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diff --git a/40287-0.txt b/40287-0.txt new file mode 100644 index 0000000..addd58f --- /dev/null +++ b/40287-0.txt @@ -0,0 +1,2502 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 40287 *** + + THE TREATMENT + OF HAY FEVER + + BY ROSIN-WEED, ICHTHYOL AND FARADIC + ELECTRICITY, WITH A DISCUSSION OF THE OLD + THEORY OF GOUT AND THE NEW + THEORY OF ANAPHYLAXIS + + BY + + GEORGE FREDERICK LAIDLAW, M.D. + + Consulting Physician to Yonkers Homoeopathic Hospital; to St. Mary's + Hospital, Passaic; and to the Ann Mary Memorial Hospital, Spring + Lake, New Jersey; Consulting Physician to Cumberland Street + Hospital, Brooklyn, Department of Public Charities + + Formerly Professor of Practice of Medicine in the New York + Homoeopathic Medical College; formerly Visiting Physician to Flower + Hospital; to Hahnemann Hospital and to the Metropolitan Hospital, + Blackwells Island, Department of Public Charities, New York + + BOERICKE & RUNYON + NEW YORK + 1917 + + + + + COPYRIGHT, 1917, BY + BOERICKE & RUNYON + + + + +PREFACE + + +The essentials of this book, rosin-weed, ichthyol, and faradism, were +announced at the Baltimore meeting of the American Institute of +Homoeopathy, in June, 1916, and published simultaneously in the _New +England Medical Gazette_ and in the _Journal of the American Institute +of Homoeopathy_ in December, 1916. They were presented also at the New +York City branch of the United States Hay Fever Association in July, +1916; at the annual meeting of the same Association at Bethlehem, New +Hampshire, in August, 1916; and rather widely printed in the public +press of New York and Boston in the summer of 1916. + +As a suggestion to those who may wish to follow the subject of hay +fever in its recent interesting developments, chapters have been added +on the old conception of gout, the new theory of anaphylaxis and +treatment by diet, by pollen extracts and by bacterial vaccines. + + + + +CONTENTS + + PAGE + I. The Diagnosis 9 + II. Rosin-weed 14 + III. Ichthyol and the Point in the Naso-pharynx + that Controls the Symptoms 17 + IV. Menthol and Eucalyptol 20 + V. The Faradic Current and Other Forms + of Electricity 27 + VI. Hay Fever as Urticaria 38 + VII. Dr. Gueneau de Mussy. Hay Fever as + Urticaria Again 44 + VIII. Hay Fever as Gout 51 + IX. The Uric Acid Theory 66 + X. Hay Fever as Anaphylaxis 76 + XI. Immunizing with Pollen Extracts 91 + XII. The Bacterial Vaccines 108 + XIII. Diet 113 + XIV. Rosin-weed Again. Historical and + Pharmacological 123 + + + + +THE TREATMENT OF HAY FEVER + + + + +CHAPTER I + +_THE DIAGNOSIS_ + + +Under the name "hay fever" I include rose-cold and the so-called +hyperæsthetic catarrh or vaso-motor rhinitis, all characterized by +intense itching of the eyes, nose, and throat, free discharge, sometimes +asthma, the attacks being precipitated by strong odors, dust, or pollen. +There are many forms of the disease, some occurring in May or June, some +as early as March, before the budding of vegetation, some even in the +winter; but the large majority of cases occur in August, coincident with +the flowering of late summer vegetation, notably the rag-weed and +golden-rod. It is not so well known that the California privet, so +widely used in hedges and parks, aggravates many patients, especially in +June and July, when the scent of the flowers is strong. Others are +irritated instantly by the odor of crude oil that is spread so freely +on the roads in summer, by metal-dust, and by the cinders of a railway +trip. Some patients are sensitive to one irritant, some to many +irritants. I knew one man whose itching of the eyes began in March, nose +and throat following in April and May, cough in July and August, who was +sensitive to each and all of these irritants from March to October every +year for thirty years. + +If we follow the modern tendency and classify the cases according to the +specific irritant, we shall have an endless number of varieties +according to the endless number of possible irritants; and where will +you classify the man who is subject to them all? In the present state of +our knowledge, it seems better to regard the sensitiveness to irritants +as the characteristic of these cases and to think of them as different +forms of the same disease. In most text-books this idea is expressed by +the terms _hyperæsthetic catarrh_ and _vaso-motor rhinitis_; but there +are serious pathological objections to the terms _catarrh_ and +_rhinitis_. These objections and the reasons for regarding the lesion as +an angioneurotic oedema are discussed in Chapter VI, on Hay Fever as +Urticaria, to which the reader is referred. + +An additional reason for regarding all these varieties as superficially +differing forms of the same disease is the fact that all of them are +curable by the same methods. I am aware of the danger of error in this +argument, the persuasive but misleading _Analogieschluss_, and would not +advance it too strongly. However, for all practical purposes except the +vaccine treatment, described in Chapter XII, all these hyperæsthetic +cases may be regarded as varieties of the same disease. + +With a patient suffering from hay fever, as with a patient suffering +from any other disease, the first thing to do is to take the history and +make an examination. Usually, the nature of the case will be clear from +the history, but it is a mistake to rest here without looking into the +nose and throat. In the nose, you may find anything from a polyp to a +shoe-button, any of which may require mechanical removal before you will +make any progress with your medicines, no matter how well selected. +Usually, you will find nothing but a swelling of the mucous membrane of +the turbinates with free discharge. If you are an adept at examining the +nose, you will probably search for the sensitive areas, touching of +which causes a spasm of sneezing. These may be found anywhere in the +nose, but most commonly at the anterior and posterior ends of the middle +and inferior turbinated bones. I apply ichthyol to the naso-pharynx to +test the sensitive area described in Chapter III. + +What constitutes a gross lesion requiring surgical removal? Competent +men differ widely and the practice of the same man has differed widely +at different stages of his career. For a time there was enthusiastic +cutting of septal spurs and burning of redundant mucosa and cauterizing +of sensitive areas. I think that the relation of the nose specialist to +hay fever is similar to the relation of the abdominal surgeon to +neurasthenics. The more experienced he becomes, the more he advises +letting them alone or using gentle measures. Distinct polyps should be +removed. + +Having finished the examination and found no gross lesion requiring +surgical removal, the treatment must be decided. The easiest plan for +both patient and physician is to give rosin-weed, as described in +Chapter II. + +The most painful for the patient but often effective in severe cases is +the application of ichthyol, as described in Chapter III. + +If the patient is systematic and will attend to it, the ichthyol may be +replaced by the _frequent_ spraying with menthol and eucalyptol, as +described in Chapter IV. + +The best treatment of all, but that which takes the most time of both +patient and physician, is the use of electricity, as described in +Chapter V. + +Consider the possible importance of diet in the case, as described in +Chapter XIII. + +Finally, ponder on the nature of hay fever, as discussed in Chapters VI +to X, and the advisability of using vaccines or pollen extracts, and you +will have done your whole duty by your patient and by your art. + + + + +CHAPTER II + +_ROSIN-WEED_ + + +For many years the fluid extract of rosin-weed has been known in my +family as a remedy for rose-cold and hay fever. This use of it was +discovered by my father, Dr. Alexander H. Laidlaw, in the epizoötic days +of 1872, when horses were dying by the thousands all over the United +States and Canada. Though he knew it first as a horse medicine, its use +seems to be forgotten in veterinary practice, for I find no mention of +it in available veterinary books, old or new. + +In my father's practice this remedy acquired considerable fame, and I +still receive a letter or two every summer from distant cities from some +one who has heard of the miraculous medicine. For many years it was his +intention to give this remedy to the world in proper form, supported by +competent testimony; but, in a busy life, with many projects +unfulfilled, this was never done. During my own professional life I have +been interested in many things that seemed more important than hay +fever and have not heretofore taken up the matter of publishing our +experiences with the drug. Realizing that there were many hay fever +victims both in this country and in Europe who might just as well be +getting the relief that this drug would give them if they only knew +about it, and having no desire to profit by my possession of the secret +of this remedy, I made the announcement last summer, first to the +American Institute of Homoeopathy and next to the United States Hay +Fever Association. I announced it first to my old society, the +Institute, believing that my friends there, who have known me many +years, would credit my statements as made in good faith and give the +drug a fair trial. + +=The Dose.= Beginning ten days before the expected attack, give ten drops +of the fluid extract of rosin-weed in a little water four times daily, +after meals and on retiring. To children, give five drops. If the +symptoms of hay fever appear, increase the dose to twenty and even +thirty drops and continue this dose through the entire hay fever +season. + +It is better to begin ten days before the expected attack, for, in hay +fever, as in all periodic diseases, prevention is better than cure, +requires smaller doses, and is more certain. However, few patients are +wise enough to anticipate trouble. Most patients apply for treatment +when, literally, the disease is in full blast, and most of my +observations have been made on the latter class. In case the disease has +already begun, start with the same dose, ten drops. If not relieved in +three days, increase the dose by five drops every third day up to thirty +drops. If the symptoms should be relieved by the smaller dose, it is +unnecessary to increase it. + +=Cure Or Palliation?= In regard to the permanence of the cure, most +patients require it for several seasons. Some need it every season for +many years. A few are permanently cured in one season. + +For further information about the plant, rosin weed, its preparation and +use in medicine, the reader is referred to Chapter XIV. + + + + +CHAPTER III + +_ICHTHYOL AND THE POINT IN THE NASO-PHARYNX THAT CONTROLS THE SYMPTOMS_ + + +While the use of rosin-weed was discovered by my father, the value of +ichthyol in the treatment of hay fever and the point in the naso-pharynx +that controls the symptoms are discoveries of my own or, at least, I +fondly think so. In current medical literature, I find no reference to +it. In Merck's _History and Preparation of Ichthyol_, a summary of its +use to 1913, ichthyol is advised in hypertrophic and atrophic rhinitis, +but hay fever is not mentioned. Reference to recent books, as Coakley, +Ballenger, Ivins, Bosworth, Kyle, Grayson, show no knowledge of the use +of ichthyol in hay fever nor of the spot in the naso-pharynx that +controls the symptoms. + +The point of the matter is this. In hay fever, the itching and redness +of the eyes, nose, and throat are controlled from a sensitive point in +the naso-pharynx. Local applications to this point will relieve almost +instantly not only the itching of the throat but also the itching of the +eyes and nose and all symptoms of the disease. In some cases such relief +carried out for several seasons makes permanent cures. + +My knowledge of it came about in this wise. At about the age of sixteen +I developed a rose-cold that began in June and extended into September. +A few years later it began in April and lasted until October. By one of +those ironical tricks that fate plays on the great ones of the earth, +rosin-weed, the family remedy that cured everybody else, gave me only +partial relief. It is unnecessary to follow in detail the various +experiments made. This was long before the days of Dunbar's pollantin, +Holbrook Curtis' ambrosia, adrenalin, and the modern vaccines. I did not +think cocaine a safe drug and never used it, preferring the hay fever to +the cocaine habit. About this time ichthyol was introduced by Merck for +the treatment of catarrh of all mucous membranes and I found that +ichthyol, used in a certain manner, relieved the symptoms completely. On +swabbing the naso-pharynx with pure ichthyol, there was a severe +burning sensation for a minute or so, but, when the burning subsided, +there was great relief, not only of the itching throat but also of the +itching of the eyes and nose. That is, in the customary swabbing of the +naso-pharynx, we touch a point that controls the whole group of symptoms +of the eyes, nose, and throat. + +In those days the laryngeal and pharyngeal tonsils were very much to the +fore in medical discussions, and at first I thought that this point was +probably the pharyngeal tonsil of Luschka. However, judging from the +location of the most severe burning, the controlling point is rather on +the upper surface of the soft palate. The exact location of this point +is not of practical importance. If you swab each side of the +naso-pharynx with plenty of ichthyol, the reflex contraction of the +pharynx while the swab is in it will spread the ichthyol over the right +territory. + + + + +CHAPTER IV + +_MENTHOL AND EUCALYPTOL_ + + +The ichthyol treatment described in the last Chapter is very effective, +but it burns severely for a few minutes and, for this reason, some +patients will not endure it. With children, it is impossible. Another +disadvantage to the patient and, sometimes, to the doctor, too, is that +it requires the patient to come to the doctor every day for the +application, though Dr. Hollister tells me that he had one patient who +learned to apply the ichthyol to her own naso-pharynx and, what is more +wonderful still, kept up the treatment long enough to get well. In +recent years I have hit on a treatment that is more comfortable than +ichthyol and in many cases equally effective, though a little slower in +giving relief. It can be carried out by the patient with little trouble +and requires no skill in handling nasal swabs, an important matter with +nervous patients and children. + +I have found that the ordinary solution of menthol and eucalyptol and +thymol in liquid albolene will relieve hay fever if applied to a certain +spot a certain number of times a day. At this point I can see the +reader's face assuming an expression of pained surprise. What is there +wonderful about that? Is there not a bottle of this solution on the +table of every doctor in the country and does not every modern textbook +on the Nose and Throat advise inhaling vapor of such a solution to +relieve hay fever? True. Note that I did not say that simply spraying +this solution in the nose and throat will cure hay fever. I said that it +must be applied to a certain spot a certain number of times a day. It is +a case of the technique being more important than the remedy; for I have +no doubt that there are other medicines than ichthyol and menthol that +will relieve if put on the right spot. The reason that every doctor has +not discovered for himself the full value of this commonly used solution +is that he did not put it on the right spot and he did not use it often +enough. + +=The Right Spot=, as related in the chapter on Ichthyol, is either the +vault of the pharynx or the upper surface of the soft palate. + +=Frequency.= Once or twice a day is insignificant. It must be used every +hour or oftener when the symptoms are acute. Here I borrow an idea from +the dermatologist who learned long ago from Unna that when an ointment +rubbed on twice a day fails to cure an eczema, it may be cured by +keeping the same ointment constantly applied to the part, day and night. +The naso-pharynx of the hay fever patient requires the same continual +application of the cure and we come as near as possible to a continual +application by applying the solution every hour or two. + +Such frequent applications are impracticable as office treatments, but +must be carried on at home or at business by the patient or a member of +the family. If an expert hand is available to spray the naso-pharynx, +the tip of the atomizer should be pointed forward so that the spray is +directed into the posterior nares and the posterior surface of the soft +palate as well as the vault of the pharynx. An adroit patient may learn +to do this, but even an adroit patient, unfamiliar with the anatomy of +the throat, may spray only the front of the palate and fail to get the +solution correctly applied. To avoid these mistakes and insure the oil +getting on the right spot, the patient should be taught the following +simple technique. + +=Method of Application.= Taking an ordinary atomizer full of the oil, the +patient lies on the back with the head low or on one flat pillow. He +must be able to breathe freely through the nostril to be treated. +Usually, one side of the nose is free and he begins with that side, +inhaling the oily spray freely. He then remains lying on the back with +the head low while the oil runs backward into the naso-pharynx, +especially on the upper surface of the soft palate, where it burns a +little but not nearly as much as ichthyol. After two minutes or so, the +other side must be treated, but it must first be opened up so that the +patient can breathe freely through it. This is done by turning on one +side so that the stuffy side is upper-most. In a few minutes this side +will open up and the spray can be inhaled through it freely back into +the throat. To be thorough, the patient treats each side several times. +For the first few days the treatment should be carried out every hour or +so. After a few days or a week mild cases get perfect relief and even +severe cases may drop to four treatments daily. Such a method is far +safer than cocaine, which should never be put in the hands of the +patient for any purpose whatever. + +For obstinate cases ichthyol remains the most effective of the local +applications. With those adults who can learn to spray the naso-pharynx +and who are heroic enough to bear the sharp burning for a few minutes +for the sake of ultimate relief, I mix one-tenth ichthyol with the +albolene spray solution. Ichthyol leaves the throat raw and +uncomfortable for a few minutes. For this reason it should not be used +as frequently as the albolene solution. + +Ichthyol does not mix well with the albolene, but precipitates quickly. +As it does not mix readily by shaking, the mixture must be stirred +before using. The manufacturers, McKesson and Robbins, were good enough +to experiment in their laboratory with mixtures of ichthyol and +albolene. They report that they were unable to make a satisfactory +combination and that "the only way to get a permanent mixture of the two +would be by a process of emulsion, which would be too thick for spraying +purposes." + +It may be objected that my newly discovered point in the naso-pharynx is +merely the posterior end of the inferior turbinated bone, as described +by Mackenzie and Sajous and others long ago, and that the spraying of +the nasal passages simply benumbs the sensitive areas, anterior, middle, +and posterior, that are well known to rhinologists. This may be so. At +any rate, the method just described makes possible a treatment of these +areas in every case, though far from skilled assistance. The treatment +by cautery must always remain a treatment by the skilled specialist in +selected cases. Even if my sensitive spot in the pharynx is nothing new, +this method will at least place in the hands of thousands of hay fever +sufferers a simple method of relief, which thought there is more +satisfaction than in being reputed the discoverer of the resurrection +bone itself.[1] + +FOOTNOTES: + +[1] Throughout the middle ages, there was a firm belief in the existence +in the human body of an indestructible bone which was thought to be the +necessary nucleus of the resurrection body. With the revival of +dissection and the study of anatomy in the sixteenth century, many +anatomists searched for it eagerly but it was never found. + + + + +CHAPTER V + +_THE FARADIC CURRENT AND OTHER FORMS OF ELECTRICITY_ + + +The distinguished dermatologist, Dr. Duncan Bulkley, used to argue that +lupus erythematosus was a neurosis because he could cure it with +phosphorus and thought so highly of this _tour d'esprit_ that he made it +the subject of a Presidential Address. + +In the same way I might argue for my favorite theory that hay fever is a +neurosis, an angioneurotic oedema, because it is curable by +electricity; or that electricity cures hay fever because it is a +neurosis. These are examples of reasoning by analogy, found so +frequently in medical writings, so plausible and so perilous, leading +more often to error than to truth. So I will not argue the matter at +all, but simply state the result of my observation that faradic +electricity cures hay-fever. This electric treatment takes time and +trouble, but if both physician and patient are willing to take that +time and trouble, more permanent cures may be secured than by any other +treatment known to me. + +The use of electricity to cure hay fever is one of those bits of +therapeutic gold that lie long hidden in medical literature, are found +for a moment, and quickly lost again. Back in 1875 Beard and Rockwell +speak of two cases, one cured and the other relieved by descending +galvanism. In 1871, Neftel relieved a case of hay asthma by galvanizing +the vagus; but recent books know nothing of it. Monell, Bigelow, Massey, +and Bartholow know electricity about the nose only as a cautery. +Tousey's big book suggests the local application of the high frequency +current in hay fever, of which more anon at the end of this Chapter. + +It was from none of these that I stumbled on the fact that faradic +electricity would cure hay fever. In 1894 there appeared in New York a +patriarchal old gentleman with a queer idea that he could cure +pneumonia, tuberculosis of the lungs, and asthma by manipulation. He was +Dr. Orrick Metcalfe, of Natchez, Mississippi, a brother of Dr. John T. +Metcalfe, long one of the leading physicians of New York and Professor +of Medicine in the College of Physicians and Surgeons. Dr. Metcalfe +visited various hospitals, trying to interest physicians in his method, +demonstrating it freely to whomever would attend. He had a hard time +with the Philistines, who, for his brother's sake, would receive him +politely in their clinics, give him any number of charity patients to +work on, but seldom take the trouble to go personally and see what he +could do. He remained in New York for several years, during which time I +watched his work and was convinced that the principle was sound and the +results good. He made one striking cure of a patient of mine, an old +lady who for many years had a most obstinate cough that she had taken +all over the world, to Egypt and Switzerland and Colorado, without +relief. Dr. Metcalfe treated her by his manipulation in the winter of +1896, cured the cough so thoroughly that it has never returned, now +twenty years, as I know personally, because the old lady still consults +me for minor ills. Let me add this tribute to his memory, that there +never lived a more unselfish, practically benevolent physician than +Orrick Metcalfe, true to the noblest traditions of medicine, working +away at his hobby, not because it was profitable, which it was not, but +because he believed it to be true, constantly seeking with open mind to +improve his methods and to learn better ways. + +In regard to asthma and pneumonia and phthisis, his starting point was a +supposed stiffness or rigidity or lameness of the muscles of respiration +as the first step in the chain of events, and his effort was to limber +up at as early a time as possible this stiffness of the muscles. By +manipulating the muscles of the chest, neck, back, and abdomen, he would +find certain points that hurt or where the muscles were plainly tight or +stiff. Continuing the manipulation, he would have the patient take deep +breaths and try to cough. Often, when a certain spot was manipulated, +the patient would begin to cough without prompting. Such a spot was his +delight to find. He would continue to manipulate it, encouraging the +patient to cough and expectorate, holding that free expectoration +brought relief to the lesion. In pneumonia the expectoration was often +bloody, which pleased him mightily. I have seen him thus manipulate a +consumptive only a few hours after a hemorrhage and encourage him to +expectorate, in such direct contradiction to our usual policy of +absolute rest that I trembled inwardly for the patient. + +The possible relation between a muscle-bound chest and dyspnoea is +easily understood, but those of us who watched him could not see a clear +connection between the muscle-bound chest and pneumonia or phthisis. +However, in some later paper I will return to this part of Dr. +Metcalfe's work. To return to asthma, Dr. Metcalfe used to say that he +thought there was some way of relieving the tight muscles better than by +manipulation and regretted his unfamiliarity with electricity, which he +thought might be that better way. I gave him a spare battery that we had +around the office, but the old dog cannot easily learn new tricks and +the old doctor stuck to what he knew and had relied on for so many +years, his own fingers. He treated hay fever by manipulating the eyes, +nose, and both the inside and the outside of the throat, wherever the +itching appeared. + +About this time a patient applied for relief of attacks of asthma that +were brought on by inhaling dust. Every time he stirred the papers on +his desk--and being an artist, his desk was always dusty--he had a +disagreeable attack of asthma. Here was an opportunity to test the +Metcalfe theory of tight muscles. As I was much more familiar with the +faradic battery than with manipulation and it was more agreeable to use, +I placed one sponge on the back of the neck and with the other twitched +the muscles over the chest. To include all the respiratory muscles, I +exercised those of the neck and throat, the abdomen and back, as well as +the pectorals and the muscles about the scapulæ. Until one stops to +think of it, he does not realize the extent of the respiratory muscles. +Almost every muscle from the base of the skull to the brim of the pelvis +is directly concerned in respiration. + +With the faradic current just as with the manipulating fingers, there +are sore spots that the patient describes as bruised. They may be +extremely tender, though the patient is not aware of them until you +find them with the battery sponge or the finger. These sore spots may be +found anywhere over the chest or abdomen, but are particularly common at +the attachment of tendon to bones, the joints between the ribs and the +costal cartilages and the joints of the sternum, especially the joint +between the ensiform and the gladiolus. My idea was that if there were +any stiff or tight muscles restraining the action of the ribs, the +faradic exercise would limber them up. + +I treated this patient twice a week for three months and had the +satisfaction of seeing this asthmatic sensitiveness entirely cured; for +he has remained free from it ever since, now twenty years. This case +lead me to try the current on hay fever patients, passing the current +over the eyes and nose and sometimes inside of the throat, wherever +there was itching, just as Dr. Metcalfe had done with his manipulating +finger. If cough or asthma were present, I treated them as in the case +of the artist just described. + +=Treatment.= With one sponge on the nape of the neck or between the +scapulæ, pass the other sponge over the eyes, nose, and throat for ten +minutes. Use a gentle current, just enough for the patient to feel it +but not strong enough to cause pain. If cough or asthma are present, +twitch the respiratory muscles for ten minutes more, not forgetting that +the respiratory muscles include the abdominal muscles, those of the +whole length of the spine, and the cervical muscles all around, as well +as the pectorals and the scapular muscles. + +In regard to polarity, I do not think it makes any real difference +which pole is used in each place. I am old-fashioned enough to remember +when the polarity of a faradic battery was determined by holding two +sponges of equal size, one in each hand, turning the current on quite +strong and calling the stronger one the negative. In those days I +learned to use this "negative" pole for active treatments and this is +still my habit, putting the positive on the back and twitching the +muscles with the negative. If this exposition seems crude to the modern +electro-therapeutist, I can only say that I am not writing a treatise +on electro-physics, but relating the experiences in actual practice +over a period of nearly thirty years. The customs in which I was +brought up are good enough for me until I see real reason for changing +them. The electro-therapeutist is at liberty to turn the sponges around +and use them the other way if it appeals to him as more fitting. + +One of the most brilliant cures of hay fever with faradic electricity +was made by Dr. Thomas P. Birdsall, of Pawling, New York, about fifteen +years ago. The patient was a farmer's daughter of twenty years who had +lived all her life on a farm in Putnam County and had suffered many +years from hay fever. Dr. Birdsall used the faradic current from a small +portable battery three times a week, _while the patient remained on the +farm in the irritating environment_, and in one season made a cure that +has lasted to this day. + +=Other Forms of Electricity.= It is probable that all forms of electricity +will relieve or cure hay fever. I have used the faradic current because +it was the most convenient. It is still the most convenient current for +most physicians. The old reports are of the galvanic. Ballenger +recommends the leucodescent light. I have seen several reports of the +use of the high frequency current and Tousey devotes a short paragraph +to it, as follows: + +"The author suggests the use of a glass vacuum electrode insulated by a +double wall except at its extremity, which can be applied to all parts +of the nasal mucosa but especially to the inferior and middle turbinated +bones.... A similar application may be made to the outer surface of the +nose at the sides, halfway from the root to the tip." (Second Edition, +page 598.) + +From my experience with patients I doubt whether many of them would +submit to the intra-nasal spark. A theoretical objection to using any +form of high frequency or diathermia on the outside of the nose is that, +in some skins, frequent application of these currents causes a permanent +dilatation of the capillaries of the skin, resulting in permanent +redness. I tremble to think of the wrath of the fair lady whom you +should cure of the hay fever by endowing her with a permanently red +nose. I know that these currents are used on the face freely by +dermatologists and have often made a few applications to break up a +catarrhal cold; but I have seen cases enough of capillary dilatation and +its intractability to make me pause and choose for the nose and face the +surely safe faradic current rather than the more spectacular but risky +high-frequency. + + + + +CHAPTER VI + +_HAY FEVER AS URTICARIA_ + + +The fundamental error in all the literature on hay fever is the teaching +that the lesion is a peculiar kind of catarrhal inflammation; whereas it +is not an inflammation at all, catarrhal or any other kind. The symptoms +of hay fever _resemble_ those of catarrhal inflammation, but the +resemblance is only superficial. The resemblance is striking and must be +so to have deceived so many skilled observers, but it is only +superficial, nevertheless. + +When you see a patient with eyes red and swollen, overflowing with tears +and mucus, burning and sensitive to light, you say at once, catarrhal +conjunctivitis. In the nose the sneezing, the discharge, the obstructive +swelling suggest at once catarrhal rhinitis. But stop a moment. Did you +ever cure a catarrhal conjunctivitis or rhinitis in three minutes by +moving the patient from one room to another? You can do that with hay +fever. If you can remove the patient from the irritating atmosphere, +the swelling and redness will subside rapidly, the discharge cease, and +in five or ten minutes you would scarcely know by examining the patient +that there was anything the matter with his eyes and nose. By returning +him to the irritating atmosphere the symptoms will return instantly. By +removing him again, they will rapidly subside. I have watched this many +times in my own eyes. It was in watching the changes in my own eyes and +nose that I realized that this was no catarrhal inflammation but a much +more superficial lesion. + +Did you ever see a catarrhal conjunctivitis that acted in this way or a +cold in the head in which the patient could be cured and catch a fresh +cold twenty times a day? I think you never did. A true inflammation +requires time, a few hours, for its development, and when an +inflammatory exudate oozes into the meshes of the tissue, it requires +some days or at least some hours to be absorbed. This one point of rapid +appearance and rapid disappearance would forbid our calling the lesion +of hay fever a catarrhal inflammation. + +Next, associate this rapid appearance and disappearance with the chief +symptom of hay fever, the itching, the intolerable itching, of the eyes, +nose, and throat, itching that ceases at once on removal from the +irritating atmosphere and returns instantly when the irritating +atmosphere is reapplied. Turn to the skin, the external mucous membrane. +What is that disorder of the skin that appears abruptly, presents +redness, swelling, and intense itching, and ceases abruptly after a few +minutes or a few hours according to your ability to get rid of the +irritating cause,--that can be reproduced any number of times by +exposure to the same cause? Why, hives, of course, urticaria or +angioneurotic oedema. And a hive (or urticaria or angioneurotic +oedema) is not an inflammation. It is a vascular spasm, a spasm of the +minute vessels that drain small areas of skin, causing a local stoppage +of the circulation in that small area, a turgescence or exudate, the +hive. Just as suddenly as it began, the spasm of the vessels may relax, +the swollen area is drained rapidly, and the hive disappears, leaving a +faint redness. This is exactly the case with hay fever. It is an +urticaria, a vascular spasm. The sudden onset in response to a specific +irritant and the sudden disappearance--this is no catarrhal inflammation +and no rhinitis or inflammation of any kind. + +Those cases of hives that appear quickly after chilling the skin are +perfect analogues of hay fever, appearing in response to the local +irritation of odors and dust. There are cases of hay fever that resemble +ordinary hives in being aggravated by certain foods, especially +strawberries, acid foods, and malt liquors. This has a practical bearing +on treatment; for, in such cases, simply excluding these foods from the +diet and the administration of an alkali gives relief. Again, many hay +fever subjects suffer from urticaria, as in the case reported to me by +Dr. Rice of Hawaii, in which the attacks of hay fever alternated with +urticaria. + +Sir Morell Mackenzie was wrong when he said that hay fever "had no +pathology because it leaves no permanent structural lesion behind it." +Hay fever "has a pathology" if urticaria has a pathology, for urticaria, +too, subsides and leaves no traces. However, in this statement, we +recognize the effort to state the difference between the evanescent +lesions of hay fever and the more persistent lesions of catarrhal +inflammation; which is just the difference between an urticaria that +comes and goes in half an hour and an eczema (catarrhal dermatitis) that +takes several days to develop and is attended by a real inflammatory +exudate that requires many days for its absorption. + +In our text-books, our ablest specialists perpetuate this error by +devising such names as _hyperæsthetic catarrh_, _hyperæsthetic +rhinitis_, _vaso-motor rhinitis_--and then describing a neurosis. The +two ideas will not mix. The very authors who introduce these names feel +that there is something wrong with them, for usually they take several +pages to explain what the name means. It is better to throw overboard +both the name and the idea of catarrhal inflammation or rhinitis and +start afresh. + +Recent workers with pollens come near the truth in describing hay fever +as an anaphylaxis. Right here my conception of the lesion of hay fever +as an urticaria fits into the picture and brings us one step nearer to +an understanding of the disease; for where is there a prettier example +of anaphylaxis than those very hives with which long ago I compared the +lesion of hay fever? + +Since Bostock first described hay fever in 1816, hundreds of physicians +have looked at thousands of patients, but, as far as I can discover, +there was just one observer besides the modest author of this book who +recognized the urticarial nature of the lesion of hay fever. This was +Dr. Gueneau de Mussy, to whom we will devote the next chapter. + +=The Cause Behind the Lesion.= All clinicians agree that there are two +elements in the hay fever problem,--first, the irritant; and secondly, +the abnormal sensitiveness of the patient. All are fairly well agreed as +to the irritants, pollen and dust; but what makes the patient sensitive? +This is still the dark side of the subject. Among the many theories, two +seem to deserve further study and will be considered in the chapters on +Hay Fever as Gout and Hay Fever as Anaphylaxis. + + + + +CHAPTER VII + +_DR. GUENEAU DE MUSSY HAY FEVER AS URTICARIA AGAIN_ + + +In searching through the early literature of rosin-weed, as related in +Chapter XIV I noted that the article in the _Eclectic Medical Review_ +recommending rosin-weed for asthma seemed to have been copied only in +the southern and western medical journals. I was curious to know if the +aristocratic medical editors of the east, the intimates of Bigelow and +Holmes and Warren, had deigned to notice a drug of such lowly parentage, +discovered by the Indians and indorsed by the medical heretics. I began +with the stately row of bound volumes of the Boston _Medical and +Surgical Journal_, running back to 1860, that repose on a dusty back +shelf of the Library of the New York Academy of Medicine. Looking +through the volumes around 1868, when the use of rosin-weed in asthma +was being quoted in the south and west, I found many quaint notes and +comments, but no mention of rosin-weed. To any physician who has a +taste for the history of his art, I would recommend reading a journal of +fifty years ago. So many things have been settled that those old +physicians puzzled and fought over that it gives one the sense of +amusement or lofty detachment of the gods, looking down on struggling, +wriggling humanity, yet knowing all the time how it would come out. + +In those old books I noticed abundant quips and sneers at homoeopathy, +now happily taboo in the more courteous journalism of to-day. Besides, +they are not so funny now. The doctrine of like-cures-like and the small +dose has achieved respectability. When armies all over the world are +depending on a minute dose of typhoid poison to prevent and cure typhoid +fever, when articles appear in the most respectable medical journals +advocating doses of tuberculin so small that they have never been +calculated and one-tenth grain doses of calomel instead of the +twenty-grain doses of our grandfathers, most of the merry jests have +lost their flavor to-day. Rather as I expected, in the _Boston Journal_, +I found no notice of the eclectic rosin-weed, but I found something +better, a clinical lecture on hay fever by a man after my own heart, +who, away back in 1868, had recognized the urticarial nature of the +lesion in hay fever. This was a _Clinical Lecture on Spasmodic Coryza or +Periodical Asthma_, delivered at the Hôtel Dieu, by Professor Gueneau de +Mussy, translated from the _Gazette des Hôpitaux_ by W. F. Munroe, M.D. +The lecture runs through several numbers of the _Journal_, beginning in +March, 1869, page 125. It should be read by every rhinologist and by +every physician who is treating hay fever. + +When the chemist Woehler, one afternoon in 1828, tried to make up some +ammonium cyanate by mixing ammonium sulphate and potassium sulphate and +found that he had synthesized urea, one of his colleagues said that he +was like Saul, who went out to find his father's asses and found a +kingdom. I felt the same way; only, in my case, I went out among the +asses and found a king. + +When Solomon made his despondent remark that there was nothing new under +the sun and that of the making of books there is no end, he must have +been in his library sorting out his collection of old Assyrian bricks +and found that his favorite thoughts had been said already and said +better by some old Hittite scribe a thousand years before. So I, who had +fondly thought myself the discoverer of the urticarial nature of hay +fever because I had searched the books of the specialists and found +nothing about it, was surprised to find my observation anticipated by +the Frenchman. + +_Salut!_ Hail to you across the years, Gueneau de Mussy, kindred spirit. +It is not recorded that the gray-headed Dean of a great university ever +stood you on a platform and hurled Latin adjectives at you; but in 1868 +you had the sharpest eyes and clearest mind of any of them, M.D.'s or +LL.D.'s, though bespattered with all the letters of the alphabet. + +Of all the foolish things that scientific men quarrel about, one of the +most foolish is the question of priority of discovery. A scientist who +will welcome the opinion of another scientist agreeing with him the day +after he announces his discovery will fight like a cat against evidence +that the same man agreed with him the day before. It seems to me that +if another human being confirms your work, it does not make any +difference whether he does it the century before or after your transient +existence. In fact, you should be more pleased to have it "confirmed" +the century before, because then you will have a chance to know about +it. + +Besides recognizing the urticarial nature of the lesion, de Mussy sought +the underlying cause of hay fever and thought to find it in the gouty +diathesis. He notes the occurrence of hay fever in gouty families, its +periodicity, its association with urticaria, eczema, granular +pharyngitis and asthma, all characteristics of gout or arthritism. + +As de Mussy's lecture is not readily available, I quote from the _Boston +Journal_ some of his conclusions. + +"I have dwelt at length on the constitutional condition in order to show +in what diathetic conditions spasmodic catarrh has developed. The direct +and collateral hereditary tendency appears to indicate a diathetic +origin. The two sisters belong to a gouty stock. Chronic urticaria and +granular pharyngitis are not rare in gouty families. + +"Periodicity is characteristic of many arthritic affections. The +spring-time periodicity is especially common to them. The periodicity of +this coryza places it in the same category as the arthritic affections +which generally manifest themselves by regular or irregular paroxysms. + +"If hay fever has been more often noticed in England than France, can +this be due to the greater frequency of gout in the former country? + +"Continuing the study of these analogies which, if not enough to prove a +common origin, are enough to justify further study of the question, I +find in one of my patients a morbid condition due to an arthritic +source, _i.e._, an urticaria alternating with asthmatic coryza (hay +fever), the latter appearing with symptoms such as _injection and +itching and tumefaction of the eyes which recall the cutaneous affection +to which it had succeeded_." (Italics mine. Here is my urticaria theory +expressed in 1868. G. F. L.) + +"_Behind a vast number of nervous troubles, behind a vast number of +bizarre functional anomalies stamped with a nervous imprint, we find +arthritism._" (Italics mine. Here is my pet theory of the gouty origin +of neurasthenia and perhaps Beard's _neurotic constitution_, beloved of +rhinologists. G. F. L.) + +"As to analogies between summer catarrh and urticaria, I wish to draw no +conclusions from them. If it be admitted that both are due to +arthritism, their succession and the analogy in their local development +can be understood." (My urticarial nature of the lesion again. G. F. L.) + +I might add that de Mussy reports success in preventing the appearance +of the symptoms by the use of quinine for seven or eight days before the +expected attack. During the attack he used sulphur and arsenic for the +catarrh. + +In the next chapter we will consider the fate of de Mussy's theory of +gout as the underlying cause of hay fever. + + + + +CHAPTER VIII + +_HAY FEVER AS GOUT_ + + +In the last chapter we read that the theory of a gouty diathesis as the +constitutional basis for hay fever originated with Dr. Gueneau de Mussy, +in 1868, on account of the many resemblances that he found between the +symptoms of gout and the symptoms of hay fever. We have now to consider +the fate of the de Mussy doctrine in those countries where hay fever is +best known and has been most closely studied, Great Britain and America, +Germany and France. + +=De Mussy in Great Britain and America.= If any specialist on the nose and +throat in England or America ever heard of de Mussy and his theory that +hay fever is rooted in a gouty diathesis, he is keeping the secret well, +for it does not appear in any of the books that he writes; but in every +book I find the disease attributed to the _neurotic constitution_ first +suggested by Beard. In this statement I do not include several +references to "uric acid poisoning" which is not the same thing as gout, +as will be explained in Chapter IX, on the Uric Acid Theory. + +After reading de Mussy's argument for the dependence of hay fever on a +gouty diathesis, I turned first to the English books. For centuries, +England has been famous as the home of gout and, since the Englishman, +Bostock's, account of his own case, hay fever, too, like parliamentary +government and gout, has been recognized as an inheritance of the +Anglo-Saxon race. As British physicians see more gout than any other +physicians in the world and as, for many years, they have had the best +opportunities for the study of hay fever, I turned first to the English +books, thinking that if there was any truth in the gouty theory, the +British physicians would have found it out long ago. To my surprise I +searched book after book by both British and American authors, but in +not one instance did I find hay fever associated with gout. These books +included Allbutt's _System of Medicine_, F. T. Robert's _Practice_, +Lennox Browne, Morell Mackenzie in England and, in this country, +Ballenger, Bosworth, Coakley, Kyle, Solis-Cohen, Ivins and Vehslage and +Hallett. + +No one is more saturated with the traditions of British medicine than +Sir William Osler, but, in his _Practice of Medicine_, in discussing the +constitutional causes of hay fever, he seems to know nothing of the +gouty theory. + +Besides the article on hay fever in his _Diseases of the Nose and +Throat_, Sir Morell Mackenzie wrote a comprehensive work on _Hay Fever +and Paroxysmal Sneezing_ that ran through five editions and bears on the +flyleaf the admiring comment of the _London Lancet_ that it "must be +regarded as one of the most complete expositions of our knowledge of +this curious complaint in our language." It is a wicked joy to catch +such a scholarly writer as Mackenzie napping. In a footnote he even +refers to the de Mussy lecture in the _Gazette hebdomadaire_, Jan. 5, +1872, as calling the disease spasmodic rhinobronchitis, with which name +the disease is still known in France. One suspects that the learned +Doctor was very busy that day and that the footnotes were looked up by +somebody else; for, though he gives "the most complete exposition in our +language," as the _Lancet_ puts it, of the constitutional causes +underlying hay fever, there is never a word of de Mussy's theory of +gout. + +In Osler and McCrae's _Modern Medicine_ the article on Hay Fever is +written by Professor Dunbar, of Hamburg, deviser of pollantin. Here at +last we get away from British insularity, for, in spite of his Scotch +name, Dunbar is a German. On page 863 he writes: + +"For a long time it has been believed that the predisposition to hay +fever rests on a gouty diathesis. This view is not on the face of it +inconsistent with the pollen theory. Inquiries, however, have shown that +gouty persons form only a small portion of hay fever patients." + +Finally, in the great Edinburgh _Encyclopædia Medica_, 1900, Volume 4, +Greville MacDonald, of London, in the article on Hay Fever, seems to +know nothing of the gouty theory and says innocently at the end of the +article, "No special dietary is indicated, seeing that these patients +present no tendency to lithæmia, etc." He makes the extraordinary +suggestion that, in relieving the attack of hay fever, "rather than give +the patient cocaine, it might be wise to allow the opium pipe." In the +early prescriptions for hay fever, opium sprays and nasal douches were +common enough, but this is the only time I ever heard a reputable +physician and a teacher, at that, advising a patient to "hit the pipe." + +I think that, from the evidence examined, we may say that British and +American authors know nothing of de Mussy and his theory. + +Next, I looked up the gout authorities, Ewart, Ebstein, Garrod, +Falkenstein, Lancereaux, Lecorche, each of whom wrote a bulky treatise +on Gout, but there is never a word on Hay Fever. + +=De Mussy in Germany.= For many years, whenever I have wanted to know +anything from the bottom up, historically, linguistically, +philosophically, I have turned to a German book and have always found +what I was looking for, if it is known to man. Where an American or +British author will skim over or touch a subject carelessly, not seeming +to care where the idea comes from or its relation to other ideas in +different times or countries, a German will plow steadily through the +matter from Hammurabi to Wilhelm III and lay bare all the collateral +tributaries and branches, always with an index at the end. + +First I tried Heymann's _Handbuch der Laryngologie und Rhinologie_ +(Wien, 1900) and found hay fever described in the article on _Die +Nasalen Reflexneurosen_, by Professor Jurasz in Heidelberg; but there +was no mention of gout. By this, I was truly convinced that nothing was +known on the subject. If a Heidelberg Herr Professor does not know it, +it does not exist. And "Professor Jurasz in Heidelberg" had failed me. + +However, looking further in Heymann, my faith in German thoroughness and +all-inclusiveness revived. Hay fever appears also in the article on +Acute Rhinitis, by P. H. Gerber, of Königsberg, and here, on page 371, +we find a complete "Literatur" spread out in true Teutonic style from +Bostock to date. However, Gerber does not discuss the matter of gout in +the text, but says merely, "Recently Bishop asserts that the nervous +disturbances of hay fever are due to an excess of uric acid in the +blood." + +The gouty theory of hay fever receives scanty recognition from most +German writers. Strümpell does not mention it. In his _Handbuch der +Specielle Pathologie und Therapie_, Berlin and Wien, 1904, Eichorst says +skeptically, page 326, "It has been stated often that gouty families are +especially apt to develop hay fever," and on page 330 "Grote saw hay +fever patients of gouty families cured (?) by a course of waters at +Neuenahr." + +In Eulenberg's _Real-Encyclopædie der gesammten Heilkunde_, 1887, page +509, article Hay Fever, we read: + +"Of general diseases, malaria and gout have been advanced as the basis +of hay fever, but without convincing proof." + +We may conclude, then, that while British and American physicians know +nothing about the gout theory, German physicians know about it but do +not believe it. + +Finally, in my wanderings through German encyclopædias, I came to the +many-volumed Nothnagel and here, at last, found a modern writer who knew +de Mussy and recognized the importance of his observations. At the end +of Volume 4 there is a monograph on Hay Fever by Dr. George Sticker, of +the University of Giessen, the most thorough and satisfactory book on +the subject that I have found. It may be read in English in the American +edition of Nothnagel, Philadelphia, 1902. Sticker resists the impulse to +begin with Galen, though he notes rather wistfully that John Mackenzie +of Baltimore succumbs to it. He gives the most complete statement in any +modern book of the gout theory of hay fever, but, alas, Sticker misses +the pearl in the oyster. He says nothing of de Mussy's recognition of +the urticarial nature of the lesion in hay fever. + +As this volume of Nothnagel may not be easily available to the gentle +reader, I copy a paragraph from Sticker for his or her benefit. + +Nothnagel's _Specielle Pathologie und Therapie_, Band 4, 1896. Article +_Bostock's Catarrh_, by Dr. George Sticker, page 118. "In the last few +years convincing proofs are accumulating that there is a certain +constitutional disorder on which the individual tendency to hay fever +depends. Though further careful proof is desirable, it can scarcely be +doubted that the pathogenesis of hay fever is based on that constitution +that the English and French describe as arthritic, which expresses +itself in a hereditary or family tendency to rheumatism, gout, diabetes, +obesity, migraine, furunculosis, bronchitis, asthma, etc. Bostock +himself mentioned his gouty tendency. Phoebus found it in many +patients. But it was Gueneau de Mussy who first recognized the +prevalence and necessary basis of the disease in the arthritism of the +hay fever patient; and his teaching has been accepted and enriched with +new material by Herbert, Leflaive, Lermoyez, Ruault, de Dreyfus-Brissac, +Rendu, Molinie.... And so it is probably no coincidence that, like gout, +the _morbus principum_ of Sydenham, so also the aristocratic hay fever +is a prerogative of the Anglo-Saxon race." + +Reading this praise of Englishmen and Frenchmen by a German makes one +sad to-day. Hasten the day when the old hearty comradeship in science +will return, the day when German and Frenchman and Englishman will +again praise one another's achievements ungrudgingly and each learn +eagerly as of old what the other had to teach. + +=De Mussy in France.= As might be expected, among French rhinologists and +writers on general medicine, de Mussy's teaching is well known and has +many advocates. Note that the writers mentioned by Stickerare all +Frenchmen. The usual view is well expressed by André Castex in his +_Maladies du Larynx, du Nez et des Oreilles_. Paris, 1907, page 425. + +"Hay fever attacks especially those who belong to an arthritic stock, +whose parents have had or who themselves have migraine, gravel, eczema. +This explains its frequency in England and America; for the Anglo-Saxon +race is especially subject to arthritic disorders. In France it exists +but is infrequent. In this way also we must explain why hay fever is +rare among the laboring classes who frequent the hospitals and is +observed almost exclusively among wealthy patients, people of sedentary +habits and sluggish digestion (nutrition ralentie)." + +In Brouardel and Gilbert's _Traité de Médicine et de Thérapeutique_, +Volume 27, page 66, another André, André Cartaz, expresses mild +skepticism as to the proof offered. + +"The presence of an arthritic diathesis is accepted by many authors. +Leflaive thinks it the sole predisposing cause, especially gout. During +the attack he has demonstrated, as I would say, and that is proof for +him, an appreciable decrease in the quantity of urine and percentage of +urea, an increase in uric acid and, in one case, the presence of +indican." + +Lermoyez also advises caution in accepting the gouty theory to the +neglect of known remedies for the disease. I abstract his sensible +remarks from his _Thérapeutique des Maladies des Fosses Nasales_, Paris, +1896. Article _Rhinites spasmodiques, rhume des foins_, page 300. + +"It would be a mistake to hold with the German school that the nasal +lesions were the only cause of hay fever; for these lesions are +completely absent in many true cases of the disease and, on the other +hand, many people affected with hypertrophic rhinitis breathe air full +of pollen without showing symptoms of hay fever. There is certainly a +general predisposition. In hay fever certain patients present a +peculiar idiosyncrasy, often inherited, almost always neuroarthritic. +But to say with the French school that the arthritic diathesis (trivial +diathesis, commonplace diathesis, _diathèse banale_) is the only cause +of hay fever is to make a mistake that leads to inefficient treatment." + +=Conclusion.= How this discussion of the gouty nature of hay fever escaped +English and American authors is a strange thing. British physicians +frequent French hospitals and are familiar with French medical writings. +In 1868 American physicians studied in Paris as they went later to +Vienna and Berlin. It is strange that they never brought back with them +this French theory of the gouty nature of hay fever and that no British +or American author seems to have quoted from their books. + +I must make one partial exception to this statement. In his _Diseases of +the Nose, Throat, and Ear_, Philadelphia, 1906, Professor Grayson says +that, in hay fever, there is "some diathetic state that is rooted in +defective nutrition. Whether we term this lithæmia or gout or uric acid +diathesis is immaterial, the central fact being that through intestinal +toxæmia or some disturbance of normal metabolism we have resulting a +persistent poisoning of the blood-current." + +Now this is simply substituting one theory for another without proof of +either; for the origin of hay fever in auto-intoxication is as little +proved as its origin in gout or uric acid. Auto-intoxication has simply +replaced uric acid in the Doctor's mental picture gallery; for, like +uric acid, auto-intoxication often exists in the imagination of the +physician and not in the patient. For further discussion of this point, +the reader is referred to the next chapter, on the Uric Acid Theory. + +A novel and interesting article in Grayson is the description of +angioneurotic oedema as affecting the nose and throat, page 182. He +writes: + +"I have no doubt that in this disease, as in hay fever, the +gastro-intestinal tract is the birthplace of the toxic material. +Although the disease may occur in gouty or rheumatic individuals, there +is scarcely sufficient reason for ascribing any pathological connection +between it and these other affections." + +The comment on this is that, until we know what gout is, which we do +not at present, we cannot argue satisfactorily either way. Some day I +shall tell a listening world what I know about gout. I shall elaborate +my favorite theory that the American neurasthenia, now rapidly +increasing in other countries, is a form of gout, a gout of the nervous +system. And here, too, I find that Frenchman, de Mussy, anticipating me +in his remark that "_Behind a vast number of nervous troubles, behind a +vast number of functional anomalies stamped with a nervous imprint, we +find arthritism._" The name _neurasthenia_ was not known in de Mussy's +day, but he hit off the condition neatly as "functional anomalies +stamped with a nervous imprint." + +The defect in all these discussions of the gouty or non-gouty nature of +hay fever or of neurasthenia is our lack of a sure diagnostic sign of +the disease gout. Gout occurs in two forms, typical and atypical, +irregular gout. In typical gout, with the deposits of urates in the +joints and cartilages, the diagnosis may be easy. In atypical or +irregular gout we may have a group of inflammations or functional +disturbances in any tissue of the body. From their frequent occurrence +in gouty people, we suspect them to be gouty, but can prove nothing. +When they appear in people who have never had typical gout we can only +say that a gouty origin is probable. There is no sign in the blood or in +the urine or anywhere else by which we can say that gout is or is not +present. It is in this class of atypical gout that hay fever and +neurasthenia belong, if they be gouty at all. Until somebody discovers a +diagnostic sign of gout that is available in these irregular cases, the +evidence of the gouty nature of hay fever and neurasthenia must remain +exactly what it was to de Mussy fifty years ago, analogies of symptom +groups, and not an exact laboratory diagnosis based on physiological or +chemical tests such as we have come to depend upon with such confidence +in recent years. + +One matter that should be made clear in the reader's mind is that the +so-called _uric acid poisoning_ or _uricacidæmia_ is not the same thing +as gout by any means, though Grayson confuses it with gout, as do nearly +all American authors. For fuller discussion of this point, we will pass +to the next chapter. + + + + +CHAPTER IX + +_THE URIC ACID THEORY_ + + +Uric acid is a substance about which more has been written and less +understood than many others in medicine and that is saying a great deal. +As a basis of the suboxidation theory of Bence Jones' day, as the cause +of gout with Garrod, as a step in our knowledge of metabolism and as a +popular fad, uric acid in its time has played many parts. + +=Uric Acid in Hay Fever.= In 1893, Dr. Seth Bishop announced before the +American Medical Association that "excess of uric acid in the blood +causes hay fever and nervous catarrh;" and advised elimination and +control of the uric acid as the principle of treatment. The article may +be found in the _Journal of the American Medical Association_, 1893, and +abstracted with an interesting discussion on the treatment of hay fever, +in the _Philadelphia Medical News_, 1894. This position, of course, is +also that of Haig (_Uric Acid_, seventh edition, page 386) and his +followers. + +Now, in 1893, the theory of uric acid poisoning flourished like a green +bay tree and all sorts of queer and misunderstood pathological processes +came and roosted in its branches. Patients came to our offices, not +complaining of headache or lumbago or cough, but asking for "something +for that uric acid." As patients will, they had already made the +diagnosis from the newspapers and wished our advice only for the remedy. + +As the basis of hay fever, this theory of uric acid poisoning has +apparently made as little impression as de Mussy's theory of gout on the +nose and throat specialists of this country and Great Britain; for I +find no mention of it in their books, except the brief reference of +Professor Grayson quoted in the preceding chapter. In the _Virginia +Medical Monthly_, however, I find an interesting paper by Dr. John Dunn, +Professor of Diseases of the Nose and Throat in the University Medical +College of Richmond, Virginia. Following the suggestions of Dr. Bishop, +Dr. Dunn treated his patients with diet and alkalies according to the +uric acid theory and reports excellent results. + +It may be pointed out that the successful results of the treatment by no +means prove that the condition was due to uric acid; for the diet may be +doing many other things besides controlling the movements of the uric +acid and it is probable that the effect of an alkali in the blood is not +a simple neutralizing of an acid but that it sets in motion a train of +chemical changes of great complexity. None the less, Dr. Dunn's paper is +well worth reading by every physician for its practical suggestions in +the treatment of hay fever. + +The cardinal error made by the advocates of the _uric acid poisoning_ is +that they _name the poison_. If the theory were stated that an unknown +poison or poisons circulate in the blood and cause many symptoms of +disease, as headache, gouty pains, bilious vomiting, and so on, we would +all agree that this is so. Call it the X-poison, if you will, as +Roentgen did with his unknown ray. But when you name the poison _uric +acid_, you challenge the chemist and the physiologist to test your +doctrine by chemical analysis, and when the uric acid doctrine is +tested in this way it is found sadly wanting. + +It is true that uric acid in the form of urates is found in the blood in +varying quantities, but there is no proof that it does any harm there. +In fact, there is good evidence that it does not. In the disease, +leukæmia, there is an enormous amount of uric acid in the blood, far +more than was ever demonstrated in gout or the so-called uric-acid +disorders; yet, in leukæmia, there are no symptoms of gout or any other +symptoms that have been attributed to uric acid poisoning. + +A second error of the uric acid advocates, flowing from their first +error of naming the poison, is to pour their acids and alkalies into the +blood with the childlike faith that, like good children, the acids and +alkalies will go in there and do just what they were told to do, +neutralize the uric acid, and get out. They assume that the chemistry of +the acids and alkalies is as simple inside of the body as it is outside +of it and that the blood is simply a passive mixture of chemicals. + +A third error of the uricacidites is to talk so glibly of the chemistry +of the blood and the influence of this or that food or medicine on its +chemical changes. The chemistry of blood! A subject of which the ablest +physiological chemists have but touched the fringe,--is that a knot to +be unloosed familiar as his garter by an amateur with a watch-glass and +a thread? + +In his _Lehrbuch der Organischen Chemie für Mediciner_, Leipzig, 1906, +Bunge observes slyly that he had "sometimes had occasion to remark in +private that the less a physiologist knew about chemistry, the more +irresistible was his impulse to undertake the most difficult subjects." + +When the uric acid amateur chemist comes to study the real poisons of +the blood, he will be confronted with a problem even more intricate than +uric acid, though that one is intricate enough and still unsolved. For +there are "poisons in the blood," though it is improbable that uric acid +is one of them. These poisons are the blood-proteins, so many that the +physiologist has never counted them, so minute in quantity that no +chemist has ever isolated them, so complex in structure that the ablest +chemists of the world stand appalled before a molecule that contains +sixty atoms of carbon,[1] so powerful that an undetermined fraction +smaller than one-third of a grain will kill ten thousand guinea pigs or +one hundred thousand mice, and so perfectly under control that they +circulate harmlessly in the normal blood. The marvel is that any animal +remains alive; and no animal would remain alive were it not for a system +of protection by which these poisons are rendered harmless, usually by a +slight rearrangement of the atoms in their molecule which is one of the +wonders of organic chemistry. + +We are far from knowing just what happens when we pour acids and +alkalies and foods into this witches' cauldron of blood. Rather than +impudently announcing the changes that are about to take place in the +blood when we administer a certain food or medicine, we should stand in +reverent awe before one of the most intricate and marvelous puzzles +with which nature ever challenged the chemist and the physiologist. + +Shall we therefore stop using acids and alkalies as medicines because we +do not know each step in their mode of action? By no means. We do not +know each step in the mode of action of any medicine or of our foods, +either, for that matter; but we do not for that reason stop eating. We +should still use the acids and alkalies for their effect on the patient +as far as we can see it just as we shall still go on eating food because +it nourishes us; but we shall be wise to stop talking so glibly about +what we cannot see and do not yet know, the effect of those acids and +alkalies on the chemistry of the blood. + +=Uricacidæmia and Gout.= Now, why do I speak with respect of de Mussy's +theory of gout as a cause of hay fever and so disrespectfully of the +uric acid doctrine? Are not gout and uric acid poisoning the same thing? +No. They are not; though the two ideas are usually confused by medical +men since Garrod's time and his demonstration of the increase and +decrease of uric acid in the blood of gouty patients. Gout is something +more than a simple accumulation of uric acid in the blood because of its +imperfect elimination by the kidneys. What that something is, we do not +know; but gout is, at least, a clinical entity, a definite group of +symptoms known since Hippocrates' time. Take away the uric acid theory +and you still have the disease, gout, that any of us can recognize, as +the Greeks and Romans recognized it when the word uric acid was unknown. +It is on these symptoms of gout, the clinical picture of disease, not on +any hypothetical uric acid, that de Mussy based his theory and thus far +he is on solid ground. On the other hand, _uric acid poisoning_ is +largely a figment of the imagination. Take away the uric acid, which has +never been satisfactorily proved to be there, and there is nothing left. +In not one one-hundredth part of the cases of so-called uric acid +poisoning is it proved that uric acid has anything to do with the case. + +=The Deposits of Uric Acid in Gout.= The deposit of uric acid in the form +of urates in the gouty joint has always been a strong argument for the +theory that gout, at least, is due to an excess of uric acid (urates) +in the blood. At one time, in a humble way, I was a pathologist, and +this theory of a blood overloaded with uric acid as the only thinkable +cause of its deposition in the joints never impressed me as +pathologically sound. I often compared these deposits of urates in the +joints with the deposits of lime salts so often found at autopsies in +caseous glands or small necrotic areas. The superficial observer says: + +"See what an excess of lime salts there must have been in the blood." He +is thinking of laboratory glassware and the ground around a mineral +spring that becomes encrusted with salts as the solutions evaporate. +But, in animal pathology, this is a false conclusion. The animal body is +not a test-tube and, in it, the laws of physics are modified by those of +physiology. Lime salts are deposited in the caseous gland or tubercle +not because they are in excess in the blood but because lime salts are +attracted to all caseous material from normal blood. Whether or not this +calcification is an intentional provision of nature to protect the body, +to petrify the necrotic material and make it harmless, is not the +question here, though the calcification has this effect. The point here +is that calcification of caseous glands or necrotic areas does not +presuppose an excess of lime salts in the blood. The first step is not +an excess of lime in the blood but a necrosis, after which the lime +salts will be deposited from normal blood. + +So, it has seemed to me that the deposit of urates in and around a joint +is no proof of their excess in the blood. Just as in calcification, so +in gout, the first step may be a minute area of necrosis or other local +degeneration that attracts the urates that are always present in normal +blood; or the secret of the gouty inflammation, like that of urticaria +and hay fever, may at last be found in Anaphylaxis, as described in the +next chapter. + +FOOTNOTES: + +[1] Wenn mehr als 60 Atome Kohlenstoff im Molekül sind, dann ueberlasse +ich das Object zu andern. Bunge, page 262, quoting "einen hervorragenden +Forscher auf dem Gebiete der organischen Chemie." See Bunge for +authority of these statements. + + + + +CHAPTER X + +_HAY FEVER AS ANAPHYLAXIS THE GOUTY DIATHESIS REAPPEARS_ + + +Fifty years ago de Mussy pointed to the resemblance between hay fever +and gout and claimed hay fever as a manifestation of the gouty +diathesis. As related in Chapter VII, he based his theory on the +resemblance between the history and symptoms of hay fever patients with +those of gouty patients. In his day he found both hay fever and gout +confined to the Anglo-Saxon race, both hereditary and familial, both +exhibiting urticaria, eczema, and asthma, and he recognized that the +lesion in the eyes and nose of the hay fever patient was not a true +catarrh but an urticaria. + +On the other hand, Wolff-Eisner declared that hay fever is an +anaphylaxis and this idea has been developed and confirmed by Koessler +and others so fully that we must accept it as proven. Let us examine +this matter of anaphylaxis to determine whether after all there is any +essential difference between the two views of hay fever. + +=Anaphylaxis.= The conception _anaphylaxis_ or _lack of protection_ begins +with the discovery that a harmless protein injected into a dog will so +sensitize him that, after ten days or so, another injection of the same +protein will kill him. The point is that the change has occurred in the +animal, not in the protein injected. The protein is the same as before +and can be injected once into any number of dogs without harm. In this +way we explain the cases in which drugs and foods that are harmless to +most people may be virulent poisons to those who happen to have been +sensitized by a former overdose. The widespread use of antitoxin in +diphtheria gave abundant opportunity to study the phenomena of +sensitizing a human being with one dose and killing him with another +dose of the same thing. + +The symptoms of anaphylaxis first observed were urticaria, arthritis, +and dyspnoea. Then Bruck showed that what we used to call +_idiosyncrasy_ to drugs and foods that are harmless to most people is +really an anaphylaxis, attributable to a former overdose of the same +thing. Next, it was learned that anaphylaxis may persist through life +and be transmitted to the offspring of rabbits and guinea-pigs, +illustrating the cases in human families where sensitiveness to a +certain food or drug runs down through several generations. Then the +dermatologist brought in a list of skin eruptions, urticaria in the +lead, as examples of anaphylaxis to certain foods or to poisons +generated within the body, especially in the intestines. Then asthma was +included among the anaphylactic reactions and, finally, Wolff-Eisner +pointed out that the lesion of hay fever is an anaphylaxis. I may add +here that this view of hay fever confirms my observation that the lesion +is not a catarrhal inflammation but an urticaria. + +So we have a picture of anaphylaxis as a sensitiveness to bacterial +poisons or to foods or drugs that are harmless to most people expressing +itself as an urticaria, an arthritis, an asthma or hay fever. But this +is the very group of symptoms on which de Mussy based his theory of +gout. When we add that this sensitiveness or anaphylaxis is hereditary +and that it is aggravated by foods, drugs, or pollens that are harmless +to most people, I submit that we have a pretty picture of the gouty +diathesis; for the gouty diathesis, too, is a susceptibility to +arthritis, to urticaria, and to asthma from causes that do not trouble +other people, and in gout, too, this weakness is hereditary. One thinks +of the gouty patient who cannot take iron or digitalis because it +aggravates the gouty pain and of the attack of gout that is brought on +by a glass of champagne or a piece of beef or a few strawberries that +the majority of mankind can take freely without harm. Now, if urticaria, +eczema, arthritis, asthma and hay fever form a picture of anaphylaxis, +and if these symptoms also form the picture of the gouty diathesis, is +it not probable that one of these pictures can be explained in the terms +of the other? If the anaphylaxis to the diphtheria antitoxin, horse +serum, can develop arthritis, is it not probable that the most striking +feature of gout, the inflammation of the joint, is also an anaphylaxis +to poisons yet unknown to us but the same poisons that make the gouty +urticaria and asthma? + +What if gout should prove to be a sensitization or anaphylaxis to uric +acid that does not exist in the non-gouty? This would explain the puzzle +of one patient full of gouty pains with very little uric acid in his +blood while another patient, like the leukæmic, has a blood full of uric +acid that does not trouble him. + +=The Mechanism of Anaphylaxis in Hay Fever.= The anaphylaxis theory of hay +fever is based on the observation that the epithelial cells of the +mucous membranes of the eyes, nose, and throat have not lost their +primitive power of digesting foreign protein. + +Ages ago, when we were amoebæ or little drops of protoplasm, we had no +eyes or nose or separate stomach for digesting food. The one little cell +body did everything. One of the most important powers of that cell body +was its power of digesting and assimilating food, and its most important +food was the nitrogenous food or protein from which it built up its own +body substance. Now, foreign or food protein cannot be simply absorbed +as such. Foreign protein is a poison and never tolerated in the blood. +The foreign protein used as food must first be changed into the special +kind of protein that the body can use. The foreign protein is changed by +splitting its molecule into its simplest parts and then recombining them +in the desired form. The complex protein molecule, containing those +sixty atoms of carbon that gave the Schrecklichkeit to the German +professor of chemistry as related on page 71, is split up again and +again into simpler forms. The end products are harmless, but the early +splittings produce both poisonous and non-poisonous products. The +end-results of these successive splittings, the splinters, as it were, +are then combined by the amoeba to form its own kind of protein or +body substance. + +As we rose in the animal scale, instead of being an amoeba of a single +cell, we became constructed of millions of tiny cells and began to set +aside certain groups of cells to do special work, the eyes for seeing, +the ears for hearing, the lungs for breathing, the digestive organs to +prepare our food and a sheath of harder cells over the outside of the +body that we call our skin and mucous membranes. Specialized as those +cells have been for many generations, they have never forgotten that a +foreign protein is a food or, perhaps, an enemy, to be split up and +decomposed at sight. So, the epithelial cells of the mucous membrane of +the nose and eyes, though they have no longer anything to do with +digesting our food, secrete a ferment or enzyme that can split up any +protein that may happen along. This process is called _parenteral +digestion_ or digestion outside of the intestines; and this theory of +the parenteral digestion of protein is the foundation of the anaphylaxis +theory of hay fever. + +During the growing months of the year the air is full of pollen that is +blown in everybody's eyes and nose. In that pollen is a proteid that is +digested by the secretion of those mucous membranes, proceeding exactly +as food is digested in the stomach and intestines, splitting up the +complex proteid molecule into simpler groups, and forming both poisonous +and non-poisonous substances. In the normal eyes and nose this splitting +of the protein proceeds slowly, forming only minute amounts of poison. +As absorption from the eyes and nose is slight, no unpleasant effects +are produced. + +The first step in the development of hay fever is supposed to be a +disturbance in this digestion of protein in the eyes and nose, by which +larger amounts of poison are formed and absorbed by the mucous membrane, +producing the first poisoning, which, like the first injection into the +dog, sensitizes the mucous membrane to other doses of the same poison. +It is supposed that disturbance in the protein digestion may be caused +by stoppage of the nasal passages, with excessive accumulation of +proteid, inhalation of excessive amounts of pollen, forming excessive +amounts of poison, or, perhaps, insufficient secretion, so that the +splitting-up process is not hastened to its conclusion of harmless +products. The anaphylaxis theory halts a little at this point and is not +exactly clear about the mechanism of that first poisoning. + +After the first poisoning, the epithelia are permanently injured and +remain more permeable to protein. They also develop the power of making +large amounts of the digesting enzyme, which is absorbed into the blood +and is supplied to all the tissues of the body, so that all tissues, +including the skin, can decompose the pollen protein. Advantage is +taken of this distribution of the protective enzyme in the skin +reaction, in which a small area of skin denuded of its superficial +epithelia reacts in the form of a hive-like swelling when the pollen +that originally affected the patient is brought in contact with it. + +The next time that the pollen reaches the eyes and nose the mucous +membrane is ready for it with an abundant secretion of enzymes to +destroy it. In this intense digestion of the proteid, quantities of the +poisonous substances are formed which irritate the eyes and nose worse +than before, explaining why hay fever becomes worse with successive +attacks. + +The inherited form of hay fever is explained by the well-known +transmission of anaphylaxis to the offspring. The first case in the line +of descent must start with a severe poisoning that lays the foundation +of the anaphylactic inheritance. + +I would submit to the enthusiastic immunologist that this first +sensitization which he takes for granted but cannot prove is the weak +spot in his hypothesis. This is the point where he needs help, and it +is at just this point that de Mussy's neglected theory of gout completes +the picture. The immunologist has not explained why I, a boy growing up +with other boys, inhaling the same amounts of pollen as they, catching +no more colds than they, and never having any serious illness, became +sensitive to pollen while the others did not. There is no recollection +of any "first poisoning" by pollen that might have started the +anaphylaxis. But, says the immunologist, it was your parents who were +sensitized and you inherited the anaphylaxis. Now, my parents lived to +old age and had no sign of hay fever, though my brother had it and my +children are beginning to sneeze and rub their eyes suspiciously in June +and August. But if you associate hay fever with the gouty diathesis, as +the clinical histories seem to justify, you enlarge immensely your +opportunity to prove ancestral sensitization to whatever unknown poison +originally produced the gouty sensitization. This view does not restrict +you to ancestral hay fever, but extends it to gout or to any equivalent +of gout. + +The best work in English on hay fever as an anaphylaxis is the +monograph of Karl K. Koessler in Forchheimer's _Therapeusis of Internal +Disease_, 1914, Volume 5, page 671, to which the reader is referred for +a full discussion of the subject. The same author gives an abstract of +his work in the _Illinois Medical Journal_, 1914, page 120. This article +in Forchheimer is the most complete that has been written since +Sticker's time and covers the ground from Sticker, who knew not +anaphylaxis, to Wolff-Eisner, who is not available in English. + +I was gratified to find in Koessler a sympathetic soul. He thinks, as I +did, that the monograph of Sticker in Nothnagel is the best review of +hay fever that we have. He calls it "a remarkable monograph and the +standard work on the subject." But why, oh why, K. K. K., in your own +masterly article in Forchheimer, did you follow Sticker all through his +historical chapter but leave out all that he says of de Mussy's theory +of gout or arthritism as the constitutional basis of hay fever and also +leave de Mussy and every reference to his work out of your list of +_Literature_? The German books are more liberal. While most of them +ignore de Mussy and his theory in their text, they all list his writings +in the _Literatur_. Has the microbe of bacteriology and the laboratory +bitten you so virulently that you can find no place for the gouty +diathesis even in an index? + +I know that the gouty diathesis is out of date. In fact, all diatheses +are out of fashion. Nobody speaks of them now. They went out with the +medical philosophies of the eighteenth century. Cellular pathology with +its wonderful revelation of the anatomical seat of disease and +bacteriology, with its still more wonderful revelation of the external +cause of disease, so dazzled the eye and the mind that we forgot that +the sensitive animal body behind the attacking microbe had its changes, +too, its changes in body chemistry that could not be stated in terms of +cells and bacteria. The pendulum is swinging back now to a consideration +of the constitution of the body on which the microbe or poison acts, its +_resistance_ or _immunity_, its _anaphylaxis_ or _allergie_. With these +holiday and lady terms, are we not trying to describe what our ancestors +knew as _diathesis_? For what is the old conception of diathesis but +just such a hereditary weakness or lack of defense or tendency to +disease that our ancestors recognized clinically but could not +demonstrate, elusive, difficult to detect, but nevertheless there; like +the dog who has been sensitized to an otherwise harmless proteid, who +seems well and is well in everything except his susceptibility to that +one special cause of disease? + +Bacteriology, which first took away the idea of diathesis, is now giving +it back. The discovery of the tubercle bacillus as the cause of +tuberculosis banished the _tubercular diathesis_ apparently forever; +but, step by step, through bacteria and then toxins and antitoxins and +now through anaphylaxis and allergie, bacteriology is bringing back the +old conception of an inherited or acquired susceptibility to attack. +Call the old tubercular diathesis a _sensitization_ and you have made it +the most modern of modern discoveries. So, also, step by step, through +bacteriology with its toxins and antitoxins and now with anaphylaxis, +from the philosophic ash-heap on which we thought to have thrown it for +good and all, like an old family cat that we thought was dead, comes +creeping back that old conception of a gouty diathesis or arthritism, +not as dead as we thought it, to complete the explanation of the +existence of hay fever. + +I am far from saying that calling hay fever a form of gout ends the +subject. I say only that bringing such a common and puzzling disorder as +hay fever in line with such a common and puzzling disorder as gout +brings us a long step nearer to solving the puzzle that lies behind both +of them; and I say also that, in the records of this work, the name of +Gueneau de Mussy, who first recognized this relation clinically, +deserves a place. + +Gout as an anaphylaxis, hay fever as an external expression of gout, +what a vista of therapeutic possibilities is opened up by these simple +experiments with pollen extracts and foods. The subject ramifies in +every direction, touching the gouty form of Bright's disease, gouty +heart disease, endocarditis and pericarditis, the popular "hardening of +the arteries," which may prove after all not to be due to meat in all +cases or alcohol in all cases but certain foods in certain cases, the +increase in deaths from heart disease and kidney disease in the fifth +decade of life. The correlation of these gouty problems with this work +in the prevention and cure of hay fever anaphylaxis awaits a Lister or a +Pasteur or a Koch who will have an eye to see and a patient industry to +search and find. + +When you have established hay fever as anaphylaxis or lowered resistance +to a specific proteid, you may be sure that the immunologist will seize +the patient as his own, carry him off to the laboratory, and there +attempt to raise his resistance or develop immunity to the attacking +proteid by giving minute doses of the poison gradually increased. The +success of this procedure will be related in the next chapter. + + + + +CHAPTER XI + +_IMMUNIZING WITH POLLEN EXTRACT_ + + +The idea of preventing disease and poisoning by preparing the body with +minute doses of that poison, gradually increasing until the body is +immune, is an ancient one. The practice is Ur-alt, as my favorite German +history books say; for it has been found among savages and primitive +peoples and is practised in a crude way by every boy who accustoms +himself to that noxious weed, tobacco. Then, there are the Psylli, whom +Lucan tells of, who were by heredity immune to snake poison and who +could make the favored stranger immune by inoculating him with small +doses (_Pharsalia_, Book ix); and old King Mithridates, of Pontus, who +believed in preparedness and kept himself prepared for the attentions of +his faithful subjects by taking small doses of poison every day, keeping +himself immune should by any accident some poison slip into his porridge +(_Pliny_, Book xxv). Old King Mithridates was a good immunologist. He +knew the transient nature of immunity and kept the treatment up. He +knew that, if he stopped taking the poison for a week or so, he would go +into a state of anaphylaxis and the next dose would kill him; so he kept +himself in a state of anti-anaphylaxis by not permitting too long a time +to elapse between doses, after the most approved rules of modern +immunology. That patient whom Goodale immunized against horse-asthma who +objected to a treatment that had to be taken for the rest of her life, +should learn of old King Mithridates the true practice of immunity. + +This is still the weak point of artificial immunity; it does not last +very long. You can immunize a guinea-pig or a patient to almost anything +now-a-days by giving him minute doses gradually increased but the +immunity passes off quite rapidly when the treatment is stopped. We have +still something to learn from Nature in this respect. Nature can give us +one dose of yellow-fever or scarlet-fever or small-pox or measles and +make us immune for life but your artificially produced immunity may last +for a few weeks or months only. Our closest imitation of natural +immunity is vaccination against small-pox. Here we produce an actual +disease, cow-pox; yet, even here, we are not at all sure how long +immunity lasts. Even in Jenner's time, the original belief in protection +for life came down to seven years and our modern health boards would +vaccinate every two years or, in the presence of an epidemic, more +frequently. + +However, Nature is a wasteful worker, wasteful of her material, and she +kills a great many of her children with measles and scarlet-fever and +small-pox and yellow-fever while immunizing the lucky ones. A Health +Board that would kill so many people while immunizing the rest would be +a public scandal. Yet it is probable that Nature's way is the most +effective and that the best immunizer is the disease itself, as Koch +found with tuberculosis among his guinea-pigs that the best protection +against tuberculosis was inoculation with living tubercle bacilli, not +with dead ones; and the autopsies show that the majority of the human +race that grow up at all have been successfully immunized against +tuberculosis by a mild local attack of the disease. + +As yet, no one has had the boldness to inoculate human brings with +living bacteria and to imitate Nature in her manner of killing off all +the sensitive subjects in order to preserve the rest. This was formerly +done by inoculation with small-pox but the unfortunate results of the +practice compelled its abandonment among civilized people. Even Nature's +immunity is not perfect in all diseases, as many a patient with his +sixth attack of grippe or third pneumonia or fortieth year of hay fever +has learned most feelingly; and this irregularity of natural immunity +bears directly on the proposal to immunize patients against hay fever by +small and increasing doses of the offending pollen. If the natural +disease does not confer lasting immunity, you will have some difficulty +in conferring lasting immunity artificially, as the immunologist is just +now discovering. His immunity passes off so rapidly that he is now +searching for a method of immunizing that can be carried on for many +years without tying the patient to a laboratory for life. It is right +here that I believe that homoeopathy has valuable methods that can be +applied to the situation. + +But we must not jump to conclusions. Because we can immunize +successfully against one disease, it does not follow that the same +methods will immunize against another disease. Each disease is a problem +in itself and may require its own methods. Nor because we can immunize +the guinea-pig in the laboratory, does it follow that the same methods +are applicable in the human patient. The only proof that we can immunize +against hay fever is to immunize against hay fever. So, to the subject! + +=Passive Immunity.= The first man to attempt to apply the methods of +modern immunity to hay fever was Dunbar, of Hamburg, in 1903, with this +_pollantin_. He attempted to duplicate in hay fever the triumph of +antitoxin in diphtheria by injecting a horse with increasing doses of +pollen until the horse became immune to large doses of pollen and his +blood full of antibodies. Dunbar expected to confer passive immunity on +the hay fever patient by transferring to him this horse serum with its +antibodies. There is no better example of the rule that each disease +requires its own methods of immunity. While diphtheria antitoxin is +harmless to the diphtheria patient, the serum of the pollen-immunized +horse nearly killed the first patient Dunbar tried it on, who happened +to be his assistant, a sufferer from hay fever. It is probable that +pollantin is based on the wrong principle, that hay fever is not, like +diphtheria, a poisoning by a toxin to be antidoted by an antitoxin. +However, to Dunbar belongs the credit of first attempting to put the +treatment of hay fever on a scientific basis and he introduced the +method of testing the patient that has been followed by all later +workers, dropping the pollen extract in the eye. + +In the _Centralblatt für Bakteriologie, Referate_, xxxvi, s. 453, there +is an account of a most unseemly quarrel between Dunbar and Weichardt, +the latter claiming that before leaving Hamburg, he suggested the idea +of pollantin to Dunbar. Weichardt has since put on the market another +hay fever specific, called _graminol_, which is the blood-serum of +cattle that have fed on the offending grasses during the hay fever +season. The theory is that the blood of the cow contains antibodies to +those grasses and that passive immunity can be conferred on the hay +fever patient by transferring those antibodies to his blood. + +This is the old, old experiment that has been tried so many times in +many diseases and has so often failed. It reminds us of the many +attempts to confer on the tuberculosis patient the natural immunity +possessed by the jackass by injecting the patient with the blood serum +of that friend of man. The result of these experiments left some doubt +as to who merited most the name of jackass, the doctor, the patient or +the patient beast. Both pollantin and graminol have been praised highly +in Germany but neither of them have succeeded so well in this country. +Perhaps a shrewd advertising campaign had something to do with it; for +the combination of a German scientist and his manufacturer can give +points to any Yankee in exploiting the public with sure cures for the +sick. + +=Active Immunity.= In active immunization, the real pioneers, after +Mithridates, were the homoeopaths, who, for many years, have given +small doses of poison ivy to prevent ivy poisoning and small doses of +the poisons of infectious diseases to prevent and cure those diseases; +but the homoeopath did not realize the transient nature of immunity +and the necessity for continuing the treatment for many months or years, +nor did he adopt the principle of increasing the dose to the point of +toleration. + +The first to attempt active immunization and cure of hay fever by +injecting extracts of the pollen that causes the disease appears to have +been Noon, working in Wright's laboratory in London. The work was +continued by Freeman, their work being reported in the _Lancet_, 1911, +i, page 1572 and ii, page 814. They found the English spring form of hay +fever due to the pollen of grasses. By dropping extracts of various +pollens into the patient's eye, after the manner of Dunbar, they +concluded that their patients were most sensitive to timothy grass and +they used timothy extract exclusively in the treatment. Freeman states +explicitly that a patient immunized against timothy grass is immune to +all other grasses of that season; that it is unnecessary to immunize +him to each particular grass, thus differing from some of our American +observers who use the skin reaction to determine the particular pollens +to which the patient is sensitive and inject every one of those pollens +in the treatment. + +Independently of these British observers, Karl Koessler, of Chicago, in +1910, attempted to immunize patients against hay fever by injecting +pollen extracts. Like Noon and Freeman, he used the eye reaction to test +his patients and found them most sensitive to rag weed. Just as the +Englishmen had used only timothy grass in their cases, Koessler used rag +weed exclusively. His work is reported in his article on Hay Fever in +Forchheimer's _Therapeusis_, Volume V and also in the _Illinois Medical +Journal_, 1914, page 120. + +=Selecting the Pollen. The Skin Reaction.= The next step in the +development of the pollen treatment was to substitute the skin reaction +for the eye reaction in testing the patient's sensitiveness to various +pollens. The advantage of the skin reaction over the eye reaction is +that it permits testing many pollens at the same time and does not +distress the patient as does a sharp eye reaction. + +While Noon and Freeman selected the one typical pollen of spring, the +timothy grass pollen, and Koessler selected the typical fall pollen of +the American hay fever, rag weed, for all cases of that season, later +workers, using the skin reaction, go to the extreme of injecting the +patient with each and every pollen to which his skin reacts. Oppenheimer +and Gottlieb carry this individualization to the point of attempting to +discriminate by the skin test the patient's varying resistance to his +different pollens at each treatment. This resistance may rise for some +and fall for other pollens so that six or eight different pollens in +different doses must be injected separately at each treatment. This is +individualizing the case with a vengeance and requires an expenditure of +time and skill (I almost said _skin_) that must be rather expensive for +the patient. + +A series of light scratches are made on the skin of the forearm or the +inner side of the arm where the skin is delicate. The scratch must be +only superficial and not draw blood. Really the best method is to make +a round denuded spot by twirling a small brad-awl. A drop of extract of +different pollens or a speck of the pure pollen protein is rubbed into +each scratch and the result awaited for fifteen minutes. Within that +time, a redness and swelling, like a hive or a bite, will appear at some +of the scratches. + +This swelling is the skin reaction to that pollen. Its appearance +indicates the presence in the skin of reaction bodies to that pollen. It +is argued, and partially proved by practice, that the pollens to which +the skin reacts are the pollens to which that patient has been +sensitized and these pollens are selected for administration. + +=The Dose.= The first dose of pollen extract is the danger dose and +differs for each patient according to his susceptibility for a given +pollen. It is determined by dropping the pollen extract into the eye or +rubbing it on the skin. To avoid anaphylactic shock, this dose must be +incredibly small. Noon and Freeman's first dose was one-third c. c. of +the weakest dilution of which one drop in the eye would cause +hyperaemia. This was usually four drops of a millionfold dilution in +water. Later doses were never more than 1 c. c. of a 1 to 100,000 +dilution "to avoid unpleasant reactions." + +Goodale begins with five drops of that dilution that just fails to cause +a skin reaction. Later, to avoid the risk of shock, he advises one-tenth +of this dose. + +Koessler's theoretical initial dose of rag weed extract is one drop of +the weakest dilution that will just redden the conjunctiva. As he finds +rag weed more toxic than the English timothy, his actual first dose is +one-half of this theoretical dose. The actual first dose will vary from +one drop of a 1 to 1,000,000 to one drop of a 1 to 20,000 dilution, the +smaller of which he estimates to contain of pollen protein one +one-hundredth part of a millionth of a gramme or .000,000,01 gramme. + +Shade of Samuel Hahnemann, the first and greatest homoeopath! And they +drove you out of Leipzig into poverty and exile for teaching that in +using drugs that are similar to the disease there is serious danger of +aggravating the disease; that the dose must be extremely small; and that +disease so sensitized the patient that a dose so small as to be +inappreciable in health becomes active in disease! + +The smaller doses of pollen extract are given every three or four days +and increased as rapidly as possible, judging the increasing tolerance +or resistance by a diminishing eye or skin reaction. With larger doses, +the interval is longer, a week or ten days. The pioneer, Noon, and all +workers since, warn against increasing the dose too fast, for the +reactive power of the patient is easily exhausted, his resistance +lowered and he may be left more sensitive than before. + +=Dangers of Pollen Injections.= Treatment by pollen injection is beset +with dangers for the unlucky patient. It has been noted how Dunbar +nearly killed his first patient by injecting the serum of the horse that +had been immunized to pollen. All experimenters, without exception, say +that the injection of pollen extract is attended with danger to the +patient, danger of anaphylactic shock, and warn against the use of any +but the most infinitesimal doses. The hay fever patient is a human being +who, in some way, has been sensitized to pollen. He is in a state of +exquisite anaphylaxis and a dose of pollen injected into his blood may +kill him in twenty minutes. Goodale reports shock (faintness, nausea, +vomiting) in two patients following the mere rubbing of a drop of pollen +extract into a scratch on the skin. Evidently the scratch was too deep +and the pollen poison was absorbed rapidly into the blood instead of +being stopped by the deep epithelia. I have seen a similar absorption +and general reaction in children after a skin test with tuberculin, when +the tuberculin entered the blood through too deep a scratch. + +Another danger lies in the instability of the pollen extracts. Koessler +expressly warns against commercial preparations of pollen protein +because of the danger of decomposition. His extracts do not keep more +than three weeks and are dangerous to use after that time. On the other +hand, Goodale, making his extracts with 15% alcohol, reports them as +active and fit for use after more than one year. Oppenheimer and +Gottlieb object to commercial preparations on different grounds. The +commercial preparations contain many different pollens so as to be sure +to include those to which the patient is sensitive. They point out that +in these mixtures, the dose of the individual pollens cannot be adjusted +to the changing conditions of the patient and, in addition, injecting +into the blood of the patient pollens to which he is not already +sensitive may sensitize him to these pollens also and leave him worse +than before. + +There is the lesser danger that the patient will not be immunized by the +injections but become more sensitive to his old pollens than he was +before, as Noon pointed out in his first paper; for artificial immunity +is a difficult thing to control and is by no means as easy as it looks +in the book. Nor is it as easy to immunize a human being over many years +of life, subject to so many conflicting influences, as it is to immunize +a guinea-pig living in a cage. + +To lessen the dangers and enable the patient to keep up his immunization +for many months and years, Goodale borrowed an idea from Schloss, who +fed his egg-oat-meal-almond anaphylaxis patient minute doses of these +foods until he so raised his resistance that he was able to eat them in +ordinary quantities without harm. Such artificial resistance must be +kept up by eating a small quantity of the food each day or it will be +lost (old King Mithridates again). As most of the pollens are not edible +and as patients react to botanically allied plants, Goodale tried +feeding the patient over long periods of time with vegetables and edible +plants that were allied to the offending pollens, expecting that, as in +Schloss's patient, some minute part of the protein would pass unto the +blood unchanged and maintain the protection. So far, these feeding +experiments have failed. Trial with homoeopathically potentized +pollens over long periods of time has not been made. + +=Conclusions on Pollen Extracts.= My conclusions on the pollen treatment +are that it is in line with our best practice of immunity but that it is +still in an experimental stage, the pollens are possibly dangerous even +in the hands of a skilled immunologist. In a disease that is usually so +easily controlled by rosin-weed, faradism and ichthyol, I would not +expose a hay fever patient to the very real danger of anaphylactic +shock. The conditions governing immunity stated in the beginning of this +chapter still hold good. It is transient. Already some of the early +workers have discontinued the practice. The despair of Goodale has been +quoted. Scheppegrell, probably the first in this country to use the +pollens, has given them up and advises the patient to keep away from his +irritant and to have the weeds cut in all cities as the best treatment +obtainable (_Journal of the A. M. A._, March 4, 1916, page 710). The +most hopeful aspect of the pollen extracts seems to me to be their +administration all around the year in high dilutions, _more +homoeopathico_, and to this practice I believe the immunologist will +eventually come. + +=Pollen Extracts not Vaccines.= Some manufacturers and all British writers +speak of pollen extracts as _vaccines_ and of immunizing the patient as +_vaccination_. This seems an unnecessary confusion. We have two kinds of +vaccines already, the cow-pox vaccine and the killed cultures of +bacteria introduced by Wright. For an account of the use of these +vaccines in hay fever, we will pass to the next chapter. + + + + +CHAPTER XII + +_THE BACTERIAL VACCINES_ + + +In his paper in _The Lancet_, the pioneer in the use of pollen extracts, +Freeman, observed that "many cases of supposed hay fever" were simply +acute bacterial catarrhs. He excluded hay fever by the lack of any +reaction when timothy extract was dropped into the eye. The bacterial +infection was proved by culture from the eyes and nose, usually yielding +the staphylococcus. The final proof was the cure of the patient by an +autogenous vaccine made of the offending microbe. In the past few years, +this observation has been confirmed and many cases of cure of "hay +fever" by bacterial vaccines have been reported in the journals. The +bacteria were chiefly staphylococci, rarely the pneumococcus or the +micrococcus catarrhalis. + +Oppenheimer and Gottlieb report cases of mixed hay fever where the skin +reacts to pollen but the pollen extract failed to cure. In these cases, +they found a bacterial catarrh of the eyes and nose. They suppose a +vicious circle, the catarrhal inflammation and the hay fever +sensitiveness mutually interfering with each other's recovery and they +succeeded in curing the patient by using the appropriate pollen extract +and the bacterial vaccine at the same time, believing that while the +pollen extract was raising resistance to the pollen poisoning, the +bacterial vaccine was raising resistance to the bacterial catarrh. + +While hay fever is not strictly a catarrhal inflammation, the cure of +hay fever by curing a coexisting catarrhal rhinitis or conjunctivitis +seems easily possible. The surgeons taught us long ago that some cases +of "hay fever" need nothing but good drainage of the nose, which they +secured by freeing the nose from obstruction. Every physician sees mild +cases of hay fever recover on various popular catarrh treatments. The +tablets sold by homoeopathic pharmacies, containing iodide of arsenic, +naphthalin and quillaya, cure many cases of hay fever and these are the +same drugs that cure catarrhal rhinitis. It is easily possible that my +old inheritance, rosin weed, cures hay fever by curing the coexisting +catarrh; for it was a famous remedy among the eclectics for catarrhal +inflammation of the nose, throat and bronchial tubes. + +If, then, operations or remedies that cure catarrhal rhinitis cure also +some cases of hay fever, there is nothing inherently improbable in +expecting the bacterial vaccines to cure some cases of hay fever, for +the vaccines have made many cures of catarrhal inflammation. However, +the physician using them should understand that they are not specific +drugs against the pollen anaphylaxis but against a supposed catarrh or +bacterial infection. He will be well advised to control the treatment by +taking cultures from the nose to make sure that the bacteria are there, +determine the variety present and, if possible, have an autogenous +vaccine made up for treatment. + +I have no personal experience with the vaccines in the treatment of hay +fever, though I know their value in ordinary catarrhal conditions. As +remarked in the chapter on Pollens, I have succeeded with the milder +methods of rosin-weed, faradism and ichthyol. However, bacterial +vaccines are much safer than pollen extracts, the technique of their +use is not as complicated and they are well worthy of trial in +refractory cases if bacteria are demonstrated in the eyes and nose. I +might remark here that this demonstration will seldom fail; for you can +get a culture of the staphylococcus from almost any nose. + +=The Word Vaccine.= Used in connection with the treatment of hay fever, +the word _vaccine_ is confusing, for it has been applied to two totally +different kinds of medicine, the bacterial vaccines and the pollen +extracts. Physicians intending to use _vaccines_ in the treatment of hay +fever should make sure which they are using; for the methods and dosage +of the one are quite different from those of the other. Sir Almroth +Wright, to whom the whole world is indebted for his work in preventive +medicine, started the trouble by calling his killed bacteria _vaccines_, +having in mind the prevention of bacterial diseases as the familiar +vaccine prevented small-pox. Now, _vacca_ is Latin for cow, _vaccinia_ +is properly cow-pox and the virus of cow-pox that we use in vaccination +against small-pox is properly called _vaccine_. With a paucity of +vocabulary unexpected in an Irishman, Wright called his killed bacteria +_vaccines_ because he used them to prevent disease, using the word as +synonymous with _preventive_. As cow-pox vaccine is the greatest +preventive we know, the word _vaccine_ might be justified when applied +to the bacterial cultures or to the pollens or to any preventative of +disease. But when you leave pure prevention and apply these remedies to +the _cure_ of disease, the word _vaccine_ loses even this shadow of +justification and the present confusion results. One American house +makes a laudable attempt at a more exact terminology by calling the +killed cultures of bacteria _bacterins_. Still, the word _vaccine_ for +killed bacterial cultures has been advertised so deeply into the medical +mind that it is firmly rooted there and not likely to be disturbed by +mere considerations of etymology. As for the pollen extracts, they are +yet young and impressionable. It would be better to leave off the word +_vaccine_ as applied to them and call them what they are, _pollen +extracts_. + + + + +CHAPTER XIII + +_DIET_ + + +Until recently, diet in hay fever was a matter of avoiding meat and +strawberries and the result was usually unsatisfactory. With the +conception of hay fever as an anaphylaxis and the recent studies in food +anaphylaxis, the subject of diet in hay fever assumes a new and inviting +aspect. + +This new view of diet in hay fever begins with Schloss's masterly study +of a case of food anaphylaxis reported in the _American Journal on +Diseases of Children_, 1912, No. 6. A good review of the subject with +references to the literature will be found in the special Hay Fever and +Anaphylaxis number of the _Boston Medical and Surgical Journal_, August +10, 1916, especially the article by Talbot. + +Some physicians have long insisted that they could relieve hay fever by +diet. For instance, I once asked a physician of large general practice +what he did for hay fever. He smiled in an incredulous way that I have +noticed before among people who never had hay fever and replied, "I find +that if people will stop eating strawberries and not eat too much meat, +they soon get rid of their hay fever." This answer surprised me for I +knew that in his long practice, he must have seen many cases of hay +fever and my experience had been that diet had no influence on the +symptoms. + +Then, there is Professor Dunn, already quoted in Chapter IX, who +believes in the uric acid theory and says that, in his opinion, "hay +fever is the result of improper eating and living." He has been able to +prevent the annual attacks by using cold baths and excluding meat, tea, +coffee and alcohol from the diet. + +Any patient who can get rid of the annoying symptoms of hay fever by +such simple means of diet and bathing should be urged to try it, whether +he believes or disbelieves in the "uric acid poisoning" on which the +treatment is based. My own experience leads me to believe that most hay +fever patients require something more than dietary regulation to control +the disease. For instance, in my own case, the disease appeared at an +age when I had never taken tea, coffee or alcohol, during the summer +vacation when I was living a hygienic out-door life, playing ball, +cycling and swimming every day in the salt water. I remember one summer +in camp by a lake among the pines, in which I lived Dr. Dunn's hygienic +life for many weeks, drinking no tea, coffee or alcohol, eating chiefly +fresh fish and green vegetables and swimming daily. My experience can be +paralleled by many hay fever patients that as long as I remained among +the pines, I was in perfect health but on going down into the valley, +one breath of fragrant wind blowing over the fields would cause instant +itching and swelling of eyes and nose and all the previous hygienic life +up at the lake was no protection against the disorder. I have seen the +hereditary form develop in three children of one family while they were +at the seashore, bathing daily in salt water and living a care-free, +active, out-door life, never taking tea, coffee or alcohol and not much +meat. + +So, I concluded long ago that there must be two kinds of hay fever, one +kind curable by diet, bathing and exercise and another kind in which +habits of living and eating made no difference; and I had seen mostly +the other kind. + +Now, there may well be cases of hay fever as there are known to be cases +of that other anaphylaxis, asthma, that are pure examples of food +anaphylaxis. In such a case, detecting the irritating food and removing +it from the diet is the proper path to cure. The error in our former +practice was to divide foods into good and bad for certain diseases. We +should rather think of foods as good or bad for a particular patient. + +The plain people long ago crystallized their experience in diet in the +maxim that what is one man's meat is another man's poison, but your +scientist will never believe anything until he sees it in a test-tube +and physicians have kept on a few centuries behind the rest of the world +prescribing _diet_ for all cases of the same disease irrespective of +whether or not it agreed with the patient. Witness the rigid _diets_ for +tuberculosis and Bright's disease. So, inevitably, there had to be a +_diet_ for hay fever and equally inevitably, the same diet did not agree +with everybody. + +Scientific men are fond of stating in scientific terms what everybody +else knows already. While we have known for a long time that some foods +did not agree with everybody, science is just now demonstrating that one +man's meat is literally another man's poison by testing the different +food proteins on the skin and calling the condition _food anaphylaxis_ +or _food allergie_. + +As the patient reader of the chapter on Pollens will remember, the +anaphylaxis or sensitiveness of the patient to particular pollens is +tested by rubbing a speck of different pollens into scratches on the +skin. This skin reaction as a test of anaphylaxis was used by Schloss +with different foods before it was adopted in hay fever; and it has been +taken up by the dermatologist also. The dermatologist has long suspected +that certain skin diseases, as urticaria, and eczema, are aggravated or +produced by certain foods but he has been unable to demonstrate just +what foods were at fault. The problem was confused by the fact that he +had found no guiding principle. Food that one patient could eat with +impunity brought out a beautiful eczema or urticaria on another +patient. The uric acid theory was one effort to solve this problem but +it was not comprehensive enough and it was not true. Forbidding +_nitrogenous foods_ has been a favorite formula with some and they +straightway advised milk, which is highly nitrogenous. The recent +recognition that food sensitiveness is an anaphylaxis and the detection +of the foods at fault by the skin reaction may supply the missing +guiding principle that was needed to adjust a diet to the individual +needs. + +The poisonous element in food is the protein. The food itself will serve +for the skin test but it is better to use the pure food protein, which +gives clearer reactions and avoids contamination. Proteins of all our +common foods are now obtainable in the drug trade put up in tiny +capsules ready for the test. + +The skin is cleansed with soap and water and dried. A number of little +spots are denuded of their superficial epithelia by twirling a small +brad-awl, which should not scrape deeply enough to draw blood. Most +workers speak of scratching the skin but the brad-awl scrapes to the +proper depth more quickly and easily. The spots are marked with the +names of the foods to be tested, as milk, beef, potato, oats, etc., and +a drop of a five per cent solution in water of the respective proteins +is rubbed into the spots. One spot is left as a control, into which +normal saline or 3% solution of milk sugar is rubbed, as the proteins of +commerce are made up with milk sugar. Within five or ten minutes, there +appears a redness and swelling, as with the pollens. As with the +pollens, a patient who at any time has been poisoned or, as we now say, +_sensitized_ by any of these foods, still has circulating in his blood +or fixed in his skin the reactive bodies to that food. These reaction +bodies react to that food on the skin by redness and swelling. Food +proteins that cause no redness and swelling are thought harmless for +that patient. Foods that cause the reaction are thought to be those to +which the patient has been sensitized and to which he has not developed +or maintained an efficient defence. There is a contradiction here; for +the reaction merely shows the presence of defense bodies in the blood +and does not tell us whether that defence is or is not efficient. +However, even if the argument limps, the results reported are +encouraging. Some striking cures have been reported by simply excluding +these foods from the diet. The test is simple and harmless if the +scratch is not too deep and _if the protein is not injected beneath the +skin_. If injected beneath the skin or rubbed into a deep scratch, the +food proteins, like the pollen proteins, may be dangerous. If they are +absorbed rapidly into the circulation of a patient who happens to have +been sensitized to any of them, there is serious danger of anaphylactic +shock. + +If these observations prove reliable, here is a method of selecting a +diet for the individual patient that surpasses in accuracy anything that +we have ever known. If hay fever is ever a food anaphylaxis, this method +of testing the food sensitiveness of the individual patient promises +much; but these observations are still too new and unconfirmed and the +skin reaction too uncertain to rely on it implicitly yet. There was a +time, back in 1908 to 1910, when the skin reaction for tuberculosis too +was highly valued. Enthusiasts proposed to test all the school children +and all the soldiers and all the factory workers and segregate the +tubercular by the skin test. The diagnosis of tuberculosis was to be put +in words of one syllable. + +That dream is over. Tuberculin skin reactions have now been made by the +million and we know that a positive reaction means nothing but that, at +some time, the patient has been infected with tuberculosis. The skin +test does not tell us whether he has recovered long ago and built up a +good defense or whether he is still sick with tuberculosis and will die +of it. It reacts equally well in the healthy, vigorous subject who at +one time has had a mild tuberculosis and recovered, in the patient with +early phthisis and in the advanced case. In Kraus and Levaditi's +_Handbuch der Technik und Methodik der Immunitätslehre_, 1911, page 205, +von Pirquet himself, the grandfather of all the skin tests, says, "A +positive skin reaction indicates with certainty that the organism has +been infected with tuberculosis. Of the localization, extent and +prognosis of tubercular infection, a positive skin reaction gives no +conclusion." Yet hundreds of physicians to-day are making diagnoses of +tuberculosis by the skin test; for if there is one thing more difficult +than to get a new idea into a doctor's head, it is getting it out again +when the idea proves fallacious. So, I view these skin reactions for +food and pollens with some suspicion of their real value in diagnosis +and prognosis and as guides to treatment. Still, Talbot says, +"Experience has shown that when a positive skin test is obtained for a +food and that food is then excluded from the diet, the general condition +of the patient almost invariably improves and in many instances a cure +results." May his words prove true. + + + + +CHAPTER XIV + +_ROSIN-WEED AGAIN HISTORICAL AND PHARMACOLOGICAL_ + + +When we wish to learn anything about American medical literature, we +turn to the big Index Catalogue of the Library of the Surgeon-General. +The botanical name of rosin-weed is _silphium_. In the Index Catalogue, +the word _rosin-weed_ does not appear, but, in the first series, under +_silphium_, there are ten references, and thereby hangs a tale. + +=Ancient Silphium.= In ancient Greek and Roman medicine there was a famous +gum called _silphion_ (Latin _silphium_) which, like all popular +medicines, was the better for being brought from a far country and for +being a little mysterious; for it was brought across the Mediterranean +from Cyrene, where it had been originally presented to the inhabitants +of that favored place by the gods. Learned botanists have discussed at +length what plant produced this gum and have concluded that, like its +neighbor in Egypt, the papyrus plant, it has disappeared from the +earth. Even in Dioscorides' time the plant was getting scarce and there +came a day when in all Cyrene there remained only a single silphium +plant, which was piously presented to that worthy representative of the +gods, the emperor Nero. + +In the year 1817, an Italian, Della Cella, returning from an expedition +of the Egyptian Pasha against the neighboring Arab tribes, reported that +he had discovered the ancient silphion growing on the site of old +Cyrene. He brought back specimens of the plant which were identified as +a species of thapsia. Several expeditions brought back more specimens +but there was little general interest until Laval, in 1859, saw the +commercial possibilities in a revival of this wonder-medicine and put +the famous old cure-all on the market as a specific for consumption, +under the name of _silphium Cyrenaicum_, backed by the endorsement of +all the ancients from Hippocrates to Pliny. Seldom has even a French or +German drug house found so distinguished a company of medical +authorities to endorse its wares. Whereat, there began a brisk +discussion in the European journals, first, whether the ancient +silphion had been found and, secondly, whether, if found, it was worth +anything. Both questions being finally decided in the negative, the +ancient silphion passes again into the twilight of tradition; all of +which entertaining tale may be read at great length in the _Dictionnaire +Encyclopædique des Sciences Médicales_, Paris, 1881, Volume 9. + +Now, with one exception, all the references to _silphium_ in the Index +Catalogue refer to this _silphion_ controversy and have nothing to do +with our American _silphium_ or _rosin-weed_. The exception is the +reference to Dr. Goss, to be related presently. + +=The American Silphium.= On the American prairies from Ohio south and west +to Texas, as far north as Wisconsin and south to Florida, there grows +abundantly a plant unknown in Europe and better known here to botanists +than to physicians. From the gummy juice that exudes from the leaves and +stem, Linnæus himself named the genus _silphium_ in memory of the +ancient silphion of Cyrene and the plain people called it _rosin-weed_. +There are more than twenty species of rosin-weed or silphium, all +probably similar in their medicinal virtues. The species that we have +used in hay fever is the _silphium laciniatum (Silphium gummiferum, +Ell.)_ This species is known also as the compass-plant or pilot-weed +because the large lower leaves present their faces north and south, as +we may remember from our boyhood tales of the plains where the trapper +never lost his way because he had simply to look down at his feet and +there was the compass-plant pointing faithfully to the north. + +=Rosin-Weed among the Indians.= This rosin-weed is not a poisonous plant. +Children all over the west gather the resin for chewing-gum as the +Indians did before them and horses eat it freely, being thereby +protected from the heaves, as the frontier tradition goes. Rosin-weed +was valued highly by the Indian. He chewed the gum to make his breath +sweet and drank a decoction of the root to make him live forever. The +rosin-weed of the Indian is the parallel of the ancient silphion, the +opoponax or _all-healing juice_ of southern Europe, the spruce gum and +pine tar of rural America and the more valued resins of the East where, +in Othello's time, the trees dropped down their medicinal gum; for we +find the native gums used all over the world for the same diseases, +cough and consumption and urinary distress, always with a dash of +mystery and the idea of prolonging life. + +=Rosin-Weed among the Eclectics.= One would have thought that the early +American botanic physicians who worked so industriously to introduce +American plants and who learned the use of many native plants from the +Indians, would have adopted such a popular remedy but I find no mention +of it in their books. The learned writer in the _Dictionnaire des +Sciences Médicales_ was correct in writing, in 1821, Volume 51, page +312, that there were several varieties of silphium, all growing in +America, but that none of them as yet had been used as medicines. + +It was reserved for a successor of the old botanic school, an eclectic +physician, Dr. H. B. Garrison, to introduce rosin-weed into medical +practice as a specific for asthma in an article in the _Eclectic Medical +Review_ in 1868. This article was abstracted in the _Pacific Medical and +Surgical Journal_, in the _Nashville Journal of Medicine and Surgery_ +and in Francis Porcher's _Medical Botany of the Southern States_, second +edition, 1869 (not in the first edition of 1863). Dr. Garrison noted +also the popular belief that heaves or asthma did not exist in horses on +the prairies where this plant grew. + +For a few years, rosin-weed became popular and was widely commented on +in the eclectic journals; but it soon dropped out of sight and is not to +be found in any eclectic text books to-day. + +ROSIN-WEED AMONG THE HOMOEOPATHS. Rosin-weed comes into the +homoeopathic school through "the indefatigable Dr. Hale," as Richard +Hughes calls him. The homoeopathic school owes much to Dr. E. M. Hale, +who enriched our materia medica with many American plants, most of them +drawn from the eclectic school and, be it noted, Dr. Hale gives full +credit to that school from which the new medicines came. Dr. Hale did +masterly work in proving the new remedies and verifying the observations +of the eclectic physicians and published his _Characteristics of New +Remedies_ in 1864. In 1868, Dr. Garrison published his paper on the use +of rosin-weed in asthma and Dr. Hale, in his third edition of 1873, +included rosin-weed under the name _silphium laciniatum_, as follows: + +SILPHIUM LACINIATUM +_ROSIN-WEED_ + + Syn. (page 544) Compass-plant, Polar-plant, Rosin-weed. + + Analogues, Cubeba, Copaiva, Terebinthina. + + Officinal preparations.--Tincture of leaves: dilutions. + + Catarrhal affections and diseases of the mucous + membranes.--Eclectic. + + Chronic catarrh of the nasal passages. + + Chronic laryngitis and bronchitis. + + _Asthma_, hurried (breathing?) with concomitant catarrhal + affections of the bronchial mucous surfaces. + + (It is a popular domestic remedy in _asthma_. Eclectic physicians + value it highly in throat affections. Some homoeopathic + physicians, Drs. Small, Kendall and others have used it with + gratifying results.--Hale.) + + _Horses_ that eat of the leaves mixed in hay are cured or relieved + of the _heaves_ and chronic loose cough. + + Catarrh of the bladder. + +Dr. Hale did not prove this remedy. All symptoms except the last one are +clinical, that is, they disappeared while the patient was taking the +remedy but they have not been produced on the healthy. The last symptom +is a pathogenetic symptom verified by cure. There is, however, a proving +of silphium but it is buried deep in the dust that covers old reports +and has not seen the light of day for many a year. I reprint it here +from the _Hahnemannian Monthly_, Volume 8, June, 1873, page 536, from +the report of a meeting of the Philadelphia County Homoeopathic +Society. + + "Silphium lac.--Dr. G. A. Hall, in the April number of the Medical + Investigator gives a summary of a proving. (The first decimal + trituration was given in doses of two grains gradually increased to + ten grains every two hours.) + + "It produces a scraping, tickling and irritation of the fauces and + throat; nausea, sick, faint feeling and a sense of goneness in the + epigastrium; a desire to hawk and scrape the throat, throwing off a + thin viscid mucus. The irritation extends up the posterior nares, + involving the mucous membrane of the nasal passages, producing + sneezing, followed by a discharge of limpid, acrid mucus from the + nose, attended with constriction and pressure in the supra-orbital + region. Engorgement and thickening of the mucous membrane of the + throat as far down as could be seen; rough cough, attended with + the expectoration of yellow mucus; contraction and tightness of + lungs, constant disposition to raise; hacking, spasmodic cough; + tongue covered with whitish slimy coat attended with dry sensation + as if burned with hot soup; urine high colored and scant, frequent + passages with sense of heat at the meatus urinarius during passage + of urine; stools natural in form but covered with whitish, slimy + mucus. An internal feverish sensation; pulse not accelerated; want + of appetite. + + "=Clinical Observation.= For ten years, I have used silphium in + asthma with large quantities of stringy mucus, in influenza, + coryza, catarrh, and believe it to be the best remedy we have in + phthisis when gray or yellow mucus is expectorated copiously, + causing rapid exhaustion. I use the second decimal trituration in + one or two-grain doses every two hours until expectoration is + diminished perceptibly and then at intervals of four or six hours + until expectoration is diminished to a degree consistent with other + symptoms of the case." + + +In spite of this good start, rosin-weed did not have any better fortune +with the homoeopaths than with the eclectics. It never got into the +text books. After transient popularity in the journals, it sank back +into obscurity and has remained as a remedy for asthma in the memory of +a few of the older practitioners from whom it is occasionally handed on +by oral tradition. + +It was in 1872 when rosin-weed was enjoying its brief publicity and when +the epidemic of epizoötic among the horses created a public interest in +veterinary medicines, that my father, Dr. Alexander H. Laidlaw, +discovered its remarkable curative power in hay fever, as related in +Chapter II. + +=Rosin-Weed among the "Allopaths."= Rosin-weed never got into the +Pharmacopoeia but it is none the worse for that. More people have been +poisoned by the drugs inside of the Pharmacopoeia than by those +outside of it. Except the few comments by western and southern medical +journals, it was practically unknown in the dominant school, as shown by +there being only one reference to it in the Index Catalogue. This is an +article by Dr. Q. J. M. Goss, of Marietta, Georgia, in the _Nashville +Journal of Medicine_, 1887, xx, page 60, in which Dr. Goss praises +rosin-weed highly for its power to cure catarrh of the mucous membranes, +comparing it to the balsams, cubeb and turpentine, and relating the cure +of two cases of asthma. + +In the Library of the New York Academy of Medicine, there is a thin +pamphlet by Dr. Goss, entitled _New Medicines_, which I suspect to be +taken chiefly from Dr. Hale's _New Remedies_, in which he says of +silphium laciniatum, "It has proved for me one of the best remedies in +humid asthma. I have made several brilliant cures with the tincture of +this plant and the tincture of ptelea trifoliata in doses of 30 drops +each four times a day in simple elixir.... In acute diseases of the +mucous membranes, the dose should be small, 5 to 10 drops; but in +chronic inflammation, the dose may be 30 drops of the saturated +tincture. It is a valuable remedy in chronic bronchitis and tracheitis. +It will soon become a popular remedy in mucous diseases." + +This prophecy of popularity was scarcely borne out; for, with the +exception of the article by him in 1887, rosin-weed drops out of sight +and is found in no books published in the last forty years. + +=Pharmacology.= For the following information, I am indebted to the +Botanical Department of Parke, Davis & Co., whom I wish to thank for +their unfailing courtesy in replying to my inquiries about this little +known plant: + + "Rosin weed is a general name for all species of the genus + _silphium_ of which there are more than twenty species; some of + these species, however, have special names. Three species are + usually mentioned as being used for medicinal purpose. We list them + with their synonyms as follows: + + Silphium perfoliatum, Lin. Indian cup, ragged cup, cup plant, rosin + weed. + + Silphium terebinthinaceum, Lin. rosin weed (true), prairie dock. + + Silphium laciniatum, Lin. Syn. S. gummiferum, Ell. compass-plant, + polar plant, pilot plant, rosin weed. + + It is more than probable that all the species of the genus are + equally effective from a therapeutic point of view." + + +We have always used the fluid extract of the herb. Goss and Hale used +the tincture of the fresh leaves and so the homoeopaths have always +used it. Since looking into the history of the plant, I recall a remark +of that wise old physician, Rademacher, in regard to chelidonium. _Ich +bin kein Freund von Extrakten._ He preferred the tincture of the fresh +plant. Tinctures of the fresh plant were Hahnemann's preference too, and +it may well be that with rosin-weed also, the tincture preserves the +medicinal power better than the extract. + +=Mode of Action.= If the proving of rosin-weed made by Dr. Hall is +reliable, we must conclude that rosin-weed cures the symptoms that it +produces in the healthy and it must be regarded as acting on the +homoeopathic principle. I must own that I am a little suspicious of +provings that match so closely the long established popular use of a +drug and, in this case, believe that we must wait for confirmation of +this proving before accepting it as sound. Rosin-weed has always seemed +to me to be a harmless herb, which is shown also by its use among +children as chewing gum. I have never noticed the "tonic, diaphoretic or +diuretic effects" attributed to it in eclectic medicine and believe that +they must be feeble. The only unpleasant effect that I have noted is +nausea after large doses, sixty drops or more, and this in very few +patients. Vomiting is rare, is never serious and ceases spontaneously +when the stomach is empty of the drug. + +At the Baltimore meeting of the American Institute of Homoeopathy, +where the use of rosin-weed in hay fever was first reported, Dr. John +Sutherland, of Boston, made the proper criticism that if rosin-weed was +harmless and could not produce any effect on the healthy body, he could +not understand how it had any power to cure. To this, I had no answer +except that I had both taken and given large doses for many years to +patients of all ages and had never seen any symptoms develop. Another +speaker suggested that, like calcarea and silica, potentization would +develop pathogenetic powers that were not evident in the crude drug. +This I have never tried. As related in the chapter on Bacterial +Vaccines, I suspect that the curative power of rosin-weed in hay fever +lies in its power of relieving a coexisting catarrh, of which theory we +have the confirming evidence that other methods that cure catarrh, nasal +operations, bacterial vaccines, homoeopathic remedies, have often +cured a coexisting hay fever. Since that discussion, I have found Dr. +Hall's proving. It would be a pleasure to find that our old family +remedy for hay fever really acts on the homoeopathic principle but I +believe that the question needs the verification of further proving. + + + + +Transcriber's Notes: + + Footnotes have been placed at the end of chapters. + Obvious punctuation errors repaired. + All oe ligatures have been replaced with "oe" (eg: "homoeopathic") + + page 52 "posioning" changed to "poisoning" (uric acid poisoning) + page 57 "familes" changed to "families" (gouty familes are especially) + page 69 "urid" changed to "uric" (so-called uric-acid disorders) + page 95 "Immutiny" changed to "Immunity" (Passive Immunity) + page 97 "Inthe" changed to "In the" (In the Centralblatt für) + + + + + +End of the Project Gutenberg EBook of The Treatment of Hay Fever, by +George Frederick Laidlaw + +*** END OF THE PROJECT GUTENBERG EBOOK 40287 *** |