ability and safety, when used with the proper precautions. After the applications, the nasal passages should be carefully cleansed with some mild antiseptic solution (as Dobell's), and the eschars removed as soon as possible, especially where the cauterization has been made on a surface that nearly approaches the opposite wall of the naris. I frequently give iron and quinine internally after an application.

The most important rule to be observed in carrying out the treatment is to be thorough. So long as any sensitive area remains, the patient is not cured. The main treatment must be carried out between the seasons for the attacks, and I prefer to begin as soon as the attack is over. It is important, also, to see the patient during the next season, as it is impossible to discover all the sensitive areas until the season arrives. The remaining sensitive spots are then to be cauterized.

I have seen the most gratifying results by following this method, though I have one case on record where the patient was cured without the use of any cautery, but only by simple applications of astringents and general treatment.

In cauterizing, my method is to destroy as little tissue as possible. The cavernous tissue is a normal one, and the process of engorgement and swelling which occurs in the varying states of the temperature and of the atmosphere is a normal one, and, in proper limits, preservative to the health. To attempt, then, anything like its entire extirpation, even if that were possible, except where it is clearly required, is unwise.

At the same time, constitutional measures, chiefly addressed to the nervous system, are generally, though not always, indicated. The drugs I most frequently use are the valerianates of iron, quinine and zinc, arsenic or hydrobromic acid (Gardner's syrup). In all cases of debility the general health must be built up by the usual tonics. Each case has to be made a separate study. If the treatment be properly carried out, the prognosis for a radical cure is decidedly good. Had time permitted, I should have illustrated this paper by more cases from my own practice, but, as it does not, I must be content to present these observations as a résumé of my work up to date.

HAY FEVER.

ASTHME DE FOIN.

HEU-ASTHMA.

BY ISRAEL P. KLINGENSMITH, M. D.,

Of Blairsville, Pa.

At no time in the world's history, since the day Dr. John Bostock, in 1819, presented the first formal paper on this subject to the London Medico-Chirurgical Society, have more eager scientific workers been in the field in the pursuit of knowledge and its practical application to disease In no subject can you find a better proof of this fact, than in the disease now under consideration. I will not occupy your valuable time by giving a detailed history of the symptoms, course and duration of the disease, but will confine myself to submitting to your consideration the results of my investigations so far as they bear broadly and directly upon the method of treatment I propose to advocate. In very few diseases do we find such a diversity of opinion in regard to the cause, as in hay fever. Bostock attributed it to heat, while his contemporaries differed on

this point. Since that period many theories have been advanced, but considerable diversity of opinion exists even at the present time. Until within the last five or six years, inquiry has been directed to the investigation of the exciting cause of the attack, and the predisposing or more important causes of the disease have been overlooked. Most of the literature upon the subject of hay fever, hay asthma, autumnal catarrh, or by whatever name it may be designated, is devoted to the extraneous or exciting causes of the malady in question, and numerous remedies, which serve simply to divert the mind of the sufferer, without resulting in any practical benefit, are suggested. Each patient coming under our observation should be subjected to a thorough rhinoscopic examination, allowing all fine-spun theories and extrinsic causes to take care of themselves. To Dr. W. H. Daly, of Pittsburgh, Pa., belongs the honor of first calling the attention of the profession to the important part which diseases of the naso-pharyngeal cavities play in the production of hay fever, who, in a paper read before the American Laryngological Association, in May, 1881, showed that the exciting causes of the disease are innocuous in those cases in which disease of the naso-pharyngeal cavities does not exist, and proved further, from clinical evidence, that the disease is a curable one, by removing the intrinsic local cause and restoring the parts to a normal condition. The succeeding year Dr. John O. Roe, of Rochester, N. Y., read a paper before the Medical Society of the State of New York, practically corroborating the investigations of Dr. Daly. In 1884, Dr. Hack, of Freiburg, Germany, a special laborer in this field, made known the result of his investigations, also holding the view that pathological conditions of the nasal mucous membrane play the most important part in the production of the disease. The investigations of other observers substantially affirm the same theory. In reference to my own personal experience, I will simply say, that of the thirteen cases that have come under my personal observation, in each one of them has disease of the nose or naso-pharynx existed. The numerous exciting and extrinsic causes which have been supposed to bring on attacks of hay fever would occupy several pages, and I will therefore simply refer to a few of the more prominent. In those cases where local irritability or any deviation from the normal condition of the nasal cavities exists, an attack may be brought on by almost any exciting agent, an odor or vapor, dust, light or heat, the pollen of flowers or grasses. In some cases I have known the attack to date from a severe cold. In support of the view that almost any agent may produce a paroxysm, I will mention the case of a patient who is so susceptible to the influence of ipecac and Dover's Powder as to be able to produce an attack at any time by their inhalation. More recently the case of a young man, a miller by profession, has come under my observation, in whom the paroxysms are produced by the inhalation of small particles of flour while following his occupation. During the past few years great advances have been made in bringing the treatment of hay fever within the radius of a more scientific standpoint, based upon a nearer approach to a rational pathology of the disease. Based upon my own investigations, as already stated, I am compelled to adopt the view that in each case of hay fever does a condition of the nasal or naso-pharyngeal cavities exist varying from the normal. When we view these facts and theories with a view of carrying out a rational plan of treatment, we should in every case make a thorough anterior and posterior rhinoscopic examination. In a great majority of cases a chronic nasal catarrh exists, with sensitive areas not confined to any particular portion of the mucous membrane. In other cases I find a true hypertrophic condition either anterior or posterior, or both. Polypi or deflections of the nasal septum may also act as a prominent factor in the propagation of the disease. Fully believing that hay fever is due to local irritatives brought in contact with a diseased condition of the nasal mucous membrane, I am therefore compelled to call attention to the radical treatment as the chief mode of relieving or curing the disease. This plan in the hands of Daly, Roe and others, beside myself, has been followed by the most

lasting and signal success. When nasal polypi exist I remove them by means of Allen's nasal polypus forceps or Jarvis' snare, always making sure to thoroughly cauterize the base with the galvano-cautery or glacial acetic acid. If large hypertrophies, either anterior or posterior, are found, they should be removed by means of the Jarvis snare. Smaller hypertrophies and sensitive areas I destroy by using the galvano-cautery, chromic acid or glacial acetic acid, giving preference in the order named. All surgeons have favorite instruments and appliances, giving preference to some, while discarding others. The battery in use by me now for several years was devised by Dr. Seiler, of Philadelphia, and fulfills every indication required by the operator. The current can be controlled by the foot of the operator, thus giving him the use of both hands, and the temperature of the knife can be regulated to any degree of intensity. In using the galvano-cautery I introduce an Allen's hard-rubber nasal speculum, through which the electrode is placed on the spot to be cauterized, after which it is brought to a cherry-red heat; great care must be taken to have the electrode at the proper temperature when applied to the tissue about to be destroyed, as, when too hot, free hemorrhage may result, and when too cold great pain will be produced. As a certain amount of inflammation is necessarily produced, not too large an incision should be made at any one sitting. My preference is given to the galvano-cautery, since it can be brought more fully under the control of the operator than chromic acid, and is less painful than glacial acetic acid. The pain produced, as a rule, is but momentary, except occasionally in persons of a highly nervous organization, when I apply a four per cent. solution of hydrochlorate of cocaine, either by means of the atomizer or an aluminium probe enveloped in cotton. The operation should be repeated about once a week, or as often as admissible, being governed by the degrees of inflammation produced, until all hypertrophies and sensitive spots are destroyed. During the intervals of the operations the patient is directed to use an insufflation, such as Dobell's, or some other alkaline solution. In the application of chromic or acetic acid I use the Bosworth's application. The treatment should be commenced about two months before the accession of the attack, and the nasal cavities should be restored to as nearly a normal condition as possible, relieving them of all hypertrophic conditions and sensitive areas. While I am of the opinion that treatment should be commenced several weeks prior to the expected attack, yet in no case do I desist from operating even when the disease is at its height. In several such cases have I known the intensity and duration of the paroxysms to be shortened. Of the thirteen cases upon which my observations are based, nine have been practically cured, and four, in whom the treatment could not be carried out perfectly, were greatly benefited. In conclusion, permit me to say, that I have tried to outline, in as brief a manner as possible, the essential points of this method of treatment, but, as will be observed, much pertaining to the minor details has been necessarily omitted which is essential to a proper understanding of the subject.

DISCUSSION.

Mr. LENNOX BROWNE, of London, Eng., expressed his general assent with the views expressed by the authors of the papers, and made a few remarks on details. He remarked the papers contained nothing new. He considered in some cases the pollen an exciting cause, in others the sole cause; the former generally held. He thought that often good might be done by gentle methods, as vaseline protection, etc. Cocaine, if long continued, might prove injurious. In using the galvano-cautery a dull-red heat is best, and least likely to produce hemorrhage.

Prof. E. FLETCHER INGALS, of Chicago, thought nothing more could be said upon the two papers than had already been said by Mr. Lennox Browne, but he was interested in what the last speaker had said regarding the heat of the electrode. He thought if the naris was first treated with vaseline or fluid cosmoline, it made little

difference whether a red heat or a white heat were employed, provided the electric currents were not cut off before the electrode was removed from the tissues, excepting in cases of deep incisions, in which hemorrhage was very likely to follow the use of an electrode at a white heat.

Prof. W. E. CASSELBERRY, of Chicago, said—I am convinced that hay fever is primarily occasioned by local pathological lesions within the nose or naso-pharynx being acted upon by an irritant. It follows that thorough removal of the pathological condition will radically cure the disease, but it is essential that its cauterization be thorough, that all sensitive or diseased areas be removed. Many having been but partially treated and but partially or not at all relieved, speak adversely of the method, and unfairly so. Since the cautery cannot be applied oftener than once a week, to operate thoroughly requires not two months, the time mentioned, but often four, five, six or even more months; and it should be thoroughly understood with the patient, when treatment is commenced, that it is to be carried to a finish.

Dr. STUCKY, of Lexington, Ky., thinks the majority of cases require general treatment. He summarizes as follows: In thirty-four cases the majority were neurasthenic, and required constitutional treatment. He never uses the galvanocautery at white heat; has better results from dull red. If the sensitive area is hypertrophied tissue, he uses chromic acid. He usually prefers glacial acetic acid, applied every second or third day, and destroys every sensitive area, no matter how many or the location. His after treatment is soothing and protective, and consists of daily applications of vaseline. Three months was the longest time he had to treat

a case.

Dr. JOHN N. MACKENZIE, of Baltimore, Md., remarked, in regard to Dr. Thomas' reference to the sensitive area located by him some years ago, that he now maintained that the posterior end of the inferior or turbinated bones and septum were the sole spots from which pathological reflexes are obtained. Pathological reflexes may be gotten from any portion of the membrane, but the area indicated by him he believed to be the most sensitive. Dr. M. then related his experiments with artificial flowers, to counteract the criticism of Prof. Bosworth and Dr. Thomas. Gave a brief résumé of his theory of hay fever and allied affections and criticised the various theories hitherto advanced.

Dr. J. SOLIS-COHEN, of Philadelphia, Pa., believed that much of the difficulty in understanding hay fever was due to too much specialism. In pre-rhinoscopic days the general physician knew nothing of the condition of the nose, and recent workers in rhinoscopic fields seem to know too little of general medicine. His own opinion closely coincided with that of the preceding speaker, but he would attribute the constitutional conditions of the sympathetic portion of the nervous system, and the resultant conditions of its vasomotor terminals in the vessels of the nasal mucous membrane to a lack of equilibrium in the nervous strength of the patient. This might be due to hereditary conditions or to acquired ones, whether from deprivations, from excesses or from overwork. Hence, given a patient in this condition, the action of an irritant to which he is very sensitive will precipitate the attack of hay fever. If neurasthenic, his nervous system requires tonic treatment. If neurasthenic, it requires sedatives. This condition of system must be treated for long periods after the subsidence of an attack in order to get the patient into such a condition of his nervous system as would render him less susceptible to the irritation when the period for his hay fever recurs. This might take a very long time, and require the hay fever subject to be under the observation of his physician during the entire interval.

Dr. RIDGE, of Camden, New Jersey, believed, from his own experience, that hay fever was of sympathetic origin.

Dr. VON KLEIN, of Dayton, Ohio, did not believe that the nose suffered from the constitution, but rather the constitution suffered from the nose. not a neurosis.

Hay fever is

Dr. MASON, of Bloomington, Ill., related his personal experience of having his hay fever renewed on a railway train, after a supposed cold of two years' duration. The cause appeared to be smoke from the locomotive. He cited two cases in which it was undoubtedly caused by mental impressions—one in which a child suffered by imitation of her father's symptoms during several years, to be relieved when her father was cured; in the other case, a physician had aggravated symptoms of hay fever after hearing a paper read on the subject. Coughs are often produced by hyperæsthenic areas in the naso-pharynx, which may be cured by using glacial acetic

acid.

Dr. FRANK O. STOCKTON, of Chicago, Ill., remarked-To my mind the causes of so-called hay fever are three; namely, constitutional, local and external; and the fault with gentlemen who follow this specialty is that they seek to find one cause alone for this disease.

Dr. S. S. KOSER, of Williamsport, Pa., objects to the theory of the neurotic origin of the disease, from the fact that many of these people are attacked on a given day of the month in every year, and to conclude it is entirely constitutional is, to my mind, illogical. I know a lake far up in the Alleghanies to which persons resorted with perfect immunity until this year, and during this season they have suffered, though always heretofore they escaped.

Dr. R. H. THOMAS, in closing the discussion, said that his object in preparing his paper had been largely to show that the theories which bring forward neurasthenia, or nasal obstruction, or the existence in the healthy upper air passages of areas of special sensation whose irritation would produce such reflex phenomena as asthma, etc., were not supported by clinical facts. He was surprised to hear it asserted that only two views existed as to the etiology of hay fever; the view she had referred to were all held, and, in fact, the discussion which was now closing had of itself been sufficient to bring out a great variety of opinion on the subject. His assertion that the occurrence of an attack of hay fever in a patient who had previously suffered from the disease, by the sight of an artificial rose, had no bearing on the power of a real rose to produce an attack, had been called in question. He thought his position a sound one. The instance merely proved the power of imagination. He had read of cases where individuals supposed to be very ill of hydrophobia had recovered at once on being told the dog that had bitten them was not rabid. All the symptoms in such cases were due to imagination, yet few doubted the existence of genuine hydrophobia. One of the gentlemen who had taken part in the discussion had spoken as if the results obtained by him (Dr. Thomas) in endeavoring to locate the sensitive areas had been carried out during the hay fever season, when all parts of the nasal passages were hypersensitive.

The paper had distinctly said that the observations had been exclusively carried on between the seasons. The result of these observations, as far as they had gone, told against the theories that were based on the special sensitiveness of any particular parts of the naso-pharyngeal tract.

In regard to the use of the term "idiosyncrasy," he did not consider that the