LIBRARY OF CONGRESS. Chap Copyright No Shel£_;R£1 UNITED STATES OF AMERICA. SECOND COPY, v'^R'D r ^ JUL 3-18.99 HAY-FEVER AND ITS SUCCESSFUL TREATMENT HOLLOPETER Frontal sinus Orifice of the posterior ethmoidal cells Orifice of the sphenoidal sinus Sphenoidal sinus \ Orifice of middle ethmoidal cells Superior turbinal bone ' i Orifice of frontal sinus Upper orifice of nasal duct Orifice of Eustachian j tube / Middle turbinal bone Inferior turbinal bone Orifice of the antrum Orifice of infundibulum Lower orifice of nasal duct Skction of the Nose, showing the Turbinal Bones and Meatuses, with the Openings in Dotted Outline. HAY-FEVER ITS SUCCESSFUL TREATMENT W. C. HOLLOPETER, A.M., M.D. clinical professor of pediatrics in the medico-chirurgical college of philadelphia ; physician to the methodist episcopal hos- pital ; pediatrist to the medico-chirurgical hospital, to st. Joseph's hospital ; fellow of the Ameri- can ACADEMY OF MEDICINE, ETC., ETC. f SeconD Bfcitfon, IRexusefc anD jEnlar^eD PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1899 * JO 8465? Copyright, 1899, by P. Blakiston's Son & Co. WM. F. FELL & CO., ELECTROTYPERS AND PRINTERS, 1220-24 SANSON! STREET, PHILADELPHIA. 1 3S0S2 JUN9 St er of con'^ v PREFACE. Having had remarkable and uniform success with a simple treatment of hay-fever for the last ten years, during which time I have given com- plete relief to over two hundred patients in my private practice, and having made a thorough clinical study of this affection, as well as an ex- haustive review of the literature relative to it, I feel justified in presenting the results of my labors in this short treatise. There is little to be said definitely about the etiology of the disease. It is undoubtedly caused by an external irritant, possibly containing a micro- organism or a toxin, which becomes especially active in the nasal passages of an individual pre- disposed by systemic debility or local abnor- mality. We acknowledge the element of neurotic disturbance, but to dogmatically define its exact cause and modus operandi is beyond us. v Vi PREFACE. In order that the best thought of the subject may be presented to the reader, I have compiled, arranged, and annotated the most worthy litera- ture, and I acknowledge my indebtedness to the many writers quoted. The most of my original communication is devoted to the all-important point in the discussion — the successful treatment. A complete bibliography is appended. W. C. HOLLOPETER. 1428 North Broad Street, Philadelphia, July, 1898. PREFACE TO THE SECOND EDITION. Encouraged by the cordial reception of this little monograph, as evidenced by a call for a second edition within a year, the author has endeavored to revise and enlarge the text so as to include the special treatment of each of the various types of hay-fever cases. The bibliographic section has also been brought up to date. W. C. HOLLOPETER. 1428 North Broad Street, Philadelphia, yz/^, i8gg. TABLE OF CONTENTS. PAGE Synonyms, ' . 9 Definition, . 10 General Remarks, 12 History, 18 Exciting Causes, 30 Heat, 30 Light, 32 Dust, 34 Ozone, Benzoic Acid, etc., 35 Various Other Exciting Agents, 36 The Pollen Theory, 41 Predisposing Causes, 47 Race, 47 Geographic Distribution, 49 Heredity, 52 Sex, 54 Age, 55 Education, 55 Occupation and Mode of Life, . 56 The Neurotic Theory, 57 Vasomotor Susceptibility, 59 Idiosyncrasy, 60 Local Disease Theory, 62 The Uric Acid Theory, 64 Defective Nutrition, 68 Gastro-intestinal Causes, 7 1 Time of Occurrence, 72 vii Vlll TABLE OF CONTENTS. PAGE Duration, 76 Symptoms, 78 Complications and Sequelae, 84 Pathology, 87 Diagnosis, 94 Prognosis, 98 Treatment, 102 General, 102 Local, 107 Prophylactic, Hygienic, and Systemic, 116 Bibliography, 127 Index, ...» 147 HAY-FEVER. Synonyms. — Autumnal catarrh, Bostock's ca- tarrh, coryza vasomotoria, coryza vasomotoria periodica, hay-asthma, idiosyncratic coryza, June cold, July cold, nervous coryza, nervous catarrh, paroxysmal sneezing, peach cold, periodic hyper- esthetic rhinitis, pollen catarrh, pollen poisoning, pruritic catarrh, pruritic rhinitis, ragweed fever, rhinitis sympathetica, rhinitis vasomotoria, rose catarrh, rose cold, summer bronchitis, summer catarrh, summer catarrh from idiosyncrasy, sum- mer fever, typical early summer catarrh, vaso- motor coryza, vasomotor rhinitis. Latin eq. — Catarrhus aestivus, coryza vasomo- toria periodica. French eq. — Catarrhe d'ete, catarrhe de foin. German eq. — Fruhsommerkatarrh, Heuasthma, Heufieber. Italian eq. — Asma dei mietitori, febbre del fieno, asma del fieno. 9 10 HAY-FEVER. Definition. — The term " hay-fever " was first used to designate the form of disease occurring in the autumn in distinction from like affections which occur in other seasons. So universal, however, has become its use that it is now employed to designate all the forms of what may be called the periodic influenzas, irrespective of seasons. Hay-fever may be defined as an affection of the upper air-passages occurring periodically, usually at or near a fixed date in the early autumn, some- times in the spring or summer, characterized by its sudden onset and as sudden termination in certain atmospheric conditions, by swelling and tumes- cence of mucous membranes of the nasal fossae and adjacent cavities, irritating discharges therefrom, and various symptoms of coryza, and occasionally by asthmatic paroxysms. It always results from the combination of a special predisposition, from de- praved resistance or lowered vitality of the general system or a local lesion, and an exciting cause, believed to be a micro-organism or peculiar toxin, generally arising from pollen or dust deposited upon or in the mucous membrane of the upper air- passages. The important predisposing causes are : DEFINITION. I I heredity, idiosyncrasy, neurotic temperament, peculiar susceptibility of the vasomotor system, generally debilitated condition, deranged assimi- lation, and a local lesion. Hay-fever has been defined as a neurosis, as an idiosyncrasy, as a catarrhal affection, and as a type of influenza, and as various combinations of these. The deposition of some special irritant is universally regarded as the exciting cause. 12 HAY-FEVER. GENERAL REMARKS. The idea of an external irritant in hay-fever pervades most views of it. There can be no doubt, however, that there is usually an underlying sys- temic condition which renders individuals sus- ceptible to the disease. It may, in addition, be accepted as conclusive that the nasal abnormali- ties found in hay-fever subjects are as often inci- dental as causative. They are seldom exclusively provocative of the susceptibility, and they are not the results of repeated attacks. Exactly what this underlying condition of susceptibility is has been variously regarded. The nature of the irri- tant has been widely and scientifically investigated. While all theories advanced are in part more or less tenable, none of them alone is satisfac- tory. The condition is always, however, one of lowered resistance, general or local. If general, it may be of neurotic, lithemic, idiosyncratic, gastric, intestinal, or diathetic origin. It is, therefore, my belief, that in hay-fever there is always, first, an exciting agent, and, second, a system predisposed by debility of some character GENERAL REMARKS. I 3 to the influence of this irritant. The overwhelming testimony as to the character of this irritant points to its derivation from something external to the body of the sufferer. Moreover, it is absolutely certain that without the action of an external irri- tant genuine hay-fever does not occur. The elab- orate and ingenious experiments of Blackley, not only upon himself but upon other individuals, clearly indicated the pollen of flowering plants as an active, exciting cause. It has never been shown that, although pollen, healthy or unhealthy, may be a mechanical irritant and thus account for many cases, it is not also a chemic irritant when it has fallen upon a susceptible soil. It has been claimed that hay-fever is caused by a toxin gener- ated by a fermentative process in the pollen which has fallen into the alkaline solution of the nose ; and it has been shown that acid solutions stop the movements of many micro-organisms and sperma- tozoa, and that alkaline solutions in the nares have given little or no benefit in attacks of hay-fever. It has also been shown that the affection is more common among men than among women, and that the blood of the latter is the less alkaline. Arnold, in 1896, stated that just what constitutes 14 HAY-FEVER. the irritant is not determined, and said it is likely that not healthy pollen but some fungoid growth is responsible, since threshers of grain, at other times without ill-effects, have complained of attacks of hay-fever after threshing smutty or moldy grain, especially oats. Helmholtz, himself a sufferer from hay-fever, discovered peculiar micro-organisms in his nasal discharges. These vibrios were never found by others, and this fact is supposed to controvert his theory. It has not been shown conclusively that they have been sought for by other investigators, and it is likely that they have not, since attention has been called away by the pollen and other theories. The antiseptic quinin solution employed by Helmholtz, while extensively used with good results for the subsequent decad, was not invari- ably accompanied by relief. Later, the relief that was given by quinin solutions was said to be psychic. This allegation may well be understood when it is considered that many other theories as to the causation of hay-fever, particularly the pollen, abounded soon after Helmholtz's expositions. Some very interesting investigations by Strang- ways, of St. Louis, in 1897, urged him to conclude GENERAL REMARKS. I 5 that the amount of pollen in the air is altogether too small to have an injurious mechanical, medici- nal, or poisonous influence. He calculates that for every square foot of surface there is one ragweed,^ and inquiry showed that mere elevation of several hundred feet above the earth's surface does not give relief from this distressing affection. Strang- ways found that ragweed pollen probably floats to iooo feet elevation ; but, if the limit is placed at 500 feet, it would give for every plant 500,000 cubic feet of air, not for one day but for six weeks ; 1. e. 9 if the whole plant was pollen there would be still only one part of pollen to fifteen or twenty billion parts of air. The rose and the golden-rod are in even smaller quantities. Strangways' estimates showed that there was not more than one grain of pollen for every thirty respirations. He advanced the theory that, while pollen plays a part, it does not irritate mucous membrane nor produce vasomotor paresis by its direct influence, but that a protoplasmic substance found in pollen and in the vegetable kingdom, acting as a ferment, causes the formation of a toxin which is the real exciting cause. There can be little doubt that the neurotic ele- 1 6 HAY-FEVER. ment has been present in many, if not most, cases of hay-fever, and evidenced by depression, general lowering of tone, or exhaustion of the nervous system. The neurosis need not be acquired ; in fact, it is often hereditary, which w r ill be discussed later. Holmes believes the disease to be in great part a neurosis with other debilitating conditions. The fact that the better educated classes are most prone to this affection indicates the influence of neurotic tendency as well as exhaustion of the nervous system or debility or depression thereof. The premonitory symptoms of this affection, as ably shown by Sajous, show the neurotic elements. He well asks, " If the local irritant is the only cause, why does the respiratory tract, the portion of the body first and most exposed to its effects, not become immediately influenced ? " This au- thor also shows a case following enteric fever, the debilitating and exhaustive character of which is well known, one preceded by malarial fever and another by bronchitis, pertussis, and varicella. Of the various other theories advanced are the lithemic, the intestinal or gastric, due to lack of proper assimilation, and the uric acid diathesis. GENERAL REMARKS. \J The views herein advanced are not at all inconsis- tent with the idea that the diatheses exercise a predisposing influence in producing the affection, which influence is debilitating and devitalizing. The local theory alone is not conclusive nor satisfactory; viz., that the disease is due to chronic nasal catarrh, or a local lesion, upon which the exciting cause acts. There is no doubt that dis- eased areas are more sensitive to the irritant, and especially so in cases of lowered vital energy and lessened normal resistance, general or local ; but a large number of cases show no local disease. In all of the theories respecting this affection there is more or less regard for the agency of pollen in provoking the paroxysms of the disease ; but as every one is exposed to the irritant, in those affected the soil must be prepared for the seed, that is, before the deposition of the pollen or dust or exciting agent there must be a morbid condi- tion preexisting, which can so far be characterized as to call it lowered vitality or general or local resistance, which springs from a variety of causes. HAY-FEVER. HISTORY. Exactly when hay-fever was recognized as a distinct affection is not known. Beschorner shows that it was known in the sixteenth century. In 1565 Botallus reported a case. Van Helmont and Binninger in the seventeenth century speak of it. A similar distressing catarrhal affection, but due to the rose, is instanced in " Acta nat. curios. Ephemerides," Dec. II, Ann. V, obs. 22, and again in the same journal, Dec. Ill, Ann. V and VI, obs. 193, a case of annually recurring profuse nasal catarrh is mentioned. John Floyer, London, 1698, noticed that there were peculiar cases of asthma in which the attacks were longer and more acute in summer than in winter. In Good's " Study of Medicine " there is a reference to a case related by Timaeus in 1667, of an attack of an asthmatic nature caused by the odor of roses and ipecac. Riedlin, in his " Lin. Med.," p. 177, in 1695, wrote of the odor of roses causing a catarrh of the head, resembling hay- fever. C. L. Parry, of London, records a case in 1809 and another in 181 1. Elliotson, in 1821, HISTORY. 19 tells of a patient who had had hay-fever since 1789, and of another who was sixty-six years of age and who had had the disease from his seventh year, i. e. y since 1755, and of a third who had been afflicted for many years. Just when and where the term " hay-fever " or u hay-asthma " arose it is impossible to say, but probably it was popularly so named. The emana- tions from dry hay were first thought to have caused it. Dr. Bostock, who was himself a suf- ferer, in 1 8 19, found that the laity knew of the affection, although it was not recognized as a distinct disease by the profession. He objected to the term u hay-fever/' which was already em- ployed to designate it in his day, contending that moist heat, sunshine, dust, and* fatigue were more potent in its causation than emanations from dry hay. It seems remarkable that the profession in England were unfamiliar with hay-fever as a distinct affliction, especially as their king, George IV, was a sufferer from it. In 1828 Bostock, who had first described the disease to the Medico- Chirurgical Society of London as a " case of a periodic affection of the eyes and chest," pub- lished some further observations on the complaint 20 HAY-FEVER. under the title " Summer Catarrh," or " Catarrhus yEstivus." In 1828 MacCulloch included it in his " An Essay on the Remittent and Intermittent Diseases," but advanced no special views. In 1830 Augustus Prater published notes of a case seen in Paris. In 1831 Dr. Elliotson, in London, briefly described the affection; and in 1833 he discussed the complaint more fully and opposed Bostock's theory of heat and rejected the hay- theory of its origin, but declared grasses to be more important factors ; and he first pointed to pollen as the probable cause of the disease. In 1847 Dr. Ramadge detailed reports of cases and believed " effluvia from flowers " caused it. In 1850 Gream first alluded to dust as an exciting cause and proposed nux vomica as a remedy. In 1852 Dr. Laforgue, of Toulouse, wrote his essay "Observation de catarrhe d'ete," in which he up- held heat as the cause, after the view of Bostock. But in the next year, 1853, in " L'Abeille Medi- cale," an anonymous contributor, reciting his own case, advocated hay-emanations and not heat as the exciting agent. In 1854 Phoebus, of Giessen, concluded from his study of 154 cases that sun- light was the active cause of the attacks. In HISTORY. 21 1857 Watson ascribed the malady to the presence of vegetable matter in the atmosphere. In 1859 Phoebus again published the results of his circu- lar of inquiry. He went into the subject more thoroughly than any of his predecessors, and from sunlight he shifted to ozone as the theoretic cause of the malady. In this same year Hyde Salter named as the exciting agents "bright, hot, dusty sunshine," a full meal, and hay, and recited two interesting cases. Another writer, Walshe, in the same year, referred to hay-fever as a singular variety of nasopulmonary catarrh, and he first called attention to the fact that the disease, in his own person, " always disappeared in crossing the Atlantic." In July, i860, Dr. Cornaz, of Neufchatel, Switz- erland, in a paper on hay-fever, described six cases, and concluded that the flowers of grasses were the cause of the disease, and he was followed on the 20th of August of the same year by Dr. Labosse, of Nitry, France, in a paper entitled " Nouvelle Observation de Catarrh de Foin," in which he spoke of three persons whose symptoms occurred at the time certain flowers were in bloom. In 1866 strong light and great heat were ad- 22 HAY-FEVER. vanced as aggravating causes by Dr. Wm. Abbotts Smith. In his published work, " On Hay-fever, Hay-asthma, or Summer Catarrh," he rejected the ozone theory of Phoebus. In 1867 the nervous origin of the disease was first advanced by Dr. William Pirrie, who spoke of two forms, — one a spasmodic form caused by external irritants, the other arising from the action of light and heat upon the central nervous, the cerebrospinal, and sympathetic systems. In the same year, Helmholtz, who, though not a general practitioner, while suffering from hay-fever, began to treat it with a quinin solution and found that he was relieved thereby. Two years later he de- tailed to C. Binz, of Bonn, Germany, by letter, the history of his sufferings, and recommending his solution as a ready means of relief and even of prevention, which was in accord with the findings of Binz that the quinin solution was poisonous to infusoria. In this letter Helmholtz propounded the theory that the symptoms were caused by vibrios which, though latent at other times in the nasal fossae and sinuses, were excited to activity by the heat of summer. It has since been thought that the organisms found by Helmholtz, by means HISTORY. 23 of the microscope, in the nasal discharges during an attack were probably fragments of mycelium- like threads which develop from pollen-cells under the influence of the heat and moisture of the nasal chambers and which contain the minute fovilla of the pollen-cells. The use of the quinin solution which Helmholtz so successfully employed on himself became very popular and found many strong advocates in the profession until the exten- sive researches of Blackley in regard to pollen in 1873. In the meantime, in 1870, Dr. George Moore advocated a complex theory of the disease, really combinations of preceding theories. In the same year Roberts issued a short, practical paper, claiming to be the first to observe excessive cold- ness of the tip of the nose as the " pathognomonic " symptom of hay-fever and desiring credit to be accorded him for this discovery. In 1872 Morrill Wyman, of Cambridge, Mass., distinguished two different forms of the disease; naming that occurring in August "autumnal catarrh," peculiar to America, and that of the spring or early summer "June cold" or "rose cold," more prevalent in England. Dr. Wyman first attempted to define the geo- 24 HAY-FEVER. graphical limits of the disease, and called atten- tion to the important fact that residence in certain elevated regions brought certain and complete relief in most cases of autumnal catarrh. He stated that a lady from Lynn, Mass., a great sufferer, accidentally observed in 1853 that her catarrh passed by while she was traveling in the White Mountains, and that for the following ten years she visited the region and escaped the disease. In i860 Jacob Horton,of Newburyport, Mass., wrote Dr. Wyman that the White Mountains gave the only relief. In 1873 Charles H. Blackley, of Man- chester, endeavored to show that pollen mainly, if not exclusively, caused the malady, and by exten- sive experiments showed that the amount of pollen in the atmosphere at great elevations was to that in the air at ordinary breathing levels as nineteen to one. He proved, by very ingenious and care- fully conducted series of experiments, that the pollen of grasses and flowers was the sole cause of hay-fever in himself, and that in two other patients the severity of the attacks was directly related to the amount of pollen in the air. His subsequent observations made it extremely prob- able that pollen is an important factor in the HISTORY. 25 causation of hay-fever, although all kinds of dust may be sufficiently irritating to excite the par- oxysms. This was in opposition to the views of Phoebus and of Pirrie, both of whom suggested heat, strong light, and ozone as the exciting causes. Pirrie had also suggested disturbance of the central nervous system as an important etiologic factor. He was supported in this view in 1876 by Morrill Wyman, then of New York. In the same year Beard, of New York, published his mono- graph, the information for which had been pains- takingly gathered from replies to two hundred circulars which he had issued to medical men all over America, somewhat after the manner of Phoebus ; although, unlike Phoebus, Beard had himself seen and treated many cases. From his data he drew the conclusion that the immediate exciting causes were more than thirty in number, and that secondary causes might increase this list to more than one hundred. He also showed from his statistics that the nervous temperament existed in a great proportion of the sufferers, and that nerve tonics were of some value. In 1877 Marsh, of Tuckerton, New Jersey, published an essay in which he accepted completely the pollen theory. 26 HAY-FEVER. He first called attention, in this paper, to the activity of the pollen of Ambrosia artcmisicefolia y or common ragweed, as by far the most active of the pollens in America in producing the attacks. In 1882 Daly, of Pittsburg, first called atten- tion to the fact that a diseased condition of the nasal cavities was an important factor in the pro- duction of the exacerbations of the disease. Roe, of Rochester, in 1883, advocated the same theory, but added that " removal of the diseased tissue removes susceptibility to future attacks." In the same year, Sajous' essay appeared in which he advanced idiosyncrasy as a heretofore unconsid- ered element in the cause of hay-fever, and laid stress upon the three essential factors in the pro- duction of an attack; viz., first, an external irritant, second, a predisposition of the system, and, third, a vulnerable or sensitive area. In 1883 Hack accepted the local theory of the causation of the disease. In 1884 Harrison Allen, of Philadelphia, attributed the affection to a permanent or tempo- rary obstruction of one or both nasal chambers. In this year, J. N. Mackenzie, of Baltimore, termed the disease " coryza vasomotoria periodica," be- HISTORY. 27 cause it is essentially a coryza. He says: " The well-recognized, but imperfectly understood per- sonal susceptibility to certain forms of local irri- tation, which is the sad prerogative of sufferers from this disease, has always been the stumbling block in its investigation and the rock upon which the various speculations as to its nature have been wrecked." He demonstrated that " there exists in the nose a well-defined sensitive area whose stimulation through a pathologic process or through ab extra irritation is capable of producing an excitation which finds its expression in a reflex act or in a series of reflected phenomena." He thus claimed functional derangement of nerve cen- ters as essential to the disease. It was also in 1884 that Sir Morell Mackenzie asserted that the uni- versal cause of the disease was pollen, although he did not deny that other irritating particles, e. g. y ipecac, if persistently brought in contact with the mucous membrane of the nasal chambers, may produce it. In 1885 Seth S. Bishop advocated the uric acid theory of the origin of the disease. In 1887 Sir Andrew Clark, in the Cavendish Lecture in London, emphasized the doctrine of 28 HAY-FEVER. the three great causative factors, — viz., first an exciting agent, generally pollen ; second, the neu- rotic habit ; and, third, a local morbid condition of the nasal mucous membrane. Since then many articles have appeared upon the subject, but no striking innovations in the possible etiology of hay-fever have been offered. In 1893 Macdonald said, we ought not to describe hay-fever as a disease but merely as a train of symptoms — a train of physiologic reflexes instigated by an unwarrantably small provocation in certain individuals more susceptible to the influ- ence thereof than the rest of their kind. Early in 1897 Grayson, of Philadelphia, stated that " the neurotic habit may exist but is not essential to the disease, and the nervous system is implicated as a victim, not as a culprit." He claimed that hay-fever is a defect, not of the nervous, but of the nutritive system, believing that the digestive tract is the cradle of the systemic error. In October, 1897, Edmund W. Holmes, of Philadelphia, stated his belief to be that hay-fever was largely a neurosis, originating in local disease of the nasopharynx, the characteristic manifesta- HISTORY. 29 tions being in part direct, the result of central nervous modifications, and in part reflex, from the action of various mechanical irritants, aided by local and constitutional factors when they exist, and by seasonable and climatic influences, the periodic and peripheric susceptibility being in particular expressions of certain impressions. 30 HAY-FEVER. EXCITING CAUSES. It being generally recognized that there are two elements entering into the causation of hay-fever, viz., an exciting agent and a predisposing or preexisting condition, regard will be given the subject of causation from this standpoint. A great number of agencies have been re- garded as the direct causes of this disease, but opinion in the main has assigned pollen as the essential factor, acting upon the preexisting condition or predisposition. It may be better, however, to give a resume of other agencies before regarding this subject of pollen. The most important of these are heat, light, dust, ozone, overexertion, ipecac, lycopodium, cou- marin, benzoic acid, chocolate, or several of these in combination. Heat. — No attempt to signify or designate a definite cause was made by the early writers until 1819, when Bostock first described the malady and ventured the view that it was due to the influence of solar heat. He attributed his own EXCITING CAUSES. 3 I prolonged sufferings to the exposure to the sun's rays and fatigue. Some time after, Phoebus attributed the affection to " the first heat of summer," which, he stated, "is a stronger cause than all the grass emanations put together." Phoebus subsequently modified his views so as to regard the first heat of summer as acting only in an indirect manner as an exciting cause, and admitted that hay and the blossoms of rye caused exacerbations. It can not be con- tended, at this day, that heat alone will provoke the disease. In the plains of India when the heat is greatest it is not found, although later in the year, in the cooler months and before vegetation is burned up, it does appear ; but among the hills of India where the climate is milder and the grasses and cereals are in blossom hay-fever exists. At sea, when vessels are becalmed and heat is most intense, and in the great heat of the desert hay-fever is not found. Pirrie shows that great heat is common to all cases, even when the vegetable world is looked to for the cause, and strangely points out that the premonitory feelings of an attack coincide with those caused by high temperature. One of the most interesting cases 32 HAY FEVER. from this standpoint is that of an Englishman, who, although not a medical man, is well known to science — Richard Proctor. The asthma — for it took this form — occurred only during the cold months, and was always aggravated by a rime or hoar-frost, especially if the latter was followed by a bright, sunny day. It is a striking fact that in regions compara- tively free from the disease persons subject to it become worse on warm days, or when the wind blows from the South. It has been found by expe- rience that while this aggravation by winds is in most part due to the presence of more pollen, the higher temperature is also in a measure respon- sible. Hot, dry days are more favorable to the dissemination of pollen than rainy ones, and it becomes especially active when hot, dry periods follow stormy weather. In the light of Blackley's experiments upon the amount of pollen in the atmosphere, these facts would seem to explain the action of heat and sunlight as an active cause in the production of the exacerbations of hay-fever. Light. — Phoebus was dissatisfied with the view of the influence of solar heat, and thought that the longer days, which produce a more continuous EXCITING CAUSES. 33 action of light, were perhaps to blame; but where light is strongest and lasts the longest — indeed, in the land of the " midnight sun " — hay-fever is practically unknown. Pirrie called attention to the fact that exposure to strong light aggravated the symptoms of the attack. The foregoing case of Richard Proctor is an instance of the truth of this. There is an instance of the widow of a cler- gyman whose attacks, most severe in summer, were aroused by sunlight in the early morning. Ingals knew a clergyman who was unable to cross the street on a hot day without sneezing violently unless he carried an umbrella. Persons with sen- sitive mucous membranes, especially subjects of hay-fever, are, no doubt, sometimes liable to at- tacks of sneezing from sunlight ; but these symp- toms must not be mistaken for true hay-fever. Ingals states that he knew an individual in whom attacks of sneezing were brought on by exposure to bright gaslight. Gaslight was also regarded by Beard as a cause of this affection. However, Morell Mackenzie shows that gaslight is employed more in winter when the affection does not prevail than in the English spring and American autumn, when the affection most prevails. Nothing can 3 34 HAY-FEVER. exceed the reflected glare of sunlight at sea on a bright day, yet it is upon the sea that exemption from attacks of hay-fever is universally found. Dust. — From his scientific investigations upon the subject, Beard, whose published work is a model, concluded that it was extremely probable that dust occasionally caused hay-fever. Out of 198 cases of hay-fever reported by him no less than 104 attributed the affection to dust. One hundred and forty-two of these cases, however, occurred between May and September, the usual hay-fever season ; and the lay, not the trained professional, mind advanced the causes. Some attributed the affection to " indoor dust "; some to "cinders." These data of Beard, therefore, must be taken cum grano salts. More especially is this so since a paroxysm of sneezing and subsequent coryza, frequently brought on in normal health by the mechanical irritation of dust or even strong odors, should hardly be dignified as an attack of hay-fever. In England, in February, March, and April, when strong east winds often blow clouds of dust against the face, the symptoms of hay- fever do not appear, whereas in June and July, EXCITING CAUSES. 35 when dust is comparatively little, the affliction is most extant. Holmes stated that even in winter-time stirring among old books or in an old garret the exposure to the fine dust therefrom would, by simple me- chanical irritation, produce an attack in him. It has been the consideration that dust, or pollen act- ing as any other form of dust, could be kept from entering the nasal chambers that has given rise to the various inventions to purify the air before it enters the nose, such as plugs of cotton or wool, and veils (which, in addition, soften the glare of the sun and lessen the irritating action of winds upon the face). Every hay-fever sufferer knows the little value of such device. Ozone, Benzoic Acid, etc. — From the vast quantity of facts and observations gathered to- gether by him, Phoebus, who previously had ascribed sunlight as the cause of hay-fever, en- deavored to extract a complete theory of the disease. He suggested an excess of ozone in the atmosphere as a possible cause. It remained, however, for Blackley, in 1873, by his great endeavors and scientific methods of investigation, to disclose the fallacy of this theory. He pur- 36 HAY-FEVER. posely breathed air highly charged with ozone for five or six hours without effect ; and without inconvenience he inhaled ozone artificially pre- pared and in quantities far exceeding that found in the same volume of atmospheric air. This same physician also studied upon himself the effects of benzoic acid, a substance shown by Vogel to be contained in Anthoxanthum odoratum and Holcns odoratus, the two species of flowering grasses to which the causation of hay-fever has been attributed. Likewise he investigated the odorous principle of many flowering grasses, cou- marin, and the volatile oils which impart to many plants, such as peppermint, juniper, rosemary, and lavender, their characteristic perfume. In all these cases the results were negative. Various Other Exciting Causes. — These are in numberless variety and many of purely idiosyn- cratic nature. Emanations from dry hay, sun- light, gaslight, heat, minute organisms as supposed by Helmholtz, the " mange " insect, dusts of all kinds, bad air, railway smoke, brimstone matches, flowers and fruits, odors from dogs, cats, horses, cattle, rabbits, guinea-pigs, and wild animals, have all been held responsible for the paroxysms. EXCITING CAUSES. 37 Ward Smith records linseed meal and mustard as exciting causes. Win. Murrell mentions pow- dered May-apple (podophyllum), the effluvia of clean pocket handkerchiefs fresh from an ironing table, locust-tree blossoms, mulberry blossoms, and fruit. The exhalations from feathers have been regarded as causes. It is well-known that various drugs like ipecacuanha and lycopodium give rise to attacks, and sulphur has been men- tioned as a cause. Sir Thomas Watson names a servant in St. Bartholomew's Hospital affected by ipecac. Cullen tells of an apothecary's wife who, whenever ipecac was triturated in the shop, had an attack of hay-fever. He also mentions the vicinity of a rice-threshing floor as a provocative cause. Itzigson tells of a merchant who had hay-fever paroxysms whenever fresh coffee was handled in his presence ; and it is recorded of a dyer that he could not work when the wood of the oak (Quercus tinctorid) was lying about. The author knows of a case in a physician in whom violent paroxysms of sneezing are induced by the tasting of chocolate. It is related in the " Twentieth Century Practice of Medicine " that a hay-fever patient fond of tomatoes and watermelons was unable to eat 38 HAY-FEVER. of them during the usual hay-fever season without most violent disturbance of the gastro-intestinal tract. Bastian was subject to attacks of an affec- tion like hay-fever while dissecting the Ascaris megalocephala, a parasite infecting the horse. Hyde Salter tells of a clergyman affected by the vicinity to a dead hare, and who was thus able to detect the presence of a poacher. H. Charlton Bastian had like effects from the " mange " insect of the horse. Ringer and Murrell tell of a young gentleman made worse by the vicinity of horses or stable people. Once, while in the theater, an attack suddenly supervened without any appreci- able reason until a horse galloped upon the stage. Macdonald, in 1893, mentioned a patient who, two or three hours after having patted his horse with his gloved hand, inadvertently put it to his face, and was immediately seized with a violent par- oxysm. The odor from the inner aspects of the legs of the horse was very irritating to one writer a " sufferer." Ringer and Murrell cite the case of a gentleman who, subsequent to an acute pleurisy, was ever after a subject of " hair-cater- pillar asthma," and was immediately attacked if by any chance he touched a caterpillar. EXCITING CAUSES. 39 The difficulty of sometimes finding some excit- ing agent is shown by the case of Drenger. After searching several years in vain for the cause of attacks of hay-fever caused by entry into a certain room in a house, and after ransacking nearly everything in the house, a mattress was sus- pected, and, upon removal, was satisfactorily shown to be the offending agent. The odor of peaches, of violets, of the mign- onette, of chocolate, of musk, and of pepper- mint, has come in for a share of the blame. Trosseau relates of himself that attacks came on when he entered a room in which there were violets. The botanist Broussais was often im- peded in his work by attacks caused apparently by the odor of a rose. Hunerswolff and Morell Mackenzie each cite a case in which the perfume of the rose produced attacks of coryza. The former's account is in the " Ephemerides," and has been often referred to. The latter's case proved rebellious to treatment, and the sufferer had, at last, to banish these flowers from her gar- den. That this peculiar antipathy to flowers is often imaginative is shown by John N. Mackenzie, who cites the case of a subject of hay-fever to 4 « ^ << " Sept. I " Sept. 10, " 7 " " u 10 " M 20, " I case. " " 20 " " 30, " 2 cases. Of Bosworth's eighty cases the greatest num- ber, fifty-one, occurred between August ioth and August 27th. The usual date assigned for the commencement of paroxysms of hay-fever is the 29th of August. This form of the disease, com- 74 HAY-FEVER. mencing in the latter part of August, is designated as autumnal catarrh. Many patients have asserted that they are attacked annually on exactly the same date, and even the same time of day, each year. There can be little doubt that the psychic influence or pecu- liar mental anticipation may have a great deal to do with this circumstance. An attack may be brought on by the influence of the imagination. Phoebus gives the history of a case in which attacks of sneezing were brought on " while look- ing at a beautiful picture of a hay field." The well-known instance of J. N. Mackenzie, in which an attack of hay-fever was brought on in a suscep- tible individual subject to rose cold by means of an artificial rose may be explained on this ground. Bosworth considers that the time of occurrence is influenced by psychic causes, and is analogous to the recurrence of chills in intermittent fever, and considers that deception as to the actual time of occurrence might be proved in hay-fever as in in- termittent fever, in which changing the hands of the clock may lead to a change in the regular re- currence of the chills. Prince gives the history of a case in which a hay-fever subject under the influ- TIME OF OCCURRENCE. 75 ence of autosuggestion, by means of writing fre- quently on paper and thinking, day and night, in leisure moments, and of slight hypnotism, pre- vented the premonitory symptoms of hay-fever, and she was free from the annual attacks for sev- eral years, when they recurred and continued yearly thereafter. Prince asks, may it not be that the reason why certain places, such as Dublin, for instance, are reputed to have a specific influence against attacks, is the counter-suggestion thereby given that the patient will be free from attacks at such places? j6 HAY FEVER. DURATION. Pirrie states that it is next to impossible to defi- nitely decide the duration of hay-fever attacks, as seasons, age, temperament, locality, treatment, and other circumstances tend to cause variations in different years and in different individuals. Treat- ment will do much to curtail the duration of the more prominent and distressing symptoms, but if left to themselves it is seldom they depart under three or four weeks. A writer in the " Twentieth Century Practice of Medicine " estimates the dura- tion as from four to six weeks, according to the patient's surroundings and the atmospheric condi- tions. Asthmatic attacks may last from a few hours to three days and disappear suddenly. Morell Mackenzie states that attacks last from a few hours to several days, or even longer, finally ceasing almost as suddenly as they came, and leav- ing no trace either in local lesions or in systemic disturbance. Bosworth gives eighty cases, show- ing the durations of the annual attacks as follows : From May I to frost, I case. " " 15 " May 25, to July I, . . . 3 cases. DURATION. 77 From May 10 to Aug. I, I case. " June I " July I, 2 cases. " " I " " 14, I case. " " I " frost, 5 cases. " " 10 " July 4, 4 H " " 10 " " 26, 5 '• " July 1 " Sept. I, I case. « « IQ a A ug< If j it " " 10 " Sept. 1, 1 " 11 " 25 " frost, 4 cases. 44 Aug. 10 " Aug. 27, to frost, ... 51 " All forms of hay-fever terminate with the first frost, and the long interval in which one may suffer is shown by the first case above from May 1st to cold weather. In the United States some who are attacked in May recover by the first of July ; some attacked in July are well by the 15th of August; some attacked in August re- cover by November 1st, while some unfortunates suffer throughout the period from May to Novem- ber. The June type may be followed by a Sep- tember visitation or become a permanent August attack, or the August type may disappear in cer- tain individuals and reappear as a June cold. 78 HAY-FEVER. SYMPTOMS. Although the affection is called hay-fever, there is seldom any degree of pyrexia, and, as a fever, it is not a decided one. There are two well-known types of the disease, — the catarrhal and the asth- matic. The onset of an attack is occasionally marked by feelings of general malaise, a loss of appetite, and depression of spirits. Indeed, these symptoms more or less characterize the entire course of the attack. A " tickling in the roof of the mouth " one week before the onset was felt by a patient of Sajous. Another speaks of dull pains in the head and back two weeks before ; chills and shuddering ten days before the attack is experi- enced by another, while a large proportion com- plain of palpebral pruritus from two to ten days before the onset of the nasal symptoms. It is only in those subjects whose hay-fever is of some years' standing, Sajous points out, that the pre- monitory symptoms are present, and gives in evidence the testimony of a fellow-physician, viz. : " My attacks for some years past came with much regularity, about August 12th to August 14th. SYMPTOMS. 79 On these dates this year I arranged to be on the water, on Lake Ontario and the St. Lawrence River, and entirely escaped everything like sneez- ing and irritation of the nose and eyes. Still I had the usual hot and slightly irritable skin, then an eruption of urticaria, accompanied by dis- ordered stomach. This experience is precisely the same as in 1880, except that then I was on the Atlantic." Macdonald, in 1893, had a patient whose earliest symptoms were a curious coldness and pallor of the nose even in warm weather. In this connection it maybe observed that in 1870 Roberts conceived the " pathognomonic symptom " to be coldness of the tip of the nose. Beard divided the symptoms into local and con- stitutional. Among the latter he regarded fever, loss of strength, the altered appetite and the ner- vous system, considering under this last, depres- sion, indisposition to labor, sense of fullness and heaviness of the head, pain in the forehead and behind the ears, partial deafness, restlessness at night, inability to sleep, a sense of suffocation, and general irritability. For the local phenomena, he looked upon the skin, in the heart, chest, mouth and nose, eyes and ears. 80 HAY-FEVER. The periodicity of the attacks is a prominent symptom and is difficult to explain. Some pecu- liar psychic influence occasionally acts to pre- cipitate an exacerbation. In no other way can we explain the cases of John N. Mackenzie and Morell Mackenzie already cited. Analogous to this remarkable periodicity are those cases of intermittent fever wherein each alternate day, at a given hour, the chill occurs. This is generally true, moreover, not only of ourselves, but of the world around us. As Holmes has beautifully shown in this connection, health and disease afford abundant illustration : The fixation of the number of heart-beats, of the respiratory movements, of the cycle of menstruation, or of the period of gestation are all recognizable in their unfailing occurrence, but their determination thereof, then, rather than at some other period, can not be ex- plained. So, in disease, are the mutations of the enteric temperature, the recurrence of the hectic, of the regularity of the return of the types of ague upon the second, third, or fourth days, or of hay-fever upon its annual date. We must recog- nize these phenomena as fixed, further we can not go. "As the rhythm of physiologic effects is under SYMPTOMS. 8 1 the control of the central nerve ganglia, and as intermittency is a peculiarly marked feature of so-called nervous disorders, so far the annual return and the variations are evidences of the neurotic origin of hay-fever." The onset of an attack of hay-fever begins with a sense of irritation referred to the upper nasal chambers, a sense of fullness or tightness across the bridge of the nose. There is an itching or burning sensation of the inner canthus of one or both eyes, which may be accompanied by con- vulsive movements of the eyelid, an itching or tingling in the roof of the mouth. Spasmodic sneezing soon occurs, and pain in the eyeballs and in the frontal regions develops. The parox- ysms are more or less violent and prolonged. Arnold tells of sneezing in a patient for twenty- five times in close succession, forcing the pulse at the height of the attack to one hundred and twenty beats to the minute. These paroxysms are followed by an abundant, thin, serous discharge from the nose. The mucous membrane of the nasal fossae swells so as to block up the nasal passages, and respiration through the nares be- comes impossible. The escape of serum from the 6 82 HAY-FEVER. nostrils seems to increase the intense irritation and makes the sneezing worse. The discharge from both eyes and nose gradually grows thicker and may become semipurulent. There is often a certain amount of chemosis, and sometimes pho- tophobia, besides the usual pricking and stinging of the conjunctival surfaces. There are frequent transient paroxysms of lacrimation, and there is often much swelling of the eyelids as well as of the conjunctivae. The face becomes puffy and edematous, and the senses of taste and smell become impaired. The pharynx, mouth, and ton- sils share in the engorgement and become red, and simultaneously the inflammation of the eyes, nose, and throat becomes intense and painful. Swallowing may become so difficult that there is little rest night or day. Insomnia is common and is often attended by nervousness and a sense of suffocation out of all proportion to the gravity of the condition. Cough is not a constant feature, but in a considerable proportion of cases it comes on in the second week, and lasts through the attack. Generally it is spasmodic and so inces- sant at night that sleep is impossible, and there are soreness and pain resulting from the straining SYMPTOMS. 83 of the diaphragm and intercostal muscles. Bron- chitis does not usually result, and expectoration is absent or scanty until late. Cough may con- tinue after all other symptoms have ceased. The pulse and temperature are not generally altered, but later in the attack the temperature may be raised two or three degrees, doubtless from dis- turbed rest. A ft sufferer" records that, in some, the genito-urinary and rectal passages give the first warning by intense itching and burning. In one instance, a more than generally severe paroxysm induced rupture of the capillaries in the lacrimal caruncle of the right eye, causing engorgement of the organ and displacement of the visual axis, with consequent double vision for some days. The direct and reflex changes in the vocal apparatus vary from loss of timber and harshness to complete inability to utter nasal vowels and consonants. The disorder varies much in intensity even in the same person within short intervals of time, so as to almost give an intermittent character to the complaint. 84 HAY-FEVER. COMPLICATIONS AND SEQUELS. The attack finally ceases almost as suddenly as it came on, leaving no trace of local lesion or systemic disturbance. It is accompanied in some patients with nettle-rash. Asthma is a late symptom, coming on after the acute symptoms have abated, and cough has existed for some time. It may appear at the height of the at- tack. It is more common in autumnal catarrh than in the early forms. Its period, as a rule, begins at the fourth week, and it does not vary from ordinary asthma. It is sometimes periodic, occurring at the same hour night after night. Paroxysms appear associated with antecedent bronchial rather than nasal symptoms. Nasal reflex phenomena, without cough, may occasion paroxysms. Persistent cough more usually exists in the intervals between paroxysms. Beard says that four-fifths of the sufferers have cough or asthma. The symptoms are not usually of equal severity each year. Asthma generally comes on in the daytime, a little ropy mucus being expectorated, and later, an abundant frothy secre- COMPLICATIONS AND SEQUELjE. 85 tion. There may be only a slight remission, the dyspnea continuing so long as exposure con- tinues. The attacks rarely produce emphysema of the lung, and sooner or later recovery ensues. Bosworth estimates that the asthmatic attacks come on earlier each year in those who have suffered from hay-fever in connection with asthma, and he believes that an attack of hay-fever is especially liable to develop an attack of bronchial asthma as a natural consequence of the disturb- ance in the nasal chambers. He also observed a number of cases in which hay-fever symptoms gradually abated while the asthma became a prominent factor, and, again, that victims of hay- asthma finally acquired the perennial form of the disease, — the attacks occurring at all seasons without reference to the presence of pollen in the air. As already evidenced in Sajous' case, in a number of cases the attacks are preceded by cutaneous eruptions. Laflaive cites cases with urticaria and eczema preceding the onset of hay- fever. Facial pruritus and herpetiform eruptions are occasionally seen. J. N. Mackenzie speaks of an inflammation of the external auditory 86 HAY-FEVER. meatus in all respects analogous to that of the nose in hay-fever, occurring repeatedly in a lady during the summer months. Besides asthma, already mentioned, there is little tendency to permanent ill-effects except thickening of the nasal mucous membrane from the prolonged irritation. Taste and smell may be impaired during and for a long time after the attack. General irritability and nervousness may be more or less persistent. Elderly sufferers for a long time may have weakened hearts which intermit during attacks, which may recover with returning health or result in cardiac dilatation. Wyman mentions pneumonia in three cases during attacks. In one case the catarrh ceased for two weeks to return after the pneumonia disappeared, when asthma also came on for the first time. PATHOLOGY. * 87 PATHOLOGY. Morell Mackenzie states that hay-fever, leaving no permanent structural lesion behind it, can not, therefore, be strictly said to have any pathology. Surely it is that no distinct specific organisms have been found. Sajous calls attention to the distinct physiologic functions of the two regions of the nasal cavities, the olfactory and the respira- tory. The filaments of the olfactory nerve cover the superior turbinated bones, and the upper third of the middle turbinated bones, and the corre- sponding portion of the septum. Thus the upper portions of the nasal cavities are devoted to the sense of smell and do not enter into the pathology of hay-fever. The respiratory portion of the nose includes all the surfaces below the olfactory. It is under the control of the vasomotor nerves of the sympathetic system, and is quite sensitive to local or peripheral irritation. This sensitiveness resides in the terminal filaments of the sensory nerves, dis- tributed over the surfaces of the mucous mem- branes. The membranes of the posterior areas of the nasal fossae are supplied with several branches 55 HAY-FEVER. of the sphenopalatine ganglion, which enter by the sphenopalatine foramen. This ganglion possesses a sympathetic root derived from the carotid plexus through the vidian nerve, thus establishing a con- necting link between the nasal mucous membrane and the sympathetic system. In health the nasal mucous membrane pours out from twelve to sixteen ounces of watery serum daily, which — that it may warm, moisten, and cleanse the inspired air on its passage to the lungs — is diffused over the convex surfaces of the turbin- ated bones. The centers in the medulla, through the vasomotor, control and regulate this process of serous exudation; the nicety of which regulation is seen in the adjustment thereof to the varying hygroscopic and thermic conditions of the atmos- phere. The experiments of John N. Mackenzie, in 1884, showed : 1. That in the nose there exists a w r ell-defined sensitive area whose stimulation, through a local pathologic process or through an extra irritation, is capable of producing an excitation which finds its expression in a reflex act, or in a series of re- flected phenomena. PATHOLOGY. 89 2. That this sensitive area corresponds, in all probability, with that portion of the nasal mucous membrane covering the turbinated corpora caver- nosa and the most sensitive spots covering the pos- terior end of the inferior turbinated body and the septum immediately opposite. 3. That nasal cough is caused only by stimula- tion of this area. 4. That the tendency to evolution of reflex phenomena varies in different individuals, and is probably dependent upon the varying degree of excitability of the erectile tissue. These sensitive areas correspond to the distribu- tion of the sphenopalatine branches of the superior maxillary nerve, as distinguished from the nasal branch of the ophthalmic, which latter supplies the more anterior portions of the nasal fossae. The former nerves, derived through the ganglion of Meckel, therefore, probably contain the vaso- motor nerves which govern the erection of the tur- binated tissue, and, hence, the localization of the sensitive areas becomes the key to the mechanism of the paroxysms. Nevertheless, Beard was in- clined to transfer the point of greatest excitability from the peripheral ends of the nerve filaments to 90 HAY-FEVER. the nerve-centers themselves, because it seems a more comprehensive explanation of the varied phases of the disease. Roe explained that the more frequent occur- rence of asthmatic paroxysms at night might be brought about by the gravitation of blood to, or the contact of polypi upon, these sensitive areas. Sajous thought it was evident that there were three areas capable of producing reflex symptoms in the course of a paroxysm of hay -fever, and that the three combined formed the key to the local nervous element, not that the three areas must take part, but in some, one of them, in others, two of them, etc. In the asthmatic cases, he noticed that both anterior and posterior areas were sensi- tive, the latter especially so. Capp pointed out two distinct spots or areas of the mucous membrane of the nasal cavities, one at the posterior and one at the anterior extremity of the inferior turbinates, one or both of which may be supersensitive in individual cases; also a spot in the anterior nasal chambers at the upper angle formed by the septum. All these are ex- quisitely sensitive, and, when irritated, produce extensive reflex symptoms. Trouble appears to PATHOLOGY. 9 1 begin at one or all of the points, while the rest of the Schneiderian membrane is in normal condition ; but with sneezing, hyperemia and hyperesthesia ensue, and, through continuity, may extend to throat, ears, and eyes. In speaking of the three reflex areas, Holmes said that it is regarded that all points of the cav- ernous tissue are not equally susceptible to irrita- tion ; the sensitive areas are the inferior turbinates (the posterior and middle reflex areas) and the portion of the septum immediately opposite, being particularly related to cough and asthma; the anterior, in the vestibule, to sneezing, lacrimation, and other catarrhal symptoms. We might com- pare these reflexes with certain other cases of reflex asthma (not hay-fever) benefited by removal of the tonsils. Bosworth regarded the continuous sneezing as pathognomonic and holds that the hyperemia is " confined entirely to the large venous sinuses, the capillaries proper not being congested," and speaks of the watery, serous discharge with the bluish-gray " tinge of the mucosa verging on opalescence, the surface of the mem- brane being covered with slightly viscid, watery 92 HAY-FEVER. serum, which gives it a glassy, semitranslucent aspect." During an attack of hay-fever the erectile tis- sues of the nasal passages and the posterior throat become distended, the blood-vessels are engorged, groups of lymph-cells fill the lymphatic spaces, the mucous surface is crowded with migrating leuko- cytes (white blood-corpuscles), younger epithelial cells are vacuolating and proliferating, secretion is increased in quantity and altered in character and composition, sensation is heightened, intensified, altered, or benumbed, and the whole metabolism of the affected region is profoundly disordered. Examination of the lower borders of the turbinated bones will disclose the mucous membranes of the nasal cavities arranged in thick, loose folds, owing to the peculiar distribution of the network of arteries and veins which go to make up " cavern- ous tissue." It is peculiar to this tissue that it may suddenly be engorged with blood, extremely distending it, and as suddenly emptied and the engorgement relieved. It is especially thick over the inferior turbinated bones and over the lower and posterior part of the nasal septum, and also upon the lower edge of the middle turbinated PATHOLOGY. 93 bone. In acute conditions the engorgement and distention soon subside. In chronic states the mucous membrane becomes markedly thickened and the blood-vessels enlarged and tortuous. The subsidence of the engorgement can not occur, and as a result there is a greater or less degree of closure of the nasal passages. The mucous membrane of the nasal cavities in hay-fever does not present the characteristic features of an acute inflammation. The impact of pollen or exciting irritant causes complete relaxa- tion of the large veins of the turbinated bodies and an exudation of serum, which relaxation continues so long as pollen or the irritant is in situ, but as soon as it is removed the normal caliber is again restored and the attack subsides. Deviations of the septum or chronic rhinitis are occasionally found concurrent with the disease, but can not be regarded as characteristic. 94 HAY-FEVER. DIAGNOSIS. Hay-fever may be distinguished from asthma, common catarrh, bronchitis, acute rhinitis, remit- tent fever, and catarrhal conjunctivitis. The salient feature of hay-fever is its periodicity or annual recurrence. This is part of its very nature, is the central point of diagnosis, is its chief charac- teristic, and to its elucidation, Holmes says, all existing theories tend. Beard states that hay- fever is like asthma in the following points : 1. It is hereditary; 2. It is more or less periodic; 3. It is paroxysmal ; 4. It is correlated to other functional nervous affections ; 5. The paroxysms are excited by great variety of irritants ; persons being differently affected ; 6. It is singularly obstinate and is relieved by the same remedies. Bosworth considers hay-fever dependent upon : 1. A neurotic habit; 2. Pollen in the atmosphere ; 3. A disordered condition of the nasal passages. DIAGNOSIS. 95 While asthma is dependent upon : 1. A general neurotic condition; 2. Obscure conditions of the atmosphere; 3. Diseased bronchial (not nasal) mucous mem- branes. It is the comparative suddenness of the onset as well as its sudden departure, the violent parox- ysms of sneezing, and the character of the nasal discharges which are the peculiar features of hay- fever. The first attacks are likely to be mistaken for ordinary coryza, but here the abrupt onset, the characteristic edematous puffiness of the eyelids, the absence of constitutional symptoms will indi- cate the difference. In children, moreover, attacks of hay-fever are most liable to be mistaken for acute colds or rhinitis, — but here, again, the above points may serve to distinguish, together with the sequence of the symptoms, the time of year, and the physical signs of an acute bronchitis, if it ex- tends so far. The approach of cold weather and the coincident departure of the symptoms will make clear a diagnosis, while the history of pre- vious attacks at the season of the year most favor- able to hay-fever, the presence of certain irritants, and the general condition of the bodily symptoms 96 HAY- FEVER. may be of aid in distinguishing the affection. In acute rhinitis there are several stages, viz. : First, a dry stage, lasting for a fe\V, say twelve, hours; second, a serous discharge, lasting two or three days; and, third, a mucopurulent discharge for from three to five days, — while the entire attack runs its course in from five £0 ten days if no com- plications ensue. In hay-feter there is no dry stage; the discharge from- the outset is purely serous and never mucopurulent during the entire course. The nasal discharge in hay-fever is some- times slightly opaque, and it may contain some few epithelial cells and viscid mucus. In acute rhi- nitis examination of the nares will show an inflam- matory area while hay-fever shows none. Hay- fever is a vasomotor paresis, and is easily diagnosed from inflammatory coryza by the swollen bluish- gray appearance of the inferior turbinated bones, and by the fact that the first train of symptoms continues through to the end. Examination of the nares will disclose occlusion due to the swol- len turbinated bones lying in contact with the septum. The appearance of the mucous mem- brane itself is characteristic and only slightly resembles an inflammatory process. It is mark- DIAGNOSIS. 97 edly swollen, not .bright red as in rhinitis, but bluish-gray, covered with a thin, slightly viscid, watery serum, giving it a glassy, semitranslucent, at times opalescent appearance. Again, the marked puffiness of the eyelids, the great suffusion of the eyes, the photophobia, and even epiphora are distinguishing features of hay-fever. The sensitive areas spoken of, particularly those on the lower and posterior parts of the septum and the inferior turbinated bones, are of value in differ- entiating hay-fever, and the markedly pronounced paroxysms of sneezing are very prominent in hay- fever. People are subject in the changeable climate of spring and early summer to catch colds, and espe- cially is this true of those prone to catarrh. These cases are sometimes mistaken for hay-fever. The readiness, however, with which they yield to anti- catarrhal treatment shows their nature. 98 HAY-FEVER. PROGNOSIS. The prognosis is invariably good as to life. Sufferers often live to advanced ages. Hay-fever is no bar to life-insurance, but unless rationally treated the chances of permanent cure are very small. There are few exceptions to the rule that the tendency is, when once established, to an annual recurrence, unless the predisposing causes are removed, or there is removal of or away from the exciting cause. Beard states that hay-fever has no effect on longevity, and that, judging from observation and analogy, this affliction may act as a kind of safety-valve for the nervous diathesis, preventing other and more serious disorders, and thus becoming the friend rather than the enemy of life. When once attacked, unless properly treated, escape is rare in any subsequent year. Even changes in constitution in extreme age are no bar or protection. It rarely skips a year, provided locality and influ- ence are the same. Absolute immunity is only obtainable at the price of temporary exile. There is no proof that hay-fever is generally milder or PROGNOSIS. 99 severer in certain years all over the world or over a country, yet evidence is satisfactory that in certain localities it varies greatly in different years. Now and then, but not often, the tendency to the disease seems to be outgrown. In one of Beard's cases the disease skipped two years. Dr. Gibbons, of California, mentions a terrible case in which the attacks in successive years . became lighter and lighter and finally disappeared entirely. With respect to increase or decrease of sever- ity of symptoms with advancing years there is no constant law. In some cases the disease grows milder, in others severer, in others still, years of comparative mildness alternate with years of comparative severity. The early form may change into the later form. There is no doubt, however, that attacks may change from the early to the late form, and vice versa, and in advancing years may be milder. Bosworth states that the younger the patient the better is the promise of relief; and that rose cold, belong- ing more especially to early life, is to be regarded more favorably than other forms. Macdonald IOO HAY-FEVER. has observed spontaneous disappearance in children, perhaps due to an increase, pari passu with growth and development of nervous stability. As regards the termination of each individual attack the prognosis is invariably favorable ; ces- sante causa, cessat effectus. There is almost equal certainty that with the same causative influences the attacks will reappear upon exposure to the ex- citing cause. It is peculiar, too, that the disease of one year's standing has proven as obstinate as one of from twenty to thirty years' duration. In these instances, it may be a question as to how firmly fixed has become the neurotic habit. W. W. Bulette, of Colorado, in 1896, as a re- sult of his own experience, made the assertion that more than eighty per cent, of hay-fever suf- ferers can be permanently and effectually cured. Thorough examination of the patient and elimina- tion of every possible source of irritation and pathologic condition is necessary. / desire to be more emphatic, and from my results in the treatme?it of over 200 cases dining the last ten ears, I believe that the curability of the disease can not be questioned. That all cases can be cured is questionable ; but we can unhesitatingly say that a PROGNOSIS. 10 1 majority of cases are curable, and that positive relief, without change of residence or inconvenience, can be afforded during the period of occurrence, if treatment is directed along the lines laid down in the following chapter. 102 HAY-FEVER. TREATMENT. The proper treatment of hay-fever has always been a subject of many and diverse opinions; and the so-called specifics have been as numerous as the theories of causation. From time to time, nearly every drug in the pharmacopeia has been employed ; and many have been fashionable for a very brief period and finally abandoned. The an- tiseptics, the antispasmodics, the escharotics, the astringents, and the sedatives have one and all had their advocates, have flourished and fallen into dis- use. Early in my experience in the treatment of hay-fever I followed one authority after another, shifted from drug to drug, until finally I employed almost exclusively in uncomplicated cases the simple methods herein described. During the last ten years I have had under my care over 200 well-marked cases of hay-fever, of which I possess, in nearly all, complete histories, and I have not failed to relieve a single patient who has persisted in the treatment. I not only prevented the paroxysms, but subdued their violence and controlled the attacks when well established. I am free to confess that I secured TREATMENT. 103 success rather empirically, and not until many stubborn cases had yielded could I deduce satis- factory conclusions. The logical parallel of my methods is found in antiseptic surgery. The ponderous technic of Lister is now replaced by simple antisepsis or surgical cleanliness; so the simple, though strict, sterilization of the nasopharynx is often the certain means of arrest of the painful phenomena of hay- fever. By a daily sterilization of the nares and post- nasal spaces the victims of hay-fever may remain in the city attending to their usual duties, surrounded by dust, or in the country amid blooming flowers, without any fear of the distressing symptoms — a consummation devoutly to be wished for by the great army of hay-fever sufferers. Some years ago, in the dispensary, I had made a somewhat prolonged bacteriologic study of the nasal secretions of young children waiting for treatment for various simple disorders, and it was found that although a child might have no consti- tutional indication of infection whatever, often the bacteria of diphtheria, pneumonia, or tuberculosis, as well as many unrecognizable forms of micro- organisms, were present in the nasal secretions. 104 HAY-FEVER. Thus I was led to appreciate the well-known fact that the various bacteria deposited in limited num- bers on healthy nasal mucous membranes ultimately perish. Unless the general vitality and resistance of the mucous surfaces are lowered by internal causes, or an entrance is made through some local lesion, possibly the result of previous disease or injury, unhygienic environment, or overwhelming expos- ure, hay-fever will not occur. Conceded that an external irritant is necessary to cause the disease, to prevent or cure it we must either prevent the irritant from reaching the points of exposure, fortify these vulnerable spots, or remove or render inert the irritant when already lodged. In hay- fever the vulnerable spot is undoubtedly somewhere within the nasopharynx. It is now conceded that the nose and throat are channels for the entrance of the bacteria of many infectious diseases ; and I feel sure that as I have limited the extension of house-epidemics of scarlet fever, diphtheria, whoop- ing-cough, and measles by a carefully conducted antiseptic toilet of the nose and throat, in the same manner I have prevented the dreaded paroxysms in cases of hay-fever. All writers on this subject advocate vaguely the TREATMENT. IO5 treatment of the nose and adjacent parts ; but almost invariably definite nasal treatment is directed to previous local disease or to the em- ployment of escharotics, astringents, or anesthet- ics. Antiseptic solutions are advised for their local action rather than with an idea of cleansing the nares, and are used in quantities too small to remove or render inert the irritant. Removal from the source of irritation — a complete change of environment during the period of recurrence — has been the best prophylactic means previously at our command, but this is most inconvenient and impracticable to many of the sufferers. Equally impracticable is such an alternative sug- gestion as that of Morell Mackenzie, that when people can not flee to the mountains or the mid- ocean they should remain indoors, and " if they must go out they ought to plug the nose with cotton-wool and protect the eyes by wearing spectacles with large frames, accurately adapted to the circumference of the orbit." I offer as an acceptable and reliable substitute for the change of climate a simple local treatment. The infection and disturbance of the nasal mucous membrane is undoubtedly the exciting 106 HAY- FEVER. factor in originating the paroxysms, and to this we must confine our efforts early if we are to gain any success in treatment. The first step in the local treatment is to learn, by careful examination of the nasal chambers, whether we have present any abnormal condition which renders their mucous surfaces supersensi- tive, or any well-marked defects, such as polypi, deviated septums, or hypertrophies. Frequently a simple chronic rhinitis precedes a tendency to permanent turgescence of the whole nasal cham- ber; in such a case a free cleansing of the nasal mucous membrane is quite easy, but when we have a polypus blocking the way, or a badly de- viated septum, progress in treatment will be slow. I believe that, as a rule, local disease is only inci- dental and not in any way provocative, except as it renders the surrounding mucous membrane unhealthy, thus inviting infection and precipitating the true paroxysms. However, any abnormal condition existing in the nasal avenues must be corrected so far as pos- sible, because it renders complete sterilization of these parts difficult or impossible, and weakens the normal resistance of the mucous membrane, thus TREATMENT. IO7 inviting periodic infection. I believe that the acute infective diseases, particularly in children, may be prevented by most thorough and repeated sterilization of the nasopharynx, and just as house- epidemics are never excusable evils so I claim the same to be true of hay-fever. Local Treatment. — The important result to be obtained through treatment is the prevention of the paroxysms, and, ultimately, the entire re- moval of the recurring habit periods. Years ago I was led to treat my hay-fever patients suffering with watery nose, weeping eyes, and bronchial and frequently asthmatic cough by cleansing the naso- pharynx with a hand-ball atomizer containing a warm solution of boric acid (ten grains to an ounce of water) or Dobell's solution, after which I care- fully wiped the mucous membrane and applied menthol and liquid cosmolin freely to the parts. This procedure afforded considerable temporary relief in a large number of cases when there was present simply turgescence of the whole naso- pharynx. When, however, polypi or evident hypertrophies existed this treatment was not suffi- cient. After the polypi were removed or the hypertrophic tissue destroyed I would continue 108 HAY-FEVER. the alkaline wash, practising the sterilization and applications to the parts with my oily solution. It would be a long story to trace in detail the gradual abandoning of one drug after another from the mildest alkaline wash up to the strongest caustic application of Williams — the solution of the iodid of mercury of the strength of I : iooo up to I : 250. The chromic-acid application, nitrate of silver, carbolic acid, tincture of iodin, quinin solution, perchlorid of mercury, and many of the more powerful caustics and tissue-destroying appli- cations so frequently resorted to in the early his- tory of the treatment of the disorder, I have long ago discarded. These remedies, while sometimes possessing merit, were not lasting, and were fre- quently more painful than the paroxysms they were supposed to check ; they could only be resorted to in those hopeless cases in which the patient would willingly suffer any pain rather than the distressing hay-fever paroxysms. The stronger solution of iodid of mercury (1 1250) was so very severe as to often necessitate an hypo- dermic injection of morphin to control the agony, and in addition it produced an acute catarrh of a severe type lasting several days. TREATMENT. IO9 All of the above severe caustic remedies have in turn occasionally proved of value; but my ex- perience of late years has led me to avoid all powerful applications. For the last ten years I have generally used the following solution : R • Sodium bicarbonate, Sodium borate, of each, § iss Carbolic acid, ^j Glycerin, § ij Rose-water (25 per cent.), . . . . q. s. O j . Sic — Teaspoonful to one ounce of warm water. This I thoroughly use in both nostrils, first by means of a hand-ball atomizer ; after which, with a curved aluminum applicator or Harrison Allen's nasal cotton-carrier, I very carefully swab the whole nasopharynx. I scrub most carefully and gently every portion of the mucous membrane ', being sure to reach between the turbinated bones and all around and over every slight prominence. I then as carefully dry the membrane with clean cotton, and use freely a mild solution of menthol, eucalyptus, and camphor in albolin, in proportions as follows : R . Menthol, gr. x Oil of eucalyptus, 3J Pulverized camphor, 3 ss Albolin, g ij. IIO HAY-FEVER. I loosely plug the nose for a few minutes to retain the oily application. It is important to sterilize most thoroughly the three sensitive areas of the nose, as we are unable to determine whether one or more may be affected, and by this mild yet thorough treatment we cleanse effectually the whole nasal chamber. This treatment was so extremely simple that for a long time I doubted the real extent of its value, but as so many extreme sufferers have expressed their great relief, and were willing and anxious for me to continue the applications, I have concluded to offer my methods in full con- fidence of their reliability, with a warning that for successful treatment the instructions for cleans- ing and scrubbing must be followed in the strictest detail. Good results need not be expected by simple irrigation and swabbing — the whole nasal mucous membrane must be thoroughly washed and gently scrubbed before the oily applications are used. I have found many persons who will not tolerate the use of carbolic acid, even in so mild a solution as that given above, the weakest solution frequently causing a severe urticaria or a painful rhinitis. TREATMENT. I 1 1 When various idiosyncrasies to carbolic acid forbid its use, I select as the second best detergent hydro- gen dioxid,and commence with the following mix- ture : R . Hydrogen dioxid, Glycerin, Distilled water, of each, ^ij. With this I spray the nose most thoroughly, fol- lowing it up with plain warm sterile water to re- move the accumulation of foam that will neces- sarily collect in the nasal spaces. A few days prior to the date of the onset, I increase the strength of the hydrogen dioxid solution, using something like the following : R. Hydrogen dioxid, § iv Glycerin, Distilled water, of each, ^ij. This must be removed also by means of the sterile water, as already mentioned. In a number of cases I have found glycerin objectionable as a vehicle, producing an irritation of much annoyance. In such cases I omit the glycerin and substitute so much more distilled water. In a few cases the hydrogen dioxid produced an inflammation of the mucous membrane that would require its 112 HAY-FEVER. dilution. We find so many personal idiosyncra- sies in a large number of hay-fever sufferers that one might go on indefinitely with modifications of treatment, but, as in general practice, it is our aim as successful physicians to treat the individual pri- marily, and we can not dogmatically hold fast to any special drugs. In the few obstinate cases, in which sterilization seems to provoke additional trouble, and the slightest manipulations of the nose and throat pre- cipitate violent paroxysms, I use on the nasal mucous membrane the following powder : R. Morphin. sulph., gr. iv Boracic acid, gj Powdered camphor, g ss Powdered starch, 3 iv. SiG. — To be used as a snuff frequently. If patients object to the use of the snuff, and occasionally we will find some who will do so for cosmetic reasons, I prescribe the following, to be taken internally : R . Tinct. of deod. opium, 3 iiss Spirits of chloroform, 3 ij Aromatic elixir, q. s. gij. SiG. — A teaspoonful in water every four hours for the first two days. (Not to be renewed.) TREATMENT. I I 3 Some physicians claim that relief can not be afforded to hay-fever patients without using cocain or eucain at some time during the management of troublesome cases. It is very exceptionally that I resort to either; possibly an unusual case will re- quire one or more applications to control a local storm, yet the majority of patients never receive any cocain from my hand. In several severe cases that came to my notice after the disease had been well established, when I had no chance to conduct a preliminary course of sterilization, I have been forced to prescribe some- thing like the following : Menthol, gr. viij Boric acid, . . . . gr. xxx Albolin, ^ij Solution of Eucain " B " (4 per cent.), ^ ij. This is applied carefully and thoroughly on cotton applicators to the mucous membrane of the nasopharynx. It may control the attacks, and it frequently aborts them and keeps the patient decidedly comfortable. I have found the direct application of the remedy more satisfactory than the atomizer. In some cases, for a few days this application must be made two or three times daily. 8 114 HAY-FEVER. H. L. Swain recommends the local use of the aqueous extract of the suprarenal glands in cer- tain chronic conditions of the hay-fever type, as % powerful local vasoconstrictor and contractor of erectile tissue. The local effect can apparently be obtained any number of times without entailing a vicious habit, such as might result from cocain. Ingals and Ohls report that they have obtained much relief in these cases by the use of an ex- tract of suprarenal capsule prepared as follows : Adrenals (Armour's), 5j ; boric acid, gr. xvj ; cinnamon water, 5iv ; hot camphor water, §j ; hot distilled water, enough to make §ij. Mix, macerate for four hours, and filter. This solution remains stable for several weeks. It is used as a spray four or five times a day. I have not had occasion to resort to the local application of this substance, but I have had one patient who was distinctly benefited by internal administration in doses of gr. ^ to gr. j, as often as four times a day. He was a catarrhal young man of neurotic temperament, who came to me during the first week of his attack, and who objected to the usual routine sterilization of the nasopharynx. Surgical Treatment. — In making an analysis TREATMENT. I I 5 of the abnormalities of the nasopharynx in hay- fever cases, the personal equation enters so largely that, necessarily, statistics are unreliable. What one observer would consider pathologic, another might overlook or call normal. However, I can safely say that in the great majority of my cases there was a decidedly catarrhal nasopharynx, and that in at least one-half there was deviated septum, hypertrophy of the turbinated regions, or polyp. In some cases a combination of all existed. In about ten per cent, of my cases I was satisfied to pronounce the anatomic conformation and the state of the mucous membrane as practically normal. It has been my experience that only when gross lesions exist is surgical treatment indicated, and then it should precede the usual sterilization methods. Indeed, so frequently successful has been the thorough cleansing of the nares, that in many cases of gross hypertrophy I have neglected removal. If, however, the sterilizing and cleans- ing treatment did not bring relief, I would resort to the galvanocautery or needle for hypertrophy, or the snare for polypi, after which my nasal cleansing process would be satisfactorily con- Il6 HAY-FEVER. tinued. In cases of deviated septum I rarely felt the necessity for correction, but most carefully fol- lowed out the thorough cleansing, unless the case presented itself some months before the expected paroxysm, when correction could be made safely. A large percentage of my patients during the last five years, anticipating the periods of recur- rence, have willingly presented themselves for an annual course of preliminary local treatment* This is extremely necessary to successfully de- stroy the nerve-habit and to effect a cure. General Prophylactic, Hygienic, and Sys- temic Treatment. — In old cases, when the nerve- habit has long been formed, treatment should commence at least two or, better, three weeks before the anticipated recurrence of the parox- ysms. All bodily irregularities must be corrected and tendencies to constipation or dyspepsia re- moved. Amylaceous indigestion should be cor- rected by the exclusion from the dietary of too starchy foods. For the elimination of excessive uric acid, or other waste products, and to relieve constipation, the systematic administration, morn- ing and night, of effervescent sodium phosphate is invaluable. If the appetite is not good, the regu- TREATMENT. 1 1 7 lar use of the tincture of nux vomica, ten to twenty drops three times a day, is strongly indi- cated. In anemic cases pills of carbonate of iron or, probably still better, the pills of valerianate of quinin, iron, and zinc are necessary. In nervous cases with anemia, valerianate of zinc, one grain with two grains of the compound asafetida pill, two or three times a day (after Morell Mackenzie), will be found valuable. Careful diet, a tranquil mind, and moderate exercise are essential. Out- door exercise, with a daily tepid bath followed by vigorous friction of the whole body, will help to eliminate waste material. The patient should not unnecessarily expose himself to direct rays of the sun, as they are calculated to excite intense reflex irritation of the sensitive nerve centers. Much trouble may be averted by the use of a sunshade or umbrella and by the avoidance of exercise in the sun. It must be understood that with the general hygienic and constitutional treatment the course of local prophylaxis by daily sterilization is most necessary. The treatment of neurasthenic cases, or those in which a decided derangement of the gen- Il8 HAY- FEVER. eral system as well as of the nervous energy exists prior to the attack, requires the greatest tact and skill. If there is little local catarrhal disturbance there will be great difficulty in combating the dis- ease in the face of the depressed vitality and les- sened nervous resistance. In such cases I place the patients upon a diet, somewhat like that in the appended list, and urge strict adherence to it. After obtaining careful urinary analysis and other clinical data, I often further specialize in the diet, or I may increase the variety according to the needs of the individual. In these cases I always urge the drinking of large quantities of water, un- less there is some strong contraindication. Neu- rasthenics will often avoid water between meals. I at once order systematic massage. If the patient does not care for a masseur, I order a daily tepid bath of a temperature between 8o° and 85 ° F., with a coarse towel rubbing, followed by a douche of cold water along the spine. This should be continued for at least two weeks prior to the onset of the paroxysms. Rest for the overtaxed function is imperatively demanded. Unfortunately, this is easier prescribed than carried out. In wealthy patients the Weir TREATMENT. 1 1 9 Mitchell rest-cure often gives brilliant results. In other cases a change of scene and a temporary rest from business or society may be accepted when the sanitarium would be out of the question. Quiet resorts on the seacoast or in the mountains are desirable. Nothing is better than two or three weeks on the ocean. A compromise may be ob- tained by having the patient give up a portion of the daily duties and go to bed earlier at night. The patients should not be allowed to discuss their ailments too freely. Horseback riding, bicycling, rowing, and walking — in fact, any outdoor diver- sion not too violent — are to be recommended. If the patient suffers from insomnia, careful ad- ministration of a hypnotic may help to reestablish the sleep-habit. .At first give a warm bath, and a glass of warm milk or malted milk before retiring. If this and other similar measures do not avail, ten grains of trional powder may be given two hours before going to bed. If the patient is accustomed to wake after a short sleep, the trional should be given at bedtime. Full amounts of sleep are necessary to neurasthenics. Depressants, such as the bromids, chloral, and the opiates should be avoided. Any coexistent gastric or cardiac trouble 120 HAY-FEVER. must be carefully treated, and the bowels kept open regularly. The diet that I find most desirable to follow, generally speaking, is that which is applicable to the gouty or uric acid diathesis. General Rides. — The diet should be liberal, but not stimulating, with moderation in animal foods, and very little of foods having a tendency to pro- duce acids in the system, such as starches, sugars, fats, and fermented liquors. Patients may take soups — clear or vegetable — and weak beef-tea or broths. Fish. — Fresh fish and raw oysters. Meats. — To be taken once a day only — mutton, chicken, underdone roast, sweetbread. Eggs. — Moderation. White of eggs, raw, or shirred in drinks, such as lemonade, occasionally. Farinaceous. — In small quantities. Toast, stale bread, bread from whole wheat, rye bread, milk- toast, rice, crackers. Vegetables. — Fresh, green varieties preferable ; celery, lettuce, watercress, cucumbers, onions, cabbage, salads, sparingly of baked potatoes, young peas, string beans, and spinach. Desserts. — Oranges, lemons, apples, apricots, TREATMENT. 121 pears, peaches, cherries, blanc mange (not after meals, however), stewed fruit. Beverages. — Water, plentifully, especially before meals; plain soda, milk, buttermilk, weak tea or coffee (without sugar), toast-water, lemonade. Min- eral waters, such as Saratoga Vichy, Berkley (Hot Springs), Lithia Water, Carlsbad, and Crab Orchard. Stimulants. — Light Hock ; Bordeaux in small quantities and well diluted. Articles Forbidden. — Patients must avoid rich soups, hard-boiled eggs, fried and made dishes of all kinds, entrees, pickles, spices, veal, pork, duck, goose, salmon, lobster, crab ; preserved, dried, and salted meats ; salt fish, pickled pork, asparagus, old peas, beans, tomatoes, mushrooms, truffles, dried fruit, preserves, pies, pastry, rich puddings, patties, new bread, cheese, sweets, malts, sweet wines, strawberries, rhubarb, cider, fermented drinks, beer. Asthma. — About five to ten per cent.of my whole number of hay-fever patients have suffered more or less from asthma. Asthma, as a sequel in these cases, manifests itself about the end of one week or ten days after the expected paroxysms of hay-fever, and is induced usually by some undue exposure or 122 HAY-FEVER. a damp or rainy day. My asthmatic patients, I find, were among those irregular in treatment, or those who had first called late in the disease. In these cases much mucus had accumulated in the larger tubes. If I can not clear the bronchial tubes by an emetic dose of ipecac, I prescribe somewhat as follows : Potassium iodid, 3 ss Ammonium muriate, 3 ss Syrup of Yerba Santa, gj. A teaspoonful exhibited every two hours gen- erally brings relief. A number of asthmatic patients require a solution of nitroglycerin, one per cent. Of this, one drop every three hours for two or three days is given. Occasionally it seems im- perative to give morphin. Some of my asthmatics have informed me that they can bring about imme- diate relief by plunging both hands in hot water and taking a drink of whisky, followed by a large draft of hot water. It is possible for some per- sons to voluntarily combat their asthmatic attacks, and for this reason they should be encouraged to practise certain breathing exercises until they can in a measure control their respiratory apparatus. Asthmatics usually have, however, a preexistent TREATMENT. I 23 catarrhal state of the bronchial tubes, which ex- hibit marked vasomotor changes on slight irrita- tion. If I see these patients early, I prescribe five- minim capsules of the oil of sandalwood four times a day, and by the time their period arrives, the bronchitis is fairly well cleared up. The inhalation of the fumes of burning niter- paper or specially prepared powders, or of cigar- ettes, gives relief in many cases. The powders used at the Brompton Hospital by Sydney Martin contain one part each of anise and niter, two parts of stramonium leaves, and five grains of tobacco to the ounce ; one teaspoonful is to be burnt on a plate and the fumes inhaled. A pill containing % of a grain of morphin, with y^- of a grain of atropin sulphate, given at bedtime, is sometimes useful in connection with the inhalations. Extract of stramonium (-^ of a grain) may be substituted for the atropin. S. Solis-Cohen has used successfully the follow- ing formula : R. Morphin sulph., gr. \-\ Strychnin sulph., g r - eWV Hyoscin hydrobrom., ........ gr. -%^-q. M. Sig. — Give hypodermically at bedtime. 124 HAY-FEVER. The following may be administered at night : R. Camphor, gr. ss Dover's powder, gr. vj Sugar of milk, gr. x. Make four powders. SlG. — Take one on retiring. Van Sweringen calls attention to a line of treat- ment in a very obstinate case of bronchial asthma that was attended by remarkable results. The attack had lasted for two weeks, during which time all the antispasmodics had in turn been ex- hausted, and the patient had secured but a period of two hours' freedom at any one time. Finally, based on the theory that if asthma was reflex it must be under the control of Setschenow's inhibi- tory center, and that anything that would stimu- late the inhibitory center would lessen the reflex- spasm, quinin and strychnin were given, with excellent results. The dose of the quinin was seven grains. The extract of nux vomica was given in ^-grain doses, and to this was added y£ of a grain of codein sulphate. In the interval the iodids were continued. However, the use of sedatives and inhalations must be limited, especially in the milder and un- TREATMENT. 125 complicated forms of asthma, while efforts to benefit the patient's general condition are strongly indi- cated. Diet is an important part of the treatment of many cases. Not all cases of asthma are due to uricacidemia, but nearly all cases are benefited by attention to the diet and elimination of excess uric acid. Of remedies that may be continuously admin- istered to patients who have frequently recurring attacks, two are most constantly used — namely, iodid of potassium and arsenic. The iodid maybe most conveniently given with stramonium, as in the mixture devised by Martin, which consists of Y^ of a grain of extract of stramonium, two grains of extract of licorice, three grains of iodid of potassium, and five minims of chloric ether. This mixture may be given two or three times daily in cases of asthma. It possesses two disadvantages, however. The stramonium leads, in some cases, to paralysis of accommodation, but by diminishing the dose, the patient soon ceases to experience dis- comfort from the remedy. If given alone, the iodid must be administered in five-grain doses two or three times daily, the medicine being discontinued from time to time. 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Re- porter, Phila., 1890, lxiii, 153-156. Berkart (J. B.), The Pathology of Hay-fever. Lancet, Lond., 1890, ii, 12, 69. Hurt (W. J.), Etiology and Treatment of Hay-fever. In- diana M. J., Indianap., 1890, 1, ix, 219. Rixa (A.), Contribution to the Therapeutics of Hay-fever. Therap. Gaz., Detroit, 1890, 3 s., vi, 311-313. 1891. Bullock (J. E.), Hay-fever and Excessive Sneezing. Prov. M. J., Leicester, 1891, x, 324-327. Gluck (I.), The Treatment of an Attack of Hay-fever. Med. Rec, N. Y., 1891, xxxix, 564-566. Leal (M.), Some Observations on Hay-fever. J. Ophth., Otol., and Laryngol., N. Y., 1891, iii, 334-339. 142 HAY-FEVER. Loebinger (H. J.), Terpine Hydrate in the Asthmatic Stage of Hay-fever. N. York M. J., 1891, liv, 657. Rixa (A.), Further Contribution to the Therapeutics of Hay- fever. Therap. Gaz., Detroit, 1891, 3 s., vii, 811. United States Hay-fever Association. Manual for 1891. Scientific Essays, etc. 1891, 76 pp., 8vo. Perkins (C. E.), Some Points on the Pathology and Treat- ment of Hay-fever. Cleveland M. Gaz., 1891-2, vii, 267-273. 1892. Kyle (D. B.), The Treatment of Hay-fever by Means of Cocaine Phenate. Med. News, Phila., 1892, lxi, 676. Szohner (J.), Contribution to Etiology and Treatment of Hay-fever. Trans. Pest. Med.-Chir. Presse, Budapest, 1892, xxviii, 371. Taylor (J. I.), Hay-fever and Its Treatment. Memphis M. Month., 1892, xii, 7-1 1. Tyrrell (R. S.), A Predisposing Cause of Hay-fever. Canad. Pract., Toronto, 1892, xvii, 344-346. U. S. Hay-fever Asso. Manual for 1892. Scientific Essays, etc. 66 pp., i6mo. Williams (P. W.), Hay-fever and Hay-asthma. Bristol M.-Chir. J., 1892, x, 84-96. Macdonald (G.), A Clinical Lecture on Hay-fever and Asthma. Clin. J., Lond., 1892-3, i, 390-396. 1893. Bishop (S. S.), A New Pathology and Treatment of Nervous Catarrh. J. Am. M. Ass., Chicago, 1893, xxi, 809-813. Treatment (The) of Hay-fever. J. Am. M. Ass., Chicago, 1893, xxi, 798-803. (Discussion.) 1894. Bishop (S. S.), A New and Successful Treatment of Hay- fever. The Views of the Profession. Med. News, Phila., 1894, lxiv, 197-201. BIBLIOGRAPHY. I43 Wilson (J. C), Hay-fever. American Text-book of the Theory and Practice of Medicine (Pepper), 1894, ii, 452. Wolfe (A. C.)i Treatment of Hay-fever. J. Am. M. Asso., Chicago, 1894, xxiii, 457-459. Wolfe (A. C.)i Hay-fever. Columbus M. J., 1894-5, xiii, 3S7-397. 1895. Aulde (J.), Autumnal Catarrh and Its Rational Treatment. Alkaloid Clinic, Chicago, 1895, ii, 171-173. Bicycling in Hay-fever. Med. Rec, N. Y., 1895, xlviii, 142. Brunson (R.), Operative Interference in Hay-fever. Hot Springs M. J., 1895, iv, 129-131. Capp (W. M.), About Local Treatment in Hay-fever. Phila. Polyclin., 1895, iv, 417. Cohen (S. S.), A Case of Hay-fever. Internat. Clinic, Phila., 1895, 5 s., iii, 81-86. Prince (M.), Hay-fever, Due to Nervous Influences, Occur- ring in Five Members -of Same Family. Am. Gynaec. and Paediat., Boston, 1895, viii, 638-642. Smith (F. G.), Palliative Treatment of Hay-fever. Med. Rec, N. Y., 1895, xlviii, 484. Treatment of Hay-fever. Kansas M. J., Topeka, 1895, vii, 496. Grayson (C. P.), The Neurotic Habit as a Causative Factor of Hay-fever. Univ. M. Mag., Phila., 1895-6, viii, 789- 793- 1896. Abercrombie (P. H.), Valerianate of Zinc in Hay -fever. Brit. M. J., Lond., 1896, i, 967. Amos (A. R.), Recent Views of the Causation of Asthma, Hay-fever, and Allied Affections, and Their Treatment. Tri-State Med. J., St. Louis, 1896, iii, 405-410. Arnold (H. A.), Hay-fever and Its Complications. Med. and Surg. Reporter, Phila., 1896, lxxv, 528-530. 144 HAY-FEVER. Bishop (L. F.), Hay-fever and Its Successful Treatment. Laryngoscope, St. Louis, 1896, i, 21-28. Bulette (W. W.), Treatment of Hay-fever. Med. Fort- nightly, St. Louis, 1896, x, 476-481. Bulette (W. W.), Treatment of Hay-fever. Tr. Colorado M. Soc, Denver, 1896, 88-97. Cheatham (W.), Hay-fever ; The Best Treatment for Stay- at-homes. Laryngoscope, St. Louis, 1896, i, 225-228. Hunsberger (J. N.), Hay-asthma. Med. and Surg. Re- porter, Phila., 1896, lxxv, 777. McCassy (J. A. 3.), Hay-fever. Med. Progress, Louisville, 1896, xii, 380-382. Sticker (G.), Der Bostock'sche Sommerkatarrh. Spec. Path, u. Therap., Nothnagel, Wien, 1896, iv, 2. H. 2. Abth. 85-H5. Strangways (W. F.), Hay-fever: A Successful Treatment Founded on a New Theory. Phys. and Surg., Detroit and Ann Arbor, 1896, xviii, 1-8. Sufferer (A), Periodic Autumnal Catarrh: Hay-fever. Med. Age, Detroit, 1896, ii, 513-526. Wilson (N. L.). Uric Acid as a Factor in the Production of Hay-fever. N. York M. J., 1896, lxiv, 836-839. 1897. Abbotts (W.), On Hay-fever, Hay-asthma, or Summer Catarrh. Lond., 1897, Butler & Tanner, 82 pp., i2mo. Capp (W. M.), A Contribution to the Symptomatology of Hay-fever. Med. News, N. Y., 1897, lxii, 520. Elias (J. P.), Bostock's Zomerkatarrh. Med. Weekbl., Amst., 1897-8, iv, 133-138, 149. Goenner (A.), Ueber Heufieber. Cor.-Bl. f. schweiz. Aerzte, Basel, 1897, xxvii, 233-241. Grayson (C. P.), The Rational Treatment of the Constitu- tional Factor in the Causation of Hay-fever. Therap. Gaz., Detroit, 1897, 3 s., xiii, 653-655. BIBLIOGRAPHY. 145 Holmes (Edmund W.), Hay-fever. Med. and Surg. Rep., 1897, xxvii, 513. Ingals (E. F.), Hay-fever. Twentieth Century Practice of Medicine, ii, 183. Lewis (F. D.), Hay-fever. J. Oph., Otol., and Laryngol., N. Y., 1897, ix, 327-332. Mason (A. L.), Hay-fever. Syst. Prac. M. (Loomis), N. Y. and Phila., 1897, ii, 178-185. Miiller (J.), Ueber Heufieber. Wien. med. Presse, 1897, 1632. Strangways (W. F.), Hay-fever. Laryngoscope, St. Louis, 1897, ii, 213; Phys. and Surg., Detroit and Ann Arbor, 1897, xix, 270. 189S. Cheatham (W.), This Year's Experience with the Treatment of Hay-fever for Stay-at-homes. Louisville Med. Monthly, 1898-9, iv, 286. Clark (C. E.), A Plea for Radical Treatment of Hay-fever. Kansas City Med. Index, 1898, xix, 37-40. Goodhart (J. F.), On Asthma and Hay-fever. Syst. Medi- cine (Allbutt), N. Y. and Lond., 1898, v, 286-310. Hollopeter (W. C), Hay-fever and Its Successful Treat- ment. 8vo, P. Blakiston's Son & Co., Philadelphia, 1898. Weaver (W. H.), Hay-fever. Journal Am. Med. Assoc, 1898, xxx, 1334-1336. 1899. Dunn (J.), Uricacidemia as the Cause of Hay-fever and Asthma. Charlotte Med. Jour., 1899, xv, 171-177. Rixa (A.), Prevention of Hay-fever. J. Am. Med. Assoc, Chicago, 1899, xxxii, 120. Wright (E. W.), The Prevention of Hay-fever. N. Y. Med. Jour., May 6, 1899. INDEX Age, influence of, 55 Allen, Harrison, 26, 63 Anglo-Saxon races, frequency of cases in the, 47 Areas, sensitive nasal, 62, &J Arnold, 1 3, 81 Ascaris megalocephala as a cause, 38 Ashhurst, Samuel, 61 Asthma as a late symptom, 84 diagnosis from, 94 treatment of, 121 Atlantic, cases on the, 50 Australia, cases in, 49 Bacteriologic study of nasal secretions, 103 Bastian, 38 Beard, G. M., 25, 33, 34, 48, 51, 52, 54,56,57,72,79,88, 94, 9S Beecher, Henry Ward, cases in the family of, 53 Benzoic acid, as a cause, 36 Beschorner, 18 Bibliography, 127 Binz, C, 22 Bishop, S. S., 27, 64, 65, 66 Blackley, Chas. H., 13, 24, 35, 55 Blackley, experiments of, 40 Blossoming dates, mutability of, 45 Bostock, J., 19, 30 Bosworth, 51, 53, 59, 63, 64 73, 74, 76, 85, 91, 94, 99 Botallus, 18 Broussais, 39 Bullette, W. M., 52, 100 Canada, cases in, 50 Capp, W. M. , 67, 90 Cardiac involvement, 86 Caterpillars as a cause, ^8 Causes, exciting, 30 predisposing, 47 Cavernous tissue, nasal, 92 Chaveau, 48 Chills, analogv to recurrence of, 74 Chocolate as a cause, 37 Cinders as an exciting cause, 34 Clark, Sir Andrew, 27 Cleansing of the nares, 115 Cocain, 113 Coffee as a cause, 2>7 Complications, 84 Conklin, 65 Cornaz, 21 Coryza, diagnosis from, 95 Cottonwood fever, 5 1 Cough as a symptom, 82 147 148 INDEX. Cough, persistent, between par- oxysms, 84 Cullen, 37 Cutaneous eruptions as compli- cations, 85 Daly, W. H., 26, 62 Darwin, 45 Definition, 10 Denmark, cases in, 49 Diagnosis, 94 Diatheses, theory, 16 Diet, 120 Discharges, nasal, 82 Drenger, 39 Duration, 76 Dust as a cause, 19, 34 Dysphagia as a symptom, 82 E Ebstein, 65 Elliotson, 18, 20 Emanations from dry hay as a cause, 19 England, distribution of cases in, 49 Erectile tissues, nasal, 92 Eucain, 113 Exciting causes, 30 Experiments of Blackley on the pollen theory, 40 Eye-symptoms, 81 Fatigue as a cause, 19 Feathers as a cause, 37 Fever during an attack, 8^ Floyer, 18 France, cases in, 49 French, rarity of cases among the, 48 Fruit as a cause, 37 Fungoid growth as a cause, 14 Gaslight, influence of, 22 Gastro-intestinal causes, 70 General remarks, 12 Genito-urinary organs, involve- ment of, 8^ Germans, rarity of cases among the, 48 Germany, cases in, 49 Gibbons, 99 Grasses, varieties of, causative, 43 Grayson, C. P. , 28, 68 Gream, G. Y., 20 H Hack, W., 26, 60, 62 Haig, 64 " Hair-caterpillar asthma," ^8 Handkerchiefs, effluvia from, as a cause, 37 Hare, odor of, as a cause, 1,8 Heart, involvement of, 86 Heat as a cause, 19, 30 Helmholtz, 14, 22, 36 Heredity, influence of, 52 Herzog, 62 Holmes, E. W., 35,45 , 47, 55, 56, 61, 63, 68, 80, 91, 94 Horses, odor of, as a cause, 38 H iiners wolff, 39 Hygienic treatment, 116 I Idiosyncrasy, influence of, 60 Imagination, influence of, 39, 74 India, cases in, 49 Indian, case in an, 48 Indigestion as a cause, 69 INDEX. 149 Ingals, 33 Insomnia as a symptom, 82 Insurance, effect on, 98 Intermittent fever, analogy to, 74 Ipecac as a cause, 37 Italy, cases in, 49 Itzigson, 37 Ivy-poisoning, analogy to, 44 Jacobi, 48 Kinnear, 59 K Labosse, 21 Laforgue, 20 Life insurance, effect on, 98 mode of, influence of, 56 Light as a cause, 32 Linseed meal as a cause, 37 Local disease theory, 17, 62 treatment, 107 Locust-tree blossoms as a cause, 37 Longevity, effect on, 98 Lycopodium as a cause, 37 M MacCulloch, 20 Macdonald, 28, 49, 79, 99 Mackenzie, J. N., 26, 39, 48, 59, 62, 63, 74, 88 Mackenzie, Morell, 27, 33, 39, 40, S3, 54,5Mo, 76,87,117 Males, prevalence in, 54 Mango-tree as a cause, 44 Marsh, E. J., 25,44 Mattress as a cause, 39 May apple as a cause, 37 Mays, Thomas J., 65 Micro-organisms in the nasal discharges, 22 Moore, George, 23 Mucous membrane, nasal, 93 Mulberry blossoms as a cause, 37 Muller, J., 70 Murchison, 65 Murrell, William, 37, 38 Mustard as a cause, 37 Mutability of blossoming dates, 45 N Name, origin of, 19 Nasal abnormalities as causes, 12 symptoms, 81 Negro, case in a, 48 Nervous supply to the nares, 89 Nettle-rash as a complication, 84 Neurasthenic cases, 1 17 Neurotic element, 15 theory, 57 New Zealand, cases in, 49 Norway, cases in, 49 Nose, coldness of, 79 Nutrition, defective, a cause, 6S Oak as a cause, 3J Obstruction of the nares as a cause, 63 Occupation, influence of, 56 Occurrence, time of, 72 Ocean, cases on the, 44 Odors of fruits and flowers as causes, 39 Onset, symptoms of, 81 Origin of the name, 19 Ozone as a cause, 35 Parry, C. L., 18 Pathology, 87 Peaches, odor of, as a cause, 39 Periodicity, 80 Phoebus, P., 20, 31, 32, 35, 54, 74 ISO INDEX. Pirne, W., 22, 31, 33,49 Pneumonia as a complication, 86 Podophyllum as a cause, 3J Pollen, first reference to, 13 kinds of, 42 theory, 40 Polypi, Bosworth's views rela- tive to, 63 Prater, Augustus, 20 Predisposing causes, 47 Premonitory symptoms, 78 Prince, M., 54, 59, 74, 75 Proctor, Richard, case of, 32 Prognosis, 98 Prophylactic treatment, 116 Protoplasmic substance as a cause, 15 Pruritus ani during an attack, 83 Psychic influence in the causa- tion, 39, 74 Pulse during an attack, 8^ Quinin solution as a remedy, Quinquaud, 65 Race, influence of, 47 Rag-weed as an exciting cause, 43 Ramadge, 20 Rectum, involvement of, 8^ Recurrence, period of, 72 Regions of the nasal cavities, 87 Riedlin, 18 Ringer, 38 Roberts, W. C. , 23, 79 Robinson, B., 60 Roe, J. O., 26, 62, 90 Roman wormwood as an ex- citing cause, 53 Russia, cases in, 49 S Sajous, C. E. de M., 26, 48, 53, 62, 78, 90 Salter, Hyde, 21,38 Scotland, cases in, 49 Sea, cases at, 44 Sensitive areas of the nares, 62, 87 Sequelae, 84 Serum, nasal, 88 Sex, influence of, 54 Smell, involvement of, 86 Smith, Ward, 37 Smith, W. A., 22, 44, 47, 50 Sneezing in, 81, 95 Solis-Cohen, J., 59 Solis-Cohen, S., 60 South America, cases in, 49 Spain, cases in, 49 Spontaneous disappearance of the recurrences, 100 Sterilization of the nares, 115 Strangways, W. F., 14 Sunlight, influence of, ^^ Sunshine as a cause, 19 Suprarenal extract, 1 14 Surgical treatment, 1 14 Swallowing, difficult, 82 Sweden, cases in, 49 Symptoms, y8 Synonyms, 9 Systemic treatment, 116 T Taste, involvement of, 86 Tea-drinking, influence of, 48 Temperature during an attack, 8 3 Theory, idiosyncrasy, 60 local, 17, 62 neurotic, 57 pollen, 40 uric-acid, 64 Thornwaldt, 64 Timaeus, 18 INDEX. 151 Time of occurrence, 72 Tomatoes as a cause, 37 Toxin as a cause, 13 Treatment, 102 preliminary local, 106 prophylactic, hygienic, and systemic, 116 surgical, 114 Trosseau, 39 Types, 78 according to duration, 77 U United States, distribution of cases in the, 50 Uric-acid theory, 64 Van Helmont, 18 Vasomotor control, nasal, 88 susceptibility, theory of, 59 Vibrios in the discharges, 22 Vogel,36 Voice, changes in, S^ W Walshe, 21, 44, 50 Watermelons as a cause, 37 Watson, 21 Sir Thomas, ^ White Mountains, immunity in, 51 Wilson, J. C. , 44 Wyman, Morrill, 23, 48, 50, 51, 53,54,55 HUMPHREY'S MANUAL OF NURSING. MEDICAL AND SURGICAL. A complete Text-Book for Nurses, including General Anatomy and Physiology, Management of the Sick-Room, Appliances used in Sick-Room, Antiseptic Treatment, Bandaging, Cooking for Invalids, etc., etc. Sixteenth Edition. With 79 Illustrations. BY LAWRENCE HUMPHREY, M.A., M.D. 12MO. CLOTH. PRICE $1.00. St. Joseph's Hospital, Seventeenth and Girard Avenue, Philadelphia, March 15, 1893. Messrs. P. Blakhton, Son f subjects adopted by the author is excellent." THE BEST GENERAL TEXT-BOOK. BOOKS ON MASSAGE. Massage and the Original Swedish Move- ments. Illustrated. And Their Application to Various Diseases of the Body. A Manual for Students, Nurses, and Physicians. By Kurre W. 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" The task of abridging the subject of materia medica for the use of trained nurses is far from an easy one, as it is necessary to use good judgment in putting in what it would be well and helpful for her to know without leaving out the necessary part. Moreover, to arrange the subject in a practical and sys- tematic manner for the purpose of teaching and ready reference is a difficult matter. The author of this book has succeeded admirably in doing this, and the work is sure to be in great demand by nurses." A NEW EDITION, JUST READY. GOULD'S POCKET MEDICAL LEXICON. 21,000 MEDICAL WORDS PRONOUNCED AND DEFINED. A Pronouncing Lexicon of Medical "Words Specially Adapted for Nurses, Including Many Useful Tables and a Dose List. BY GEORGE M. GOULD, M.D.. Author of "An Illustrated Dictionary of Medi- cine , Biology , and Allied Sciences," "The Student's Medical Dictionary," etc. Pocket Size. 522 Pages. Gilt Edges, Full Morocco. Price $1.00; with a Thumb Index, $1.25. OVER 90,000 COPIES OF GOULD'S DICTIONARIES HAVE BEEN SOLD. " Gould's Dictionary, Pocket Edition, is the most complete and convenient I have seen." — Marion E. Smith, Head Nurse, Philadelphia Hospital, Phila. " The Pocket Dictionary is a little gem." — L. J. Gross, Head Nurse , Bujfalo General Hospital. " I have examined Gould's Dictionary, and consider it the best dictionary in a small compass that I have seen. The price, too, is most reasonable I shall recommend it to all our nurses." — F. Hutcheso7i, Head Nurse, Flower Mission Training School for Nurses, Indianapolis , bid. " 1 shall certainly have the nurses each send for a copy of the dictionary. It is just what they need, and is a nice size to carry." — Harriet Sutherland, Head Nurse, Margaret Pillsbury Hospital, Concord, N. H. &g=* Every nurse should have a copy of this little book in order to intelligently pursue her studies and to thoroughly understand the physician's directions. It furnishes a vast amount of informa- tion not to be obtained in the regular text-books. Catalogue No. 8. June, 1899. CLASSIFIED SUBJECT CATALOGUE OF MEDICAL BOOKS AND Books on Medicine, Dentistry, Pharmacy, Chemistry, Hygiene, Etc., Etc., PUBLISHED BY P. Blakistons Son & Co., Medical Publishers and Booksellers, 1012 WALNUT STREET, PHILADELPHIA. SPECIAL NOTE. — The prices given in this catalogue are absolutely net, no discount will be allowed retail purchasers under any consideration. This rule has been established in order that everyone will be treated alike, a general reduction in former prices having been made to meet previous retail dis- counts. Upon receipt of the advertised price any book will be forwarded by mail or express, all charges prepaid. We keep a large stock of Miscellaneous Books, not on this catalogue, relating to Medicine and Allied Sciences, pub- lished in this country and abroad. Inquiries in regard to prices, date of edition, etc., will receive prompt attention. Special Catalogues of Books on Pharmacy, Dentistry, Chemistry, Hygiene, and Nursing will be sent free upon application. J^-SEE NEXT PAGE FOR SUBJECT INDEX. Gould's Dictionaries, Page 8. SUBJECT INDEX. 4&~ Any books not on this Catalogue we will furnish a price for upon application. SUBJECT PAGE Alimentary Canal (see Surgeiy) 19 Anatomy (see Miscellaneous).. 14 Anesthetics 3 Autopsies (see Pathology) 16 Bacteriology (see Pathology) 16 Bandaging (see Surgery) 19 Brain 4 Chemistry 4 Children, Diseases of 6 Clinical Charts 6 Compends 22, 23 Consumption (see Lungs) 11 Dentistry 7 Diagnosis 17 Diagrams (see Anatomy, page 3, and Obstetrics, page 16). Dictionaries . 8 Diet and Food (see Miscella- neous) 14 Dissectors 3 Domestic Medicine 10 Ear 8 Electricity 9 Emergencies (see Surgery) 19 Eye 9 Fevers 9 Gout .... 10 Gynecology 21 Hay Fever 20 Heart 10 Histology 10 Hospitals (see Hygiene) 11 Hygiene 11 Insanity 4 Latin, Medical (see Miscella- neous and Pharmacy) 14, 16 Lungs 12 Massage 12 Materia Medica 12 Medical Jurisprudence 13 Microscopy 13 M ilk Analy sis (see Chemistry) 4 Miscellaneous 14 Nervous Diseases 14 SUBJECT. PAGE Nose 20 Nursing 15 Obstetrics 16 Ophthalmology 9 Osteology (see Anatomy) 3 Pathology 16 Pharmacy 16 Physical Diagnosis 17 Physical Training (see Miscel- laneous) 14 Physiology 18 Poisons (see Toxicology) 13 Popular Medicine 10 Practice of Medicine 18 Prescription Books 18 Railroad Injuries (see Nervous Diseases) 14 Refraction (see Eye) 9 Rheumatism 10 Sanitary Science 11 Skin 19 Spectacles (see Eye) 9 Spine (see Nervous Diseases) 14 Stomach (see Miscellaneous)... 14 Students' Compends 22, 23 Surgery and Surgical Dis- eases 19 Syphilis 21 Technological Books 4 Temperature Charts 6 Therapeutics 12 Throat 20 Toxicology ■ 13 Tumors (see Surgery) 19 U S. Pharmacopoeia 16 Urinary Organs 20 Urine 20 Venereal Diseases 21 Veterinary Medicine 21 Visiting Lists, Physicians'. {Send for Special Circular.) Water Analysis (see Chemis- try) 4 Women, Diseases ot 21 ' The prices as given in this Catalogue are net. Cloth binding, unless otherwise specified. No discount can be allowed under any circumstances. Any book will be sent, postpaid, upon receipt of advertised price. SUBJECT CATALOGUE OF MEDICAL BOOKS. 3 J$&~ All books are bound in cloth, unless otherwise speci- fied. All prices are net. ANATOMY. MORRIS. Text-Book ot Anatomy. 2d Edition. Revised and Enlarged. 790 Illustrations, 214 of which are printed in coiors. Just Ready. Cloth, $6.00; Leather, $7.00 ; Half Russia, $8.00 " Taken as a whole, we have no hesitation in according very high praise to this work. It will rank, we believe, with the leading Anato- mies. The illustrations are handsome and the printing is good." — Boston Medical and Surgical Journal. Handsome Circular of Morris, with sample pages and colored illus- trations, will be sent free to any address. BROOMELL. Anatomy and Histology of the Human Mouth and Teeth. 284 Illustrations. #4 50 DEAVER. Surgical Anatomy. A Treatise on Human Anatomy in its Application to Medicine and Surgery. With about 400 very Handsome full-page Illustrations Engraved from Original Drawings made by special Artists from dissections prepared for the purpose. Three Volumes. Royal Square Octavo Cloth, $2 . co ; Half Morocco or Sheep, $24 00; Half Russia, $27.00 ECKLEY. Practical Anatomy. A Manual for the use of Students in the Dissecting Room. 1 ased upon Morris' Text-Book of Anatomy. With over 20J Illustrations. Nearly Ready. GORDINIER. Anatomy of the Central Nervous System. With many Illustrations, the majority of which are original. Just Ready. Cloth, $6.00; Sheep, $7 00 HEATH. Practical Anatomy. 8th Edition. 300 Illus. $4.25 HOLDEN. Anatomy. A Manual of the Dissections of the Human Body. Carefully Revised by A. Hewson, m.d., Demonstrator of Anatomy, Jefferson Medical College, Philadelphia. 311 Illustrations. 7th Edition. In Press. HOLDEN. Human Osteology. Comprising a Description of the Bones, with Colored Delineations of the Attachments of the Muscles. The General and Microscopical Structure of Bone and its Develop- ment. With Lithographic Plates and numerous Illus. 8th Ed. $5.25 HOLDEN. Landmarks. Medical and Surgical. 4th Ed. $1 00 MACALISTER. Human Anatomy. Systematic and Topograph- ical, including the Embryology, Histology, and Morphology of Man. With Special Reference to the Requirements of Practical Surgery and Medicine. 816 Illustrations. Cloth, $5.00; Leather, #6.00 MARSHALL. Physiological Diagrams. Life Size, Colored. Eleven Life-Size Diagrams (each seven feet by three feet seven inches). Designed for Demonstration before the Class. In Sheets, Unmounted, $40.00 ; Backed with Muslin and Mounted on Rollers, $60.00; Ditto, Spring Rollers, in Handsome Walnut Wall Map Case, $100.00; Single Plates — Sheets. $5.00; Mounted, $7.50. Explanatory Key, .50. Descriptive circular upon application. POTTER. Compend of Anatomy, Including Visceral Anatomy. 6th Ed. 16 Lith. Plates and 117 other Illus. .80; Interleaved, $1.25 WILSON. Human Anatomy, nth Edition. 429 Illustrations, 26 Colored Plates, and a Glossary of Terms. $5.00 WINDLE. Surface Anatomy and Landmarks. Colored and other Illustrations. $1.00 SUBJECT CATALOGUE BRAIN AND INSANITY. BLACKBURN. A Manual of Autopsies. Designed for the Use of Hospitals for the Insane and other Public Institutions. Ten full- page Plates and other Illustrations. $1.25 GORDINIER. The Gross and Minute Anatomy of the Central Nervous System. With many full-page and other Illustrations. 8vo. Just Ready. Cloth, $6.00 ; Sheep, $7.00 GO WERS. Diagnosis of Diseases of the Brain. 2d Edition. Illustrated. $*-5o HORSLEY. The Brain and Spinal Cord. The Structure and Functions of. Numerous Illustrations. $ 2 -5o LEWIS (BEVAN). Mental Diseases. A Text Book Having Special Reference to the Pathological Aspects of Insanity- 26 Litho- graphic Plates and other Illustrations. 2d Ed. Just Ready. $7.00 MANN. Manual of Psychological Medicine and Allied Nervous Diseases. Their Diagnosis, Pathology, Prognosis, and Treatment, including their Medico- Legal Aspects ; with chapter on Expert Testimony, and an Abstract of the Laws Relating to the Insane in all the States of the Union. Illustrated. $3.00 REGIS. Mental Medicine. Authorized Translation by H. M. Bannister, m.d. $2.00 STEARNS. Mental Diseases. Designed especially for Medical Students and General Practitioners. With a Digest of Laws of the various States Relating to Care of Insane. Illustrated. Cloth, $2.75; Sheep, $3.25 TUKE. Dictionary of Psychological Medicine. Giving the Definition, Etymology, and Symptoms of the Terms used in Medical Psychology, with the Symptoms, Pathology, and Treatment of the Recognized Forms of Mental Disorders, together with the Law of Lunacy in Great Britain and Ireland. Two volumes. #10.00 WOOD, H. C. Brain and Overwork. .40 CHEMISTRY AND TECHNOLOGY. Special Catalogue of Chemical Books sent free upon application. ALLEN. Commercial Organic Analysis. A Treatise on the Modes of Assaying the Various Organic Chemicals and Products Employed in the Arts, Manufactures, Medicine, etc., with concise methods for the Detection of Impurities, Adulterations, etc. 8vo. Vol. I. Alcohols, Neutral Alcoholic Derivatives, etc., Ethers, Veg- etable Acids, Starch, Sugars, etc. 3d Edition, by Henry Leff- mann, M. d. fust Ready. * #4-5o Vol. II, Part I. Fixed Oils and Fats, Glycerol, Explosives, etc. 3d Edition, by Henry Leffmann, m. d. Just Ready. $350 Vol. II, Part II. Hydrocarbons, Mineral Oils, Phenols, etc. 3d Edition, by Henry Leffmann, m.d. Nearly Ready. Vol. Ill, Part I. Acid Derivatives of Phenols, Aromatic Acids, Tannins, Dyes and Coloring Matters. 3d Edition. In Preparation. Vol. Ill, Part II. The Amines, Hydrazines and Derivatives, Pyridine Bases. The Antipyretics, etc. Vegetable Alkaloids, Tea, Coffee, Cocoa, etc. 8vo. 2d Edition. $4 .50 Vol. Ill, Part III. Vegetable Alkaloids, Non-Basic Vegetable Bitter Principles. Animal Bases, Animal Acids, Cyanogen Compounds, etc. 2d Edition, 8vo. #4-5° Vol. IV. The Proteids and Albuminous Principles. 2d Edition. Just Ready. $4- 5° Appendix Volume. Containing a Review of the whole work with many new methods, etc. In Preparation. MEDICAL BOOKS. ALLEN. Chemical Analysis of Albuminous and Diabetic Urine. Illustrated. $225 BARTLEY. Medical and Pharmaceutical Chemistry. A Text-Book for Medical, Dental, and Pharmaceutical Students. With Illustrations. Glossary, and Complete Index. 5th Edition, carefully Revised. Just Ready. Cloth, £3.00 ; Sheep, $3.50 BARTLEY. Clinical Chemistry. The Examination of Feces, Saliva, Gastric Juice, Milk, and Urine. Just Ready. $1.00 BLOXAM. Chemistry, Inorganic and Organic. With Experi- ments. 8th Ed., Revised 281 Engravings Clo.,$4.25; Lea., $5.25 CALDWELL. Elements of Qualitative and Quantitative Chemical Analysis. 3d Edition, Revised. $i-5° CAMERON. Oils and Varnishes. With Illustrations. $2.25 CAMERON. Soap and Candles. 54 Illustrations. $2.00 GARDNER. The Brewer, Distiller, and Wine Manufac- turer. Illustrated. $i-5o GARDNER. Bleaching, Dyeing, and Calico Printing. $1.50 GROVES AND THORP. Chemical Technology. The Appli- cation of Chemistry to the Arts and Manufactures. Vol. I. Fuel and Its Applications. 607 Illustrations and 4 Plates. Cloth, $5.00; Half Morocco, $6.50 Vol.11. Lighting. Illustrated. Cloth, $4. 00; Half Morocco, $5.50 Vol. III. Lighting — Continued. In Press. HOLLAND. The Urine, the Gastric Contents, the Common Poisons, and the Milk. Memoranda, Chemical and Microscopi- cal, for Laboratory Use. 5th Ed Illustrated and interleaved, $1.00 LEFFMANN. Compend of Medical Chemistry, Inorganic and Organic. Including Urine Analysis. 4th Edition, Rewritten and Revised. .80; Interleaved, $1.25 LEFFMANN. Analysis of Milk and Milk Products. Arranged to Suit the Needs of Analytical Chemists, Dairymen, and Milk Inspec- tors. 2d Edition. Enlarged, Illustrated. $1 .25 LEFFMANN. Water Analysis. Illustrated. 4th Edition. $1.25 LEFFMANN. Structural Formulae. Including 180 Structural and Stereo-Chemical Formulae. i2mo. Interleaved. $1.00 MUTER. Practical and Analytical Chemistry. 2d American from the Eighth English Edition. Revised to meet the requirements ol American Medical Colleges by Claude C. Hamilton, m.d. 56 Illustrations, fust Ready. $i-z$ OETTEL. Exercises in Electro-Chemistry. Illustrated. .75 OETTEL. Electro-Chemical Experiments. Illustrated. .75 RICHTER. Inorganic Chemistry. 4th American, from 6th Ger- man Edition. Authorized translation by Edgar F. Smith, m.a., ph.d. 89 Illustrations and a Colored Plate. $i-75 RICHTER. Organic Chemistry. 3d American Edition. Trans, from the 8th German by Edgar F. Smith. Illustrated. 2 Volumes. Vol. I. Aliphatic Series. 625 Pages. Just Ready. $3.00 Vol.11. Aromatic Series. In Preparation. SMITH. Electro-Chemical Analysis. 2d Edition, Revised. 28 Illustrations. $1 25 SMITH AND KELLER. Experiments. Arranged for Students in General Chemistry. 3d Edition. Illustrated. .60 STAMMER. Chemical Problems. With Answers. 50 SUBJECT CATALOGUE. SUTTON. Volumetric Analysis. A Systematic Handbook for the Quantitative Estimation of Chemical Substances by Measure, Applied to Liquids, Solids, and Gases. 7th Edition, Revised. 112 Illustrations. $4.50 SYMONDS. Manual of Chemistry, for Medical Students. 2d Edition. $2.00 TRAUBE. Physico-Chemical Methods. Translated by Hardin. 97 Illustrations. Just Ready. $1.50 ULZER AND FRAENKEL. Chemical Technical Analysis. Translated by Fleck. Illustrated. Just Ready. $1.25 WOODY. Essentials of Chemistry and Urinalysis. 4th Edition. Illustrated. In Press. *** Special Catalogue of Books on Chemistry free upon application . CHILDREN. CAUTLIE. Feeding of Infants and Young Children by Nat- ural and Artificial Methods. $2.00 HALE. On the Management of Children. .50 HATFIELD. Compend of Diseases of Children. With a Colored Plate. 2d Edition. .80; Interleaved, $1. 25 MEIGS. Infant Feeding and Milk Analysis. The Examination of Human and Cow's Milk, Cream, Condensed Milk, etc., and Directions as to the Diet of Young Infants. .50 POWER. Surgical Diseases of Children and their Treat- ment by Modern Methods. Illustrated. $2.50 STARR. The Digestive Organs in Childhood. The Diseases of the Digestive Organs in Infancy and Childhood. With Chapters on the Investigation of Disease and the Management of Children. 2d Edition, Enlarged. Illustrated by two Colored Plates and numerous Wood Engravings. $2.00 STARR. Hygiene of the Nursery. Including the General Regi- men and Feeding of Infants and Children, and the Domestic Manage- ment of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. $1.00 TAYLOR AND WELLS. The Diseases of Children. Illus- trated. A New Manual. 746 pages. Just Ready. $4.00 CLINICAL CHARTS. GRIFFITH. Graphic Clinical Chart for Recording Temper- ature, Respiration, Pulse, Day of Disease, Date, Age, Sex, Occupation, Name, etc. Printed in three colors. Sample copies free. Put up in loose packages of fifty, .50. Price to Hospitals, 500 copies, $4.00 ; 1000 copies, $7.50. With name of Hospital printed on, .50 extra. KEEN'S CLINICAL CHARTS. Seven Outline Drawings of the Body, on which may be marked the Course of Disease, Fractures, Operations, etc. Pads of fifty, £i.co. Each Drawing may also be had separately, twenty-five to pad, 25 cents. MEDICAL BOOKS. SCHREINER. Diet Lists. Arranged in the form of a chart. With Pamphlets of Specimen Dietaries. Pads of 50. .75 DENTISTRY. Special Catalogue of Dental Books sent free upon application. BARRETT. Dental Surgery for General Practitioners and Students of Medicine and Dentistry. Extraction of Teeth, etc. 3d Edition. Illustrated. Nearly Ready. BLODGETT. Dental Pathology. By Albert N. Blodgktt, m.d., late Professor of Pathology and Therapeutics, Boston Dental College. 33 Illustrations. $ I - 2 S BROOMELL. Anatomy and Histology of the Human Mouth and Teeth. 284 Handsome Illustrations. Just Ready. $4-50 FLAGG. Plastics and Plastic Filling, as Pertaining to the Filling of Cavities in Teeth of all Grades of Structure. 4th Edition. $4.00 FILLEBROWN. A Text-Book of Operative Dentistry. Written by invitation of the National Association of Dental Facul- ties. Illustrated. $2.25 GORGAS. Dental Medicine. A Manual of Materia Medica and Therapeutics. 6th Edition, Revised. Cloth, $4.00; Sheep, $5.00 HARRIS. Principles and Practice of Dentistry. Including Anatomy, Physiology, Pathology, Therapeutics, Dental Surgery, and Mechanism. 13th Edition. Revised by F. J. S. Gorgas, m.d., d.d.s. 1250 Illustrations. Cloth, $6.00; Leather, $7.00 HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 6th Edition. Revised and Enlarged by Fer- dinand F. S. Gorgas, m d., d.d.5. Cloth, $5.00; Leather, $6.00 HEATH. Injuries and Diseases of the Jaws. 4th Edition 187 Illustrations. #4-5o HEATH. Lecture^ on Certain Diseases of the Jaws. 64 Illustrations. Boards, .50 RICHARDSON. Mechanical Dentistry. 7th Edition. Thor- oughly Revised and Enlarged by Dr. Geo. W. Warren. 691 Illus- trations. Cloth, $5.00; Leather, $6.00 SEWELL. Dental Surgery. Including Special Anatomy and Surgery. 3d Edition, with 200 Illustrations. $2.00 SMITH. Dental Metallurgy. Illustrated. $1.75 TAFT. Index of Dental Periodical Literature. £2.00 TALBOT. Irregularities of the Teeth and Their Treatment. 2d Edition. 234 Illustrations. ^3.00 TOMES. Dental Anatomy. Human and Comparative. 263 Illus- trations. 5th Edition. Just Ready. $4.00 TOMES. Dental Surgery. 4th Edition. 289 Illustrations. #4.00 WARREN. Compend of Dental Pathology and Dental Medi- cine. With a Chapter on Emergencies. 3d Edition. Illustrated. Just Ready. .80; Interleaved, $1.25 WARREN. Dental Prosthesis and Metallurgy. 129 Ills. $1.25 WHITE. The Mouth and Teeth. Illustrated. .40 *** Special Catalogue of Dental Books free upon application. SUBJECT CATALOOUF. DICTIONARIES. GOULD. The Illustrated Dictionary of Medicine, Biology, and Allied Sciences. Being an Exhaustive Lexicon of Medicine and those Sciences Collateral to it: Biology (Zoology and Botany), Chemistry, Dentistry, Parmacology, Microscopy, etc., with many useful Tables and numerous fine Illustrations. 1633 pages. 4th Ed. Sheep or Half Dark Green Leather, $10.00; Thumb Index, $11.00 Half Russia, Thumb Index, $12.00 GOULD. The Medical Student's Dictionary. Including all the Words and Phrases Generally Used in Medicine, with their Proper Pronunciation and Definition, Based on Recent Medical Literature. With Tables of the Bacilli, Micrococci, Mineral Springs, etc., of the Arteries, Muscles, Nerves, Ganglia, and Plexuses, etc. 10th Edition. Rewritten and Enlarged. Completely reset from new type. 700 pp. Hall Dark Leather, $3.25 ; Half Morocco, Thumb Index, $4.00 GOULD. The Pocket Pronouncing Medical Lexicon. (21,000 Medical Words Pronounced and Defined.) Containing all the Words, their Definition and Pronunciation, that the Medical, Dental, or Pharmaceutical Student Generally Comes in Contact With; also Elaborate Tables of the Arteries, Muscles, Nerves, Bacilli, etc., etc., a Dose List in both English and Metric System, etc., Arranged in a Most Convenient Form for Reference and Memorizing. A new Edi- tion, enlarged by 200 pages. Just Ready. Full Limp Leather, Gilt Edges, $i.on ; Thumb Index, $1.25 90,000 Copies of Gould's Dictionaries Have Been Sold. *** Sample Pages and Illustrations and Descriptive Circulars of Gould's Dictionaries sent free upon application. HARRIS. Dictionary of Dentistry. Including Definitions of Such Words and Phrases of the Collateral Sciences as Pertain to the Art and Practice of Dentistry. 6th Edition. Revised and Enlarged by Ferdinand J. S. Gorgas, m.d., d.d.s. Cloth, $5.00; Leather, $6 00 LONGLEY. Pocket Medical Dictionary. With an Appendix, containing Poisons and their Antidotes, Abbreviations used in Pre- scriptions, etc. Cloth, .75; Tucks and Pocket, $1.00 MAXWELL. Terminologia Medica Polyglotta. By Dr. Theodore Maxwell, Assisted by Others. $3.00 The object of. this work is to assist the medical men ot any nationality in reading medical literature written in a language not their own. Each term is usually given in seven languages, viz. : English, French, German, Italian, Spanish, Russian, and Latin. TREVES AND LANG. German-English Medical Dictionary. Half Russia, $3.25 EAR (see also Throat and Nose). BURNETT. Hearing and How to Keep It. Illustrated .40 DALBY. Diseases and Injuries of the Ear. 4th Edition. 38 Wood Engravings and 8 Colored Plates. $2.50 HOVELL. Diseases of the Ear and Naso-Pharynx. Includ- ing Anatomy and Physiology of ihe Organ, together with the Treat- ment of the Affections of the Nose and Pharynx which Conduce to Aural Disease. 122 Illustrations. 2d Edition. Preparing. PRITCHARD. Diseases of the Ear. 3d Edition, Enlarged. Many Illustrations and Formulae $i-5° WOAKES. Deafness, Giddiness, and Noises in the Head. 4th Edition. Illustrated. $2.00 MEDICAL BOOKS. ELECTRICITY. BIGELOW. Plain Talks on Medical Electricity and Bat- teries. With a Therapeutic Index and a Glossary. 43 Illustra- tions. 2d Edition. $1.00 JONES. Medical Electricity. 3d Edition. 112 Illus. In Press. MASON. Electricity ; Its Medical and Surgical Uses. Numer- ous Illustrations. .75 EYE. A Special Circular of Books on the Eye sent free upon application. ARLT. Diseases of the Eye. Clinical Studies on Diseases of the Eye. Translation by Lyman Ware. m.d. Illustrated. $1-25 DONDERS. The Nature and Consequences of Anomalies of Refraction. With Portrait and other Illustrations. 8vo. Just Ready. Half Morocco, $1.25 FICK. Diseases of the Eye and Ophthalmoscopy. Trans- lated by A. B. Hale, m. d. 157 Illustrations, many of which are in colors, and a glossary. Cloth, $4.50 ; Sheep, #5.50 GOULD AND PYLE. Compend of Diseases of the Eye and Refraction. Including Treatment and Operations, and a Section on Local Therapeutics. With Formulae, Useful Tables, a Glossary, and in Illustrations, several of which are in colors. Cloth, .80; Interleaved, $1.25 GOWERS. Medical Ophthalmoscopy. A Manual and Atlas with Colored Autotype and Lithographic Plates and Wood-cuts, Comprising Original Illustrations of the Changes of the Eye in Dis- eases of the Brain, Kidney, etc. 3d Edition. $4.00 HARLAN. Eyesight, and How to Care for It. Illus. .40 HARTRIDGE. Refraction. 104 Illustrations and Test Types. 9th Edition, Enlarged. Just Ready. $1.50 HARTRIDGE. On the Ophthalmoscope. 3d Edition. With 4 Colored Plates and 68 Wood-cuts. $!-5o HANSELL AND REBER. Muscular Anomalies of the Eye. Illustrated. Just Ready. $1.50 HANSELL AND BELL. Clinical Ophthalmology. Colored Plate of Normal Fundus and 120 Illustrations. #1.50 JESSOP. Manual of Ophthalmic Surgery and Medicine. Col- ored Plates and 108 other Illustrations. Just Ready. Cloth, $3 00 MORTON. Refraction of the Eye. Its Diagnosis and the Cor- rection of its Errors. With Chapter on Keratoscopy and Test Types. 6th Edition. $1.00 OHLEMANN. Ocular Therapeutics. Authorized Translation, and Edited by Dr. Charles A. Oliver. Just Ready. #!-75 PHILLIPS. Spectacles and Eyeglasses. Their Prescription and Adjustment. 2d Edition. 49 Illustrations. #1.00 SWANZY. Diseases of the Eye and Their Treatment. 6th Edition, Revised and Enlarged. 158 Illustrations, 1 Plain Plate, and a Zephyr Test Card. $3.00 THORINGTON. Retinoscopy. 3d Edition. Illustrated. $1.00 'WALKER. Students' Aid in Ophthalmology. Colored Plate and 40 other Illustrations and Glossary. $ 1 5o 10 SUBJECT CATALOGUE. FEVERS. COLLIE. On Fevers. Their History, Etiology, Diagnosis, Prog- nosis, and Treatment. Colored Plates. $2.00 GOODALL AND WASHBOURN. Fevers and Their Treat- ment. Illustrated. #3.00 GOUT AND RHEUMATISM. DUCKWORTH. A Treatise on Gout. With Chromo-lithographs and Engravings. Cloth, $6.00 GARROD. On Rheumatism. A Treatise on Rheumatism and Rheumatic Arthritis. Cloth, $5.00 HAIG. Causation of Disease by Uric Acid. A Contribution to the Pathology of High Arterial Tension, Headache, Epilepsy, Gout, Rheumatism, Diabetes, Bright's Disease, etc. 4th Edition. $3.00 HEALTH AND DOMESTIC MEDI- CINE (see also Hygiene and Nursing). BUCKLEY. The Skin in Health and Disease. Illus. ,40 BURNETT. Hearing and How to Keep It. Illustrated. .40 COHEN. The Throat and Voice. Illustrated. .40 DULLES. Emergencies. 4th Edition. Illustrated. $1.00 HARLAN. Eyesight and How to Care for It. Illustrated. .40 HARTSHORNE. Our Homes. Illustrated. .40 OSGOOD. The Winter and its Dangers. .40 PACKARD. Sea Air and Bathing. .40 PARKES. The Elements of Health. $1.25 RICHARDSON. Long Life and How to Reach It. .40 WESTLAND. The Wife and Mother. $1.50 WHITE. The Mouth and Teeth. Illustrated. .40 WILSON. The Summer and its Diseases. .40 WOOD. Brain Work and Overwork. .40 STARR. Hygiene of the Nursery. 5th Edition. £1.00 CANFIELD. Hygiene of the Sick-Room. $1.25 . HEART. SANSOM. Diseases of the Heart. The Diagnosis and Pathology of Diseases of the Heart and Thoracic Aorta. With Plates and other Illustrations. $6.00 HISTOLOGY. STIRLING. Outlines of Practical Histology. 368 Illustrations. 2d Edition, Revised and Enlarged. With new Illustrations. $2.00 STOHR. Histology and Microscopical Anatomy. Translated and Edited by A. Schaper, m.d., Harvard Medical School. Second Edition, Revised and Enlarged. 292 Illustrations. $3.00 MEDICAL BOOKS. HYGIENE AND WATER ANALYSIS. Special Catalogue of Books on Hygiene sent free upon application. CANFIELD. Hygiene of the Sick-Room. A Book for Nurses and Others. Being a Brief Consideration of Asepsis, Antisepsis, Dis- infection, Bacteriology, Immunity, Heating, Ventilation, etc. $1.25 COPLIN AND BEVAN. Practical Hygiene. A Complete American Text-Book. 138 Illustrations. New Ed. Preparing. KENWOOD. Public Health Laboratory Work. 116 Illustra- tions and 3 Plates. $2.00 LEFFMANN. Examination of Water for Sanitary and Technical Purposes. 4th Edition. Illustrated. $ J -25 LEFFMANN. Analysis of Milk and Milk Products. Illus- trated. $ x -25 LINCOLN. School and Industrial Hygiene. .40 MACDONALD. Microscopical Examinations of Water and Air. 25 Lithographic Plates, Reference Tables, etc. 2d Ed. $2.50 McNEILL. The Prevention of Epidemics and the Construc- tion and Management of Isolation Hospitals. Numerous Plans and Illustrations. $3-5o NOTTER AND FIRTH. The Theory and Practice of Hygiene. (Being the 9th Edition of Parkes' Practical Hygiene, rewritten and brought up to date.) 10 Plates and 135 other Illustrations. 1034 pages. 8vo. $7.00 PARKES. Hygiene and Public Health. By Louis C. Parkes, m.d. 5th Edition. Enlarged. Illustrated. $2.50 PARKES. Popular Hygiene. The Elements of Health. A Book for Lay Readers. Illustrated. #1.25 STARR. The Hygiene of the Nursery. Including the General Regimen and Feeding of Infants and Children, and the Domestic Management of the Ordinary Emergencies of Early Life, Massage, etc. 6th Edition. 25 Illustrations. $1.00 STEVENSON AND MURPHY. A Treatise on Hygiene. By Various Authors. In Three Octave Volumes. Illustrated. Vol. I, $6.00; Vol. II, $6.00; Vol. Ill, $5.00 *** Each Volume sold separately. Special Circular upon application. WILSON. Hand-Book of Hygiene and Sanitary Science. Wiih Illustrations. 8th Edition. $300 WEYL. Sanitary Relations of the Coal-Tar Colors. 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Illustrated. .80; Interleaved, $1.25 FULLERTON. Nursing in Abdominal Surgery and Diseases of Women 2d Edition. 70 Illustrations. I1.50 SUBJECT CATALOGUE. COMPENDS. From The Southern Clinic. " We know of no series of books issued by any house that so fully meets our approval as these ? Quiz-Compends?. They are well ar- ranged, full, and concise, and are really the best line of text-books that could be found for either student or practitioner." BLAKISTON'S ? QUIZ-COMPENDS? The Best Series of Manuals for the Use of Students. Price of each, Cloth, .80. Interleaved, for taking Notes, $1.25. 4GJ* These Compends are based on the most popular text-books and the lectures of prominent professors, and are kept constantly re- vised, so that they may thoroughly represent the present state of the subjects upon which they treat. &§~ The authors have had large experience as Quiz-Masters and attaches of colleges, and are well acquainted with the wants of students. JfcS" They are arranged in the most approved form, thorough and concise, containing over 600 fine illustrations, inserted wherever they could be used to advantage. 4^* Can be used by students of any college. &$~ They contain information nowhere else collected in such a condensed, practical shape. Illustrated Circular free. No. 1. POTTER. HUMAN ANATOMY. Sixth Revised and Enlarged Edition. Including Visceral Anatomy. Can be used with either Morris's or Gray's Anatomy. 117 Illustrations and 16 Lithographic Plates of Nerves and Arteries, with Explanatory Tables, etc. By Samuel O. L. Potter, m.d., Professor of the Practice of Medicine, Cooper Medical College, San Francisco ; late A. A. Surgeon, U. S. Army. No. 2. HUGHES. PRACTICE OF MEDICINE. Part I. Sixth Edition, Enlarged and Improved. By Daniel E. Hughes, m.d., Physician-in-Chief, Philadelphia Hospital, late Demonstrator ot Clinical Medicine, Jefferson Medical College, Phila. No. 3. HUGHES. PRACTICE OF MEDICINE. Part II. Sixth Edition, Revised and Improved. Same author as No. 2. No. 4. BRUBAKER. PHYSIOLOGY. Ninth Edition, with new Illustrations and a table of Physiological Constants. Enlarged and Revised. By A. P. Brubaker, m.d., Professor of Physiology and General Pathology in the Pennsylvania College of Dental Surgery ; Adjunct Professor of Physiology, Jefferson Medical College, Philadelphia, etc. No. 5. LANDIS. OBSTETRICS. Sixth Edition. By Henry G. Landis, m.d. Revised and Edited by Wm. H. Wells, m.d., Instructor of Obstetrics, Jefferson Medical College, Philadelphia. Enlarged. 47 Illustrations. No. 6. POTTER. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Sixth Revised Edition (U. S. P. 1890). By Samuel O. L. Potter, m.d., Professor of Practice, Cooper Medical College, San Francisco ; late A. A. Sur- geon, U. S. Army. MEDICAL BOOKS. 23 PQUIZ-COMPENDS ?— Continued. No. 7. WELLS. GYNECOLOGY. By Wm. H. Wells, m.d., Instructor of Obstetrics, JeffersoD College, Philadelphia. 150 Illus- trations. No. 8. GOULD AND PYLE. DISEASES OF THE EYE AND REFRACTION. A New Book. Including Treatment and Surgery, and a Section on Local Therapeutics. By George M. Gould, m.d., and W. L. Pyle, m.d. With Formulae, Glossary, Tables, and 111 Illustrations, several of which are Colored. No. 9. HORWITZ. SURGERY, Minor Surgery, and Bandag- ing. Fifth Edition, Enlarged and Improved. By Orvillb Horwitz, b. s., m.d. , Clinical Professor of Genito-Urinary Surgery and Venereal Diseases in Jefferson Medical College ; Surgeon to Philadelphia Hospital, etc. With 98 Formulae and 71 Illustrations. No. 10. LEFFMANN. MEDICAL CHEMISTRY. Fourth Edition. Including Urinalysis, Animal Chemistry, Chemistry of Milk, Blood, Tissues, the Secretions, etc. By Henry Leffmann, m.d., Professor of Chemistry in Pennsylvania College of Dental Surgery and in the Woman's Medical College, Philadelphia. No. 11. STEWART. PHARMACY. Fifth Edition. Based upon Prof. Remington's Text-Book of Pharmacy. By F. E. Stewart, m.d., ph.g., late Quiz-Master in Pharmacy and Chemistry, Phila- delphia College of Pharmacy ; Lecturer at Jefferson Medical College. Carefully revised in accordance with the new U. S. P. No. 12. BALLOU. VETERINARY ANATOMY AND PHY- SIOLOGY. Illustrated. By Wm. R. Ballou, m.d., Professor of Equine Anatomy at New York College of Veterinary Surgeons ; Physician to Bellevue Dispensary, etc. 29 graphic Illustrations. No. 13. WARREN. DENTAL PATHOLOGY AND DEN- TAL MEDICINE. Third Edition, Illustrated. Containing a Section on Emergencies. By Geo. W. Warren, dd.s., Chief ot Clinical Staff, Pennsylvania College of Dental Surgery. No. 14. HATFIELD. DISEASES OF CHILDREN. Second Edition. Colored Plate. By Marcus P. Hatfield, Profes- sor of Diseases of Children, Chicago Medical College. No. 15. HALL. GENERAL PATHOLOGY AND MORBID ANATOMY. 91 Illustrations. By H. Newberry Hall, ph.g., m.d., late Professor of Pathology, Chicago Post-Graduate Medi- cal School. Second Edition. No. 16. DISEASES OF THE SKIN. By Jay T. Schamberg, m.d., Instructor in Skin Diseases, Philadelphia Polyclinic. With 99 handsome Illustrations. Price, each, Cloth, .80. Interleaved, for taking Notes, $1,25. In preparing, revising, and improving Blakiston's ? Quiz-Com- pends ? the particular wants of the student have always been kept in mind. Careful attention has been given to the construction of each sentence, and while the books will be found to contain an immense amount of knowledge in small space, they will likewise be found easy reading ; there is no stilted repetition of words ; the style is clear, lucid, and dis- tinct. The arrangement of subjects is systematic and thorough ; there is a reason for every word. They contain over 600 illustrations. Morris' Anatomy Second Edition, Revised and Enlarged. 790 Illustrations, of which many are in Colors. Royal Octavo. Cloth, $6.00 ; Sheep, $7.00 ; Half Russia, $8.00. 'Erotn. The Medical Record, New York. " The reproach that the English language can boast of no treatise on anatomy deserving to be ranked with the masterly works of Henle, Luschka, Hyrtl, and others, is fast losing its force. During the past few years several works of great merit have appeared, and among these Morris's "Anatomy " seems destined to take first place in disputing the palm in anatomical fields with the German classics. The nomencla- ture, arrangement, and entire general character resemble strongly those of the above-mentioned handbooks, while in the beauty and profuseness of its illustrations it surpasses them. . . . The ever-growing popularity of the book with teachers and students is an index of its value, and it may safely be recommended to all interested." *** Handsome Descriptive Circular, with Sample Pages and Colored Illustrations, will be sent free upon application. JUl*