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diff --git a/40287-8.txt b/40287-8.txt deleted file mode 100644 index 21488f2..0000000 --- a/40287-8.txt +++ /dev/null @@ -1,2896 +0,0 @@ -Project Gutenberg's The Treatment of Hay Fever, by George Frederick Laidlaw - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org - - -Title: The Treatment of Hay Fever - By rosin-weed, echthyol and faradic electricity, with a - discussion of the old theory of gout and the new theory - of anaphylaxis - -Author: George Frederick Laidlaw - -Release Date: July 20, 2012 [EBook #40287] - -Language: English - -Character set encoding: ISO-8859-1 - -*** START OF THIS PROJECT GUTENBERG EBOOK THE TREATMENT OF HAY FEVER *** - - - - -Produced by Bryan Ness, Griff Evans and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive/American Libraries.) - - - - - - - - - - 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 THIS PROJECT GUTENBERG EBOOK THE TREATMENT OF HAY FEVER *** - -***** This file should be named 40287-8.txt or 40287-8.zip ***** -This and all associated files of various formats will be found in: - http://www.gutenberg.org/4/0/2/8/40287/ - -Produced by Bryan Ness, Griff Evans and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive/American Libraries.) - - -Updated editions will replace the previous one--the old editions -will be renamed. - -Creating the works from public domain print editions means that no -one owns a United States copyright in these works, so the Foundation -(and you!) can copy and distribute it in the United States without -permission and without paying copyright royalties. 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