may have the difficulty of pathologic easily controlled 1Vhile the loss of infractures. In a few cases, cortisone also flanimation is a danger in the presence affects other dutiess glands, particularly of infection, ii iníection is controlled by the pancreas to produce diabetes. It is antibiotics the shrinkage of the nasal tisour feeling that the thyroid also prob- sue affords both symptomatic improveally is affected. The degree has not yet ment and lessening of the histamine probeen measured At the moment, extra- ducing the allergy ·50 DAVID I. DOLOWITZ apparent, for we are finding that not pollenate. He was thus able to show only histamine, but many amines, as sero that he could control the hay fever sensitonin, carnesine, etc., all act in the same tivity but that histamine would be seway. creted in the urine as soon as the pol- Drs. Eyring and Dougherty have pos- len appeared. The second mechanism tulated that sodium or potassium may be is local (letoxification which we have just transported by a cliclation process, using been discussing. The third is the action histamine, across the fibroblast's inem of the steroids. brane. The basic idea of chelation is that The steroids decrease production of ions produce a voltage difference across ground substance in hyaluronidase and a cell membrane and thus electrically thus tend to limit the spread of the histransport molecules. The mechanism tamine. I much stronger mechanism, differs from the formation of the tisual however, occurs tlırough the action of covalent bond in that the metal ion does cortisol, wluch is piched up by the fibronot sliare its electrons, but is held by a blasts and toughens their cell membranes force of attraction, and thus the chelator against listamine's transport of sodium can move the ion without being chenuc- into tlie cell. Tlius the chain reaction is ally changed. It is felt that the meclian arrested, isnı by which inflanimation is produced The difference in action between the is fundamentally due to the enhanced steroids and liepurin should be noted transport of sodium across the fibrous By understanding these actions we are membrane. The sodium is accompanied no longer limited to the sterous but have by molecules of water across thic meni a new mechanism available to us for the brane into the cell In time, the accumi control of allergies. lation of water causes the fibroblast to When the action of the adrenals on alswell and finally to break. This releases lergy was first (liscovered, it was felt the histamiine complex, which is still that a control was now available for this chemically unchanged and thus able to at discase l'nfortunately, its usc as a drug tack the remaining cells Thus cach cell clemonstrated that it is not without broken down actually promotes the de- dangers The use of cortisonc decreases struction of neighboring cells, and a the activity of the adrenal glands, and chain reaction of destruction results when the patient faces a stress, the Death would always be the end result of glands may not be able to produce sufthe locly were not able to control inflans ficient hormone to cover the period of mation. This is easily seen in an adre shock This is extremely important to nalectomized animal as inflammation will remiember, for should a patient require often set up a chain reaction resulting in stirgery after having cortisone, or lic prut cleath. through a series of stresses, it is ex. In the average goal, the chain retremely imxrtant that additional corti. action is controlled ly three mechanismis. sene lie adiled to suplenient that which First is the excretion of lustamine. This thie boily can produce, Otlicrwisc death was demonstrated by Bram Rose in aby shock may result. most ingenious experiment. lle gave Further, it lias been found that through ACTH to patients with known allergy to the reduction of inflammation, cortisone ragweed scveral days before the plants will perniit infections to sprcail rapidly ·CORTICOSTEROIDS IN ALLERGIC DISEASE 51 throughout the body Therefore, one capsular cataracts are produced by the must be certain which organism is in use of steroids. These are so well known fecting the body and, further, certain that one need not discuss them. that one can control it with either a While the steroids are dangerous, if chemotherapeutic or antibiotic agent in tised properly in small, non-continuous order to prevent the infection's spread. bursts they are of great help in hay fe- Il one does not have such control of in ver, urticaria, hives, sinusitis and polyp fection, it is better not to use the adrenal. formation. By decreasing the ground extracts. substance they decrease the edem, and Thirdly, cortisone has been found to hence the size of the turbinates and the decalcify bones through allowing the polyps Histamine spreads through the escape of calcium. If used too long, one body more slowly and the allergy is more may have the difficulty of pathologic easily controlled. While the loss of infractures. In a few cases, cortisone also flammation is a danger in the presence affects other ductless glands; particularly of infection, if infection is controlled by the pancreas to produce diabetes It is antibiotics the shrinkage of the nasal tisour feeling that the thyroid also prob sue affords both symptomatic improvealily is affected The degree has not yet ment and lessening of the histamine probeen measured. At the moment, extraducing the allergy ·THE DIAGNOSIS AND MANAGEMENT OF NON-GRANULOMATOUS UVEITIS ROBERT S COLES, VI. D. New York, New York plasnia cells and lymphocytes which give rise to the characteristic granulomatous picture. Woods' contribution to the classification of uveitis is a landmark. However, certain valid criticisms of it can be made. These criticisms can be made on clinical grounds, on patlıological grounds, and on inimunological grounds First, in terms of the clinical grounds, I frequently find it very difficult to notice any difference between the 11011- I would like to discuss the diagnosis granulomatous and the granulomatous and management of uveitis under four states Is far as I am concernel, onc subheadings, classification, pathogensis, will merge imperceptibly into the other. cliagnostic procedures and management. I have often seen patients who had non- I think the last two depend upon classi- granulomatous uveitis, but when I looked fication and pathogenesis, and for that in a seck later, it was a typical picture of reason I will start by discussing, briefly, granulomatous divertis, and vice versa. 1 the classification of uveitis have almost come to the conclusion that The most important advance in tlus the difference is one of degree due to freld was made in 1947 when loods the insult to the oczılar tissics, which resubdivided uveitis into non-granuloma- sults, fet us say, in a greater outwuring tous and granulomatous niveitis, which he of epithelioid cells and the formation of based upon the different pathological these large mutton-fat precipitatcs. In pictures found an enticleated eyes. He leptospirosis where actual organismal 111- called the first type non-granulomatous vasion of the che occurs, we biase a typy. treitis, and a picture of this condition cal non-granuloniatous picture. And in taken from Woods' book show's intense two of the prime allergic diseases of the cellular infiltration with lymphocytes, cyc, namely, endophthalmutis phakoanapilasnia cells and monocytes. Woocis con- phylactica and sympathetic oplitima, siders this type of reaction to be pri- which undouiitedly are diseases of a lze marily of the allergic variety. lle con- persensitive nature, the clinical pictures siders the second type to be due to or typical of the granuloniatous reaction Fanismal invasion which gives rise to a with tardaceous, heavy, mutton-fat kii's, specific reaction termed the granuloma- loss frade flare and cluaracteristic mora tous reaction. This is characterized by phologic changes. .ind so, clinically. giant cell 'formation, epithelial cells, this classification feases us in doubt. 52 ·53 NON-GRANULOMATOUS UVEITIS l'athologically, it can be criticized as ture, organismal invasion is not required. sell Ashton fias pointed out that the All that is neerled is antigen and antiterm "granulomatous reaction" nierely body. A slide of the spleen of a patient applies to those chronic inflammatory re. who had a fatal hypersensitive reaction actions which occur over a prolonged to 10dine showed a typical granuloniatous period of time since any protracted in- picture. And another slide showed giant fection will develop the characteristic cells which formed in the spleen of a rabbit treated with serum sickness type picture of a granulomatous reaction, with or without actual organısmal invasion, if of antigen-antilody reaction. Goldgraber and Krismer have stated that the patholong enough in duration. Also, mert substance can give the typical granulomatous logical occurrence of granulomata is evidenice picture for example, wood, beryllum, per se of a hypersensitive state. We do not feel that it is possible to silica, talc, etc., give beautiful granulomas when the eye is examined, histologically. classify uveitis solely as granulomatous Ind lastly, Frenkel and Jacobs have or non-granulomatous At the New shown that in the organismal invasion York University-Bellevue Medical Cenwhich occurs in toxoplasmosis, there is ter we have developed the habit of clasabsolutely no tendency for granulomas sifying uveitis in the simplest fashion, to form namely, whether it is anterior or posterior uveitis, panuveitis, acute or chronic, Immunologically, also, this classifica and then we give it a secondary, morphotion can be criticized. Rich believes that logical classification; we state whether it is possible to get the typical granuloma or not it is of the non-granulomatous or tous picture in the eye, as elsewhere in the granulomatous variety. the body, purely on the basis of an anti The following table outlines the magen-antibody reaction. In other words, jor pathogenic mechanisms which exist to get this definite granulomatous pic in uveitis TABLE I a. C PATHOGENESIS FOCI OF INFECTION 2 DIRECT ORGANISMAL INVASION Bacteria b Viruses Spirochetosis Treponima pallidum Leptospirosis d Protozoa Toxoplasma Parasitic diseases Fungus infections 3 HYPERSENSITIVITY 4 SYSTEMIC DISEASES Regarding foci of infection, it seems to the concept of focs of infection. regrettable to me that it is only in oph- think every other major branch of medithalmology that we still find adherence cine has more or less discarded this cone 1 ·54 ROBERT S COLES cept, including the rheumatologists, who which were similar only on two acca. at one time looked for foci of infection sions—similar, i.e., in the cje and in the in secking the cause of arthritis. In our sinuses. As far as I am concerned, the experience, we have not had too much concept of foci of infection is not very success in curing uetis by eliminating tenable. foci of infection. However, I must give The next possibility is that of direct you the other side of the coin. There organismal invasion causing uveitis. In are many people who believe very strong- this country all attempts to isolate Lacly in foci of infection and I respect their teria from the anterior chamber during opinion. Halland and Whorlton, for ex the height of the uveal attack, anterior or ample, recently have claimed that chronic posterior, have been unrewarding. Von genitourinary tract infections are associ- Sallmann, Brown and many others, inated with a pleuro-pneumonia type of or- cluding ourselves, lave never recovered ganism and give rise to an anterior type any organisms from the aqueous. In of uveitis. They claimed considerable Europe, reports of recovering organisms, improvenient of the uveitis coincident most commonly nonpathogenic staphylowith clearing of the G. L'. infection with Cocci, are frequent. Howeier, if staplı oxytetracylinc. Cattarall, in England, or strep organismal invasion did play a found a liigh incidence of genitourinary role m the causation of anterior uveitis, tract infections but, on the other hand, }}'e would expect purulent reactions, cerhe was unable to alter the uveitis by carly so with the more pathogenic ones. controlling the G. U. pathology. Castro- Lastly, we would cxpect the uveitis to be viejo fecis very strongly that patients audal by antibiotics, which it isn't with keratitis and ireitis respond well considerable antount of work 117s when their foci are remos ed. However, been one in recent years on viruscs, al. I have lots of good company, Hogan, though it las been shown definitely that Kimura, and Thygesen in San Francisco, no virus cxists with a specific trophis have completely given up the scarch for for the nical tract. In the literature, I foci of infection Schlacgel also has have come across only two reported isobcen rather doubtful of any good com lations of viruses from the aqueous during from the clinination of foci of in ing the course of anterior incitis. Both fcction. Also, Bennett, in Englandi, reports were of the isolation of herpie's states tliat the English probably have tlic simplex virus At the Proctor Foundaworst teeth in the world, yet the inci tion nuch virus study has been perforridence of uveitis among them is no higher ed Thy geson, Kimura and Ilogan rethan in any other group I have spoken prort that three days after the injection of to many oculists who told me that they viruses into the anterior chamber in aniclid have patients wliose un citis improved mals, that it is impossibile to recover after tonsillectoniy, but I have not been them. It may be that virus isolation techable to track one down. In France, Of. nics have been in dejate. Sow, this fret and Sarraut fcel that 35% of all may be because, as you know, the virus anterior uveitis is due to foci of infecis an obligatory intracellular parasite and tion located in the paranasal sinuses. necils cells to live oil, and usually only However, in a large series of patients, aqucous is aquiratcs. l'erhap, if sc they were able to recover microorganisms could aspirate a little bit of tlic iris at the ·55 NON-GRANULOMATOUS UVEITIS same time, we would find virus But which manifests itself in the eye. esen though viruses have not been isolat The most important protozoon in the ed from the anterior chamber I think causation of uveitis is the toxoplasma that they do play an important role in the Tlus organism has been recovered frecausation of uveitis I think they do it quently and Table II shows the number secondarily: I think it is secondary to of times that toxoplasma has been revirus infection elsewhere in the body covered from the human eye. TABLE 11 RECOVERY OF TOXOPLASMA FROM HUMAN EYES Ant Dye Titer Author Sex and Age Duration Type Eyo lavolved VS Post. Skull X ray Viru. lence Before After Neg 1.64 High Jacobs, L. Fair, J. Male, 30 8/2 yrs Acquired Post Jos. &.ckarton, 1. yes 1954 I wk 1 4096 2 wks 1 128 Sinca birth Habegzer, 1954" Mole, 2 mos Female, 45 yrs Congen. Post OD stal Congen Post OD-Now ital OS-old Hydro 16000 7 cephalic! Neg. 1.204816000 High 7 8 yrs Pos. I 12B 116 Low Hogon.MJ Zwongart, P. Lowy 1, 1958" Male, 20 yrs Congen-Post JOD-old ital healed central CR OS-Active lesion Pillat, Thalhammer Male. 11 1957 ves > Ant OU 7 16384 1 256 2 3 mos 173 In regard to fungi, there is a great it a little bit difficult to accept this as a deal of interest which lias been aroused cause of chronic Urentes The only hisby Dr. Alan C Woods in a recent paper toplasmosis I have seen is as a systemic on histoplasmosis in which he postulated disease, and these are sick people. that histoplasmosis is a possible common Our next pathogenetic mechanism is cause of seints I haven't had any ex most important, hypersensitivity. Table perience with histuplasmosis as a cause III shows a classification of hypersensiof uveitis 2nd I must confess that I find tivity as it may be responsible for uveitis TABLE 111 CLASSIFICATION OF ALLERGY OF THE UVEA I. ANAPHYLACTIC AND ATODIC OCAPTION 2.) -, Urui me lorure is, lues, toxoplasmosis, brucellosis مما nous uveal pigment} to autogenous les protein) ·54 ROBERT S. COLES In our cept, including the rheumatologists, who which were similar only on two occaat one time looked for foci of infection sions-similar, i c., in the cye and in the in sccking the cause of arthritis sinuses. As far as I am concerned, the experience, we have not bad too much concept of foci of infection is not very success in curing uvetis lvy climinating tenable. foci of infection. Ilowever, I must give The next possibility is that of direct you the other side of the coin. There organismal invasion causing urcitis. In are many people who believe very strong this country all attempts to isolate Lacly in foci of infection and I respect their teria from the anterior chamber during opinion. Ifalland and Whorlton, for ex the height of the liveal attack, anterior or ample, recently have claimed that chronic posterior, have been unrewarding. Von genitourinary tract infections are associ- Sallmann, Brown and many others, in. ated with a pleuro-pneumonia type of or- cluding ourselves, lave never recovered fanism and give rise to an anterior type any organisins from the aqueous. In of uveitis. They clained considerable Europe, reports of recovering organisms, improvement of the uveitis coincident most commonly nonpathogenic staphylowith clearing of the G U. infection with cocci, are frequent. However, if staph oxytetracylinc. Cattarall, in England, or strep organismal invasion did play a found a lugh incidence of genitourinary role in the causation of anterior uveitis, tract infections but, on the other hand, we would expect purulent reactions, cerlie was unable to alter the uveitis by tamly so with the more pathogenic ones. controlling the G. U pathology. Castro- Lastly, we would expect thc uveitis to be vicjo fccis very strongly that patients anded by antibiotics, which it isn't with keratitis and ventis respond well A considerable amount of work has when their foci are removed However, been done in recent years on viruses, al- I have lots of good company, Hogan, though it has been shown definitely that Kimura, and Thygesen in San Francisco, no virus exists with a specific tropluism have completely given up the scarch for for the uveal tract. In the literature, I foci of infection. Schlacgel also has have come across only two reported 150- been rather doubtful of any good com lations of viruses from the aqueous during from the elimination of foci of in- ing the course of anterior uveitis. Both fection. Also, Bennett, in Englane, reports were of the isolation of lerpes states that the Englislı probably have the simplex virus. At the Proctor Foundaworst teeth in the world, yet the inci- tion much virus study has been performdence of uveitis among them is no higher ed. Thygeson, Kimura and Ilogan rethan in any other group. I have spoken prort that three days after the injection of to many oculists who told me that they viruses into the anterior chamber in anidid have patients wirose uveitis improved mals, that it is impossible to recover after tonsillectomy, but I have not been them. It may be that virus isolation techable to track one down. In France, Of- nics have been inadequate. Now, this fret and Sarraut fcel that 35% of all may be because, as you know, the virus anterior uveitis is due to faci o infcc- is an obligatory intracellular parasite and tion located in the paranasal sinuses, needs cells to live on, and usually only However, in a large series of patients, aqucous is aspirated. Perhaps if we Lurra The internyos microorganismis could aspirate a little bit of the iris at the ·$5 NON-GRANULOMATOUS UVEITIS same time, we would find virus But which manifests itself in the eye. even though viruses have not been isolat The most important protozoon in the cd from the anterior chamber I think causation of uveitis is the toxoplasma. that they do play an important role in the This organism has been recovered frecausation of 1veitis I think they do it quently and Table II shows the number secondarily, I think it is secondary to of times that toxoplasma has been revirus infection elsewhere in the body covered from the human eye, TABLE 11 RECOVERY OF TOXOPLASMA FROM HUMAN EYES Dye Titer Author Ser and Age Duration Type Ant Vs Post Eye Involved Skull X-ray lence Before After Neg High Jacobs L. fovt, J. Mole, 300'72 yrs Aequired Post os Bickorton, J., yrs. 1954 1.4096 2 wks. I 128 Habogger, 1954 $ 6000 2 Male 2 mos Femole, 45 yrs Since Congen Post OD birth ata! 7 Congen Post OD-new ital iOS-old Hydro cephalic Neg. 1 2048 9.14000 High Pos 112B 1.36 Low Hogan M 3. Zweigart, P Laws A., 1958 Male, 201 8 yrs Ys Congen Post ODold ital healed central CR OS-Active lesion 7 Piltot, Thalhammer. Male, 11 ) 3 mos. 19571 Vrs Ant OV 7 4.16384 1 256 7 In regard to fungi, there is a great it a 111le bit difficult to accept this as a deal of interest wluch has been aroused cause of chronic uveitis The only hisby Dr. Alan C. Woods in a recent paper toplasmosis I have seen is as a systemic on histoplasmosis in which he postuiated disease, and these are sick people. that histoplasmosis is a possible common Our next pathogenetic mechanism is cause of useisis I haven't had any ex most important, hypersensitivity Table perience with histoplasmosis as a calise III shows a classification of hypersensiof uveitis and I must confess that I find tivity as it may be responsible for uveitis. TABLE M CLASSIFICATION OF ALLERGY OF THE UVEA 1. ANAPHYLACTIC AND ATOPIC REACTIONS Uveitis from Sera, pollens, animal proteins, foods, drugs, angioneurotic edema 2. MICROBIALLERGIC REACTIONS Nann, strepto. 6. * Altline nature 3 AUTO ammatory response tuberculosis, lues, foxoplasmosis, brucellosis AI nous uveal pigment) to autogenous les protein ·56 ROBERT S. COLES The first group, anaphylactic and berculin in patients with anterior uveitis atopic reactions of the livea, definitely than in those with posterior uveitis. occurs. Uveitis may also be due to pol. I would like to discuss autogenous allen, and I have 110w collected six instances from the literature. In addition, amples of these are synipathetic ophthallergic reactions I think the best exwliile discussing pollens with Dr. Prewitt, he mentioned a patient whose tivci. mia and endophthalmitis anaplıylactica. tis was directly associated with a sperabout sympathetic ophthalnia leads to I think that analysis of what is known cific pollen. An interesting instance is the realization that this is primarily a reported by Walker of a woman who had a severe anterior uveitis and who finally schnig proposed, in 1910, that uvea pighypersensitive disease. Ever since Eltrad to be hospitalized. When she enment was a cause of sympathetic ophtered the hospital her liveitis cleared dramatically, only to recur when she thalmia, evidence has accumulated to butwent home. Further investigation retress this concept. In the twenties, Friedenwald developed a skin test employing vealed that she had a pet cat at home IIcal pigment, which he found was posand that she was highly sensitive to cat dander They took away her cat and itive only in patients with sympathetic her tiveitis cleared up. ophthalmia Under the sec. Woods isolated a specific ond category of microbiallergic reactions, ophthalmia ilule there is much that antibody in patients with sympathetic allergy is apparently the main factor. we don't know about sympathetic oph- Currently, there is a belief that the thalmia, inost of the evidence would instreptococcus plays a very important role clicate that this is a reaction of hyperin the causation of uveitis, We ran a sensitivity, perhaps triggered by some large series of serial antistreptolysin low grade infection or conjunctivial titers in patients with uveitis and in a saprophyte. control group In this study we could find 130 correlation between serologic evi- Endophthalmitis anaphylactica is of a similar nature, I think In this instance, dance of streptococcal disease and the the lens is the antigenic substance Witpresence of uveitis. We do not feel that mer has skin tested these patients and he the streptococcus is an important factor has also done antibody studies on the in the causation of uveitis. aqueous and he has found that these pa- Tuberculasis had a tremendous vogue trents do have specific antibodies to their in the past as a cause of uveitis, but the own lens protein So I trunk this comes "therapeutic test" for tuberculosis has into the category of an allergic mechanshown that tuberculosis is not as com ishi I thuk basically, as we go down mon in uveitis as it was originally thought the line even in the large group of nonto be. However, the fact that tubercle specific uveitides, that eventually we may bacilli can give rise to allergic reactions find that these represent autoalicrgy to is intriguing and I think that some anuveal pigment. Possibly an antigen terior uveitis nay conceivably be hyper- unites with the mucopolysaccharides of sensitivity to the tubercle bacilus. the aveal tract, forms a hapten-like consmight add that skin tests revealed a high- plex which then leads to autosensitizaincidence of nositive reaction to tu tion, with rectirrent bouts of uveitis, 1 ·57 NON-GRANULOMATOUS UVEITIS In any search for causative agents in I would like to briefly discuss some of meitis it soon becomes apparent that these systemic diseases and their liveal there is a large number of systensic dis manifestations. I have listed them in eases which are associated with uveitis Table IV, TABLE IV SYSTEMIC DISEASES ASSOCIATED WITH UVEITIS RHEUMATIC DISEASES SARCOIDOSIS SPIROCHETOSIS A. Syphilis B. Leptospirosis VIRUS OISEASES TUBERCULOSIS TOXOPLASMOSIS TROPICAL DISEASES PSYCHOSOMATIC FACTORS I have excluded all of the degenerative the changes occurring in the anteriar segconditions, such as osteoarthritis, which ment. The second type of uveitis found are not associated with uveitis. Approxi- with rheumatoid arthritis is a slow formiately 2% to 5% of patients with the pid, smoldering uveitis which is uvematoid arthritis will develop anterior sponsive to all tynes of therapy and can uveitis. The average time for develop- eventually lead to cataracts, phthisis bulbi This second Sent usually is from two to four years, or secondary glaucoma although it sometimes takes twelve years variety seems to be very closely associuntil tveitis becomes manifest. Uveitis ated, I final, with the more severe type of associated with rheumatoid arthritis can joint mamiestations, manifest itself in two different patterns The juvenile form of theumatoid arth- The first type can appear as a unilateral, ritis is a fulminating disease. These acute, anterior uveitis which recurs over children usually core clown with hepaa period of years, usually associated with tosplenomegaly, severe jout manifestavery me thin K Ps, sense aqueous tions and high lever They are very flare and many cells of the lymplioid type sick childrens Occasionally they present in the anterior chamber This type usu a severe uvenis, and later develop the ally gets better with or without treat pical classical picture of juvenile rheumient 111 about 4 10 6 weeks and usually matoid arthritis We have seen this in causes to damage with the instal attack two patients In these patients, tests to It is only as a result oi repeated attacks determine the presence of the rheumathat synechiae and other permanent told factor are positive. changes appear which lead to recesible The second rheumatic disease of issdamage frequently, changes in the pos- portarice in uveitis is at:kylosing spondylstriot segment occur, such as edema of This is a completely different disthe nucula and occasionally a papsllitis. case from sheumatoid arthritis although This type of isreitis is unrelated to the in the past they were considered sometenty of the triatoid atilirius Any what somlar. The incidence of uveitis Hual loss which occurs is due only to in ankylosing spondylitis is, of course, ·56 ROBERT S, COLES Tlie first group), anaplıylactic and Jerculin in patients with anterior uveitis atopic reactions of the livea, definitely than in those with posterior tivcitis. occurs. Uveitis may also be due to pol. ics, and I have now collected six in- I would like to discuss autogenous alstances from the literature. In addition, lergic reactions. I think the best exwhile liseussing pollens with Dr. Pre amples of these are sympatictic opitia. witt, he mentioned a patient wiose uvei. nia an endaplıthalmitis anaphylactica. tis was directly associated with a spe. I think that analysis of what is known cific pollen. An interesting instance is about sympathetic oplithalmia leads to reported by Walker of a woman who had the realization that this is primarily a a severe anterior uveitis and who finally hypersensitive disease. Ever since Ejhad to le fospitalized. Whion slic cniselinis proposed, in 1910, that uvcal pigtered the hospital hier uveitis ment was a cause of sympathctic ophleared dramatically, only to rccur when she thalmia, evidence has accumulated to buttress this concept went honic Further investigation rc- In the twenties, Fric. vealed that she had a pct cat at home clanwald devcloped a skin test employing and that she was lriglily sensitive to cat tiveal pigment, which he found was posclander. They took away lier cat and itive only in patients with sympathetic oplithalma Voods isolated a specific her uveitis cleared tip. Under the second category of mici obiallergic reactions, phthalmia. ivhile there is much that antiboly in patients with sympathetic allergy is apparently the main factor, we don't know about sympathetic opti- Currently, there is a belief that the thalmia, nost of the evidence would instreptococcus plays a very important role (licate that this is a reaction of fryperin the causation of uveitis. We ran a scnsitivity, perhaps triggered by some large series of serial antistreptolysin low grade infection or conjunctivial titers in patients with uveitis and in a aproplyte control group. In this study we could find no correlation between serologic cvi. Endophthalmitis anaphylactica is of a simmlar nature, I think. In this instance, cience of streptococcal disease and the thic lens is the antigenic substance. (Vitpresence of uveitis. We do not feel that mer lias skin tested these patients and lic the streptococcus is an important fnctor has also done antibody studies on the in the causation of uveitis, aqucous and he has found that these pr- Tuberculosis had a treniendous vogue tients do liave specific antibodies to their in the past as a cause of yveitis, but the myyn lens protein So I think this comes "tliertpeutic test" for tuberculosis has into the category of an allergie mechasshown that tuberculosis is that as com 15111. I think basically, as we go down aron in uveitis iis it was originally thought the line cven in the large group of nonto be. However, the fact that tubercle specific uveitides, that eventually we may bacilli can give rise to allergic reactions find that these represent autoallergy 10 is intriguing and think that soine anlivcal pigment. Possilly an antigen terior uveitis may conceivably be hyper- unites with the mucopolysaccharides of sensitivity to the tubercle bacillus. I the uveai tract, forms a lapter-like commiglit ad that skin tests revealed a high- plex which tlien leads to autosensitizaer incidence of positive reaction to tu- tion, with recurrent bouts of uveitis.

·59 NON-GRANULOMATOUS UVEITIS LABORATORY FINDINGS: Increased serum Globulins (A/G Reversal High Cott, Low P+ Sedimentation rate Radiographic findings Nickerson-Kviem test positive 85% Positive Biopsy One of the common causes of uveitis, I think we need not dwell too long on especially in Negroes, is sarcoid. Uveitis spirochetosis Although syphilis can comprises 55% to 60% of all ocular in cause uveitis, it is not a common cause. 1olvements in sarcoid, and uveitis in sar We have had quite a few positive serolcoid is wicked Usually the onset is ogies but none which we felt was related gradual although sometimes there are to the uveitis. acute episodes These patients develop iris nodules, rapid formation of synechiae Leptospirosis, however, is a cause of and very large mutton fat K.Ps., which uveitis but should be suspected only appear in triangular formation on the when there is a history of exposure, such bottom of the cornea Large cells are as in laboratory workers. The ocular seen in a very slow convection current, manifestations usually appear from four and despite intensive therapy severe to six months after the disease has been posterior synechiae develop Many peri- contracted, although they do occur as pheral antenor synochiae also appear I early as two weeks or as late as eighteen am certain that the tendency to synechiae months afterward. Approximately 10% formation in these patients is related to to 41% of the patients with leptospirosis the change in the systemmc albumin- develop anterior uveitis, resulting in a globulin ratio which they have low grade, chronic condition. The pafrequently these patients will do extretne tient whom I saw was a young resident ly poorly despite intensive therapy with in surgery. He was a Swiss boy who Incal and systemic steroids and my dri- had been working with rats in Zurich alics The prognosis can be extremely when he developed leptospirosis. Six bleak in this disease One aspect which months later, during his surgical resihas not been emphasized enough in the dency at our hospital in New York, he Herature is that not only does sarcoid developed a mild anterior uvestis, with affect the anterior segment but there are not too much flare but with a red eye olien marked tundus changes as well and much photophobia in the course of The reins exlubit sheathing, tortuosity one year, a mature cataract appeared in and segmentation They seem engorged the aliected eye. He also developed an and full and "tallow spots" appear along. acute glaucoma which we thought was side there. These were first described due to steroids Following cataract ex. dv Tranchischetti, s ho so named them traction, his condition became quiescent. TABLE VS1 VIRUS UVEITIS 1. ASSOCIATED WITH SYSTEMIC VIRUS DISEASES Influenza Exanthemata Mumps d Infectious Mononucleosis and Hepatitis All top . b ·58 KOBERT S. COLES much liigher than in any of the other and since we have a large arthritis clinic reumatic diseases. The incidence is re at Bellevue hospital, I see it fairly freported to lie 8% to 20%, although Ves- quently. Ankylosing spondylitis occurs tordal states that 30% of patients with nostly in patients from twenty to forty ankylosing spondylitis will have anterior years old. If a patient in that age group tivcitis. Laitenen, in Finland, studied a presents with an anterior uveitis, I think group of patients with anterior non-gran we should question liim very thoroughly ulomatous uveitis and found that 30% of as to the presence of low back pain. We these patients liad undiagnosed ankylos- sliould also get x-rays of the lumboing spondylitis, discovered in x-rays of sacral spine, since frequently ankylosing the lumbo-sacral region. I believe spondylitis is not clinically manifest; wc ankylosmg spondylitis is quite common, have to clicit it; we have to find it. TABLE V RHEUMATIC DISEASES 1. RHEUMATOID ARTHRITIS (R. F. present) Adult form Juvenile form (Still's disease) 2. ANKYLOSING SPONDYLITIS Marie-Strumpell) (R. F. absent) 3. REITER'S DISEASE 4. GONOCCAL ARTHRITIS 5 GOUTY UVEITIS Reiter's disease and gonococcal arthri on gout, tells me he lias seen over four tis are both associated with anterior hundred patients with gout, and states uveitis, migratory polyarthritis and urethat lie has never seen one with livettis. thritis. It is practically impossible at time to differentiate the two I do not It so happens that I have a patient who think gouty uveitis exists as an entity. lias gout and also uscitis, but I think Dr. Gurman, one of our great authorities they are tinrelated. TABLE VI SARCOID OCULAR FINDINGS. Gradual onset-usually bilateral Iris nodules Rapid formation synechiae Lardaceous K.P.'s Slow convection current, large cells Periphlebitis retinae Cuffing, Sheathing. Tortuosity. Segmented, Engorged veins Tallow spots SYSTEMIC MANIFESTATIONS: Lymphadenopathy, Skin eruptions Hepatosplenomegaly, Bone lesions ·61 NON-GRANULOMATOUS UVEITIS Differential dsagnosis is made by the dye that the diagnostic approacli in uveitis test, if it is positive, more than likely should be dictated by the ocular history, We are dealing with toxoplasmosis. If I think the liistory and the ocular examthe test is negative we should start look- ination are most important and in a few ing for inclusion bodies, present in the instances the diagnosis can be made with urine They can be cultivated by the out any further tests. If a patient comes usual urological technics. A complement in with herpes zoster or a history of a fixation test is also available. recent exanthemata, the diagnosis is Tropical diseases in themselves are not made. Unfortunately, these instances to common in this country, although I are all too few I would suggest doing would like to point out that in ternis of specific tests only when one suspects a I think that putting our present day population migration, we specific disease. are becoming more exposed. Certainly every patient through the same diagnos- New York City, with its large Puerto tic workup is expensive, time consuming, It Rican and Caribbean influx, has made linrewarding, and poor medicine. us entertain these diagnoses more fre shows a lack of cimical judgment, I bequently Also, with the jet age, I think lieve, to put every patient through the We can expect to see more tropical dis- same battery of identical tests We have eases. For example, a patient with lep- not foumd that foci of infection are top rosy walhed into the clinic for a routine important, as I mentioned before. In a chech He had a phthisical left eye and series of ninety-four patients, we found 111 actre usetts in the right eye. We only nine who had ENT pathology. Four cultured letirosy hacilit from the nose of these had surgery for their foci but He has the ears, the eyebrows, absence the uverfis was unimproved I think of the terminal phalanges, and the ge that the abuse of the patient with time Meral leomne facres of leprosy consuming tests as all too common. The In regard to psychosomatic factors, sedimentation rate, while frequently elesome investigators, lihe Schlaegel, cona ated, does not ad in making the diagnoader this to be an important factor in Blood counts, urinalysis, and bru- Irenes although others have not been so cells agglutination tests in ou hands tirpressed have been very unsatisfactory. These Vow I wish to discuss the diagnostic tests, we feel, are not stidicated [rocedures to be ernplayed in sveitis We think some tests are valuable when This is a thorny question because all too a specific disease is suspected Illustrauften the clinician, confused by the ab tions are the albumın-globulin ratio and $ence of anything concrete in trying to the total protein and setum calcium evalmahe a specific diagnosis, prits the q- uations, when sarcoidosis is suspected. trent through a consulerable workup In theumatoid arthritis, the finding of a This nes tum a certain sense ol 3600333- preslumen and also makes the patterit feel if thus diagnosis is suspected The dye positive latex fixation test can be of help that smething is leing done for him test in toxoplasmosis, and x-rays in tu- 31st years ago when we started diagnose berculosis, in sarcoid and in ankylosing ttc surveys at Believe Hospital 1 Itact no spordylitis, are of value and we feel are intention ul conuenining this procedure; indicated wlien these diseases are sus- I wanted to me it a fair trial 1 (elt pected on chnical grounds. Insofar as the SiS.

·60 ROBERT S. COLES a. 2. HERPETIC LESIONS Zoster b. Simplex 3. POSSIBLE VIRAL ETIOLOGY a. Behcet's disease b. Sympathetic ophthalmia c. Uveo-Meningeal Syndromes Vogt-Koyanagi Harada Sympathetic Ophthalmia? 4. CYTOMEGALIC INCLUSION DISEASE We have found in questioning our pa Behcet's chicasc, also known as the tients tliat the most constant factor in triple symptom complex, consists of hyn those with anterior uveitis is a history popyon, uveitis and aplıthous ulcers of of an antecedent upper respiratory infcc- the mucous membrane of the genitalia tion. Since upper respiratory infections ancl of the mouth This is a recurrent are often viral in nature, I feel that it discase with attacks which come on every felongs in this category. The appearance two to three wecks With cach attack of rvcitis late in the development of inthere is a decrease in vision. Eventually, fluenza, ricasles, chicken pox, or any of Ichicct's clisease burns itself out, usually in fifteen to twenty years. During tlic the cxanthemata, mumps, and more rarelivcitis attacks the vision will go from ly, hepatitis indicates a possible viral eti- 20/20 to 20/200 three or four days : ology. Influenza 18 a good example; ten and three or four days later it will be day's after contracting influenza a mild back to 20/20 Recovery is asually good transient uveitis appears I feel that 11 mhal attacks. It is a discace in which haps these are viral uveitides secondary blindness occurs through disorganization to hypersensitivity Initially they were of the anterior segment of the globe, sensitized by a circulatng virca 131 the through syneclune formation, secondary carly stages of the disease and then later glaucoma and! escritual phalusis buibi. the eye reacted allergically. Tierpetic le }}ludness can also result from changes sions can causc uvestis although more in the optic nervc properly it should be called a kerato Cytomegalic inclusion disease can also uveitis since the investis is frequently re cause uveitis. This is a relatively new lated to the cocxisting heratitis I be- cutity occurring in children, and due to lieve that occasionally in herpes simplex a virus It is a salivary gland inclusion of the corner the virus becomes fired in virus and results in an acute treitis the uveal tissues. I have two patients wluich appears in new-born and very with herpes simplex of the cornca, il- Joling cluldren, It differs from torotially associated with uveitis, who cleared plasmosis ill that in toxoplasınosis lecompletely and who now clevelop recit. sions tend to be central wlicreas in cytorent bouts of anterior ateitis without megalıc inclusion escase the lesions tend corncal involvement. I think that some to be in the periplicry. Iloth nay prewhicre down the Inne the virus has be sent with similar clirucal findings, such come fixoil in their ureal tissues and as spyleronegaly, jaundice, thrombocyto- Thic gives rise to this condition. pema, cerehral calcifications, ctc. per- ·NON-GRANULOMATOUS UVEITIS 63 TABLE IX CONTRAINDICATIONS TO THE USE OF STEROIDS UVEITIS: When due to intraocular injection Toxoplasmosis Tuberculosis Fungi Administer specific chemotherapy concomitantly INFECTION: Corneal infections due to. Fungi Herpes simplex Pseudomonas INCREASED TENSION Occasionally causes secondary glaucoma SYSTEMIC DISEASES Tuberculosis Peptic ulcer Diabetes Mental depression Acute infectious processes The indication for steroids, I think, 15 of lowered dosage, it is important to reany form of anterior uveitis. Local and member that while they all require difsystenne steroids act by depressing the ferent dosage schedules, the side effects antigen-antibody reaction and by reduc are really very much the same. It is ing the inflammatory reaction. In the simply a matter of giving a smaller posterior variety, I feel a steroid should quantity of a more potent drug. If, inbe used only when there is involvement stead of giving 300 mgs. of cortisone, of the desk or the macula by the inflam one gives 075 mg. of decadron, it still matory process In these situations it has the same physiological effect as 300 should be given with caution Whenever mg, of cortisone, although it may cut possible, specific chemotherapy should be down on some of the side reactions. I administered to cover the possible effects think that all anterior uveitides should be (f steroids We have seen patients de treated locally, and then if they don't revelop new satellite lesions while on sys- spond it is time to use systemic steroids trme sterotel therapy. For this reason such as 40 mgs. of prednisolone or its ne the to confine treatment with sys- equivalent, in divided doses I have lenne serouts in posterior lesions to a rarely felt the need of using ACTH. marhed allergic response, involvement of Only occasionally have we had a better the dish, and encroachment upon the response to ACTH than to prednisolone. macula, by the disease process One of the factors which has changed What steroid is best for systemic ad our treatment of uveitis considerably is ministrat2227? There is such a host of 2 repository form of steroid called Depe them matheted under different trade dledrol. We have been using it in the rames that it is difficult to keep track of treatment of a wide variety of inflamthem. While the manufacturers all claim matory conditions of the anterior serthe alysenet of totic side effects, because We are using it for all of our ment.

·62 ROBERT S. COLES streptococcus is concerned, our studies of stances. Therefore, we feel that an exthe antistreptolysin titers have failed to reusive workup is unwarranted and unsnow that this is an important cause of recessary. As a matter of fact, I might anterior liveitis. paraplırase a sage who stated that the Our diagnoses in a series of ninety- amount of thinking involved in studying four patients could have been made with o patient is inversely proportional to the out any laboratory aids. In other words, injount of laboratory work that is orclinical acumen is enough in most in clered: I think that is true, TABLE VII TREATMENT NON-SPECIFIC General measures Local measures Non-specific drugs and chemicals Fever therapy Steroids SPECIFIC THERAPY Against actual cause of Uveitis if known Tuberculosis Toxoplasmosis Syphilis Onchocerciasis Treatment comes under the two main of no benefit. Nydriatics put the eye Jeadings of nonspecific measures and at rest and rupture syncchiae. Of all specific therapy. Under non-specific non-specific local measures, steroids are general measures are rest, diet, etc. Lo- undoubtedly the most effective. cal non-specific measures inclucle heat, Certain non-specific drugs and chemicompresses, mydriatics and steroids cals are used as well. Salicylates still General non-specific measures include have a role, now and then we see pasteroids, chenricals and fever therapy. tients who cannot take steroids for var- Specific therapy is directed at a specific ious reasons, and they occasionally reorganism if it can be identified Unfor. spond to large doses of salicylates. More tunately, in uvcitis we deal pretty much tazolidin is a very dangerous compound with the non-specific in most instances. to use and can cause seiere hidney dis- Even if we do recognize specific condi In Europe it is used a great deal. tions such as theumatoid arthritis or sar We have used it for three or four pacoid, we still do not frave any specific lients who responded very well I do therapy for these diseases, not believe that trypsin las any value. Faracentesis is tiseful in certain in- Antibiotics should be used only for a stances. I have seen patients who, de- specific purpose in specific discases. spite diamox and steroids, maintain cle Now we come to steroids. I do not vated tension In these patients, of ten want to dwell too much on steroids for sion remains elevated for four or five I think everyone licre is as well acdays, we do a paracentesis. We do these quainted with them as I am. However, as an out-patient procedure in the clinic certain contraindications exist to steroids, and in the office. Radiation therapy is as shown in this table. ease ·63 NON-GRANULOMATOUS UVEITIS TABLE IX CONTRAINDICATIONS TO THE USE OF STEROIDS UVEITIS. When due to intraocular infection Toxoplasmosis Tuberculosis Fungi Administer specific chemotherapy concomitantly INFECTION: Corneal infections due to. Fungi Herpes simplex Pseudomonas INCREASED TENSION. Occasionally causes secondary glaucoma SYSTEMIC DISEASES Tuberculosis Peptic ulcer Diabetes Mental depression Acute infectious processes The indication for steroids, I think, 18 of lowered dosage, it is important to reany form of anterior uveitis. Local and member that while they all require dif- 54stenue steroids act by depressing the ferent dosage schedules, the side effects antigen-antibody reaction and by reduc- are really very much the same. It is ing the inſlanmatory reaction In the simply a matter of giving a smaller posterior variety, I feel a steroid should quantity of a more potent drug. If, inbe used only when there is involvement stead of giving 300 mgs of cortisone, of the disk or the macula by the inflam one gives 0 75 mg. of decadron, at still matory process. In these situations it has the same physiological effect as 300 should be given with caution. Whenever mg cortisone, although it may cut possible, specific chemotherapy should be down on some of the side reactions. I administered to cover the possible effects think that all anterior uveitides should be of steroids We have seen patients de treated locally, and then if they don't resclup new satellite lesions while on sys- spond it is time to use systemic steroids temic steroid therapy For this reason such as 40 mgs of prednisolone or its Me like to confine treatment with sys- equivalent, in divided doses I have temic sterouls in posterior lesions to a rarely felt the need of using ACTH. marked allergic response, involvement of Only occasionally have we had a better the disk, and encroachment upon the response to ACTH than to prednisolone macula, by the disease process. One of the factors which has changed 17at steroid is best for systemic ad our treatment of uveitis considerably is ministration? There is such a host of 2 repository form of steroid called Depothen marketed under different trade Vedrol We bave been using it in the times that it is difficult to keep track of treatment of a wide variety of inflamthem. While the manufacturers all claim matory conditions of the anterior seg. the alrence of toxic side effects, because ment We are using it for all of our ·62 ROBERT S. COLES Streptococcus is concerned, our studies of stanices. Therefore, we feel that an exthe antistreptolysin titers have failed to fensive workup is unwarranted and unshow that this is an important cause of recessary. As a matter of fact, I might anterior uveitis. paraphrase a sage who stated that the Our diagnoses in a series of ninety- amount of thinking involved in studying four patients could have been made with a patient is inversely proportional to the out any laboratory aids. In other words, amount of laboratory work that is orclinical acumen is enough in most in dered, I think that is true. TABLE VIIT TREATMENT NON-SPECIFIC General measures Local measures Non-specific drugs and chemicals Fever therapy Steroids SPECIFIC THERAPY Against actual cause of Uveitis if known: Tuberculosis Toxoplasmosis Syphilis Onchocerciasis Treatment comes under the two main of no benefit Mydriatics put the eye lieadings of nonspecific measures and at rest and rupture synechie. Of all specific therapy. Under non-specific non-specific local measures, steroids are general measures are rest, diet, etc. Lo- undoubtedly the most effective. cal non-specific measures include heat, Certain non-specific drugs and chemi. compresses, mydriatics and steroids. cals are used as well. Salicylates still General non-specific measures include have a role, now and then we see pasteroids, chemicals and fever therapy. tients who cannot take steroids for var. Specific therapy is directed at a specific ious reasons, and they occasionally reorganism if it can be identified. Unfor- spond to large doses of salicylates. Bu tunately, in uveitis we deal pretty much tazolidin is a very dangerous compound with the non-specific in most instances to use and can cause severe kidney dis- Even if we do recognize specific condi ease. In Europe it is used a great deal. tions such as rheumatoid arthritis or sar We have used it for three or four pacoid, we still do not have any specific tients who responded very well. I do therapy for these diseases. not believe that trypsin has any value. Paracentesis is useful in certain in Antibiotics should be used only for a stances, I have seen patients who, de specific purpose in specific diseases. spite diamox and steroids, maintain ele Now we come to steroids. I do not vated tension In these patients, if ten want to dwell too much on steroids for sion remains elevated for four or five I tunk everyone here is as well ac- However, days, we do a paracentesis. We do these quainted with them as I am. as an out-patient procedure in the clinic certain contraindications exist to steroids, and in the office. Radiation therapy is as shown in this table.

·65 NON-GRANULOMATOUS UVEITIS Spasm, and scopolamine relaxes their ac- chronic flare, but otherwise it is just a commodation and makes them much chroruc flare. It is like a man who has more comfortable I think that all we healed broken leg; he is fine but he neeel do is to treat the primary attack limps. If it dhesn't get better, give them sys In posterior liveitis, I think that we tennic steroids They do not need a foci should be a little cautious about giving of injection study. We are now freat steroids. If you suspect the presence of ing all of our acute cases with Depo- tuberculosis or toxoplasmosis, cover the Medrol; we give them scopolamine and patient with chemotherapy. This is an one sul conjunctival injection of Depo- important thing to do Use steroids only Sledrol; that holds them fine, If there is involvement of the macula or in administering systemic steroids over the papulla If there is a focus on the a long period of time, we must watch for periphery, I don't treat the patient; I tension changes In chronic anterior don't give him steroids I am accumuulatuveitis I would like to bring out just one ing a very impressive series of patients point; as a result of repeated attacks the who do very well and recover spontaneblood-aqueotts barrier in the aliary body ously with no treatment at all. Brcumes damaged and allows the passage So, in conclusion, I would like to say of a certain member of large molecules, that classification is still in doubt; I proteins which ordinarily would not be think an anatomical classification still is Scrind in the anterior chamber We the best one which we have today. have many patients who have flares but Pathogenesis still has to be worked out this is not something which requires although I think the hypersensitivity treatment; this flare is their natural state mechanism probably is the most impor- Suhen I see a flare in a patient who tant and most logical one in the causation !! nw has had many bouts of ureitis, 1 of uveitis. Diagnostic surveys in our exdon't even treat it, I just have them come perience are not too helpful, as I have IN clery three months and take a look saud Therapy, I believe, is still largely at them. These patients may develop an non-specific and we have to rely largely acute attack superinsposed upon this upon steroids ·ROBERT S. COLES acute liveitides. We give 12 c.c. (20 all worry on that score. But if you lemg.) as a subconjunctival injection in licve thc eye will have any useful functhe upper outer quadrant, and we find tion, I think it shoukl be spared, and that this has an effectiveness of from with ACTH and steroids there is much seven (lays to three weeks. Many uveitis greater opportunity to save the eye. As patients with moon facies, due to long a matter of fact, we liave had about four terni use of systemic steroids, liave been patients with sympathetic ophtalmia and controlled with Depo-Medrol used in this only one of them needed ACTH. way. The repository form is absorbech In viral diseases, such as herpes zoster, very slowly for a period of from two to Scheie claims he gets good results with three wechs and it is often so effective ACTH, I think any kind of systemic that systemic steroids are not required. steroid is adequate and that ACTH docs We have many non-English-speaking pa no more than a systemic steroid. In tients who find it difficult to understand herpes simplex, of course, you must not our instructions, nor can we rely upon use steroids. In Relicet's disease, even their takıg their medication as prescrib- though the literature says steroids are cd. By injecting Depo-Medrol, how not indicated, I must say that the only ever, we know the patient is getting the thing that has lielped my patients with proper meclication In many instances, this clisease is the steroids which they if a patient cannot tahe systemic ster have been receiving. In rheumatic disoids, we advocate the use of Depo- cases, there is no specific agent that we Medrol. It gives a lugh concentration know of which causes these diseases, so locally, without any systemic effects, and there again we go back to non-specific it lasts for some time methods. Maybe the internist is already In the treatment of sarcoid, dilation of treating the rheumatic patient witlı ster. the pupils is most important since syne- oids, and frequently this will amcliorato chiae form so rapidly, and there is very tlie uveitis a bit, so that all we need do little we can do about it if they do form. is to give lum local treatment. However, On the other hand, I think it is a good if the patient develops band shaped calidea to gonioscope these patients regu cification of the cornca, I think the vi. larly because many of them have narrow sion can be improved by the use of soangles and we want to mahe sure we are dium versenate to chelate away the calnot crowding the iris into the angle, thus ciuin This has a remarkable effcct, the causing a rim of peripheral anterior calcium just disapepars. \nkylosing synechiac. We are between the devil spondylitis is best treated with steroids. and the deep blue sea I tluk sarcoid Most treatment of uveitis must be nonpaticnts should take systemic steroids or specific, since, unfortunately, the etiol. conjunctival Depo-) Iedrol ininiecliately. ogy often is not clear. I don't believe topical steroids are enough In resumé, in anterior uveitis give the to carry them through the acute pliase; patients focal medication, such as any one they must be watched closely and have of the drop forins of hydrocortisone, and frequent gonioscopic examinations. dilate them with scopolamine. Once they The treatment of sympathetic oplıthal. are dilated, you don't liave to worry mia is quite obvious; if it is an irritable about them anymore if they are on sterfluid eye, cnucleate it at once and halt oids. They have a great deal of ciliary ·EDITOR'S COLUMN KENNETJI L. CRAFT, M. D. Indianapolis, Indiana This is Volume 1, Number 1, of the you like it. We hope that you will let Transactions of the American Society of us know what you think of it and if you Ojihthalmologic and Otolaryngologic Al- approve of the general idea of an offilergy The recommendation of the Coun- cial publication for the Society. We are cil for the establishment of this maga aware of the inadequacies of this first zine was due to several reasons. In re- edition and we hope that you will help cent years there has been a growing dis us improve future issues by sending in satisfaction with the time at which the your suggestions and constructive critsannual meeting was held and an increase cism. Would you like to see other fea- Please ing demand by the membership at large tures added, and if so, what? that the Society return to its original give us your honest opinions; we like totecting time, ie., upon the day imme sweet smelling bouquets but for this purdiately preceding the convention of the pose we prefer the real low-down. So Imerican Academy of Ophthalmology don't hold your punches. and Otolaryngology. Several years ago, A feature of the 1960 meeting was the as an inducement to persuade our Al- Instructional Course, a new departure in Icrgy Society to hold its meeting on the our annual meetings Excerpts from the last day of the Academy week, the Acad- experts at the eight Conference Tables emy offered to publish the scientific pa may be found on other pages of this volpers of the Allergy Society program in This part of the program proved the Transactions of the American Acade so popular that there have been many emy. In changing back to its original requests that the Instructional Course be time of meeting, our Society could not repeated in 1961. Plans already are unexpect this arrangement to continue Alder way to enlarge this phase of the gen- “), there were business matters and other eral program by addin more instructors Txistant items of interest which did and more subjects and by allotting more not reach the Society members through time for the presentation of these courses, the niedium of the Academy Transac- What subjects would YOU like to hear tiuns. In addition, it usually was many discussed? nonins, often more than a whole year, The general approval of the changes alter the meeting before op program made in the time of holding the meeting papers were published Another M and in the type of program presented qurtant factor was that many of the 41 was indicated by the large attendance at feres Society members do not belong 10 the Chicago meeting. The total registrathe Imcrican Acarjemy and thus do not tion of members and guests was the larg- Tre its pritlications et of recent years. Amil so was born the Transactions of The facistses of the Sherman Hotel the Imerican Society of Ophthalmologie prosed to be adequate in every respect an] (tolaryngologs Illergy. We hope for the feeling and for the annual ban- 67 time ·PRESIDENT'S PAGE LELAND H. PREWITT, V. D. Ottumwa, Iowa recognize and treat the many allergic phenomena that occur in cveryday prac tice, tlie American Society of Ophthalmologic and Otolaryngologic Allergy las arranged to give a series of round table instructional courses in the morning program. Various allergy subjects with two instructors at cach table will be arranged, where personal problems, niew information, lab tecliniques, and treatment will be discussell. Our desire is to make these courses so practical that you can The American Society of Ophthalmo- return home and practice modern, up-tologic and Otolaryngologic Allergy most ciate allergic otolaryngology and ophthalcordially invites its members and the mology. Coffee breaks will give you a members of the Anierican Academy of chance to renew old friendships and Ophthalmology and Otolaryngology to make new contacts. attend the twenty-first meeting of the The afternoon will be devoted to pa- Society at the Sherman Hotel in Chi pets of practical and scientific interest cago on Saturday, October 7, 1961, Our presented by the best qualified speakers endeavor to cooperate with the Academy on such subjects as repository therapy, by changing our meeting time from Sat- enzyniatic therapy, ocular allergy and urdays prior to the Academy to Friday psychosomatic allergy If you wish a at the conclusion of the mecting, ended particular subject discussed, hindly send in complete failure after several years' 111 your request. trial. Numerous attempts to get an eve Jake your reservations now, tell your ning earlier in the week were unsuccess friends, invite the interns and younger ful. Lack of time because of the nu men and let's make this year's meeting merous meetings available today, and one of the niost profitable and entertaincomplete mental saturation and fatigue, ing we have had to date. Allergy is on forced the change back to our original the move, let's heep up with it and its pre-convention Saturday date. modern concepts by attending and taking To satisfy a long desired need for the an active part in the meeting. You are ophthalmologist and otolaryngologist to njost cordially welcome. 66 ·BUSINESS SESSION The annual business meeting was call- the Society, except by payment of the ed to order by President Walter E. subscription fee set by the Council. The classification of Life Member shall be Owen bestowed by vote of the Society upon Dr. Owen announced that since the minutes of the last regular meeting had recommendation by the Council. been sent to each member of the Society, (2) It was recommended that a letter be written by the Society Secretary it would not le necessary to read these to the American Medical Association, minutes at the present meeting It was mured and passed that the minutes of with a copy to the Secretary of the Amern the last meeting (1959), containing also ican Otorhinologic Society for Plastic the Treasurer's report, be accepted as Surgery, such letter to state that the Juullished in the Secretary-Treasurer's American Society of Ophthalmologic and recent fetter to the membership Otolaryngologic Allergy disapproves of the undesirable publicity practices of the REPORT OF COUNCIL American Board of Plastic Surgery Dr Sam F. Sanders, speaking for the which has sponsored certain misleading Council, reported that the following mat- articles appearing in some lay magazines fors questamıng to the welfare of the So in regard to qualifications for the pracciety had been carefully considered at tice of plastic surgery. the meeting of the Council, held on Oc (3) The Council recommended that texer 7, 1900, and had been recommend the proceedings of the annual meetings el for adoption and passage by the so of the Society be published in a magaciety zine to be known as the Transactions of In amendment to the By-Laws the American Society of Ophthalmocinering a proposed new type of mem- logic and Otolaryngologic Allergy, and bership to be added to the present memthat a copy be sent to each member. It Tership classification, was recommended. was further recommended that Dr. Ken- The new classification shall be hnown as neth L. Craft, of Indianapolis, be ap 1ale lembers and shall consist of those pointed as Editor of the Transactions. texts of the Society who have Teret (4) It was recommended that Doc. from the practice of medicine or who tors De Stio and Craft be appointed as lave fx en members of the Society in a commuttee to arrange for the manufoxx1 standing for a period of twenty- facture of a distifictie plaque to be pre- 11€ years, and who shall apply to the sented to the fast-Presidents of the So- Commeil for transfer to the Life Member ciety, and to each President upon his reclassification. Lale Members shall have tirement from office. (This plaque is che guru leke of participating mall meet to take the place of the cuff links which ings and activities of the Society and currently are presented to each President shall mort le repuired to pay dues, but at the end of his term of office.) may tuot hull office nor hale yoting (5) The Council recommended that potesileges They shall not receive the the Secretary of the Sexciety notify the Hulletin or any official publicaties of proper officials of the American Acad- 69 ·68 quet. This party was held in the at- pearing in this nagazine. Juich of the tractive Skyline Terrace Room where the expense of the publication of the Transview of the city, with its skyline and actions thrus is underwritten by these beautiful Lake Michigan in the back firms. Let us express our appreciation ground, reminds one of the Top of the of this support by giving the detail men Mark in San Francisco. An excellent representing these companies a <dinner was preceded by a lavish cocktail welcome, at least, when they come calling. party furnished through the courtesy of A vote of thanks and a tip of the lat Spencer Laboratories and llampole Lab to Rovin' Joe llampsey, the official pho oratories, in collaboration as hosts. Ar- tograplier at the 1960 meeting. Joc not rangements have already been made to only helped moderate one of thic Table return to the Sherman for the 1961 met Conferences but also circulated about the ing, wiuch will be held on Saturday, Oc. other Tables, taking pictures for the tober 7. Platı now to attend. Transactions instead of harvesting the Please note the advertisements ap fast dropping pearls.

·71 BUSINESS SESSION CONVILTTEES FOR 1961 Glenn J. Greenwood Valter T. Hotchkiss The following committee appointments have been announced by President Prew- NOVINATING PROGRAM Kenneth L. Craft, Chairman Bernard 11, Barrett William H Evans Herbert P Harkins AUDITING Section on Ololaryngology Trench K Hansel, Chairman Linden J. Wallner Flerbert P. Harkins Sylvester C Missal Section on Ophthalmology Leland H Prewitt, Chaiman Freclerich H. Theodore Robert S Coles Joseph W. Hampsey, Chairman William P. Hofmann George N. Jewell orge W. Ryall LIAISON INSTRUCTION IL COURSE Victor R. Alfaro, Chairman Edward W. Harris Edley H Jones L. 2. Pang ENTERTAINMENT Kenneth L Craft, Chairman Walter [ Owen Sam H Sanciers PUBLICITY Sam Il Sanders, Chairman Jach R Anderson Bernard M. Barrett, Chairman Michael H. Barone Kelvin A. Kasper Lawrence S. Crispell ·70 BUSINESS SESSION emy of Ophthalmology and Otolaryngol (7) Tlie Council reconunended the ogy that the American Society of Oph. election of the following officers to serve thralnologic and Otolaryngologic Allergy for the coming fiscal year: strongly reconimends that more instruction courses in Allergy and Medical Oto- President..... Leland H. Prewitt, NI, D. laryngology and Ophthalmology be of- Ottumwa, Iowa fered to the members of the Acadeny. President-Elect.. Edley 11 Jones, M. D. Vicksburg, Mississippi (6) Applicants for membership in Vice-President.. the Society were recommended for elec- .... Lawrence S Crispell, M. D. tion as follows: Joplin, Missouri FELLOIVS Secretary-Treasurer, Daniel S. De Stio, M, D. Barratt, Wm. E., M. D., 30 South Park Pittsburgh, Pennsylvania Place, Painesville, Ohio Bruce, Robert G., M. D, 8130 Santa (8) The Council recommended the Clara Drive, Dallas 18, Texas election of the following Council members to serve for a period of three years: Coles, Robert S,MD, 125 East 72nd Street, New York, N. Y. lichael H. Baronc, M D., Buffalo, Draper, W Leonardi, M. D., 540 Ilerman New York Professional Bldg, Houstou 25. Texas Kenneth L. Craft, M. D., Indianapolis, Indiana Droege, Fred D, M D., 207 Medical Arts Blug., Sarasota, Florida Linden J. Wallner, M D, Chicago, Illisois Grubor, George P., M. D, 25 East Washington Street, Chicago 2, Illinois The above recommendations made by Kuhn, Arthur J, N, D, 112 Rimlach the Council were adopted by vote of Street, Hammond, Indiana members present at the annual business Maher, Joseph J, MD, 30 South Park meeting I'lacc, Painesville, Ohio President Owen presented the gavel of office to incoming I'resident Lcland Olson, Burton G, M D., McCannal II I'rewitt who congratulated Dr. Owen Clinic, Minot, North Dakota upon the success of fres year's adminis- Warren, Claude M., Jr., MD, 1720 tration, culminating in the present rcct- Springhill Avenue, Mobile, Alabama ing. Dr. Prewitt appealed to thic niem- Witchell, Ira S, JD, 2021 Grand kership for lielp and suggestions rela- Concourse, Bronx 53, Yew York tive to tlic program for next year's mect- ASSOCIATES ing, and closecl liis talk by calling atten. tion to the great potential influence pros- Chew, William, M. D., 1027 West Jlain sessed by this Society in promoting fur- Street, Leesburg, Virginia thier study and rescarch in tlic ficid of Higgins, Eugene 11., M. D., 3433 Wis- opithalmologic and otolaryngologic alconsin Avenue, N. , Washington, lergy. ADJOURNMENT . D. C.

·BUSINESS SESSION COMMITTCES FOR 1961 Glenn Greenwood Walter T. Hotchkiss The following coxnmittee appointments hace been announced by President Prew. đt: NoMIX ITING Kenneth L Craft, Chairman Bernard Barrett William H. Evans Herbert P. Harkins PROGRAMI Section on Otolaryngology French k Hansel, Chairman Linden ) Vallner llerliert P Harkins Sylvester C Niissal Schon ox Ophthalmology Leland It Prewitt, Chairman Frederich Theodore Robert S Coles AUDITING Joseph W. Hampsey, Chairman W???ram P. Hofmann George W. Jewell George IV. Ryall Liaison INSTRL CTIONAL COURSE Victor R Alfaro, Chairman Edward IV Harris Edley H. Jones LQ Pang Kenneth L Craft, Chairman Walter E Ossen Sam 1! Sanders ENTERTAINMENT 'BLICITY Sam Il Sanders, Chairman Jack R Inderson Bernard A. Barrett, Chairman Michael H Barone Kelvin A. Kasper Lawrence S. Crispeli ·70 BUSINESS SESSION . cmy of Ophithalmology and Otolaryngol (7) The Council recommended the ogy that thic American Society of Oph- election of the following officers to serve thalmologic and Otolaryngologic Allergy for the conting fiscal year: strongly recommends that more instruction courses in Allergy and Nicclical Oto- Presiclent. , ... Leland H. I'rewitt, M. D. laryngology and Ophthalmology be of- Oittinwa, lowa fcred to the memicrs of the Academy. President-Ilect, Edley 11. Jones, M, D. Vichsburg, Mississippi (6) Applicants for membership in Vice-President. the Society were recommended for elec- .Lawrence S. Crispell, M. ). tion as follows: Joplin, Missouri FELLOWS Secretary-Treasurer.. Daniel S. De Stio, .J. D). Barratt, Wm. E, M, D., 30 South Park Pittsburghi, l'cmylvania Place, Painesville, Ohio Bruce, Robert G., M. D., 8130 Santa (8) The Council recommended the Clara Drive, Dallas 18, Texas clection of the following Council men- Coics, Robert S, M. D, 125 East 72170 bers to serve for a period of three years: Strect, New York, N. Y. Michael 11. Barone, M. D., Buffalo, Draper, W. Leonard, MI. N., 540 Ilcrman New York Professional Bldg., llouston 25, Texas Kenneth L. Craft, M. 1)., Indianapolis, Droogc, Fred D, ML D., 207 Medical Isxliana Arts Bldg, Sarasota, Florida Limen J. Wallner, M. D., Chicago, Illi- Guubor, George P., 11, D, 25 East Washiington Street, Chicago 2, Illinois The above recommendations made liy Kulm, Arthur J., M. D., 112 Rimbach the Council werc adopted ly vote of the Strect, IIammond, Indiana members present at the annual business Malier, Joseph J., M. D., 30 South Park meeting. l'ace, Painesville, Ohio l'resident Owen presented the gavel Olson, Burton G, M. D., McCannal of office to incoming President Lclan 11. I'rewitt who congratulated Dr. Owen Clinic, Mlinot, North Dakota Warren, Claudic M, Jr, M. D, 1720 aspon the success of fis year's administration, culnunating in the present mect- Springhill Avenue, Mobile, Alabama mg. Dr l'rewitt appealed to the mem- Witchell, Ira S, M. D, 2021 Grand bership for help and suggestions rela- Concourse, Bronx 53, New York tive to the program for next year's mect- ASSOCIATES ing, and closed liis talk by calling attention to the great potential influence pos- Clicw, \Villiam, M, D., 1027 Il'est Main sessed by this Society in promoting fur- Strect, Lecsburg, Virginia ther study and research in the field of Iliggins, Eugene IV., V. 1., 3433 Wis- oplıthalmologic and otolaryngologic alconsin Avenue, N W., Washington, lergy. D. C. ADJOURNAIENT 11015

·BUSINESS SESSION
73
Clarysse, ), J., Bruges, Belgium
Fitch, Frank W., Chicago, Ill.
Greirer, W. R., Seattle, Wash
Tlalpin, Lawrence J., Cedar Rapids, Iowa
Klestad, W.D., Fall River, Mass
McVahon, 8 T., Denver, Colo.
Voffitt, Dwight D, Philadelphia, Pa.
Powers, W.11., Oak Park, III.
Tyson, J. M., Dulois, Pa
Walker, Jack, Sandusky, Ohio
Walker, James E., Sandusky, Ohio
Webb, James J., Blytheville, Ark
Your name should be in this list in 1961.
TIME-Saturday, October 7.
PLACE-Sherman Hotel, Chicago, Ill
OCCASION_Annual meeting of the
American Society of Ophthalmologic
and Otolaryngologic Allergy.
PLAN NOW TO BE THERE

·REGISTRATION AT CHICAGO Following is a list of those who at- Hill, Howard E., Muncie, Ind. tended the 1960 mecting at the Sherman Higgins, Eugene W., Washington, D. C. Hotel: Hitch, Donald A., Hamilton, Ontario, Canada MEMBERS Hope-Gill, Donald, Niagara Falls, On- Alfaro, Victor R., Washington, D. C. tario, Canada Anderson, Edwin R., Warren, Pa. Ilopkins, Julius H., Petersburg, Va Barone, Michael H., Buffalo, N. Y. Jewell, George M., Kokono, Ind. Barnet, E. G., Phoenix, Ariz. Jones, Edley H., Vickslurs, Miss. Barrett, Bernard M., Pensacola, Fla. Kudolla, Charles R., Casper, Wyo. Barry, William H., Kansas City, Mo. Layton, Rex G., Lewistown, Idaho Baxter, Edward J., Sandusky, Ohio Loomis, George L., Winona, Minn. Bergin, Joseph H., Alma, Mich. Lownik, Felix J., Freeport, I. Brickley, Daniel W., Jr., Marion, Ohio MicComiskey, Arthur J., New Orleans, La, Brown, Charles W., San Diego, Calif. Brown, Samuel P., Moline, Illinois Mazique, Douglas W., Chicago, III. Budetti, Joseph A., Wichita, Kansas Missal, S. C., Cleveland, Ohio O'Toole, Francis A., Clinton, Mass. Clements, Ralph M., Tuscaloosa, Ala. Craft, Kenneth L... Indianapolis, Ind Owen, Walter E., Peoria, I11. Crispell, Lawrence S., Joplin, Mo. Owsley, Guy A., Hartford City, Ind. Prewitt, Leland H., Ottumwa, Iowa Coles, Robert S., New York, N. Y. Cruthirds, Archie E., Phoenix, Ariz. Raffaele, Frank J., New York, N. Y. Davol, Rector T., Greenwich, Conn. Randolph, Theron, Chicago, Il. De Stio, Daniel S., Pittsburgh, Pa. Ringer, A. L., Springfield, Ohio Doiowitz, David A., Salt Lake City, litalı Ross, Ervin S., Cincinnati, Olio Donnell, Herbert, Waxahachie, Texas Ruddy, Lorenz IV., Sacramento, Calif. Droege, Fred D., Sarasota, Fla. Ryall, George W., Shaker Heights, Ohio Sanders, Sam H., Memphis, Tenn. Duboe, Sidney H., Los Angeles, Calif. Evans, William H., Youngstown, Ohio Schoetker, George H., Clearwater, Fla. Smith, Thomas L., Lorain, Ohio Flatley, Robert E., Moline, III. Smith, Thomas T., Omaha, Neb. Gerston, John, Columbus, Ohio Sorenson, Elmer M., Red Oak, Iowa Gill, Earl K., Corpus Christie, Texas Goldman, Ilerbert B., Rockville Centre, Thel, flenry C. Aliquippa, Pn. Stahl, Richard 11.. Cuyahoga Falls, Olio N. Y. Trunzo, Thomas H. Latrobc, l'1. Gomillion, Jesse D., Midland, Texas Wallace, Thomas II, Clearwater, Fla. Griesman, Bruno L., New York, N. Y. Wallner, Linden J. Chicago, Ill. Hall, Albert W., Berwyn, Ill. Warren, Claude M., Mobile, Ala. Hansel, French K., St. Louis, Mo. Welton, W, D., Jr., Dayton, Ohio Harkins, Herbert P., Philadelphia, la. GUESTS Hampsey, Joseph W., Pittsburgh, Pa. Hcetderks, Dewey R., Grand Rapids, Illison, A. M., Alice, Texas Mich. Christensen, E., Lexington, Ky. 72

·BUSINESS SESSION
73
Clarysse. J. M., Bruges, Lelgium
Fich, Frank W., Chicago, Ill.
Greirer,',R., Seattle, Wash
Halpin, L2#Tence J.. Cedar Rapids, Iowa
Klestad, W. D., Fall River, Mass
Jc Wahon, P. T., Denver, Colo.
Moffitt, Dwight D., Philadelphia, Pa.
l'oners, R, H., Cain
Tyson, J. M., DuBo
Walker, Jack, Sandi
Walker, James E., Sandusky, Ohio
Webb, James J., Blytheville, Ark.
Your naile should be in this list in 1961.
TIME-Saturday, October 7.
PLACE-Sherman Hotel, Chicago, Ill.
OCCASION-Annual meeting of the
American Society of Ophthalmolomic
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