' »1 •''' IffiM ■•::/:' msmm Mm LIBRARY OF CONGRESS, SJfap. — — ©npgriglji !f a.. '.T- UNITED STATES OF AMERICA. Pruritic R hinitis or Pruritus Rhinitis Catarrhus. PRURITIC RHINITIS, (Hay-Fever, Autumnal Catarrh, etc) ITS EDICAL AND OURGICAL Si Treatment ; WITH EIGHT ILLUSTRATIONS. THOS, F, RUMBOLD, M, D„ Fellow of the American Rhinological Association ; Member of the St. Louis Medical Society ; Permanent Member of the American Medical Asso- ciation, and of the Missouri State Medical Association, etc. ST. LOUIS: MEDICAL, JOURNAL PUBLISHING COMPANY. 2 6 2 2 Washington Avenue. 1885- COPYBIGHT BY THOS. F. RUMBOLD, ST. LOUTS, MO. 1885- This little Monograph is Respectfully Inscribed to THE FELLOWS OF THE AMERICAN RHINOLOGICAL ASSOCIATION. ILLUSTRATIONS. Fig. 1. Tongue Depressor. - - - 110 Fig. 2. Spray Producers. - - - - 110 Fig. 3- Antero-Posterior Section of the Head show- ing the combined direction of Spray Producers ]STos. 2, 3, 4 and 5 in the local treatment of the pharyngo-nasal cavities. - - - 111 Fig. 4. Anterior Nasal Mirrors. - - 129 Fig. 5. Pharyngeal Mirror. - - - 133 Fig. 6. Soft Palate Eetractor. - - 134 Figs. 7 and 8. Dr. Stucky's Applicators. 155 & 156. PREFACE. The subject of this little monograph is not new, yet but comparatively little has been written on it until the last two or three years. Within this short period, rapid progress has been made in the methods of treatment. The experience of the last two or three years especially, has abundantly proven that what was at one time considered as an irremedia- ble complaint is now under complete control. The methods of investigation former^ employed were barren of results, with the exception of demonstrat- ing that the names given to the ailment were mis- leading and not descriptive as they purport. The name I have suggested, Pruritic Ehinitis or Pruritus Ehinitis Catarrhus or Pruritic Ca- tarrh, is descriptive of its most prominent and con- stant characteristics, namely, itching, inflammation and flow of mucus. I have no doubt the profession will observe — as soon as their attention is called to it — a sufficient number of facts to convince them that this complaint x Preface. LS ONE OF THE VERY MANY SEQUENCES OF COMMON NASAL catarrh. This I said in a paper read before the St. Louis Medical Society in May, 1869. I made the same statement during a discussion on so-called hay- fever at the Illinois State Medical Society, at its meeting in Jacksonville, III., in May, 1874. On page 60 of my work on Hygiene and Treatment of Chronic Nasal Catarrh, is seen the same asser- tion. Although this work was not given as a whole, to the public, until Januaiy, 1831, } T et I gave a few forms (about 166 pages), in which this statement occurs, to quite a number of the members of the American Laryngological Association in June, 1880, and sent out several hundred copies of the same pages to phy- sicians in the West, as an advertisement of my book. The first rational step toward the cure of this complaint, is its treatment as a sequence of chronic inflammation of the nasal passages. Unless such a course ispersued successfully, even the results of a radical surgical procedure will only be temporary, in alleviating the pruritic symptoms. The removal of a hypera3sthetic membrane can not arrest the in- flammatory process that was the producing cause of the hyperesthesia ; this is self-evident, consequently the ultimate recovery of the patient will certainly depend upon hygienic and constitutional measures and the spray producers. I am very sure that the profession will arrive at this conclusion, after they have had a few additional years experience with this peculiar complaint. Preface. xi The manuscript of this little book has been on my table for several years. The reason for the delay in its publication, was owing to the fact that within a few years, a surgical operation was proposed for the immediate relief of the most prominent symptoms of this complaint, and I desired to test whether the claims of its efficacy were well founded. These claims were put forth by Dr. Wm. H. Daly of Pittsburgh, Pa., and Dr. J. O. Eoe, of Rochester, ]ST. Y., who, I believe, were the first to demonstrate to the profession the very great value of this proced- ure. A part of their views and experience is given in an appendix, with their knowledge and consent. In this appendix I have also given the views and experience of Dr. P. W. Logan of Knoxville Tenn., and Dr. J. A. Stuck}' of Lexington, Ky. I was com- pelled to present their valuable contributions in this form, as the part of my book containing these sub- jects had been electrotyped before their papers were received. While freely acknowledging that surgical interfer- ence will cut short the pruritic nasal symptoms, yet, I as freely say, I fear many patients will be operat- ed upon, who ought to be cured without the forma- tion of cicatricial tissue in the nasal passages, by being treated for the originating disease, the chronic catarrhal inflammation of the nasal cavities. That this latter course is successful, I know from experi- ence. Thos. F. Rumbold. St. Louis, June, 1885. CONTENTS. Preface -- - - ix. CHAPTER I. INTRODUCTION. Only Lately Attracting the Attention of the Pro- fession.— Usual methods of investigation defetive. The inflammation that prepares the patient's nasal passages for this complaint causes no pain. - 17, 21. CHAPTER II. Pruritus Rhinitis Catarrhus ;— or Pruritic Rhinitis ; or Pruritic Catarrh ; or Itching Nasal Catarrh, (Hay- Fever, Rose-Cold, June-Cold, July-Cold, Polle?i-Feve?\ Autumnal Catarrh, Ragweed-Fever, Peach-Cold, Slim- mer Catarrh, etc). The present names inappropriate : a new name suggested; table of dates of attack ; table of dates of disappearance. - 22,31. CHAPTER III. History of the Literature of Pruritic Rhinitis. 32, 40. CHAPTER IV. Pruritus Rhinitis Catarrhus (Hay-Fever, Summer Ca- tarrh, Autumnal Catarrh, etc,) — One of the Sequences xiv Contents. of Chronic Catarrhal Inflammation of the Nasal Cavi- ties. Statements taken from the early histories of patients suffering from pruritic rhinitis, or itching nasal catarrh, to prove that it is a sequence of chronic catarrhal inflammation of the nasal passa- ges. - 41, 63 CHAPTER V. Local Symptoms; Subjective and Objective. — The skin ; the eyes ; the nasal cavities ; the pharyngo-nasul cavity ; velum and uvula ; Eustachian tubes and mid- dle ears ; fauces and larynx ; the tonsils ; the trachea ; bronchial tubes and lungs ; deceptive sensations ; the voice ; asthmatics ; the heart. - 04, 74. CHAPTER VI. Constitutional Symptoms. 75,77. CHAPTER VII. Course of Pruritic Rhinitis. — Stage of non-recogni- tion ; pruritic catarrh, or the early form known as rose-cold or June-cold ; the attacks that occur in July ; the attacks that occur in autumn. - 78, 91. CHAPTER VIII. Influence of Location.— For very chronic cases ; ocean travel ; westward ; lake superior ; a tour on the con- tinent. - 92, 96. CHAPTER IX. Causes of the Paroxysms. — Dust; bright sunlight; ex- haustion from heat. ----- 97, 99. CHAPTER X. Diagnosis and Prognosis.— The first or formative stage ; differential diagnosis of the various stages of pruri- tic rhinitis (a table) ; the second or the May or June £ rms ; the third stage or the July form ; the fourth stage or the autumnal form ; the prognosis. 100, 107, Contents. xv CHAPTER XI. Treatment ; Medical and Surgical. —Alleviative treat- ment ; local applications ; tongue depressor ; spray- producers ; prescription of vaseline comp : section of the head showing- the combined direction of sp: ay- producers Nos. 2. 3. 4. and 5 in the local treatment of the pharyngo-nasal and nasal cavities; prescription of pinu* canadensis comp. electricity ; constitutional treatment; special hygiene of pruritic catarrh {hay- fever) ; protecting the head; the hair: wigs healthful to the bald-headed ;hats and caps : clothing; inunc- tion of the body ; the feet ; the sleeping room ; sleep ; the diet ; exercise ; to be avoided. Surgical Treatment.— Remarks in favor of conservative surgery ; important facts ; the kind of cases to be operated upon ; relief by surgical measures ; locating the diseased membrane ; anterior nasal mirrors ; ap- plication of the galvano-eauu ry : Jarvis's snare ; chromic acid ; nitric acid ; posterior nares ; pharyn- geal mirror ; soft -palate retractor. - - 108, 134. APPENDIX. Extracts from Dr. Wm. H. Daly's Article. - 135. 137. Extracts from Dr. J. O. Hoe's Paper. - - 138,141. Pruritic Rhinitis ; by Dr. P. \V. Logan ; President of the American Rhinological Association, etc. Ii2, 145. Pruritic Catarrh, or Hay-Fever, its Treatment ; by Dr. J. A. Stucky; Surgeon to Joseph's Hospital ; Mem- ber of the Kentucky State Medical Society ; Vice President of the American Rhinological Associa- tion, etc. - 146, 159. Index. ------- - 161. 167. PRURITUS RHINITIS CATARRHUS; ( Hay- Fever, Summer Catarrh, A l T IT M N AL C A T A R II, i. TC . ) CHAPTER I. INTRODUCTION. Only Lately Attracting the Attention of the Profession. This complaint, popularly known as "hay-fever", "rose-fever," "June cold," "Autumnal -catarrh",etc, has only of late years attracted the attention of the medical profession. I have not the least hesitancy in saying that this is due to the fact that they have only of late found the department of Ehinology one of interest, or rather one of more importance than was accredited to it a few years ago. It is a malady that has several peculiar characteris- tics, among which may be named: its re-occurring, almost uniformly at certain seasons of the year and affecting its victims to the severest degree in certain regions of the country, while at other seasons and in other regions, the great majority enjoy almost com- plete exemption from its attacks, It has another dis- agreeable peculiarity, namely, it has not until very lately been relieved by any methods of medical treat- 18 Constitution of the United States merit. Indeed so eompletjy have the profession failed to even ameliorate the complaint, that the victims have given up all hope from this quarter and in 1874 formed themselves into a society solely for the purpose of mutually search ing for relief. They have agreed to re- port at any time "during their natural life and after- ward if permitted" any remedy for their ailment. Up to last September no such remedy has been reported by their secretary. Such extraordinary measures were never before taken by any class of invalids. As a matter of interest I will give their constitution in full: "Article, I. This organization shall be called 'The United States Hay-Fever Association/ "Article, II. Its object shall be mutual benefit, and seeking for information which shall serve to releive ail sufferers with hay -fever, wherever found. "Articlf, III. Any person afflicted with hay- fever or rose-cold may become a member of this as- sociation by signing the constitution. "Article, IY. The ofiicers of this association shall consist of a president, vice-presidents, an advisory board, a treasurer, corresponding secretary, and re- cording secretary. "Article, Y. It shall be the duty of each member to report to the recording secretary the discovery of any remedy, source of relief, or exempt district which may come to his or her knowledge during their natur- ral life, and afterward, if permitted. "Article, YI. The secretary, on receipt of such Hay- Fever Association. 19 information, shall apprise each member of the associ- ation at their last and usual place of abode. "Article, VII. Honorary members may be elec- ted at any meeting of the association. "Article, VIII. The annual meeting of the asso- ciation for the choice of officers and other business shall be held at Bethlehem, N. H. on the last Monday in August in each year, at 4 P. M. Other meetings may be held September, upon the call of any six members of the board of government. '"Article, IX. This constitution may be amended at any annual meeting by vote of the majority pres- ent." The formation of this organization proves that the despair of e^er receiving relief from the medical pro- fession must have been great indeed, and it is a stand- ing condemnation of that profession. Evidently this medical inability — to give it no harsher name — is due to the fact that they have heretofore wholly ig- nored the study of the diseases affecting the nasal pas- sages and the cavities connected with them. Until a systematic course of study of this region is pursued and equally systematic investigations are made by a large number of the profession, the success- ful treatment of all the ailments sequent to catarrhal disease of the nasal cavities will not be made known. USUAL METHODS OP INVESTIGATION DEFECTIVE. The methods of investigation usually persued by those who have devoted some time to the study of 20 Defective Methods this complaint have been to receive from the sufferers their own account of their symptoms or condition, in- stead of endeavoring to ascertain the causes that pre- pared the victims mucous membrane for the attack. The answers received related to the dates of the attack and disappearance, and a number of other pec- uliarities, all of which did more to confuse and mystify than to elucidate the subject. The investigators have thus laid themselves liable to be led as far astray by these histories, as they would be from the answer of an individual who had a disease, the existence of which he had no sensible knowledge; for instance: the answers of one afflicted with a mon- omania, if questioned on the subject of his mental ail- ment. On all other subjects he could, in all probabil- ity give correct answers. So with the sufferers of this complaint; on many other matters connected with their disease, except as to the condition of their mu- cous membrane, they could give correct answers, but on this subject they are very liable to give incorrect answer, simply because there are no subjective symp- toms connected with this peculiar conditon of their nasal passages, and these are the only symptioms they could give. THE INFLAMMATION THAT PREPARES THE PA- TIENTS NASAL PASSAGES FOR THIS COM- PLAINT CAUSES NO PAIN. It is because of the non-subjective character of prolif- erative inflammation, that a large per centage of these Of Investigation. 21 sufferers state positively that they were in a perfect- ly healthy condition up to the period of their first attack and between their attacks. This shows the fallacy of allowing the victims to write the histor- ies of their own complaint, especially when the dis- ease is to be studied from these histories. This subject will receive further consideration in another portion of this work, but enough has been given to show plainly that this method of investiga- tion is exceedingly liable to be misleading. I have purposely abstained from considering purely theoretical points, such as accounting for the attacks so frequently occurring in summer and in certain re- gions of the country, while during cold weather and in a few parts of the country the victims enjoy com- parative exemption. These and other apparently inexplicable features of this neurotic rhinitis, may ultimately assist in the further elucidation of its etiology, which at the pres- ent writing is considered unknown. CHAPTER II. Pruritus Rhinitis Catarrhus ; or Pruritic Bhini- tis; or Pruritic Catarrh ; or Itching Nasal Catarrh, ( Kay-Fever, Hose-Cold, June-Cold, July Cold, Pollen-Fever, Autumnal- Catarrh, Ragweed-Fever, Peach- Cold, Summer- Catarrh, etc.)* THE PRESENT NAMES INAPPROPRIATE J A NEW NAME SUGGESTED. All the names by which this peculiarly phenom- enal complaint is known are inappropriate and mis- leading. As the medical profession should not agree to a change of a name of a disease without good and sufficient reason, I ask a part of your valuable time, while I endeavor to show from the character- istic symptoms of the complaint that the names given are misleading, that we have a more appropriate name in Pruritus Ehinitis Catarrhus, or Pruri- tic Catarrh, because the prominent symptom of this kind of nasal catarrh is an itching. It is noticeable that in giving names to diseases, it is oftentimes designed to indicate their nature, byse- * Head before the St. Louis Medical Society, May 3rd, 18S4. Present Xa:.ies Misleading. 23 lecting some prominent symptom or peculiarity of the complaint by which to designate it. When such names are sufficiently descriptive, we may not do better than to name a disease in this way. Thus, some names point to the part of the body affected, as cerebrospinal meningitis, pneumonitis, rhinitis, laryn- gitis, otitis, etc: some, the appearance of the patient while sick, as yellow fever, scarlet fever, spotted fever, some, the supposed cause of the ailment, as mala- rial fever, bilious fever, hay-fever; and still others, the time of the year in which attacks occurs, as summer catarrh, autumnal fever etc. If all of such names truly indicated what they seem to do, then they might very properly be retained, but if any of them indicate that a certain prominent fact or feature of a disease is constantly present, so as to distinguish it from other diseases, when such is not the case, then, most certainly, the misguiding name should be discarded; as its retention will be very liable to lead to an erron- eous diagnosis, and thus a case might be excluded from its proper class and, as a consequence, be im- properly treated. Recent investigations, of a very thorough charac- ter, go to prove that the various names by "which this complaint is designated, are misleading. I am not unmindful of the fact that Dr. Morrill Wyman, a high authority on this complaint, regards the spring and fall forms as separate diseases. In this, I think that he is mistaken. On this point I agree with Dr. G. M. Beard, also an excellent authority on u bayv 24 Identity of Spring and Fall Forms. fever." Dr. Beard says : " In view of the large num- ber of facts afterward obtained, and which are re- corded in this work, it was found necessary to aban- don this theory [ the two forms of the complaint ] and to admit the substantial identity of ' Autumnal Catarrh' and 'June Cold'." If the dates of attack and disappearance were erased from the history of a case of this disease, I defy, even an expert, to do better than guess the season of the year in which it occurred, nor could he make a better gues3 as to the duration of the attack. I am unable, after a very careful study of Dr. Wyman's really valuable work, to perceive the difference between the spring and fall forms of the complaint, except one of severity and that they almost uniformly occur, the one in the spring and the other in the fall ; but the individuals who have the attack uniformly in May or in June or in July, relate, identically, the same symptoms as do those whose date of attack occurs in August or Sep- tember, the fall form being the more severe. All kinds of this class of sufferers are exempt from attack by resorting to the same mountainous regions of the country and, according to my experience, all are re- lieved by the same kind of hygienic management and the same kind of constitutional and local treatment. Cases are not at all uncommon who may, for a few years, be afflicted in the early summer months but, from some unknown cause, pass the usual period of attack, and experience it either later or earlier than usual. I have a young patient under treatment now, HAY 18 NOT ALONE THE CAUSE OF ATTACKS. 25 whose first attack occurred in July, the next in May and the next in September. That others consider the name not the most suita- ble, is seen from the following quotation taken from Dr. Beard's work. lie says : " The inappropriateness or rather the insufficiency of the term hay-fever is now quite generally admitted; for even where the predisposition exists, hay of any kind, fresh or dried, acts as an exciting cause in but a minority of cases, and rarely, if ever, is it the only irritant that gives rise to the paroxysms." The name "hay-fever" indicates that hay alone is the cause of the attack, which is very far from be- ing the case. I have a patient who can handle hay at any period of the year without experiencing the least inconvenience, another one who is not the least affected by it, so long as his scalp and face are not moist with perspiration, labile this patient is per- spiring during warm months, any kind of dust, but especially that from an old carpet, instantly sets him wild with an itching sensation of the face and eyes, soon followed by the same sensation in the nostrils and by sneezing. The same objection exists with respect to the names "rose-cold," "pollen-fever," etc. It is almost univer- sally admitted that any one kind of pollen, or any one kind of flower, may seriously affect some persons, and have no bad effects on others, yet the distin- guishing phenomena, namely the itching, flow of tears, the flow of watery secretion from the nostrils 26 Seasons of the Year are are nearly alike in all patients, whether they are attacked in the spring, summer, fall or winter. If they differ, it is in degree of severity only. This brings us to the names which designate the seasons of the year in v/hich the disease occurs. If the seizures uniformly commenced in June, July or during the autumnal months, the name of the month or of the season of the year might very properly be prefixed to the word "cold" or "catarrh" or "fever" or "asthma," but my observations since 1862, and the very thorough investigations of Dr, Beard, leave no doubt that the attacks may occur in any month dur- ing the summer. Because of its so frequent appear- ance daring the summer months, Dr, John Bostock, of London, [1819] suggested the name "Catarrhus Aestivus" or "Summer Catarrh." This also is mis- leading, as well as Dr. M. Wyman's name, "Catarrhus- Autumnal is" or "Autumnal Catarrh." These names indicate that individuals could not be attacked during cold weather; but it is well known that the complaint may sometimes affect it victims as late as October, November, December and even January, according to Dr. Beard's report. I had a patient who had at- tacks in every month from April to November, and I have one now (May, 1884) under treatment who has had attacks for two years; and the whole year around whenever he is where the air is hot and dusty. (I have three patients now under treatment who have had severe attacks in the last week in January, 1885.) It does not detract from the value of these facts, Inappropriate Names. 27 to Bay that these last patients and all other like pa- tients who have been under my care, had their winter attacks much less severely than their warm weather attacks, nor is the argument weakened by the fact that the very great majority of attacks of this complaint occur in warm weather. As the very sane symptoms occur in cold weather, warm-weather names are misleading. The following tables will give, in a condensed form, the dates of attack and of disappearance, These tables, which are taken from Dr. Beard's valuable work, do not show the duration of the attack. He received his information from answers to inquiries sent to individuals afflicted with this complaint, num- bering 200. TABLE OF DATES OF ATTACK. roi q May ltolO, 2. li " 10 to 31, 6, IS June 1 to 10, 11. l< 11 10 to 80, 8. K July 1 to 10, 6. u 44 10 to 20, 6. u 46 20 to 81, 7. From Aug. 1 to 10, 7. " 10 to 20, 81. 44 20 to 31, 54. Sept. ltolO, 7. 44 10 to 20, 1. 44 20 to 30, 2. June to Sept, 1. Aug. to Jan. 1. As to dates of disappearance the answers recci were the following TABLE OF DATES OF DISAPPEARANCE. January or early winter. 2 About January 1st. - - - - - 1 Late in winter. ------] March 1st. - 1 Middle of July. ------ c Latter part of July. . - - - - - 5 28 Vegetable or Parasitic Early in August. ----- 5. Middle of August, ----- 2, Latter part of August. 1. Early in September. ----- 2. Middle of September. 13. Latter part of September. - 26. Early in October. ----- 42. Middle part of October. - - - -14. Latter part of October. - 3. Early in November. - - - - - 9. Middle of Kovember. 4. Early in December. - - - - - 1. Middle of December. - - - - 1. From September 15 to December 25. - - 1. With frost or cold weather. - - - S5. Three weeks after beginning. - - 1. Cannot state definitely. - - - - I . It is self-evident, from the facts shown by these ■tables, that "Kose-Cold," "June-Cold," "Hay-Fever," "July-Cold," " Pollen-Fever " " Summer-Catarrh," " Autumnal-Catarrh," are all inappropriate, or rather insufficient names, and that any one of them tends to mislead the physician who would allow himself to be guided by the characteristic suggested by the name. A strong point in favor of the parasitic or vegetable theory is made in the constancy and regularity of the appearance of the disease at given times with some of the victims, not only coming on at a fixed day, but the very hour, and also its almost regular disappear- ance at such times as might usually be expected that the spores of the bacteria or vegetable growths would be destroyed by natural causes. If this nasal trouble is caused by germs, why may not other nasal troubles originate from germs ? Without answering this question I will ask another : How could germs Theory not Tenable. 29 cause this trouble when they depend upon a peculiar condition of the fluids of the mucous membrane for sustenance, which condition must have been the re- sult of diseased action ? As these germs do not in this way affect a healthy mucous membrane, does this not show that diseased action was primary, and germ irritation secondary? Dr. Beard while speak- ing on the vegetable theory, says : " This suggests to almost any one the possibility that some parasitic or vegetable emanation appearing only during the season of the disease might be the cause. "If it could be shown that some at least of the symptoms were felt at other than these so-called ca- tarrhal seasons; if sufficient evidence of the occur- rence of certain phases of the malady in the winter and spring could be obtained, the parasitic and vege- table theories would be seriously shaken. "This evidence is here given. The hay-fever symp- toms that are in the winter excited by exposure to the dust of hay or of the house, or to animal emana- tions, are usually, if not always, of a transient char- acter, lasting but a few minutes or hours ; but for this brief time they are characteristic of the disease, and they do not appear in other persons." He arrives at these conculsions from answers to the following question: "Do you ever have, during the winter or spring, when exposed to any of the excit- ing causes, as dust etc., attacks resembling ' hay-fever' in a mild form, lasting perhaps for a few minutes or hours V 30 A Name that is Descriptive of its Of 200 affected individuals, 101 answered Yes, 77, "No. His special replies to the same question, contain these significant expressions: "Lots of e'm, hut mild in form/* 7 "For a few hours/' "Dust of hay will cause it." "Caused by dust," "Dust of sweeping, etc/' Pruritus Ehinitis Cata rrhus, or Pruritic Ehin- itis, or Pruritic Nasal Catarrh, or Itching Nasal Ca- tarrh, is the name that I have selected for this phe- nomenal complaint. This name is descriptive of its most prominent and constant characteristics, namely itching, inflammation and flow of mucus. The attack is ushered in by an itching of the ncse and face; this soon affects the eyes, causing intense suffering. The itching sensation in the nostrils gives rise to prolonged sneezing ; this, in turn, make3 the eyes still worse; presently, the itching reaches the soft palate and the fauces, and to relieve these parts of this same sensation, the tongue is used to rub them. As the tickling is not relieved a rasp- ing cough is tried, which is so persistently continued that the throat soon becomes sore, and in older suf- ferers, shortness of breath ensues, and symptoms of asthma are developed. I have not had a patient that did not experience this itching early in the disease, and it was always prominent. Dr. Beard, gives this as the first symptom and says of it, on page 113, " This is one of the first, oftentimes the very first local symptom of an attack.*'" Dr. Wynian, in his work on "Autumnal Catarrh*' in mentioning the local symptoms as they occur consecutively, says, on page most Prominent Symptom Proposed. 31 12. "The lining membrane of the nostrils is the part first affected : beginning with a slight tickling or itch- ing, which soon shoots upwards towards the eyes, and even into them." To repeat, because of the uniformity of this symp- tom, and the fact that it is always accompanied by inflammation, I think the name Pruritus Rhinitis Catarrhus or Pruritic Rhinitis or Pruritic Nasal Catarrh or Itching Nasal Catarrh i< more descriptive of the complaint than any of the names new given to it. This name indicates the first, the principal and the most prominent symptom and which is truly charac- istic of the malady at whatever season of the year the victim is attacked, and it is not misleading. CHAPTER III, History of the Literature op Pruritic Ehinitis. Little or no benefit is to be derived from the study of the history of the literature of this complaint. For this reason, only the outline will be given, and that as conscisely as possible. In 1819 Dr. John Bostock of London presented a paper to the London Medico-Chirurgical Society, in which he gave the first formal description of this complaint, describing his own case. The title of his paper was a "Case of a Periodical Affection of the Eyes and Chest." This paper was published in the Medico-Chirurgical Transactions, page 161, part 1. volume x. In 182-1 he gave the complaint the name of " Hay-Fever". In 1828 the same author read another paper on the Fame subject and gave the disease the name of Catarr- hus iSstivus or Summer Catarrh. This also was pub- lished in the same Transactions, Volume xn, page 437. This name is still retained by many writers. In this year (1828), Dr. Mac Culloch published " An Essay on Eemittent and Intermittent Diseases ". In this he mentions a complaint that he thought was caused by emanations from hot-houses and green- From 1829 to 1850. 33 houses, but especially from hay-fields. He says that the "common people observed that the disease was brought on by exposure during hay-making seasons." In 1829 Mr. W. Gordon published a paper in the London Medical Gazette, Volume iv, page 266, on the " Observations on the Nature, Cause and Treatment of Hay- Asthma". He thought that the flowers of grass was the cause. For this reason he thought the com- plaint should be called " grass-asthma n instead of " hay-asthma". In 1830 "Mr. A. Praster published the history of a case. In 1831 and in 1833 Dr. Elliotson referred to a com- plaint resembling this one, and published it in the London Medical Gazette. He rejects the heat theory of Dr. John Bostock, and the hay theory also, and amrms that grass and probably the pollen of flowers are the causes. In 1847 Dr. Ramadge, in his work on " Asthma/*' published in London, holds that the emanations of of grass and flowers give rise to attacks of this dis- ease, In 1850 Dr. Gream published a paper in the Lon- don Lancet, Tolume i. page 692, on the " Use of Nux Vomica as a Hemedy in Hay-Fever." In this paper he afiirms that neither the flowers of grasses or any other flowers are the producing causes, but that it is in-door and out-door dust that are the exciting causes. He observed that after a rain the victims were much relieved. 34 From 1852 to 1856. In 1852 Dr. La Forgue of Toulouse, wrote a paper on this complaint. He advocated the heat theory. In 1854 Dr. Morrell Wyman of Cambridge. Mass. being himself a sufferer of what he terms " Autumnal Catarrh," discribed the complaint in his course of lec- tures in the Medical School of Harvard University. He says " the description was drawn from my per- sonal experience, and a few cases which had come under my observation for treatment." In 1857 Dr. Watson says that this malady is caused by vegetable emanations floating in the air. In 1859 Dr. Walsh in his " Treatise on the Diseases of the Lungs," refers to this complaint and calls it a singular variety of " naso-pulmonary catarrh." He says that the complaint occurs daring hay-making time and that the odor from this and from grasses are the causes, but he states that he has the history of a well attested case in which the victim suffered from an attack while on a voyage across the Atlantic. Each day's symptoms were given. In this year (1859), Dr. H. Salter, the asthmatic author of a work on u Asthma " states the complaint is a hay-asthma and lasts during the hay-making sea- son, and adds, that heat, dust and sun shine are the agencies that most frequently excite an attack. Dr. Philip Phoebus, a professor in the University of Giessen wrote in this year also, far out stripping his predecessors in thethoroughness of his investiga- fions. From extensive correspondence, which was exten- From 1860 to 1866. 35 ded almost through the entire civilized world, he gathered many facts not before known. But he was not satisfied with his conclusions as to the etiology of the complaint ) he says that it will require more ac- curate observation to come to positive conclusions. He thought that odors of flowers, probably that of rye was the most irritating, and the irritation of dust assisted by long heat and ozone were the causes of the attacks. His investigations were published in 1862. In 1860 Dr. Koranz of Neufchatel, Switzerland, wrote a paper on " Hay-Fever," and published it in the Le' Echo Medical. He thought that the flowers of grass was the irritating cause. In May 1866 the facts known to Dr. Morrell Wyman were embodied in a paper read at the Annual meeting of the Massachusetts Medical Society in Boston. The following abstract was published in the Boston Jour- nal June 2nd, 1866. "Autumnal Catarrh : At a meeting of the Massa- chusetts Medical Society, Dr. Wyman of Cambridge gave an account of a singular catarrhal affection, or cold, hitherto undescribed, and named by him Autum- nal Catarrh. There are two annually appearing catarrhs in this country : the summer catarrh (com- monly called Eose Cold, Hay Fever or June Cold) begins the last week in May or the first week in June, and lasts four or five weeks; the other, the Autumnal Catarrh, commences the last week in August, and con- tinues till the last week in September. It begins with sneezing, itching of the eyes, especially at the inner corners, watering of the eyes, and a profuse discharge 36 Dr. Wyman's Paper. from the nostrils. The affection of the eyes is in fits, coming on suddenly, compelling the sufferer to rub his eyes violently for relief. The fits of sneezing and nose-blowing and obstruction of the nostrils are also sudden, and when the fits are over, usually in a few min- utes, go off as quick as they come. During the second week in September, a cough sets in, dry, violent, and in fits; it is increased during dry, dusty weather, and relieved by an easterly storm. It is severe in the night, and there is sometimes asthma. The disease subsides during the third week in September, and by the first of October, or the first good frost, is entirely gone. It is not an uncommon disease; Daniel Webes- ter had it annually for twenty years, and while Secre- tary of State suggested to President Fillmore the pro- priety of resigning on account of it. The late Chief Justice Shaw of Massachusetts was another victim. Medicines seem to have been most freely tried with- out materially relieving its severity or shortening its duration. Fortunately, it has been ascertained that there is a most complete and agreeable cure.* Within twenty-four hours after the sufferer arrives at the White Mountains, at G-orharn, at the Glen House, or the Waumbec, it suddenly disappears and if he re- mains till the last week in September, the usual time of disappearance, does not return for that year. The * I am astonished that such an accurate man as Dr. Wy- man, should employ the word " cure " in this sentence, when he means complete cessation of the symptoms during that catarrhal season, on condition that the victim remains in the locality named. Cure, means complete, continuous recovery without recurrence at any season, complete return to health. He does not desire that this should be inferred. From 1866 to 1867. 37 relief at Franconia is not so certain as at the north side of the mountains, though most are relieved there also." In this year (1866) Dr. W. A. Smith also published a work " on Hay-Fever, Hay- Asthma or Summer Catarrh." He thought the worst symptoms were brought on by great heat, grass and flowers. With great fairness he gives the history of a patient that jjroves that his views are not invariably correct; namely : "This year the disease first came on while I was on the sea yachting with a friend. It was a hot day in May, with wind from the southwest, the nearest land to windward being nine miles distant. I felt myself, after some exertion in assisting to hoist the sails, sud- denly seized with sneezing, and I have had it ever since."* That is up to June 13th, of that year. In 1867 Dr. W. Pirrie of London, published a work on " Hay-Asthma and the affection termed Hay-Fe- ver." He added little to the literature of the sub- ject, except the very important idea that the nervous system was a far more important factor to the com- plaint than had heretofore been supposed. " This little treatise of Dr. Pirrie is remarkable that in many respects it theoretically anticipates what I>y these statistics and facts, has been demonstrated in regard to the nature of hay-fever, and the true princi- ples of treatment as now confirmed by a large induc- tion in Europe and America. The number of his facts was so limited, and the cases he gave were so imper- fectly detailed, that none of the points he suggested * Beard on Hay-Fever, 1876. 38 From 1869 to 1870. could be considered as proved; consequently, they have not been generally received, and have excited comparatively little attention ; they were suggestions and nothing more, and they left the subject as mysteri- ous as they found it." "What author has not left the subject as mysterous- as he found it ? In 1869 Prof, Carl. Binz of Bonn, Germany, con- tributed an article to Virchow's Archives for February, on the use of quinine as a remedy for this complaint. In this article he gives a letter addressed to him from the iilustrous Helmholtz recommending the local ap- plication of the sulphate of quinine as a remedy. In this year (1869). in a paper read before the St. Louis Medical Society on the sequences of chronic nasal catarrh, I said that careful investigation would substantiate my assertion that "hay -fever" was one of the sequences of chronic inflammation of the mucous membrane of the nasal passages, giving at the same time the history of the symptoms and the treatment of the first case given in this work. In two or three years after this I re-asserted these views before the Illinois State Medical Society, at its meeting in Jack- sonville, on the occasion of a discussion on the effects of quinine when applied to the nostrils as a cure for hay-fever. In 1870 Dr. G-, Moore of London, published a work on "Hay-Fever or Summer Catarrh ; its Causes, Symp- toms, Prevention and Treatment." He favored the theory of sunlight, heat and the effluvia of hay and From 1872 to 1876. 39 flowers as will as decomposing vegetable matter. la 1872 Dr. Morrell Wymau again contributed his experience and observations of " Autumnal Catarrh (Ray-Fever.)" " A leading thought in this work of Dr. Wyman is that in the United States, under the general term hay- fever, two distinct forms of disease are included the so-called 'Rose-Cold' or 'June Cold' occurring in May or June, and corresponding to the 'hay-fever' or 'hay-asthma ' of England and the continent, and a later form, beginning in August and lasting several weeks in the fall, to which he gave the name ' Autum- nal Catarrh.' "* In 1873, Mr, Chas. H. Biaeklay an eminent surgeon of Manchester, England published a work on " Ex- perimental Researches on the Cause and Nature of Catarrh us iEstivus (Say-Fever or Hay- Asthma)," He advocates that the pollen of grass is almost exclu- sively, the cause of the attacks of the complaint, and thinks that the names " Pollen-Fever" or " Pollen Catarrh " more appropriate. He made a large num- ber of experiments with the fresh and dried pollen of the grasses and of other plants and believes that he substantiated his theory. He says that rabbits, guinea- pigs and cats are sirailiarly affected by the pollen. In June 1876, the late Dr. George M. Beard pub- lished an excellent work on this subject, and claims to have discovered, what he terms a " middle form of hay- fever." He advocates what he calls the nerve theory, and, according to my views, is far in advance of all * Beard on Hay-Fever. 40 1876. previous authors. The following quotation from the preface of his work, will give a partial idea of his views : "The theory of this book, that this disease is a com- plex resultant of a nervous system especially sensa- tive in this direction, acted upon by the enervating in- fluence of heat, and by any one or several of a large number of vegetable and other irritants, has the ad- vantage over other theories ; that it accounts for all the phenomena exhibited by the disease in this or in any other country ." In August of this same year we are gives a most carefully prepared work on fc Autumnal Catarrh (Hay- Eever)" with illustrative maps by Morrell Wyman, M. D., of Cambridge Mass. Every physician who desires to study this complaint should supply himself with this work, as well as with Dr. Beard's. This last Edition of Dr. Wyman contains his former views amplified. He holds that his Autumnal Catarrh is a different complaint from that of the early sum- mer catarrhs, i. e. the " Eose or June Cold." As I will take the liberty to make frequent quota- tions from Dr. Beard's and Dr. Wy man's valuable works, I will not, at present, give more of their views. Of course I shall differ radically from both of these talented gentlemen, but wish to acknowledge that I have received more information, in the study of this complaint, from their works, than from all the vari- ous works on this subject that has come under my notice which number in all about fifteen. CHAPTER IV. Pruritus Khinitis Catarrhus ( Hay-fever, Sum- mer Catarrh, Autumnal Catarrh, etc. ) one OF THE SEUQENCES OF CHRONIC CATARR- HAL Inflammation of the Kasal Cavities. * Authors have had a suspicion for many years, that this disease ("hay-fever") might, in some way, be connected with common nasal catarrh; consequently, they all have given this part of the subject some attention, but for various reasons they have come to the conclusion that there is no evidence of such rela- tionship. It seems to me that their methods of carrying *JRead before the St. Louis Medical Society May 10th, 1884. 42, " Defective Methods on their investigations, concerning this matter, have not been thorough enough, and with some of the authors, they have been quite defective. They have asked sufferers, all of whom, with a very few exceptions, resided at a distance, questions, the design or tendency of which they could not fully understand, not being medically educated. In fact they have taken it for granted, that these individ- uals knew the cause and course of their malady, and the questions have been so formed, that when filled out they completed the histories of just such cases, as the victims and the authors had conceived them to be. It always requires much greater medical acumen to make a diagnosis, than it does to write a prescription for a known disease. £Tow, while no medical man has been known to ask an ailing individual to write his own prescription, yet the authors on pruritic catarrh have asked their correspondents to take the more difficult part, namely, the writing out their own diagnosis, and from these papers they have studied the complaint; and what makes these narra- tions of still less value, they are, almost universally dated from a period after their first most chracteris- tic attack, and not from their initiatory symptoms. These, the sufferei'S would not recall, unless assisted by interrogations conducted by one acquainted with the peculiarities of such cases. To say the least, this is a defective method, especally when there exists a- supposition that the complaint might be secondary to of Investigation. 43 another disease. Under these circumstances, why not. make enquiry concerning their physicial con- dition previous to the first attack of pruritic rhinitis (hay-fever). Without this, their investigations are illogical, as they have left their readers ignorant of the condition of the system that might have made the attack possible, if the nasal inflammation preceded it or caused it. I am fully aware that my views on this subject are not in accord with any of the authorities, and in taking this position, it devolves upon me to prove that this phenomenal complaint is a sequence of comparatively long standing inflammation of the mucous membrame of the nasal cavites. This I will do by giving accurate and detailed histories of the physicial condition of those who have been my pa- tients, which will show that the inflammation always precedes it. It is evident that this will go far to sustain my proposition; but to make it still stronger, and because some might ssy that the co- existence of long continued inflammation in the nasal cavities was a co-incident and would not, of itself, necessarily prove that pruritic catarrh, was oc- casioned by it, I will give other evidences that will demonstrate beyond the possibility of a doubt, the relationship of the two complaints. This will be done by giving the histories of patients whose ameliorative treatment for chronic nasal inflammation, reduced the frequency and the severity of their attacks of pruritic catarrh and of a few other patients 44 Chronic Inflammation whose treatment caused an entire cessation of the disorder. In 1869, 1 made a statment before this society, that a scrutinizing investigation of the patient's condition, during that period previous to the first attack, would show that chronic nasal inflammation had rendered them liable to be afflicted with pruritic catarrh. My numerous observations, made since that date confirm me in this matter. In fact, every individual, whether patient or acquaintance, that I have seen since 1862, who had suffered from attacks of it, had been for several years afflicted by chronic catarrhal inflamma- tion of the nasal cavities. I am not prepared, at present, to give my reasons for this neurotic form of rhinitis attacking the great majority of its victims in summer days and in certain regions of the country, while during cold weather, and in a few parts of the country they enjoy com- parative exemption. These and other apparently inexplicable peculiarities, may ultimately assist in the further elucidation of its etiology, which at present writing is considered unknown. Before giving these clinical facts, I wish to show how both the investigators of this complaint and the sufferers interrogated have made grave mistakes. Upon the occurrence of an inflammation of the mucous membrane, the blood vessels are not only filled to their utmost capacity, but they are greatly enlarged by reason of their excessive engorgement, being increased from 10 to 40 times their normal The Originating Cause. 45 diameter, according to the severity of the irritation. If this inflammation should become continuous by repeated irritations for a number of years, the exces- sive amount of blood (nutrition) going to the part, causes its permanent thickening, just as an inflamed and enlarged joint will be permanently enlarged, if the inflammation shall be allowed to continue for a long time. In the case of the mucous membrane, this growth is denominated proliferative inflammation. It is during this stage of the inflammatory disease of the nasal passages, that the patient may, from some cause at present not known to the profession become affected with pruritic rhinitis. According to my observation, a most important char- acteristic of proliferative inflammation (and it is one that should be continually borne in mind), is that the patient does not experience the least sensation of pain during its progress. Xot until the caliber of the air spaces in the nostrils are so reduced in size, that respiration is thereby impeded, do they exper- ience the least inconvenience, except it may be that they have slowly, imperceptibly lost the sense of smell from the same cause j or, this abnormal process may stealthily invade the Eustachian tubes and mid- dle ears, and slowly and imperceptibly rob its victim of his hearing, but if the loss of these senses should not suggest the presence of this inflammatory process, he would be entirely unconscious of it, so perfectly pain- less is its growth. Another dangerous peculiarity of this variety of 46 Statements op Patients. inflamm alion is, that the patient rarely experiences the usual well known symptoms of" catching cold/' or at least a very severe cold, yet the proliferative process, that is the abnormal change of the mucous membrane, is continuous. It is evident that, with this state of things, it is im- possible for Dr. Beard's or Dr. Wyman's correspon- dents, to have had the least idea that they were vic- tims of this variety of inflammation, the very kind, the only kind that could prepare their nasal mucous membrane for the development of neurotic symptoms. When these physicians did not observe this condition, is to be expected that the patients could have made mention of it when not consci ous of its existence ? Statements Taken from the Early Histories of Patients Suffering erom Pruritic Ehinitis, or Itching Nasal Catarrh, to Prove that it is a Sequence of Chronic Catarrhal Inflammation of the Nasal Pas- sages. x will not attempt to give lengthy details of the early history of each patient, nor an exhaustive state- ment of the symptoms when he first visited me. Of the early history, I will give that much only that is required to prove that chronic inflammation of the nasal passages always precedes the attack of pruritic rhinitis or itching nasal catarrh, and give the dates, treatment and the result. The plan of treatment will follow at another time. Statements or Patients. 47 Physicians will be surprised at the uniformity wtih which the majority of these patients state, at their first visit, that they have been in usual good health previous to this first attack of itching catarrh, and also at the shortness of their memory concerning their symptoms for even a few days or weeks past, but if assisted by various questions, somewhat lead- ing in their character, they will be enabled to recall a sufficient number of incidents that make the history quite complete, which will be amplified by future conversations at subsequent visits during their treat- ment. The first case that I will report was, in this respect, a very decided exception as it was during my conver- sation with him that I was made certain that my views were correct concerning the relationship of this complaint to chronic nasal catarrh. Case I. Mr. Luke E. Gibson, set 43 years, a prin- ter, visited me on June 10th, 1867, desiring relief from his attacks of sneezing and asthma. These sud- den attacks commenced in July, 1865. The next commenced in July, 1866 ; on this occasion it occurred on a hot night about the middle of the month, imme- diately after he had left the printing office, between three and four o'clock in the morning. He thought the exposure to the night air was the cause of the attack. He voluntarily said that he believed that his chronic catarrh, which he had had since he could remem- ber, was "the cause of the sneezing spells." EARLY HISTORY. When a boy he had large crusts of secretion form 48 Statements of Patients. in both nostrils. As he grew older these disappeared, but with their disappearance he began to be affected with severe headaches, especially over his forehead. Both of his ears were diseased, and he had had an otorrhceal discharge since his boyhood. His first attack of itching of his face and eyes com- menced one hot morning in July, 1865, as he left the printing office. He noticed at the same time that his usual catarrh had abated to a marked degree, and that as his sneezing grew less, which was about Sep- tember, his catarrh recommenced. This has always been the case with these two complaints. My attempt, at the time, to alleviate his sufferings, was productive of positive harm. He visited me on Monday, June 24, at which time the above history was given me. At this time I took two aural polypi from his left ear. Jan. 4th, 1868, he again visited me. His catarrh was very bad, and he had severe headaches. For this he was treated about three times a week until Feb* 3d, then two times each week until the 26th. After the treatment on this day, he had a slight attack of the itching of the face and eyes, but he did not sneeze. My treatment at this time was too irritating, I was applying by the spray producer a mixture of muriate of ammonia, tincture of iodine and tincture of aconite root. He at once went to St. Paul, where he resided until Sept., but was not entirely free of his tormen- tor. May 31st, 1869. Treated him two times a week, through June and up to July 23d; after this, about once a week until Aug. 21st. He had no attack up to this date, but sometimes ex- perienced sensations of the beginning of the itching Statements of Patients. 49 of the eyes and edges of the alse of the nostrils. He passed Aug. 1870, without a recurrence of his pruritic rhinitis, but lived most of the time in the country. I have not heard of him since that date. Case II.— Dr. E. J. P., 50 years, Dentist of St. Louis, consulted me Dec. 19th, 1868, for severe frontal headache; for this I treated him until March 1st. Dur- ing his visits he informed me that he was subject to what he and his physician called "hay-catarrh." It usually attacked him in May. I recommended the continuation of the treatment as a preventive, To this he acceded. But as I was not successful in giving him a local treatment, without causing sneezing, he discontinued about the middle of May. His usual attack commenced this year on May SOth, after taking a Turkish bath on Sunday morning. For relief he immediately visited the mountains of Ten- nessee, returning to the city in the fall. March 1st, 1870, I commenced to give him treat- ment for his catarrh, this was continued for a few weeks, three times a week, then twice a week until the 14th of May, at which time he feared the itch- ing catarrh would attack him. EARLY HISTORY. At these visits I learned from him that he had been subject to sore throat, enlarged tonsils and severe headaches, as well as continual clearing of his throat in the mornings, since he was a boy. When his early history was first spoken of, he had forgotten all his early troubles about his throat and head, as these had not troubled him so much of late years, except on the occation of his visits to me. He started for Louisville, Ky., and arrived May 16th, 1870, and concluded to remain there a few days before going to Tennessee j but this visit was pro- 50 Statements of Patients. longed to the Fourth of July, at which time, as he had raissed his "hay-catarrh," he concluded to return to St. Louis. On his way home he was attacked on the cars. He continued on his journey home, remained quiet for a few days and entirely recovered. I gave him a few treatments in May, 1871. He re- mained in the city the whole of that year entirely ex- empt from his "hay-catarrh," I have not heard from him since the fall of that year. Case III.— Mr. J. Whaling, of Belleville, 111., set 37 years, consulted me May 20th, 1872. EARLY HISTORY. During the last ten years has been in much better health than before that time. When 14 or 15 years of age, he had the measels, which left him with a severe cough and diseased ears. For many years after this attack of measels, he suffered from dizziness; would not walk down stairs without taking hold of the hand rail. lias had tinnitus aurium since his ears have been affected. He now has what he calls "rose-cold," and has had it every spring during the last three years. At first the attacks were not severe, always commencing in May, sometimes the first part and sometimes in the latter part of the month. This time it attacked him after he had taken his supper on Saturday the 18th of May. I treated him but two weeks with so little benefit, that he left me. since which time I have not heard of him. Case IY.— Mr. W. K. G-., of Memphis, Tenn., jet 83 years, consulted me Aug. 22d, 1873 for "hay- fever." EARLY HISTORY. Did not remember of* being particularly liable to lake cold after he was 21 years old. Up to that age Statements of Patients. 51 lived a very exposed life. Did not remember when he did not smoke or chew tobacco. Nearly all his life had to clear his throat in the morning, and while endeavoring to do so would become sick at the stom- ach. If these efforts were made after he had his breakfast, he would throw up his meal. Treated him but eight times, with little, maybe no benefit. Save not heard from him since. Case Y.— Mr. Robt. G. Kane, of Alton, 111, get 35 years, consulted me Sept. 6th, 1873 for "grass-fever." early history. When a boy always had a running nose, and kept his mouth open. His mother tied a handkerchief over his head and under his chin, so as to make him break his " habit" of breathing with his mouth open. Could not leave it there because it smothered him. This condition of breathing lasted until he was almost a young man, at which time had his "palate" (?) (uvula) clipped off, because of a severe cough. He was at this date taken away from college, because of the cough, and was given cod-liver oil; At no time had headache, ear ache or sore throat, nor any kind of a pain, nor was he ever conscious of taking the least cold. This is the kind of case that both Dr. Beard and Dr. Wyman would say was not liable to " take cold," because the patient says that he has had no cold, therefore there would be no necessary relationship between his "grass-fever" and his very severe chronic nasal catarrh, the proof of the existence of which he had just given, yet he insists that he has never taken a cold in his life, proving that one may take cold, even very frequently, without being conscious of it, as he undoubtedly did. As I required hitnto d's3ontinue the use of tobacco, 52 Statements of Patients. which he acknowledged wasinjuringhim, he preferred to go to the Lake Superior regions, where he could carry on his excesses and still be free from his pru- ritic catarah. Case YI. — Mr. Francis B. A., Hannibal, Mo., set 34 years consulted me June 16th, 1874. earta t history. Eequired the frequent use of his handkerchief when he was a boy. Was always very small for his age until he attained his 19th year, then grew up rapidly. Up to this age they considered him very liable to take consumption, for which he took cod liver oil for nearly three years. To this remedy he attributed his sudden growth and subsequent good health. Had not been liable to very bad colds, but took slight colds eve?y winter. This he knew because ho experienced difficulty in singing. At the ago of 22 years he ac- quired the habit of smoking tobacco. In a short time, may be six months, he observed that he breathed with difficulty through both nostrils, especially through the left one, and slept with his mouth open, so that his throat was very dry and slightly sere every morn- ing. At the same time he had severe coughing spells in the morning and in his effort to clear his throat would frequently end in throwing something off his stomach. As soon as this took place he considered his cough over for that morning. The severe sneezing and the weeping of the eyes commenced last July (1873) while on a train. At that time, he would put a silk handkerchief over his nose, as he passed from one passenger car to the other; in this way he, in a measure, escaped the bad effect of the wind, the locomotive smoke and the dust. Some- times on entering the car he would sneeze fifteen or twenty times before he could attend to his duties as a Statements cf Patients. 53 conductor. This condition of his case lasted until the first snow. In the early part of this month (June 8, 1 874) he experienced the same sensation in an exag- gerated form. Treated him from the I6th to the 21st inclusive once each day, the effect was all that could be desired. His relief was so marked that he thought that the complaint was going away. Being convinced of this, he started home Sunday night the 21st, but he re- turned on Thursday the 25ih, feeling as bad as ever. As he had vexed me by going home so suddenly, and as the appearance of his eyes was far worse than when I first saw him, I, at that time, refused to take his case, but in the evening of that day, I gave him another treatment, the effect of which was not at all encouraging. The fact was, 1 had made too great an effort to benefit him by the applications, and the result proved that he was too strongly treated, or, in other words, he was over- treated, therefore made worse. I treated him Friday and Saturday, the effects of which were highly encouraging. I concluded to miss Sunday; this was found on Monday to be an error on my part, as the itching in his eyes returned to a slight degree. He was treated once each day during the next seven days. As he remained in good condi- tion, I concluded to pass the next day, Monday ; this was another error in treatment, but the itching was but slight, in fact, scarcely perceptible, but sufficient to determine me to treat him once each day for the next seven days, at which time one days intermission was again tried and found to be sufficient. He was treated every other day until Aug. 1st, at which time he went home entireljr recovered. He took spray producers with him and continued 54 Statements op Patients. the applications at such time as he felt the necessity for them. I learned that he had passed the next three years without the least return of the complaint. Since that time I have not heard from him. Case VII.— Mr. Wm. C. F., Kirkwood, Mo., set. about 50 years, consulted me May 2nd, 1874. EARLY HISTORY. Had enlarged tonsils since he has been ten years old, and frequent abscesses in the throat (tonsils) in the fall months. Has always had tinnitus aurium. Last Aug. (1873) had severe attacks of itching of the eyes and sneezing whenever he went through a clover field. A week before coming to me he felt the same sensation coming on again. As he was told his complaint was " hay- fever " he concluded to try the effect of treatment. He was quite a large man and had a few attacks of short breathing that resembled asthma. The first treatment was quite beneficial. I re- quired that he should avoid the clover and hay field, this he did. He was treated the next two days and felt so well that he passed the next day without treat- ment. May 6th came for treatment, felt well since last visit. Was not treated until the 11th ; had a slight sensation of itching and a few sneezes the day before; treated the 17th \ then again on the 19th and 23d. As he felt entirely well he concluded that he did not require further medical treatment. July 25th returned for treatment; had a few sensa- tions of return during the week. Was treated again on the 80th, Aug. 20th, 26th and Sept. 3d. As he had no evidence of his "pollen-fever " he did not deem it necessary to take further treatment at that time. Statements of Patients. 55 He passed the spring of 1875 feeling in unusually good health, but by advice avoided clover and hay fields. Oct. 23d, 1875, came again for treatment, " driven by thirty or forty sneezes that almost killed me yesterday." He sneezes very strongly, and being a man of about 225 pounds, it tortured him very much. When he sneezed yesterday, he came near falling off his chair, having no control of himself while in the spasm. Was treated again the 25th, 27th, 29th, Isov. 3d and 10th. He was treated three times in Aug. 1876, more as a precautionary measure than as a necessity. I have not treated him since; nor have I heard concerning his health, but I have every reason to think that he has remained well, as he still lives in this county. Case YIII. — Hiss O. H., principal of one our public schools, set, about 38 years, consulted me March 4tb, 1874, because of stoppage of the nostrils, severe fron- tal headache and weeping eyes. Her eyes began to itch Feb. 26th ; this had been increasing to her great annoyance and was especially severe at night. EARLY HISTORY. Has been subject to sore throat since she was a girl, also to severe headaches. For many j-ears has had to clear her throat in the morning, which occasionally made her sick at the stomach. The treatment gave her immediate relief. She was directed to come the next da}% but she did not come until the Saturday following, the 7th. She had but slight return of her symptoms. Was treated again on the 8th, 11th, 14th, 17th and 21st, and not again until Dec. 25th; then once each day until Jan. 1st, following. 56 Statements op Patients. She is still in the city, and so far as I know, re- mains well. Case IX. — J. M. C, set. 29 years, sent to me by Dr. A. B. Barbee, of this city, consulted me Sept 21, 1874, for relief of a severe tickling cough accompanied •by symptoms of " hay-fever." early history. Did not think that he took cold when a boy, at least did not know it, but had " running ears " until he was about 17 years old. Has always considered himself as one of the healthiest boys of the family. One year ago he felt itching symptoms in a slight degree, and was then informed that he was taking " hay-fever," In the early part of this month he had occasion to catch a horse that was in a timothy and clover field, and in doing so became quite warm from running after the animal. About the time he got near enough to the horse " a spell of sneezing would come ■on," which frightened the animal away from him. He had noticed that his eyelids adhered together in the morning for a few mornings before this attack came. on. To the dried, encrusted secretions that ad- hered to the eyelashes' he attributed the intense itch- ing that he had experienced. He did not sneeze more than five or six times, " but the first sneeze closed the nostrils completely." In fifteen or twenty minutes he could breath as freely as usual through the nostrils, and would continue to do so until the next sneezing spell. He was treated once each day for *six days. The first application of vaseline gave him immediate re- lief. Treated him about three times each week for seven weeks, then twice a week until J^o-v. 21st. The next spring he went to Minnesota and remained Statements of Patients. 57 free of the complaint up to two years ago, the last time I heard from him. Case X. — Miss M. M. N., New Harmony, Mo., set. 20 years. Sent by Dr. A. Ashford, consulted me June 17th, 1875 for relief from a severe attack of pruritic catarrh (hay-fever). EARLY HISTORY. Up to three years ago was very liable to take colds daring cold, damp weather. Has suffered for many years with "very severe, blinding headaches," so much so that she could not continue her studies at school. The headache had such an injurious effect on her eyes that she could not read without the aid of glasses. Has had " quinsy sore throat " almost every winter during the lastten years excepting last winter, which was passed without an attack. For one or two years past, except during the last two weeks before she came to me, she had been unu- sually free from headaches, colds in the head, sore throat and dyspepsia. This attack commenced on May 31st with short breathing which was occasioned by a tickling cough. At the same time she had weak eyes, which soon began to itch so severely that she occupied her time, for half an hour after going to bed, in rubbing them. The severest sneezing fits were usually after she had been in bed for a few minutes, or until the bed clothes sot warm. She wet handker- chiefs by the dozen. Gave her treatments on June 17th and 19th. These applications gave her so much relief that she thought she could miss one day's treatment, which she did. Was treated about three times a week until the 5th of July, at which time she had a slight" sneezing spell;" she was then treated once a day for ten daj-s, and then twice a week for three weeks. She went home 58 Statements of Patients. on the 7th of Aug. completely relieved of every symp- tom of the complaint. The next year, on Aug. 4th, 1876, she returned for treatment, but had experienced no symptoms of an attack. She had learned to treat herself by means of the spray producers. This had a beneficial effect on her head and throat. Daring this visit she received fourteen treatments between the 4th of Aug. and the 16th of Sept., at which time she returned home. Asa usual thing patients who attempt to treat them- selves make a complete failure of it, but this young lady was quite an adept in handling the instruments. I discourage self-treatment, because of the inabi- lity to use the instruments properly, and the lack of judgment as to the quantity of the remedies to be applied. I have not heard from the patient since. Case XL — Mr. L. M, R., set. 47 years, a merchant of this city, consulted me Sept. 30th, 1875, for treat- ment of a pronounced and long standing case of " hay- fever." Every year since 1863 he had to go East, North or West for relief. Hud tried almost every- thing, but found no relief; had no faith in anything except high altitudes. EARLY HISTORY. Had been liable to take cold all his life. Never did take good care of himself; is not able to do so now. (It was evident that when he did not have the attack, he did not have the least thought of the consequences' of his numerous indiscretions.) The itching of his eyes almost always commenced his trouble. The dust of his store was his great dread. He said " When I start to sneeze I believe that I would sneeze my head off r if I did not cover it with a silk handkerchief and my soft felt hat. I have tried to see how lonsc I would Statements oe Patients. 59 sneeze without my handkerchief, but I did not have the courage to stand it long enough to see if it would stop while my head was uncovered." When he first visited me his eyes were very red and his nostrils completely closed. The treatment gave bat a slight relief. He ought to have been treated the next day, bat I did not " lay the law down to him soon enough." Oct. 2nd the treatment had a very beneficial effect, But it was evident that he was not taking care of himself, except when he " had to." Was treated the 3d and 4th, then missed a day and was treated the 6th and 7th. The treatment on the 3d and 4th gave him entire exemption, so that he thought he was " not going to have a very bad spell, anyhow ;" but his sneezing returned on the 6th, on which day ho was treated. He did not feel at all assured by the treatment on the 8th, so took the cars that night for Denver, Colo., t*> which place he has resorted every fall since that time. Case XII. — Clara T., set. 8 years. Sent by the late Dr. Frank Porter, of this city, consulted me Sept. 29, 1875. Was first attacked with sneezing on Aug, 22nd, of that year, while she was gathering flowers. At this time she got her face poisoned by " poison ivy," which laid her up in bed for nearly two weeks. After she recovered from this inflammation, the sneezing would instantly commence as soon as she went into the sun or looked up into the sky on a bright day. PREVIOUS HISTORY. Always had been a small, nervous child; tonsils en- larged since infancy. Had ear disease and rupture of the membrane tympani of both ears when about 4 years old; has had no trouble with them since. Slept constantly with her mouth open and made a very 60 Statements of Patients. loud, choking noise while breathing. For two or three years she had to lay on high pillows during cold weather, to enable her to breathe without disturbing the remainder of the family. Treated her on the 29th and 30th, Oct. 1st, 2nd and 4th, These treatments relieved her so much that her mother did not bring her back until Nov. 6th, then again on the 15th and 17th. She visited me again for treatment of her enlarged tonsils, March 17th, 1876, and has since remained free from pruritic catarrh. Case XIII.— Miss Emma C, of Trenton, Mo., set. 26 years, consulted me July 30th, 1876, for relief of " rose-fever." She was attacked with this complaint three years ago. The first year the attacks were not very frequent nor severe, but the disease increased each year since. The attack commenced this year on the 4th of July, while enjoying herself at a picnic in the woods. It was so severe that she held her head in her lap for nearly one hour before she could en- dure the light, her eyes being much more affected than her nasal passages, that is they were far more pain- ful. She was enabled to go home after tying three thick veils over her face and around her head. After she arrived at her home, she had a severe chill and a high fever during the first part of the night. EARLY HISTORY. Has had chronic catarrh for many years, and with it a cough every winter. The first treatment was given with too great an air pressure on the spray producers, and. for this reason did not give the relief that I anticipated. Treated her again the next day with the best effect. These treat- ments were continued once daily for ten days, then three times a week for three weeks, at which time she was unexpectedly called home. Statements of Patients. 61 April 4th, 1878, I treated her again for three weeks, three times each week. I have no knowledge of her condition since then, but have every reason to believe that she has remained well. Case XIY.— Mr. James L., a merchant in this city, set. about 38 years, consulted me on June 6th, 1876, o;i account of a severe cold in the head. He had been a victim of hay- fever for about four years. Each year his complaint commenced about the 20th of August. Examination by the pharyngeal mirror revealed nothing unusual except chronic inflammation. I gave him ten or twelve applications with the spray producers No's 3, 4, 5 and 2. The last applica- tion started him to sneezing, which he feared would commence an attack of hay-fever, but it did not. He was relieved of the cold in the head, but received no further applications, preferring to make a visit to the West for relief and relaxation from business. He returned to my office June 4th, 1877, to be treated for a severe cold affecting his throat as well as his eyes and nose. His trip to Denver, Colo., was productive of much benefit to his health. EARLY HISTORY. At first thought he had not been subject to frequent colds while a boy, but upon conversation with his father recollected that he had had scarlet fever very severely when 7 years old, which left. him very weak for several years, especially during the winter months. When 20 years old, the late Dr. Pope took a large tumor from his nose j he had forgotten which side ; at that time his mother told him he had a bad breath. Treated him daily from 4th to the 10th. Then three times a week for three weeks which relieved him. 62 Statements op Patients. Recommended him to return during the early part of August, for preventive treatment for his "hay-fever." He did so, and was treated Aug. 9th, 10th, 11th, 12th, 13th, 14th, 16th 18th, and daily until the 23d, at which time he had his attack of hay-fever. On the evening of this day he started for Denver, Colo. As he felt entirely well by the 20th of Sept. he returned. He visited me again on July 29th, 1878, for preven- tive treatment. He was treated three times a week for three weeks; commencing on the 18th of Aug. he was treated daily for two weeks. After Sept. he was treated every other day until the 15th, then discon- tinued, entirely well. He was again treated a few times during July, 1879 and 1880. Since that time he has remained well as far as I know. As he lives in the city I am sure that he would have returned if he had not remained in good health, as I now have one of his relatives under treatment. Case XY. — Mrs. G., set. 52 years, a German from Quincy, 111., consulted me on June 26th, 1877, for ex- cessive fits of sneezing. She would sometimes sneeze as many as eighteen or twenty times before stopping, but usually not more than ten or fifteen times. These attacks would come on every ten or fifteen minutes or half hour. As she was quite a heavy woman, these sneezing spells wearied her very much. These attacks commenced five weeks previous to her visit to me, and were constantly increasing. Examination showed excessive redness of the muc- ous membrane, and it was much swollen, both nostrils being closed. Yaseline and three drops of the pinus comp. was sprayed by the No's 4 and 5, vaseline alone by the Statements of Patients. 63 No. 2. Three applications were made daily for about two weeks, then every other day for three weeks. A laxative, diuretic and tonic were prescribed. At the end of the first application her symptoms were very much ameliorated, so much so that she had no more severe sneezing fits. In two weeks all sneez- ing ceased, and every symptom disappeared after three more weeks of treatment. On May 5, 1881, she returned for treatment. After her last treatment, four years ago, she remained en- tirely well until thefollowingMarch, at which time she took several severe colds, which brought on a short- ness of breath, resembling asthma. She now lives near Decatur, III., where she thinks she has taken more cold on account of the flatness of the country. EARLY HISTORY. Up to the age of 22 years, the time that she was married, she was always sickly. Had sore throat al- most every winter, and a bad cough. Had headache until she was about 40 years old. Always had trouble in clearing her throat in the morning, and was some- times quite sick at the stomach after and while coughing. I treated ner for chronic nasal catarrh. The treat- ment lasted until July. The first three days, once daily, then three times a week until June 11th, then twice a week until July 5th. She has remained well since that time, but has re- ceived five or six treatments for her chronic nasal catarrh during Oct. 1883, and once in April, 1884. These histories of my patients prove what I pro- posed to do, namely that pruritus rhinitis catarrhus is one of the sequences of chronic nasal catarrh. CHAPTER V. Local Symptoms ; Subjective and Objective. It is impossible to give the local symptoms, so that they may be seen in every case that may come to the readers observation, for the reason that all symptoms vary according to the age of the complaint and the temperment of the sufferer, but enough can be given to pretty fully portray the peculiarities of the ailment. the skin. The skin of the nose and face is frequently the first to be affected by an itching sensation. Sometimes it is a little hightened in color, even before it is rub- bed and appears as though a rash was about to break out. Then this sensation extends to the scalp, on the back of the neck, between the shoulders and under the arms. In extreme cases the integument of the whole body suffers to some extent. After the complaint has lasted about one week, and the skin has been vigorously rubbed in the attempt to relieve it of the itching, an eruption is frequently observed, resembling prurigo. Sometimes the angles of the eyes, especially the inner, become quite in- flamed, which the ever-present itching induces the victims to aggravate by more rubbing, until small crusts form on the irritated spots. Slight ulceration The Skin and Eyes. 65 appears at the alee of the nostrils, causing considerable suffering when the itching compels the victims to severely rub the parts for relief. The same kind of breaking out, or herpetic appearance is observed around the mouth. Some cases suffer from extreme itching on the an- kles and wrists, and when rubbed, becomes swollen and sore ; then pustules appear, which when rup- tured do not quickly heal. Most patients perspire easily and freely, then the skin becomes excessively sensitive to even slight draughts of air, and become cold and clammy. A peculiarity of the eruptions is its sudden appear- ance and disappearance, lasting frequently but a few minutes or hours. When such is the case, the skin is very easily chafed, especially around the neck where the band of the under-vest rubs the parts. Dr. Wyman mentions a case who "had redness of the skin of the color of a boiled lobster, compelling him to keep bis bed five days." THE EYES. The eyes come next in the succesion of being the most early and most frequently affected, the itch- ing — the characteristic of the complaint — usually com- mences at the inner corners. If the left nostril has been the one more affected with the chronic catarrhal inflammation, then the left eye is the first and more severely affected with the itching. The irritation always reddens the conjunctiva, then the whole eye 66 The Eyes and Nasal Cavities. is suffused in tears, the lids become swollen and in the morning they are agglutinated to each other by the Meibomian secretions. On awaking in the morning this instantly gives rise to an attack of itch- ing of the eye-lids, which instantly extends to the nostrils. So "unanimously/' as one of my patients ex- pressed it, does this take place, that he was unable to say which part was first affected. This condition of things lasts but a few seconds when the nostrils are completely closed, apparently on account of the tears flowing down the lachrymal canals. The tears have a positively irritating effect on the cheeks as they now from the eyes. When the eyes are in this condition, a bright sunlight is so very ag- gravating that the victims instantly endeavor to shut out the light by placing both of his hands over his face. A dark, cool room is the only place in which he can quickly recover from his attack. A peculiarity is, that after the attack, the conges- tion of the bloodvessels as suddenly disappears as the attack appeared, leaving no visable trace behind, al- though in some cases sties are apparently the result of the excessive hypersemia of the lids. THE NASAL CAVITIES. The nose is sometimes the location from which the pruritic symptoms originate. This may be started by a slight push in any direction but especially if given side wise. I had one patient whose principal agony came from minute boils that formed but did The Nasal Cavities. 67 not entirely heal up until the season was past. In some patients the muscles connected with the nose were in almost continual sposmodic contraction a kind of coreaic condition just previous to an attack of sneezing. The nasal passages, according to Beard and Wyman are the parts that most frequently suffer first and most severely. The sneezing is occasioned by the itching. The first wink of the eyes sends the irritating tears down the lachrymal canals which in- stantly starts the itching, this is followed by sneezing and a largely increased flow of nasal mucous that com- pletely occludes the nasal passages. If the victim blows his nose, as he feels inclined to do, this will aggravate the matter, by causing a full, wedged sen- sation in the cavities. It is remarkable that the excessive congestion of the mucous membrane does not more frequently lead to nose-bleed. Dr. Wyman mentions a case who had nasal hemorrhage, I have not seen one. As soon as the paroxysm is passed, the passages slowly open so that respiration can be again carried on through them. The nostril that wa3 usually ob- structed during the chronic catarrhal stage will be the occluded one during the paroxysms. As the paroxysms are most severe and. most fre- quent in the mornings, the nasal obstruction will oc- cur at this time of the day also. The quantity of the nasal discharge, in one morn- ing varies from wetting five or six handkerchiefs to twenty. In the older cases, the secretion is of a 68 The Pharyngo-nasal Cavity watery nature, except at the close of the season, when. it is somewhat "sticky" bat with those who have had but " two or three seasons of it, " the secretion is always "sticky," and toward the close of the season, the purulent character is quite marked. In a few cases a spirt of violent exercise, to the extent of producing a gentle perspiration has an open- ing effect on the nasal passages, and a quieting effect on that days attacks, In every patient the mucous membrane was ob- served to be in an excessively hypersemic condition, and of a dark, purplish -red color. The blood vessels usually plainly visible during the chronic catarrhal stage were not in sight. The sense of smell is always obtunded, and odors, that before gave pleasure while not causing the least irritation, have usually a disagreeable effect, still they were unrecognisable. THE PHARYNGO-NASAL CAVITY. The pharyngo-nasal cavity is always less severely affected than the nasal cavity, but an itching sensa- tion is felt here also. The only means of relieving this part is by coughing, retching and vomiting. All of my patients had the coughing and retching, and. most of them had the vomiting. The mucous membrane while not so deep a red color as the superior turbinated processes, was quite dark red, and in some patients the membrane had an ©edematous appearance. Soft Palate and Larynx. 69 The subjective symptoms due to inflammation in this locality are almost uniformly felt in the throat and for this reason patients try to relieve themselves by coughing. VELUM AND UVULA. The soft palate and the uvula are very frequently the seat of an itching sensation. In severe cases, at the end of the season, the velum is frequently in a paretic condition, so much so as to allow fluids to pass up into the pharyngo-nasai cavity and nostrils. In a few cases the uvula is slightly cedematous ; in one patient it was so dropsical that it almost filled the whole space between the enlarged tonsils. In this patient the sense of suffocation on assuming the horizontal position, was so great that he slept in an arm chair ail night. In some the uvula is so much elongated that it acts as a foreign body in maintain- ing the cough. EUSTACHIAN TUBES AND MIDDLE EARS. The itching sensation sometimes extends up the Eustachian tubes to the middle ears. As soon as these cavities are reached a fine sucking sensation is experi- enced in the root of the tongue, showing that the chorda tympani nerve is affected. In about a fourth of my patients their hearing was manifestly decreased. FAUCES AND LARYNX. On account of the excessive effort to relieve the throat of the itching sensation by coughing, the whole surface is much congested and in an excessively sen- 70 The Tonsils. sitive condition, so much so that it requires some dex terity to make an examination and to apply the spray producers. A paretic condition of the faucial muscles is scru- tinies observed, and with this the parts lose their proper sensation, that is become anaesthetic, so that it is quite a labor to swallow food. THE TONSILS. The tonsils are not often swollen, but are fre- quently quite painful, and are particularly so when swallowing. This pain is sometimes felt up in the ears, or if one tonsil is alone affected the correspond- ing ear is the one in which the pain is felt, and the hearing in this ear is always defective. When both tonsils are swollen and painful, and the nostrils are closed, eating and drinking is a somewhat dangerous operation, on account of the liability of the food being either driven up into the pharyngo-nasal cavity or allowed to partly pass into the larynx; in the latter event give rise to severe spasmodic coughing and threatened asphyxia If the nostrils are occluded, so that respiration it* carried on through the mouth, the lips, gums, tongue, soft palate and throat all become dry and parched, and all seem as though it was impossible to move or use them, but as soon as a little water is taken into the mouth, and made to bathe all the parts their fac- ulties return. The secretion from the throat is quite tough if it The Trachea and Lungs. 71 is not profuse, and the effect to get rid of it frequent- ly maintains the throat in a sore condition. I have had but one patient who had severe itching in the roof of the mouth all the others had this sensation in this locality but slightly. THE TRACHEA, BRONCHIAL TUEES, AND LUNGS. The itching extends from the fauces to the larynx, and thence to the trachea and lower air passages. This sensation is the sole cause of the spasmodic ac- tion of the lower air passages, or in other words, the asthmatic symptoms. The cough does not commence until the parts are very much irritated by the endeavors of the victim to relieve himself of the itching;, For this reason the cough is observed in the second and third week of the pruritic season. The itching is sometimes felt in the trachea or at least the victim asserts that it is deep in the chest, where one would locate the wind-pipe. If the sufferer is awakened by the itching sensation in his face, eyes or nose, before he gets through at- tending to these parts with his hands, his tongue is called upon to relieve the same sensation in the roof of the mouth, and a rasping cough is raised for the purpose of relieving the throat, and instantly on this attempt being made the same sensation is felt in the larynx, trachea and even in the bronchial tubes. DECEPTIVE SENSATIONS. The sensation experienced in the throat, is occa- sioned by the itching in the pharyngo-nasal cavity. 72 The Voice. This is easily proven by the application of a soothing remedy used by means of the spray producer that throws a vertical stream. If this is the case, then it is evident that coughing or clearing the throat will not relieve the irritation located up behind the soft palate, at least five inches above the vocal cords the locality of the cough, and it is also as evident that the less that the patient coughs, the less irritation to the vocal cords, the larynx and the throat, not to mention the effect of a fruitless cough on the air pas- sages in the la rigs. Some patients are so wearied by their efforts at coughing that they can hardly stand ; the cough is especially fatiguing if the expectoration is scanty, in this case the efforts at relieveing the throat of the itching sensation is brought about by retching and frequently by vomiting. THE VOICE. The voice is soon affected, so that hoarseness is a constant symptom after two or three weeks coughing. The color of the vocal cords is the same as that of the surrounding mucous membrane, instead of being a pearly white resembling the sclerotic coat of the eye. • ASTHMATICS Toward the latter part of the "pruritic period" the symptoms seem to be less severe in the eyes, face, nasal passages than ever and a slight cough is suffi- cient to bring on short breathing or asthmatic symp- Asthmatics. 73 toms. I ana satisfied that if the patient could be re- lieved of the irritation that produces the irresistible desire to cough, the asthma would not follow and those who had but slight or no cough were as free of asthma, while those who early commenced to cough frequently and severely, were afflicted with asthma to the severest degree, in other words, the milder the pruritic symptoms the milder the asthma. A dinner, made hearty by the use of stimulants, is apt to induce short breathing, but it is not a genuine attack like the one that comes on immediately after the first coughing spell on retiring for the night, these attacks cause the victim to grasp the mantel piece for support. As the pectoral and intercostal muscles are se- verely exercised in coughing, this may give rise to a pain in the chest, which may fill the patient with fear least his lungs are becoming seriously in- volved, but even a slight examination will readily prove that they are not seriously affected, although mucous rales will be easily heard, but this will pass away in a few hours, may be to again reappear after the next paroxysm. The attacks of asthma that fol- low retching without vomiting always last longer than when there is vomiting. Why ? Because the act of vomiting clears out the pharyngo-nasal cavity quickly, whereas the retching alone does not do so, showing that irritation in this cavity can have a marked effect on the lungs, as well as on the larynx. 74 The Heart. the heart. Palpitation of the heart is a frequent sequence of of this complaint; so is an intermittent pulse. Most patients complain of a soreness in the region of the heart after they have recovered from their asthmatic attacks. The pulse is not more frequent than would be expected after the bodily exertion of the parox- ysms. Many of these patients live under the impres- sion that they have heart disease, but this organ is not affected except in sufferers who have had chronic nasal catarrh for thirty-five or forty years. CHAPTER VI. Constitutional Symptoms. A statement of the constitutional symptoms must, of course, include much that has been said concerning the local manifestations, A large proportion of these patients are so unob- servant of their conditon, that it is with difficulty that premonitory symptoms can be found to exist. A few pa- tients have stated, after being questioned several times on the subject, that they felt as though they were weaker or more nervous; that their appetite was not as good as usual; that their urine was a little more highly colored; that they did not sleep as soundly, and that they felt peevish and cross. Most of these initiatory symptoms were entirely ignored by at least two thirds of my patients. Those who did have any or all of these initial symptoms, state that they probably commenced a week or a little more before their anti- cipated attack, but were the strongest during the three or four days before the attack. Some of these patients thought that the mental anxi- ety concerning the attack, had something to do bring- ing on these symptoms, together with their loss of sleep and appetite, etc. 76 Constitutional Symptoms. In a majoirity of the patients the system was not disturbed until they had suffered, for nearly a week. Then they experienced chilliness followed by flashes of heat; their hands and feet burned so severe- ly that they felt compelled to bathe them in cool water, not cold water, as the latter always caused pain. Some preferred tepid water. "While they felt a slight burning heat over the whole of the body, yet when a cool wind struck them espec- ially on the back, they began shivering instantly, this was frequently followed by an attack of itching and sneezing. Several patients were affected with night sweats. Palpitation of the heart was a very common com- plaint, as well as a soreness or uneasy sensation in the left side of the chest, especially after sleeping on that side. With many the pulse was slightly accellerated and intermittent. All patients complain of a want of appetite, not only this, but they lose the faculty of taste to some degree. Warm drinks are the most pleasant, and hot soups keep their place throughout the entire attack, as being the most nourishing and grateful. "With the diminution of the renal secretion, there is constipation of the bowels. Some patients were af- flicted with diarrhoea, but this was nearly always found to be due to some indiscretion in eating. Indigestion and all its usual consequences, was almost always present. All patients were mentally depressed, were fretful Constitutional Symptoms. 77 and easily angered, and much given to fussiness about their meals. Forgetfulness was one of the sequences, as well as an impossibility to continue a long time in any train of thought. Many expressed doubts as to the perfectness of their sanity, or were fearful that their mind would give way under the terrible stress. The failing or wandering of the mind was most fre- quently experienced at night, on waking out cf a sleep when attacked by a sneezing spell. Two patients were so much terrified by some unaccountable fear that they would not sleep in the room without a light. These terrors would even follow them in sleep and cause them to moan loud enough to awaken those in an adjoining room. These mental symptoms were always the most severe with the asthmatics, and those who had the fall attacks or the so-called autumnal catarrh. It is remarkable that some victims will undergo these attacks and suffer from all of these symptoms and at the end of the season proclaim themselves in good health, and, because a few people have claimed in the public prints and in small works on this subject, that they are better after suffering from these attacks, they will "follow suit" and make the same expres- sions, yet every one of them, if carefully intorrogated, will give evidence of the yearly weakening of the system, that would not have occurred were it not for these attacks. CHAPTER VII. Course of Pruritic Ehinitis. Some authors who have written on this subject, -employ language, in describing the attacks of the complaint, that plainly indicates that they are not averse to using the marvelous, so much so that their remarks concerning its peculiarities, require that the exclammation point should conclude their sen- tences. Nearly the whole tenor of all they say, is gauged on this key. Even some of the sufferers themselves seem to enjoy this extravagant mode of expression as seen from the histories they give of their symptoms. Brooklyn's world-famed divine takes the lead in this style in describing his case. He shows his fondness of the graphic in detailing his attacks, and one would be really excusable in think- that he was in rather good humor with himself while giving his account of them. I do not mean to ques- tion the correctness of what he says, but I insist that the exhibition of the marvelous is manifest and i3 mis- leading. The point I wish to make is this. If a complain- In the Beginning, Attacks Irregular, 79 ant's symptoms do not come up to this marvelous gage, or his expressions are not given in this key, they are without exception, not included in the hay-fever list; consequently, the true commencement of the com- plaint is not observed, because the first, the initial manifestations are so very slight, that even the victim himself does not recognize the tendency of his symp- toms, for this reason there is no opportunity for flights ofrhtoricin describing his feelings. Not long ago, I had a patient say : "I would believe that I was affected with hay-fever, if I was not so well acquainted with the symptoms of this disease. My uncle has had it for many years. He has it on the 12th day of June every year, at the same hour in the morning and it leaves him in just five weeks, whereas my symptoms last different lengths of time, and may come on at almost any time of the first four months of the year." I know of a gentleman who said: "I had my first attack on the 20th day of April and it lasted until frost, at the same time I was in real good health. I had no regular time for my itching and sneezing, neither of which are severe. I sometimes have it one time and sometimes another. One year ago I had it in February; this year it commenced in May. One time I had it in the last week in December; this was three or four years ago. I had. almost forgotten it. I am sure that it is getting worse every year, and may be it will turn into real hay-fever if it is not stopped." 80 Cases to Prove its This is a fair history of at least thirty cases that have come under my observation. The forgetfulness of these patients, which is almost proverbial ( at least with those that I have seen ) makes it difficult to get an accurate and full history of their condition before their attack, but careful in- terrogations, made from time to time during their visits for treatment, will always elict the fact that they had attacks of itching of the eyes, face, nose, etc, with sneezing during the late winter and early spring months, and that they were thus afflicted for from one to seven years previous to the full formation of the complaint. This view of the commencement of pruritic catarrh can only be established by facts obtained from patients. This I propose to do by giving the histories of a num- ber of patients who have suffered more or less from this complaint. Case XVI. — Mrs. A. E. sst. 47 years consulted me Aug. 25 1883. Complained of having a severe cold in the head and disease of the right antrum of Highmorc. Since the middle of July 1883, she suffered from what she thought was a continous cold, accompanied by severe sneezing and itching of the eyes and throat. On her first visit she stated that she did not have these symptom at any previous time, but on further conversa- tion on this subject, on the 5th of Sept. following, she remembered having had these "sneezing spells" dur- ing the warm weather of the past five years, and that they had been gradually getting worse, these " sneez- ing spells" were accompanied by symptoms of Gradual Commencement. 81 asthma, which was more severe this year than at any time previous. Case XVII. — Dr. E. L. sot. 44 years consulted me June 13th. 1884, He had had nasal catarrh for 25 years, but not very annoying until 10 years ago, since that time, it had been noti cable to others that he took cold more frequently in warm weather, so much so that he was not able to attend to business without much suffering. In the spring, when the "fuzz" was blowing off the trees, his eyes became inflamed and all of his catarrhal symptoms were much aggravated. Towards the close of the season he had symptoms of asthma. He was sure that his " hot weather catarrh " had become more aggravated each year, and with it, his asthmatic symptoms. CASEXYIII.-Miss.M. Collinisville, 111. set. 26 years sent me, on June 3rd. 1884, by Dr. Wesseler of this city. Complains of sore throat accompanied hy severe cough and short breathing. In June 1873, upon sweeping the floor or making feather beds her eyes would commence to itch and she immediatly began to sneeze. These paroxysms lasted for nearly an hour; before this date she had the same sneezing now and then, but never so severe. These symptoms did not increase until June 1883, at this time she took a very severe cold. She was cer- tain that she had sneezed every month since that time, especially since last Christmas. At present she sneezes only when she is in a draught. Not otherwise except when exposed to dust from a carpet. Just before she sneezes she experiences itching over the eyebrows. The symptoms of sneezing are occa- sioned by emanations from a rose or other flowers. Case XIX — H. W. set 13, years. Consulted me July 3rd. 1883 complained of sneezing, swollen eyes, sore 82 Cases to Prove its throat, general debility, nose-bled every day, some- times several times a day ; takes cold easily, especially during warm weather. When he was an infant about 3 or 4 weeks old he took a severe cold. His mother thinks this was the foundation of his catarrhal trouble. In three or four months after this, took another severe cold and had inflammation of the pleura. He did not take cold like most childern but had a watery discharge from his nostrils like an adult. Fresh hay did not have any irritating effect, but old dusty hay always brought on paroxysm of sneez- ing. His mother does not remember his sneezing con- tinuously as he does at present, but knows that he has been rather sensative to all kinds of dust since he was three or four year old. Had not had attacks of asthma until the fall of 1882. All of his symptoms remained the same until 1880. Since then they have been increasing rapidly. Case XX. — Mr. A. A. set 17 years complained of sneezing and itching of the eyes. When he was 8 j ears old he caught a severe cold in the cars, that af- fected him for nearly a year. On July 18th 1875, while in Concord, ~N. H., he went into a ha}^ field and was attacked with sneezing, which was so severe as to compel him to return home. The paroxysms did not fully discontinue until evening, at this time a feather dipped in quiuine was put up his nose, but this made him sneeze more Beverly, and had the effect of maintaining the attack for nearly the whole of the night. This application of quinine was kept up for some time, with the effect, as his mother now maintains, of producing a chronic inflammation of the nasal passages, On the discontinuance of the qui- nine his paroxysms ceased. At first his phj-sician thought that he had hay fever, but as he remained Gradual Commencement. 83 -well and was able to pass through hay fields and play with hay it was concluded that he did not have the complaint. The next attack of sneezing occurred in the later part of May 1876. On its reappearance some of his friends thought he had hay-fever, but after consultation with a physician it was concluded that it was only a cold in the head, the next year he again had the paroxysms in May, at this time he was sent to Iowa where in a few days all symptoms disap- peared. In 1878 he had but few paroxysms of sneez- ing. In 1879 the complaint developed itself in full force, for which he was treated by three physicians. In 1880, his attack was postponed until the 15th of June, and for three weeks it was very severe, on the 12th of August in the same year it again commenced and continued for about one week, towards the end of September he had a third attack which lasted him for two weeks. In 1881 he did not experience any sensation until the end of September. In 1882 had it slightly in August, and a severe attack of it the first week of October. Case XXI.— Mr. W. H. M. set 42 years, consulted- me May, 12 1885. " For three years I have been sub ject to taking cold far more frequent in warm spring weather than during winter. My colds have been so severe that I have lost my voice. My eyes have been weak and watery at such times and I think they itched last spring and may be a little the year before, but at present I have to rub them to relieve them of itching which is now quite severe. I have sneezed a good deal for several years, but had not thought of having hay-fever." The above histories plainly establish the fact that pruritic catarrh manifests itself by -slight symptoms 84 Early Stage. at first, and that these gradually increase in severity until it takes full possession of its victim, or in other words, is so violent in its demonstrations that it forces recognition from every one. The course of the complaint after it has fully man- ifested itself, is of interest to the physician. From it he can determine whether or not the complaint is decreasing or increasing under his treatment. To describe the course of this complaint, I will be compelled to take the stages, consecutively, as they occur. STAGE OF NON-RECOGNITION. This is the most important stage; it commences at any time from the last week in December to the first of July ; but the period for the most frequent attacks is in May and June. The victim has been subject to colds in the head for years; he has indulged in reading at night or has smoked at night, then his eyes itch him a little, which he may blame to the smoke of his cigar; he has sneezed a little. Even if he is not the age to use glasses, he will be apt to question him- self concerning the failure of his sight, and will seriously think of doing something for this disabil- ity. He will notice that they are sticky in the morn- ing, and that they are apt to water if he suddenly goes into the light, also that this may be accompanied by a few sneezes. If these symptoms are marked, the usual symptoms that he experienced of his chronic nasal catarrh will be May and June Form. 85 proportionally lessened, showing a marked metasta- sis of the former complaint to the new one. Indeed, this characteristic is observable in all stages of chronic catarrhal inflammation of the nasal cavities and all of its sequelse, pruritic catarrh not excepted. I had one patient who imprudently ate some canned apples in June, at a time he was suffering from his attacks, which gave rise to a bowel complaint that resembled cholera morbus. While ailing with this disease, he was entirely free from his slight symptoms of pruritic catarrh, and from his severe headaches, the result of ohronic nasal catarrh. These irregular attacks of itching and sneezing may last for a few months or may be for several years, but when they assume a severer type, they then take on more regular dates of commencement, and discontin- ance, and the complaint is then given the name of rose-cold or June-cold or July-cold,^according to the season of the year in which these regular attacks occur. This brings us to the recognized PRURITIC CATARRH, OR THE EARLY FORM KNOWN A3 ROSE-COLD OR JUNE-COLD. The facts herewith given will show plainly that the earlier the attacks of pruritic catarrh, the younger the complaint, and vice versd. While these views are not acquiesed in by any au- thor that I have seen, yet I will quote from them pas- sages and histories of cases, that will prove that I am right. The two symptoms, the cough — which comes 86 Changes its form. from pharyngo-nasal irritation — and the asthma, that are taken to show the degree of the severity of the complaint, increases as the age of the complaint in- creases. This is shown by Dr. Beard, on page 111. Of 17 May cases, 4 had neither cough nor asthma, 7 had both. Of 13 July cases, 3 had neither cough nor asthma, 7 had both. Of 55 August cases, 9 had neither cough nor asthma 66 had one or had both, demonstrating that the later in the season the attacks occur, the more severe the complications. Further on he says: " Others, who dar- ing the first years have the early (May) or middle (July)form, subsequently have the late form (August). In corroboration of this, I will quote from Dr. Wyman. He gives on page 148, the histories of cases exactly similar to quite a number that I have under observation vis : "Dr. A. W. W. of Chicago. 111. — Has suffered since his eighteenth year, though for ten years it took the form of " rose cold" or June catarrh. l Finally six years ago the June visitation was 'broken up by Jonas Whitcomb's remedy, and I was congratulating myself on a cure when August came and brought with it the i big brother/ Since that time I have no further trouble in June — save it all for August/ On page 149 Dr Wyman says : " The June cold is less severe and of shorter duration; the eyes are less severely and less constantly affected; the cough is much less constant, and not spasmodic to the degree of producing retching and vomiting; asthma is less frequent at the close, but when it exists is sometimes Changes its Form. 87 more severe. * * * * * * * "Those who have June cold are seldom subjects of Autumnal catarrh. When June cold has existed it has generally ceased on the appearance of the latter disease." On this page he gives the history of some cases illustrating what I have quoted: "Mrs. H. at the age of 18 first noticed thst she was affected by the aroma of roses. The following year, while picking roses in the morning, had itching of the eyes, which became so intolerable by afternoon that she asked medical advice. After this she could not be in a room with any flowers without affection of the eyes and catarrhal symptoms. This state of things con- tinued about ten years, when she began to have her regular Autumnal catarrh, and the sensitiveness to flowers very materially decreased, but has not entire- ly disappeared." On page 150, is the following cases : " Case 10. — The yearly attack formerly commenced in June; now it commences between August 20th and 27th, and terminates September 10th to 20th." u Case 65. — Mrs. M. — At 16 had catarrh commenc- ing in June and ending about July 4th, or during hay- ing time. This occured annually for 17 years. Five years ago, after some irregularity in its period of ter- mination, it ceased altogether, and a catarrh appeared about August 1st, when near Fall Eiver, Mass. The three subsequent years she was in Origan, Illinois, when it appeared August 17th, and this year [1866] while in Charlestown, Mass,, August 24th." On page 151 is the following case: "Bev. J. H. W., who had been a subject of June cold from early infancy, writes: ' But it has changed. It always had begun in June and continued until the 38 Changes its Form. middle of July; but about ten years ago it began to reappear in Autumn. Now it has almost transfered itself from June to September. E. #., this year [1872] I have had two bad days, one in June and one in July. Last year it was about the same ; but with September came three terrible weeks, part of which I had to 'give up ; and take my bed, for the first time in ten years of preaching I lost a Sunday's duty from this cause." Many other cases of the same character could be quoted from these and other authors. I have the his- tories of 23 patients that bear the same testimony. This demonstrates the difficulty in giving the course cf this complaint, as it differs according to the age, temperment and exposures of the victims. Once that the complaint has sufficiently marked symptoms, the patient will complain of an itching of the eyes, but this always occurs after an exposure that has resulted in a cold being taken. If the itching lasts for a few minutes, the same sen- sation is experienced in the nose, then the sneezing comes on, first only a few of them, not enough to call his or her friends attention. The next day this same course is experienced by the victim and is observed by his friends, then (in the majority of instances) they tell him that he has the hay-fever. At first his attacks are not severe, and after they have passed away, he invaribly thinks that " it may not be the hay- fever, after all." I have not seen the victim of pruritic catarrh that did not say this or use words to this effect; not only this, if they pass one day, July or Middle Form. 89 they as invariably forget to take any precautions to prevent a recurrence. After they have had an attack for about a week or two, they may begin to have a cough, but this is far from being constant, except when the complaint has grown to be a few years of age, then asthma in a mild form may affect the patient. Ail their previous symptoms of chronic nasal catarrh will disappear as these new symptoms appear, yet the patient will not mark the absence of his old symp- toms unless reminded of it by some friend or some unusual circumstance. At this age of the complaint, there is no premoni- tary stage, at least very few patients can remember any thing that would resemble that experienced by older victims. The duration may be a few days, or one or two weeks, according to the care the patient takes of himselfj and to the exposures that he must encounter; about ten days is the average duration. If the first on-set passes off in three or four days, his tormentor may return with redoubled force. The date of dis- appearrnce is always uncertain in young cases, and it may be sudden or it may be gradual. THE ATTACKS THAT OCCUR IN JULY. I do not mean, by thus dividing the description of the attacks of this complaint, that they are different diseases but a difference only in severity. A good illustration of what I mean is to say that the inter- mittent, remittent and continued fevers are not three 90 All Forms one Complaint. separate diseases, but three grades of severity of the same disease. On this point I agree with Dr. Beard he says on page 110, " The unity of the different forms of hay-fever, occuring early in the summer, in mid- summer, or late in the fall, is proved by the follow- ing facts: " The symptoms in all three forms are the same in kind, differing, if at all, in degree only. The distinc- tive symptoms — the sneezing, itching, discharge from the nose and eyes, swelling and obstruction, cough and asthma, with the febrile state, nervousness, lan- guor, debility, and depression — are experienced in the early and middle as well as in the latter forms. " As seen from the tables showing the dates of attack [see index], the number attacked in July are not greater than in June, but the severity of the attacks are always greater. Some might say, that according to my theory the number also ought to be greater. It does look that way at first sight, but this can easily be explained. The early attacks are made more frequent by the greater liability to take cold, because the season of the year tends to cold-taking. Many of these attacks would not have occurred were it not for some indis- cretion that could have been easily avoided, and would not have happened in warmer weather if the victim had taken care. Thus the number of sufferers would be decreased, in proportion as the mildness of the season made it possible for indiscrete persons to be careless of hygienic measures, without taking severe colds. The symptoms of this form, the July attacks, do not Autumn Form. 91 differ in the least except as to severity and duration. More of them have cough and asthma and the attack lasts longer. To repeat them would lead to confu- sion. THE ATTACKS THAT OCCUR IN THE AUTUMN. This is the season for the attacks of this complaint after it is well formed, but the symptoms of this state also differ only in degree of severity and duration, that is, with the average number of the cases. Some of the mild autumnal grades are very much less severe than some of the severe forms of the July or May forms. But few victims of this form esc ape the cough and asthma. A peculiarity of this stage is that the victim some- times out-lasts the complaint, that is, the attacks, after coming on regularly for a number of years, slowly decrease in severity and then cease altogether. I have seen two cases of this kind. Dr. Beard relates three cases that "finally disappeared entirely." CHAPTER VIII. Influence of Location. Most of my patients were best pleased with the effects of the climate of Colorado, several of whom had visi- ted the famous White Mountains. The sunshine in the Colorado region does not have the least irritating effect on the eyes. Several were greatly relieved by a sojourn near Austin, Texas. Several have made their residence near Los Angelos, Cal., because of complete exemption from the attacks. One of these patients, a physician, says that he has never known of an in- dividual haviug an attack of pruritic catarrh while re- maining in that region. Three of my patients pre- ferred the region of Lake Superior, Sault St. Marie, and Mackinaw. Last year (1884) in August and September, three of my patients spent the whole pruritic season at home, in a darkened room, maintained cool by hanging a piece of ice, ten pounds, each day from the ceiling of their apartment, as hereafter described. Dr. Beard asked his correspondents the following question. " Are you better in the city or in the coun- try ?" Influence of Location. 93 His replies were the following : Better in the city 28 Better in the country - - - 12 No difference 8 The remainder — 162 — not answering the question in any way. This is so unsatisfactory that I consider it of little or no value. His next question was : " Where do you find the quickest and surest relief?" His replies were the following : At sea 8 At the sea-side 19 In mountainous regions 35 Some portions of White Mountains 15 .Rocky Mountains .... 7 In bed in a cool, close, dark room - 8 As before stated, three of my patients expressed the same preference that the last eight did, and one of these had been to Denver, Colo., and one to the Ten- nessee Mountains. Another of Dr. Beard's questions is the following: '•Have you ever visited elevated regions without benefit ?" His replies were " 83 No. and 17 Yes." in his detailed replies, the following places had been visited without benefit. 11 Five, specified Catskill Mountains j Lenox, Mass ; White Mountains : Little Mountain O.j Mountains of Eastern Pennsylvania and Mt. Mansfield ; Overlook (3000 feet high) ; Mountainous regions of Connecti- cut ; etc." Dr. Beard very correctly says : " The information £4 Recommendations here contained is sufficient to show that there is no rigidly defined non-catarrhal line. Elevation is but one factor." FOR VERY CHRONIC CASES. Those victims who have had the pruritic catarrh for ten or more years, would do well, after receiving the treatment for their chronic nasal trouble — as all of them have had this form of catarrh, — to visit and re- main at a location that affords them complete exemp- tion from its attacks, because the more frequently they allow the attacks to occur, the longer the attack will will remain and the more surely will it fasten itself on them. I believe that a course of treatment, for several years, followed by a prolonged visit to some region in which they can be free from attacks will ul- timately cure the complaint, except in very old patients. Under these circumstances, where will they go ? I have recommended my patients to go to one safe region one year, and another the next year, and so on ; that is, not to visit any one place, any two years in succession, as the patient may become acclimated to the place, and thus loose some of the benefits of the change. OCEAN TRAVEL. A voyage on the ocean is the most certain to be healthful to these patients. But in so doing one need not take a passage on a vessel that is transporting a large drove of cattle, sheep, hogs etc., and in this way " tempt the evil one/' Those vessels that are freighed For Chronic Cases. 95 with pine lumber, or black walnut lumber, or timber, are the best of all. A voyage in a vessel, leaving a little before the beginning of the season in which the pruritic catarrh commences, bound for some part in South America,, say Eio Janeiro is a most pleasant, trip, and one that need not be so very expensive either, a good thing to be kept in mind, by the way. WESTWARD. The next best regions are in Cplorado or California. ISTo bad reports have come from either of these States. While residing in either of these locations, the patient should not conclude that he can, with impunity, live indifferent to the laws of health. One of my patients, who visited the "Far West" said that he " was fool enough to acts as though the climate took the contract to cure him," consequently he followed his usual in- clinations in living carelessly, in utter forgetfulness of all hygienic rules. The consequence was that he did not receive all the benefit that he might have done had he lived differently. LAKE SUPERIOR. The regions around Mackinaw and Sault Saint Marie are reported as excellent for patients afflicted with this complaint. The air of this part of the coun- try, like the water of this grand lake, is remarkable for its clearness, but even here patients must not ex- pose themselves to agencies that are known to be irritating. A TOUR ON THE CONTINENT. This is most always very beneficial. Many have been permanently strengthened by a three or four 96 Europe Kecommneded. months visit to Europe. In these days of rapid and pleasant travel, a trip can be made by a patient who is very weak, with an almost certanity of immediate relief as soon as land is out of sight. A permanent residence in Europe is a sure preven- tive of further annoyance from this complaint. Al- though it is stated that when Americans return to this country, the pruritic catarrh also makes it return, yet I am fully of the opinion that were they treated for the chronic catarrhal inflammation of their nasal pas- sages while there, for a period of three years according to the age of the patient, they could return to their usual abode with immunity from the attack of the pruritic catarrh. In closing this chapter I would again urge that greater benefit will be received by the traveling vic- tim visiting one region one season, and another the next season, always looking for a new place of exemp- tion. CHAPTER IX. Causes op the Paroxysms, dust. Dust of various kinds stands at the head of the list of the causes of paroxysms, and the dust of the steam cars is the most aggravating; as this is always accom- panied by the sulphourous smoke from the locomo- tive. The next kind of dust that is to be avoided is that from an old carpet, then that from an old feather bed, then from a moss bed, after this comes the dust from old, moul dy hay and from the street. It must be born in mind that in the formative and early stages, the cause of the paroxysms is not attributed to dust alone, there must always be a tendency and oue or more other irritating agencies at work, as sunlight, heat, excesive exertion, sufficient to cause perspiration to contribute to this result; but dust, of the kind named, seems to be the most prominent. BRIGHT SUNLIGHT. Any kind of very bright light, but especially strong sunlight stands next in the list. If the victim should lie with his face to an unshuttered eastern window, 98 Irritating Agencies. and suddenly open his eyes so that the full morning light will fall upon them, an attack is almost certain. EXHAUSTION FROM HEAT. Over heating the system stands nextas an irritating influence, but with this there must also be over-exer- tion to the extent of exhaustion. As these patients are easily wearied, even moderate exercise may lead to exhaustion. The remainder of the list of irritating agencies, named as they have proved to be the most noxious, are as follows: Hay, old and musty, and fresh. Sneeze or rag-weed. Sulphur matches. Smoke. Draught of damp air. Flowers. Air of a mouldy room. Cold damp winds. Tobacco smoke. Foggy morning. Night air. Damp cloths. Of the mental conditions: manifestation of excessive ill temper; anxiety, and melancholy, are the most prominent. Indigestion is a frequent excitant of an attack. The sudden, in fact the instant response of the sch- neiderian to the irritating effect of the most of these agencies, apparently leaves no period for the incuba- tion of parasites. Notwithstanding this, I presume that, some one will soon lay claim to the discovery of Irritating Agencies. 99 "bacilaris3 peculiar to or may be a cause of this com- plaint. The effects of these irritating agencies are so instantaneous, that there is no opportunity for imagin- ation to act on the victim, as the attack is a surprise to every one of them, nor do they know positively? for some time, the cause of their paroxysms. A close investigation of the effects of these irritat- ing agencies, proves that their number is quite large, instead of being but a few things, and that hay in any form is not the chief cause of the paroxysm, dust of various kinds being far the most noxious. This dis- poses of the question as to the propriety of calling the complaint, hay-fever. CHAPTER X. Diagnosis and Prognosis. The characteristics of increasing severity of the suc- cessive stages of this disorder, is plainly demonstrated by the table facing this page. THE FIRST OR FORMATIVE STAGE. Presuming that the reader has scanned this table, the work of presenting the diagnosis will be mater- ally shortened. In proportion as prevention is more important than alleviation or cure, so is it important that a diagnosis of this complaint should be made as early possible. The only disease that might bo taken for the forma- tive stage of pruritic rhinitis is a common cold in the head. Both complaints are frequently accompanied by sneezing, but with a cold, there is no itching of the face. If itching ever so slight, should be expierenced and it occurs during warm weather, then the com- plaint may properly be called the first stage of pruri- tic catarrh. 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S'SSs fee = -s 'B c ^ s >> ^ r- ■ £ S . z ■ © s BB3 5 3 to to g ! si ^i o 5 S C ti 102 Fir^tor Formative Stage. but should it occur more frequently in warm wea- ther, then pruritic catarrh may be suspected, es- pecially if its attacks are more sudden than usual colds, and if accompanied by redness of the eyes and a profuse flow of tears. As stated, a simple cold in the head is more liable to occur at a season of the year that pruritic catarrh does not occur, yet it must be remembered, that the pruritic complaint is always preceded by symptoms of a common cold, and is usually, nay, almost univer- sally taken for a simple cold for a year or two. While Dr. Beard, in common with all authors, ig- nores common catarrh as the originating disease, yet he has passages in his work that fully confirm my views in this regard; he says: u In the first attack there is always a doubt which may not be settled until the fol- lowing year. During the first attack, the severity and obstinacy of the symptoms and the season of the year are the chief causes that excite the suspicion of hay- fever. Those whose first attacks are in infancy or early child-hood may not suspect the real nature of their disorder until they arrive at maturity. " To repeat: if the suspected symptoms be accom- panied with itching of the eyes, however slight, and with sneezing, and the attack be sudden and especially if all this occurs in warm weather, when colds are not liable to be taken, then it is altogether likely that the victim is suffering from the first, the formative stage of Pruritus Rhinitis Catarrhus. Second or May and June Forms. 103 the second or the may and june forms. At this stage, the disorder has shown itself plainly. It now stands in marked contrast to the symptoms accompanying a cold in the head. An ordinary cold is far more liable to occur at those seasons of the year in which this ailment does not us- ually occur; a cold comes on gradually, pruritic cat- arrh suddenly; the eyes may sometimes be a little reddened in a cold, in this complaint they are almost always quite red. The pathognomonic symptoms of pruritic catarrh, the itching, is not present with a cold; sneezing is ob- served in both complaints but far more severe in the former ; a cold will not disappear so completely in a few hours as will the symptoms of this ailment. Asthmatic breathing very rarely follows a cold, but it not unfrequently follows pruritic catarrh even in this stage. Dust does not make a cold in the head worse, at least it does not show marked increase because of it, whereas pruritic catarrh is almost instantly made worse by it. Usual medical treatment, such as a foot bath, a sweat a dose of quinine, etc., will cure a cold, but with this complaint it has but little ameliorating effect. A cold has no fixed time to disappear, the other disappears in four or five weeks. The pruritic catarrh is frequent- ly relieve hy change of residence to certain parts of the country, a cold is not. A cold is aggravated by cold weather the other is frequently improved. 104 Third Stage or July Form. Nearly all of these contrasting symptoms are well defined. THE THIRD STAGE OR THE JULY FORM. There is still less liability for mistaking this form of pruritic catarrh for a cold in the head; all of the features of the former complaint stand in marked con- trast. The season of the year in which it occurs, be- ing such that colds are not liable to be taken, even if patients are quite careless in observance of the laws of hygiene. Ordinary asthma might be confounded with it by the uninitiated, but the absence of the itching of the eyes, nose and face would show the mistake, besides, with asthma there is much greater impediment in re- spiration than the pruritic catarrh, except when asthma is a sequence. With asthma a cool draught of air from an open window is very refreshing, with the other it would be very aggravating. The asthma that accompanies pruritic catarrh, is al- ways preceded by the usual itching, sneezing etc. while in ordinary asthma, no such symptoms ever oc- cur. The itching and the sneezing that precedes the asthma of pruritic catarrh are the only symptoms that distinguish it from ordinary asthma, in all other res- pects they are identical. THE FOURTH STAGE OR THE AUTUMNAL FORM. This stage is so peculiarly phenomenal that none lout the most obtuse observer would take it for a com- mon cold. Every person that I have seen who had this form Prognosis. 105 of this complaint has had attacks of the earlier forms. These facts would exclude all complaints that resem- bled it in the least. Dr. Wyman, because " its existence has been doubt- ed, and still is doubted by many, even by physicians, " has taken special pains to give the differential diagno- sis between this and a common cold and acute bron- chitis, and has also given the points of difference be- tween it and pneumonia and local inflammation of the eyes, but it seems to me that the physician who would mistake the one for the other must be a very poor observer indeed ; just as likely would an educated me- dical man confound an intermittent fever for a typh- oid fever. The diagnosis of each of the four forms have now been given, and it seems to me that a comparative study of the symptoms of all of these grades, from the formative stage through the final or Autumnal stage, must convince every one that this is but one complaint, an ailment that progresses in severity, starting from a common cold in the head, showing it- self but slightly in nasal catarrh, then assuming a lit- tle more severe character in the May and June forms, then still increasing in severity in the July form, and finally culminating in the severest form, the Autum- nal. THE PROGNOSIS. This will be goverened to some extent by the stage or form that afflicts the patient. In in the first or formative stage, nothing is easier to check, I fully be- 106 Prognosis. lieve that this can be effected in patients not over fif- teen years of age, by hygienic measures alone. All cases not over thirty five years of age will be cured in one or at most two seasons of treatment, while with those over forty years of age, it may take a year or so longer. Every patient that takes good care of himself will in time completely recover. In this stage I would not recommend a surgical operation in any case, in either old or young patient, as the scar following the galvano-cautcry, or caustic acids, would be almost certain to be followed by a recurrence of inspissated masses to be blown out of the nostrils or hawked out of the throat, as soon as they attain sufficient bulk to impede respiration. These accretions will be just the size and shape of the scar. Besides being a source of very great annoy- ance it might — not always by any means — produce an unpleasant odor to the breath through the nostrils. Persistant employment of the spray producers will cure them. My experience in the treatment of the second stage, or May and June forms, leads me to say that they also will finally recover, but as the complaint has a stronger hold on them, a longer time for treatment will be required, and surgical interference may be needed to bring about the desired relief. But it must be kept in mind, as indicated above, that the smaller the operation, the better the ultimate recovery. The more confirmed the complaint, the longer will the pa- tient require fall and spring treatments to completely Prognosis. 107 eradicate the primary or originating disease, namely: chronic catarrhal inflammation of the nasal passages. The same may be said of the third and fourth forms, that is, they will require more " chronic treatment " as it were, and surgical measures will be almost cer- tain to be required. The later in the year that the victims is attacked the longer the time will be required for its treatment and the greater will be the need for surgical interference. My experience in the treatment of the Autumnal form, justifies me in saying that the course I have laid down in this work is followed by satisfactory results* CHAPTER XI. Treatment; Medical and Surgical. * The treatment of pruritic rhinitis is divided into preventive, alleviative and surgical. The preventive treatment embraces the hygienic and therapeutic treatment for chronic catarrhal inflam- mation of the nasal passages, f As catarrhal disease has prepared the patient's nasal mucous membrane so as to render him liable to take the complaint, his ulti- mate recovery will depend upon his being treated for the primary disease fall and spring, or at such times of the year as he is most liable to take cold. ALLEVIATIVE TREATMENT The alleviative treatment is divided into therapeu- tic and hygienic, and the therapeutic into local and constitutional. The consideration of these divisions will be taken up in their natural course as they would occur in the treatment of a patient on arriving at one's office. The patient has suffered a few days or weeks tor- * Read before the St. Louis Medical Society, May 17th., 1884, and published in the St. Louis Medical and Surgical Journal, Aug. 1SS4. f The reader is referred to the work on the "Hygiene and 'Treat men t of Chronic Nasal Catarrh " by the author, pp. 473. Local Treatment. 109 nient, and his nasal passages and throat are excessive- ly sensitive. In examining his pharyngo-nasal cav- ity, do not cause him to retch or cough ; while inspect- ing his nasal passages do not make him sneeze by either thrusting the nasal speculum too far up his nostrils or by pushing his nose upward or sideways. Be very careful to avoid doing anything that will cause him to sneeze. If a window or door of the ciHce is open, close it immediately, as even a slight draught of air will induce an itching sensation of the face, eyes and nostrils, which, if it lasts beyond half a minute, may bring on a paroxysm in full force. LOCAL APPLICATIONS. If a paroxysm does ensue, and indicates that it is going to last for several minutes, give the patient a little vaseline and direct him to anoint his face, neck head — if his hair is short — and hands ; rubbing the va- seline well into the skin ; have him put a silk handker- cheif over his head, and his hat over that; then direct him to pull off his boots and socks, and rub his feet well with vaseline, uncovering one at a time. It is altogether likely that his feet will be found to be damp with prespiration consequently quite clammy and cold. In this condition the vaseline will prove a very valuable remedy. This anointing and rubbing process, will materially shorten the paroxysms and lessened their severity. It will be well for the patient to repeat this course at such times as he may be attacked with a paroxysm. 110 Instruments for Making ll If ready to make a local application, give the patient the tongue depressor, tell him to place it well on his Fis. 1. Toxgue-Depressor.— The patient alone uses this instrument during examinations, applications an J operations. It should be placed well on t&e tongue, but not so far back as to cause a retching sensation. tongue, bnt not so far back as to cause him to cough or retch, then, having warmed the spray producer Fig. 2. Spray-Producers .—No. 1 . throws a stream in a horizontal direction ; applying the medicament to the fauces and tonsils, and by slight inhal- ation, the larynx and trachea are treated. No. 2, throws a stream at an angls of about 27° and is used to apply the medicament to the anterior nares as seen in Fig. 3. No. S, is not usually employed for treating pruritic catarrh, but may be used to treat the posterior wall of the phar- ynx as seen in Fig. 3. No. 4, throws a stream vertically, and treats the superior portion of the pharyngo-nasal cavity. No. 5, throws a stream at an angle of 45° and is made to enter the poterior nares, also shown in Fig. 3. ( 'No 4 ), half fill its bowl with plain vaseline and about 5 grains of the following : Local Applications. Ill I£. Vaseline gij. Eucalypti ext. (Sander & Son ; Sanharst Australia.) min x. Mix while cold. Fig. 3. [ *to<n. 76. 77. . 127. Milk. 122. Mirr >r, j h ry ig< aL 133. 8. Mobs Matrr ss. 122. Mouth. 70. 31 n cons m< ml ra n e a vain ■ - ble organ. 12-3. N- Nares, posterior. 133. Nasal cat: rrii -u ; ce I as a cause o: catarrh. 41. Nasal cavi a ^Nasai mirrors, anterior. 120. Natural life and hereafter if permitted. IS. Negative pole, how applied. 115. New name suggested. 22. Xig .t air. 93. Nightcap. 119. Nitric acid. 129. 133. Nostrils occluded. 70. Nux vomica. 33. o- Objective syrnpiorns. G4. Ocean travel. 94. Oil Eucalptus. Ill, 143, 144. Oil wint -ivreen. 113. 143. 114. Oleat !ne. 130. Operate. when to. 12>. P. Pain in the hest. 73. P f ih? heart. 74. 76. r . 2S, 98. P. ow to lessen. I' 1 - 1 infiam- - . 44. i reflector. 133 I cavity. 6S. P is. Dr. P. 34. . W. i 7. Pinna canadensis comp. 113. pole, how applied. 115. Potassium bromide. 116. Prater. Mr. A- 34. Pr •■■■•At n;;mes misleading-. Pric 's glycerine. 113. Probe, use of. 129,134. Prognosis. 105. Proliferative inflammation painless 20. 46. Pruritic catarrh a sequence of chronic nasal catarrh. 4L. 14:3. Pruritis PJiinitis Catarrims. 22, 30. 31. Q. Quinine as a remedy for '•nay-fever." 3S. Quinine, how taken. 116. Quinine as a tonic. 144. 166 InDeX. R. Ramadge. Dr. 33. Relation of Hay Asthma and Chronic Nasopharyngeal Catarrh by Dr. Daly. 135. Renal secretion. 76. Retching and vomiting. 72, 73. Rhinology. 17, 124. Rio Janeiro. 95. Rockwell. 115. Roe, Dr. J. O. xi. 129, 138. 143. Room, location of. 121. Rose-cold. 50, GO, 85. Rnmbold. Dr. 142, 147, 148, 152. S- Salter. Dr. H. 34. Sander & Son, Sanhurst, Aus- tralia. 111. Sanity doubted. 77. Sear tissue always dry. 126. Sear tissue not mucous mem- brane. 126. Seasons of the year inappro- priate names. 26. Second form. 103. Section of head, showing the application of spray producers. 111. Septum nasi. 12S. Shaving. 118. Shoes. 120. Skin. 64. Sleep. 122. Sleeping room. 121. Slippers. 120. Smell obtunded. 68. Smith. Dr. A. 155. Smith. Dr. VV. A. 37. Sneezing caused by chronic catarrh. 47. Sneezing in all forms. 25. Sneezing in various stages. Soft palate retractor. 134. Speculreof bone. 129. Spittoon. 123. Spray producers. 110, 111, 130, 144. St. Louis Medical arid Surgi- cal Journal. 108. St. Louis Medical Society, 38, 41, 117, 148. Stage of non-recognition. 84. Stages, table of differential diagnosis of. 101. Statement of patients. 46. Stucky. Dr. J. A. xi, 129, 132, 146. Stucky's. Dr. applicator, 155, 156. Subjective symptoms. 64. Sunlight, effect of. 97. Surgical measures. 128. Surgical operation, when not required. 106. Surgical operation when re- quired. 107. T- Terrors in sleep. 77. Thickening process of the mucous membrane pain- less. 45. Third stage form. 104. Throat, effect of electricity in 115. Throat, spray applied to. 113. Time of attack in various stages. 101. Index. 167 Tobacco. 123. Tobacco-smoke. 98. Tongue. 70. Tongue depressor. 110, 133. Tonic. 116, 144. Tonsils 70. Trachea. 71. Treatment. 108. Treatment, constitutional. 116. Treatment, how made. 112. Treatment. Dr. .Roe's. 141. Tubal catarrh. 127. Turbinated processes re- moval of. 128. Turbinated processes dark red and oedematous. 68. Tympanum. 127. D- United States Hay-Fever As- sociation. 18. Uvula- 69. Y- Valerinate of zinc. 144. Various stages 101. Vaseline, anointing the face, etc. 109, 119. Vaseline compound, pre- scription for, 111 143, 144, 152. Vaseline mixture, how ap- plied by the spray pro- ducer. 112, 155. Vegetable theory. 28. Velum. 69, 133. Very chronic cases. 94. Vests, cotton and wool. 119. Voice. 72. w. Walking. 123. Walsh. Dr. 34. Warm the instrument and the medicament. 112. Water, hot. 122. Watson, Dr. 34. Webster. Daniel. 36. Wesseler. Dr. 81. Westward. 95. Whisky. 123. Wigs healthful. 117. Wintergreen. oil of. 113, 143, 144. Wood. Mr. T. B. 157. Wyman. Dr. M. 23, 24, 26, 30, 34, 35, 39, 40, 46, 51. 65, 66, 86, 105. Zinc, valerianate. 144.