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HAY FEVER 
 
 And its Successful Treatment by Superfidiai library. 
 
 Organic Alteration of the Nasal 
 Mucous Membrane. 
 
 AN ESSAY READ BEFORE THE PHILADELPHIA LAKYNGOLOGIL AL SOCIETY, 
 APRIL 24, 1885. 
 
 CHARLES B. SAJOUS, M.D., 
 
 Instructor of Rhinology and Laryngology in the Post-Gradiiate and Spring Courses, 
 Jefferson Medical College; President of the Philadelphia Laryngologlcal 
 Society; Fellow of the American Laryngological Association ; Cor- 
 responding Member of Royal Society of Belgium and of 
 the Medical Society of Warsaw (Russia), etc. etc. 
 
 ILLUSTRATED WITH THIRTEEN WOOD ENGRAVINGS. 
 
 PHILADELPHIA: 
 F. A. DAVIS, Att'y, PUBLISHER, 
 
 No. 1217 Filbert Street, 
 1885. 
 

 
 Entered according to Act of Congress in the year 1885, by 
 
 F. A. DAVIS, Att'v, 
 
 In the Office of the Librarian of Congress at Washington. 
 
 All rights reserved. 
 
PREFACE. 
 
 The compavatively large number of cases 
 of so-called "hay fever" treated by tlie author 
 within tlie last four years, having enabled him 
 to note the value of certain practical points 
 in connection with its successful treatment, 
 he respectfully dedicates this little volume, 
 in which they are collected, to his profes- 
 sional brethren, hoping that the suggestions 
 which it contains will be of service to them. 
 
 Philadelphia, May 1st, 1885! 
 
HAY FEVER 
 
 AND ITS SUCCESSFUL TREATMENT BY SUPERFICIAL 
 ORGANIC ALTERATION OF THE NASAL MUCOUS 
 MEMBRANE. 
 
 HAY FEVER, also known under the names 
 of hay asthma, rose cold, summer ca- 
 tarrh, autumnal catarrh, peach cold, rag-weed 
 fever, idiosyncratic coryza, June cold, etc., etc., 
 may be defined to be an affection characterized 
 hy periodical attacks of acute rhinitis, complicated 
 sometimes with asthma, occurring as a result of 
 a special susceptihility on the part of certain in- 
 dividuals to become influenced hy certain sub- 
 stances, owing to a deranged state of the nerve- 
 centres. It manifests itself only provided the 
 mucous membrane primarily affected in the course 
 of an attack is in a state of hyjJercBstliesia, and 
 ivhen the irritating substances are present in the 
 atmosphere. 
 
 The symptoms of hay fever may be limited 
 1 
 
2 HAY FEVER. 
 
 to those of a mild coryza and last only a few 
 days, or they may assume such violent form 
 as to cause the patient great suffering. The 
 attack usually begins vpith a sensation of itch- 
 ing in the nostrils, which soon becomes very 
 intense, and causes violent and prolonged 
 sneezing. A pricking, burning sensation in 
 the inner canthi, followed by profuse lachry- 
 mation, may accompany this symptom, or con- 
 stitute the first evidence of the access. Very 
 soon the nose becomes occluded through tur- 
 gescence of its lining membrane, and respi- 
 ration through it is practically impossible. A 
 watery discharge appears, which soon becomes 
 very profuse, and its strongly alkaline char- 
 acter causes it to irritate the nostrils and the 
 upper lip, sufficiently sometimes to give rise 
 to painful excoriations. Violent sneezing may 
 begin at once, or occur when the watery dis- 
 chai'ge begins to trickle down along the intra- 
 nasal walls, and the patient makes futile 
 efforts by immoderate use of the handkerchief, 
 to clear the nose of the cause of irritation 
 
HAY FEVER. 3 
 
 and obstruction. Chilly sensations, frontal 
 headache, tinnitus aurium, loss of smell and 
 taste, violent itching at the roof of the mouth, 
 pain over the bridge of the nose, facial pru- 
 ritus, and general symptoms, such as slight 
 pyrexia, urticaria, disordered stomach and 
 flatulence, are among the possible accompani- 
 ments of this stage. 
 
 As the affection progresses, the nasal secre- 
 tion assumes more of a mucoid character, be- 
 coming at times muco-purulent. The con- 
 junctiva may become greatly inflamed, and 
 photophobia and marked chemosis follow, 
 rendering, in some cases, a prolonged stay in 
 a dark room necessary. 
 
 Premonitory symptoms are present in a 
 small proportion of the cases, especially in 
 those of long standing. Frontal headache, 
 general malaise, chilly sensations, and itching 
 at the roof of the mouth and eyes, occurring 
 from two days to two weeks before the attack, 
 are among those most frequently complained 
 of. Asthma may occur as a complication of 
 
4 HAY FEVEK. 
 
 the affection, or as its only symptom. In the 
 former case, it may present itself any time 
 during the course of the disease ; in the latter, 
 it manifests itself suddenly as soon as the irri- 
 tating agent is inhaled. In the majority of 
 eases, however, it begins a few days after the 
 primary nasal symptoms have shown them- 
 selves, and as soon as these become marked. 
 A feeling of soreness in the region of the 
 pharynx is experienced, followed shortly after 
 by hoarseness, slight cough, scanty expectora- 
 tion, and a feeling of constriction about the 
 chest, and the asthma comes on insidiously, 
 gradually increasing in intensity' as the disease 
 advances. It is generally much worse at night 
 than in the day time, relief coming on with 
 the dawn of day. In some ceases it ceases 
 with the nasal symptoms, or soon after ; in 
 others, and this forms the majority, it lasts 
 much longer, prolonging the suffering of the 
 patient over weeks and oven months. 
 
 The affection presents itself twice in the 
 year in some individuals, while in others it 
 
HAY FEVER. 5 
 
 either occurs in May or June, or during the 
 last two weeks of August or early in Sep- 
 tember. The summer variety, generally called 
 " rose cold," is not as a general thing as severe 
 as the autumnal variety or "hay fever," and 
 does not last as long. Subjects of the disease 
 can in almost every instance predict the exact 
 day, and sometimes the hour, of the onset of 
 the expected attack. 
 
 Etiology. — Since 1819, when Bostock first 
 described the affection, of which he was him- 
 self a sufferer, numerous theoiies have been 
 advanced to explain the peculiar periodicity 
 of the affection and its cause. As early as 
 1839, EUiotson pointed to pollen as the prob- 
 able cause of the affection, while twenty years 
 later, Abbott Smith, Pirrie, and Moore, as- 
 cribed its active cause to the emanations of 
 plants. In 1869, Helmholtz suggested that 
 the disease was due to the presence of vibrios 
 in the nasal cavities, which remained dormant 
 in the winter months, and became active 
 through the effect of the summer heat. Twelve 
 
 1* 
 
6 HAY FEVER. 
 
 years ago, Blackley, of Manchester, reiterated 
 EUiotson's opinion, that the affection was 
 caused by the pollen of flowers and grasses, 
 and demonstrated by a series of experiments 
 the power of these substances to bring on an 
 attack. In 1876, Beard, of New York, pub- 
 lished a monograph, in which he showed that 
 a large number of the sufferers were of a ner- 
 vous temperament, and that the exciting 
 agents were very numerous, and not limited 
 to the pollen of flowers and plants, as was for- 
 merly thought. In 1882, Daly,* of Pittsburgh, 
 published a paper, in which he attributed the 
 annually recurring attacks " to local chronic 
 disease, upon which the exciting cause acts 
 with effect," adding that "the parts should be 
 put in order, and thereby enable them to with- 
 stand the exciting influence of the next re- 
 curring crop of bacteria." In 1883, Roe, t of 
 Eochester, N. Y., advocated the same theory, 
 and stated " that hyper sesthesia is associated 
 
 * Archives of Laryngology, Vol. II. 
 
 t N. Y. Med. Jour., May 12th and 19th, 1883. 
 
HAY FEVER. / 
 
 with, or occasioned by, a diseased condition, 
 either latent or active, of the naso-pharyngeal 
 mucous membrane," and "that the removal 
 of the diseased tissue in the nasal passages 
 removes the susceptibility of the individual to 
 future attacks of hay fever." Later in the 
 same year, unacquainted with the papers of 
 Daly and Roe, I published an essay,* in which 
 I advanced " that hay fever was due to an 
 idiosyncrasy on the part of certain individuals 
 to become affected by certain emanations," 
 that " organic' alteration of the surface of the 
 nasal mucous membrane altered its sensibility, 
 and destroyed what morbid irritability might 
 have attended the nervous filaments distributed 
 over it," and, furthermore, " that hypertrophies 
 of the nasal membrane increased its irrita- 
 bility, and the intensity of the symptoms." In 
 January, 1884, Harrison Allen, of Philadel- 
 phia, in an article on the treatment of hay 
 fever,t attributed the disease to permanent or 
 
 *Med. and Surg. Reporter, December 22, 1883. 
 f Am. Jour, of Med. Sciences, January, 1884. 
 
» HAY FEVEK. 
 
 temporary obstruction of one or both cham- 
 bers, and advanced the opinion that by over- 
 coming this obstruction by the usual methods, 
 a cure could be effected. In June of the same, 
 year, J. N. Mackenzie,* of Baltimore, suggested 
 the term " Coryza vaso-motoria periodica," on 
 the ground that "the disease is essentially a 
 coryza, showing in most cases a decided ten- 
 dency to periodic recurrence, and dependent 
 upon some functional derangement of the 
 nerve-centres as its predisposing cause." 
 
 In summing up these various theories and 
 judging of their value by the practical resiilts 
 attained, it becomes evident that an important 
 step has been made in our knowledge of the 
 affection, by the recognition of the important 
 part played by the nasal mucous membrane 
 in the history of the affection. 
 
 As advocated by myself in my first paper, t 
 three conditions are essential factors in the 
 production of an access of hay fever : Firstly, 
 
 *N. Y. Med. Record, July 19, 1SS4. 
 t Op. cit. 
 
HAY FEVEK. 9 
 
 an external irrHant; secondly, a predisposition 
 on the part of the system to become hifluenced hy 
 this irritant; and, thirdly, a vulnerable or sensi- 
 tive area through tvhlch the system becomes lufla- 
 eiieed by the irritant. This theory, it seems to 
 me, not only conciliates the demonstrated and 
 irrefutable portions of the three principal views 
 advanced as to the etiology of the affection : irri- 
 tation by pollen and the emanations of plants, 
 etc. (EUiotson, Smith, Moore, Blackley, Mor- 
 rell Mackenzie) ; the neurotic element in the 
 production of the affection (Beard, J. N. Mac- 
 kenzie) ; and local disease of the naso-pharymt 
 (Daly, Roe, Hack, * and Allen) ; but it is ex- 
 empt from the fallacies presented by each of 
 these views taken separately. 
 
 As to the first condition, the elaborate and 
 persevering researches of Blackley and the 
 observations of Beard on the subject, demon- 
 strate conclusively to my mind the power of 
 certain substances to produce an access in 
 individuals susceptible to their influence. 
 
 *Wien. Med. Wochen., August, 1883. 
 
10 HAY FEVEK. 
 
 Blackley caused, by applying to the mucous 
 membrane of certain individuals, less than 
 i Jijth of a grain of the substance to which they 
 were sensitive, all the symptoms which pre- 
 sented themselves during the course of an 
 ordinary attack, while in his own person the 
 simple inhalation of pollen produced all the 
 characteristic symptoms. Cases are frequently 
 met with, in which the mere approach of cer- 
 tain substances is sufficient to bring on a 
 paroxysm even out of the usual time, while 
 the removal of the subject from the irritating 
 agent in the midst of the yearly period, and 
 while an access is present, will cause the latter 
 to cease. Again, as demonstrated by Dr. Black- 
 ley,* the attacks can be greatly modified, if not 
 prevented, by placing in the nostrils some con- 
 trivance which will purify the inhaled air of its 
 irritating substances, showing plainly the power 
 of the latter to induce a paroxysm. 
 
 Another evidence that pollen is a factor in 
 the etiology of the affection, is the regularity 
 
 * London Lancet, August 27, 1881. 
 
HAY FEVEE. 11 
 
 with whicli the majority of plants undergo the 
 different phases of their growth, each recurring 
 the same day every year, and in some the same 
 hour. This not only explains the periodicity 
 of the accesses, but the precision with which 
 most sufferers can prophesy the onset of their 
 attacks. 
 
 The mere irritating property of a substance 
 is evidently not the only factor in the produc- 
 tion of the attack. This is exemplified by the 
 fact that one subject may be affected by a 
 certain substance which will in another be 
 absolutely harmless. A gentleman under my 
 care, for instance, although a great sufferer 
 yeaiiy almost since birth, can take rag-weed 
 between his hands, crush it and inhale its ema- 
 nations without experiencing the least ill-effect ; 
 and yet this plant is recognized as one of the 
 greatest enemies of hay fever sufferers. In 
 another ease, the pollen of roses alone produces 
 the manifestations and all others are absolutely 
 ineffective. Subjects are seldom found, how- 
 ever, in whom a single agent will give rise to 
 
12 HAY FEVEK. 
 
 an access, tlie majority being influenced by 
 several substances, with, one in particular as 
 the most active. Among the substances which 
 are considered as causes of the affection, are 
 dust, the pollen of plants in general, grasses 
 and cereals, the emanations of certain flowers 
 and perfumes, fruit, animals, sulphur, smoke, 
 cinders, etc., while a small proportion of the 
 sufferers ascribe the origin of their paroxysms 
 to summer heat, sunlight, exposure to di'aughts 
 of air, etc. 
 
 Dust, as observed by Beard, is the most 
 common irritant, a fact which apparently weak- 
 ens the pollen theory, but whicli in reality 
 strengthens it. If we consider that pollen, like 
 any other substance, is subject to the laws of 
 gravitation, and that its very light weight is 
 a provision of nature to insure its far as well 
 as near dissemination, and its final fall to the 
 ground; and that immense quantities of it are 
 wafted through the atmosphere, subject to the 
 mechanical displacement of its currents, — we 
 can understand that the dust of the earth is 
 
HAY FEVEK. 13 
 
 but a part of what is generally considered as 
 dust, the principal of its other constituents 
 being an agglomeration of the pollen of all 
 the plants in the surrounding country, and 
 sometimes of those of distant districts, as well 
 as all ponderable agents capable of acting as 
 irritants. It can thus be seen that dust is the 
 most frequent cause of hay fever, because it 
 is the common carrier of all the obnoxious 
 agents. The universal distribution of dust in 
 cities as well as in the country, furnishes a 
 ready explanation for the prevalence of the 
 disease in all regions excepting in those which 
 contaminated dust, on account of its weight, 
 can only reach in very small quantities or not 
 at all, such as high altitudes, the open sea, etc. 
 The entire or partial freedom which the 
 so-called "hay fever resorts" enjoy is due to 
 this fact. Very few, if any, of these places, 
 however, enjoy absolute immunity. A strong 
 wind, which, having passed over fields and 
 become impregnated with their pollen or with 
 the dust of a country road, is liable to bring 
 
14 HAY FEVEK. 
 
 one, a few, or many of the noxious agents 
 within reach of the susceptible individual and 
 cause in him the manifestations of the disease, 
 if one or any of the substances to which he is 
 sensitive are present. It thus frequently hap- 
 pens that only one or two persons among many 
 are influenced. That some resorts insure im- 
 munity to some people and not to others, is 
 explained by the fact that this immunity de- 
 pends upon the presence within a certain 
 radius, of the irritating substance. If a plant 
 to which a subject is sensitive happens to grow 
 within that certain radius, the location will 
 naturally be unfavorable to him. 
 
 It has been frequently demonstrated that 
 hay fever can be induced at any time of the 
 year, and in regions where the disease never 
 presents itself primarily, as in high altitudes 
 or on the high seas, by the accidental presence 
 of an irritant, brought there as a part of the 
 dust covering clothes, parcels, etc. Wyman* 
 and his son were thus attacked, while spending 
 
 Morrell Mackenzie. Hay Fever, etc., London, 1881. 
 
HAY FEVEK. 15 
 
 the hay fevei* period at a resort where they 
 enjoyed absolute immunity, when a package 
 of rag-weed plant was opened there. The par- 
 oxysms brought on by handling dusty olgects 
 which have been so for some time, or those 
 occurring at sea several days after leaving 
 port, are thus accounted for. 
 
 The extreme degree of irritation occasioned 
 in most sufferers by riding in steam-cars or in 
 a carriage only during the hay fever period, 
 and due to the quantity of dust shaken up by 
 the vehicle, adds further evidence in favor of 
 the fact that uncontaminated dust is not a 
 factor in the production of an access, since 
 dust is present the year round and the mem- 
 brane is not irritated at all times of the year; 
 but that that dust becomes an active irritant 
 in this affection only when contaminated with 
 the substances to which the subject is suscep- 
 tible. This contamination only taking place 
 at a certain period each year, dust is only an 
 irritant during this period; in other words, 
 it only acts as a cause of the affection at cer- 
 
16 HAY FEVEB. 
 
 tain seasons, because it is only during those 
 seasons that the pollen in its active state is 
 present in it. 
 
 As to the second condition essential to the 
 production of an access, a predisposition on 
 the part of the system to become inordinately 
 influenced by certain substances, a close exami- 
 nation into the family history of the patient, 
 and into his own since birth, will elicit much 
 evidence towards proving that there is a sys- 
 temic dyscrasia, through which the resisting 
 power to certain diseases is diminished. In 
 a list of forty cases now before me, I find 
 that thirty-five per cent, have near relatives 
 who present a clear history of hay fever or 
 rose cold, and that forty-two per cent, have 
 asthmatic relatives. It is thus shown that in 
 a majority of cases (the percentage of family 
 histories presenting either asthma or hay fever 
 being fifty-five per cent.), there is an inherited 
 predisposition to the affection. 
 
 Going further and taking a glimpse into 
 the early life of these cases, I find that forty 
 
HAY FEVEK. 17 
 
 per cent, have had six of the diseases incident 
 to childhood, that sixty per cent, have had at 
 least five, eighty-two per cent, at least four, 
 ninety per cent, at least three, and that none 
 were exempt, while one only had but one of 
 them. These diseases were whooping-cough, 
 mea.sles, mumps, chicken-pox, scarlet fever, and 
 croup. This singular proclivity to so many of 
 these affections is certainly not a mere coin- 
 cidence, the number of cases being too large 
 to render such a proposition tenable. It seems 
 to indicate a predisposing state of the system 
 to all affections in which a neurotic element 
 plays an important part, evidenced in the ex- 
 anthemata by the eruption, in whooping-cough 
 by the abnormal irritability of the pharynx, 
 larynx and trachea, in the mumps by the 
 marked tendency to reflex metastasis, and in 
 croup by the spasmodic element inducing the 
 dyspnoeal paroxysms. That an inherent liabil- 
 ity to these diseases must be present is further 
 demonstrated by a comparison with the his- 
 tories of forty persons not subject to hay 
 
 2* 
 
18 HAY FEVEE. 
 
 fever, in whom n'mety-hvo of the so-called dis- 
 eases of childhood had occui'red, representing 
 an average of tivo and iivo-teiiths per cent., 
 while in hay fever sufferers, one hundred and 
 eif/hty-iune children's diseases had presented 
 themselves, an average of four and seven-tenths 
 per cent. 
 
 Still more curious in this connection, is the 
 fact that of the forty cases upon which these 
 remarks are based, all have had udtoopinfj- 
 cough. Of all the affections cited, this is with- 
 out doubt that in which the neurotic element 
 is most marked. Both the respiratory and 
 sympathetic nerve-centres are disturbed in its 
 early stages, while the pneumogastric becomes 
 implicated before the local causes of excita- 
 tion are established, doubtless indicating a 
 primary nervous element as a predisposing 
 cause, while the universal presence of the 
 affection in forty cases of hay fever, certainly 
 suggests a common systemic cause for both 
 diseases — an ahnorinalhi sensitive nerre-eentre 
 ■upon ivhicli tin: element of contagion or the irri- 
 tant acts ivith effect. 
 
HAY FEVER. 19 
 
 In further support of the theory of sys- 
 temic predisposition, I will enumerate a few 
 of the cases presenting the greatest evidences 
 of heredity, in which this' heredity seems to 
 exert some influence in the production of the 
 so-called children's diseases : 
 
 Case No. 14, whose mother, uncle, and 
 brother have hay fever, while his grandfather 
 and first cousin have spasmodic asthma, has 
 had the six diseases of childhood. No. 13's 
 two brothers have hay fever; his mother and 
 sister asthma; has had five (croup omitted). 
 No. 15, great gi'andfather and first cousin, 
 hay fever; grandaunt asthma; has had five 
 (scarlatina omitted). No. 31, father, hay fever; 
 great grandfather, two great uncles, asthma; 
 six diseases, while all those presenting a 
 direct maternal or paternal heredity of hay 
 fever and rose cold, with one exception, have 
 had the six diseases. 
 
 Accepting the theory as conclusive, as far 
 as the question of heredity as a factor in the 
 causation is concerned, a new problem sug- 
 
20 HAY FEVER. 
 
 gests itself : In those cases in which no evi- 
 dence of heredity appears, what is the origin 
 of the inordinate irritability? In other words, 
 the possibility of an inherited liability being 
 demonstrated, can it be acquired independently 
 of heredity? 
 
 Of the nineteen cases in which no hereditary 
 history could be traced, fftij-five per cent, have 
 had six of the children's di.seases enumerated, 
 while ei(jlitij-two ]}er cent, have had at least 
 fortr., one case only having had but two. In 
 the three cases which presented two or three 
 diseases, I find that in one case, there is a 
 subsequent history of typhoid fever, malarial 
 fever, and bronchitis, all occurring before the 
 first access of hay fever; in a second, mi- 
 graine was a frequent visitor before the hay 
 fever presented itself; while in the third, a 
 child, the whooping-cough and chicken-pox 
 had been very severe. 
 
 Taking the rationale of these sixteen cases, 
 with a history of at least four diseases, all of 
 them presenting marked neurotic element, is it 
 
HAY FEVEK. 21 
 
 not probable that a functional derangement of 
 the nerve-centres resulted, and that they were 
 thus rendered more sensitive to influences 
 which, had they been in their normal state, 
 would not have affected them f Again, is it 
 not reasonable to suppose that in the fii'st ex- 
 ception, the subsequent diseases accomplished 
 what the others had begun, debilitating still 
 more the nerve-centres, which had already been 
 weakened to a certain degree by the early dis- 
 eases ? In the second exception, a neurotic 
 element is apparent in the character of the 
 primary disease, while in the third the viru- 
 lence of the diseases must certainly have borne 
 its influence on the secondary results. 
 
 Evidence to show that a neurotic element is 
 an essential part of the affection, can easily be 
 adduced by merely investigating the origin of 
 the premonitory symptoms which are present 
 in a number of cases. It would certainly be 
 very difficult to explain their presence, were 
 we to overlook the implication of the nervous 
 system. Among the forty cases described, may 
 
22 HAY PEVEE. 
 
 be found one young man who complains of " a 
 tickling in the roof of the mouth" one week 
 before the onset; another patient speaks of 
 dull pains in the head and back two weeks 
 before ; still another experiences chills and 
 shuddering ten days before the attack, etc., 
 while a large proportion complain of palpebral 
 pruritus from two to ten days before the nasal 
 symptoms begin. 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 influ- 
 enced ? At this juncture a question naturally 
 suggests itself: What then induces these pre- 
 monitory symptoms 1 Again referring to the 
 cases, we will find that premonitory symptoms 
 only present themselves in cases in which hay 
 fever is of some years' standing. As the ac- 
 cesses become more frequent, the system 
 habituates itself to these annual or bi-annual 
 attacks, and periodicitj- becomes an element of 
 the case, marked in proportion with the degree 
 of impairment of the nerve-centres. As an 
 
HAY FEVER. 23 
 
 illustrative case, I vrill cite that of a medical 
 friend, who, in a letter to me, spoke as follows : 
 " My attacks for some years past came with 
 much regularity, about August 12th to 14th. 
 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 
 sneezing and irritation of the nose and eyes. 
 Still, I had the usual slightly hot and irritable 
 skin, then an eruption of urticaria, accompanied 
 by disordered stomach. This experience is 
 precisely the same as in 1880, except that then 
 I was on the Atlantic, on shipboard." In this 
 case, the neurotic element is distinctly shown 
 by the eruption and the gastric disturbance, 
 while periodicity alone can explain the pres- 
 ence of the symptoms at the precise time and 
 the favorable localities in which they mani- 
 fested themselves. 
 
 As to the nervous symptoms occurring 
 during the course of an attack, I am more dis- 
 posed to consider them as due to reflex irrita- 
 tion from the local trouble than as originating 
 
24 HAY FEVER. 
 
 primarily in the nerve-centres. During tlie 
 access, the susceptibility of the reflex centres 
 is developed to its utmost extent, and sunlight, 
 a draught of air, etc., will give rise to most 
 violent symptoms, which would not be the 
 case at other times. 
 
 Accepting the above as conclusiv^e in de- 
 monstrating the presence of a neurotic ele- 
 ment, another question presents itself, which, 
 left unanswered, would expose the theory to 
 potent criticism : It being a recognized fact 
 that in many individuals, there is impairment 
 of the nerve-centres, either due to heredity or 
 to disease, fully as extensive as in the worst 
 hay fever subject, how is it that hay fever 
 does not manifest itself in all these individ- 
 uals? To answer this, the third condition 
 comes to our rescue: In persons who are not 
 subject to hay fever, the nasal mucous mem- 
 brane is either in its normal state, or, if dis- 
 eased, the local trouble is not of a nature to 
 induce an abnormal susceptibility to irrita- 
 tion, and the systemic dyserasia is not awak- 
 
HAY FEVEB. 25 
 
 ened to action, while in the hay fever patient, 
 an hypersesthetic state of the mucous mem- 
 brane, either latent or due to local disease, 
 is always present, furnishing a vulnerable or 
 sensitive area through which the impaired 
 nervous system can becoiAe influenced by the 
 external in-itant. Both systemic and local ele- 
 ments must exist simultaneously to render a 
 paroxysm possible. 
 
 That the local condition of the nasal mucous 
 membrane is an essential factor in the produc- 
 tion of an attack, was demonstrated by the 
 results attained with a treatment in which this 
 point was kept in view. As long as it was 
 overlooked, all efforts to conquer the disease 
 were fruitless. As soon, on the contrary, as its 
 true importance was duly appreciated, the 
 chances of cure became greater than in any 
 chronic affection of the nose. 
 
 What evidence have we to indicate the pres- 
 ence of sensitive spots in the nasal cavities? 
 
 Some time ago, Dr. J. N. Mackenzie,* of 
 
 *Am. Jour. Med. Sciences, July, 1883. 
 3 
 
26 HAY FEVER. 
 
 Baltimore, published an interesting article on 
 " Nasal CoTigli," in which he demonstrated that 
 " there exists in the nose a well-defined sensi- 
 tive area whose stimulation through a local 
 pathological process, or through ah extra irri- 
 tation, is capable of producing an excitation 
 which finds its expression in a reflex act, or 
 in a series of reflected phenomena." It is 
 located at the posterior end of the inferior tur- 
 binated bones and the corresponding portion of 
 the septum {b Fig. 1). I have frequently been 
 able to verify this assertion, not only in the 
 production of cough, but also in the produc- 
 tion of reflex asthma, in cases in which a pre- 
 disposition to this affection existed. Professor 
 Hack,* of Freiburg, Grermany, has also demon- 
 strated that various reflex neuroses originate 
 in a diseased condition of the nasal mucous 
 membrane. Unlike Dr. John Mackenzie, how- 
 ever, he locates the area from which the reflex 
 symptoms take their origin at the anterior 
 
 *Ueber eine Operative Radical-Behandlung bestimmter Formen 
 von Migrane, Asthma, Heufieber, etc., August, 1883. 
 
HAY FEVEK. 27 
 
 extremity of tlie inferior turbinated bone (c 
 Fig. 1), and advises the removal of the latter 
 for the cure of hay fever. In eases in which 
 there was anterior hypertrophy, without a his- 
 tory of hay fever, I have not succeeded as yet 
 in producing by local pressui-e, any evidence 
 of reflex action, while in some of the cases, 
 the same procedure in the posterior portion of 
 the nasal cavity (Mackenzie's area) would elicit 
 marked reflex symptoms.* In cases of hay 
 fever, however, I have almost in^'ariably found 
 marked hypersesthesia in this portion of the 
 nasal cavity, with reflex symptoms in the su- 
 perior maxillary region. 
 
 In addition to these two sensitive areas, 
 practical experience in a large number of cases 
 has demonstrated to me that a third area, of 
 no less importance than that of Dr. J. N. Mac- 
 kenzie, exists in the anterior portion of the 
 
 *The fact, however, that the terminal fibres of the nasal 
 branches of the spheno-palatine ganglion and of the nasal branch 
 of the ophthalmic meet there and form quite a network, certainly 
 verifies the view held by Hack, as to its being a reflex area of 
 importance. 
 
28 
 
 HAY FEVER. 
 
 nasal cavity, near the angle forming the an- 
 terior boundary of the vestibule, and located 
 upon the nasal wall, as well as on the septum. 
 This area is indicated in Fig. 1 by the letter d. 
 In the great majority of persons subject to 
 hay fever, if not in all, the surface of the mem- 
 
 it., Spheno-palatine ganglion; 6, posterior area; t.', middle area; d, anterior 
 area; e, olfactory bulb. 
 
 brane in this locality is exquisitely sensitive, 
 and the contact of a probe provokes intense 
 itching and lachrymation. 
 
 It thus becomes evident that there are in 
 
HAY FEVEE. 29 
 
 the nose three areas capable of producing 
 reflex symptoms in the course of a paroxysm 
 of hay fever, and that the three combined 
 form the key of the local nervous element. 
 I do not wish to imply, however, that the 
 three areas must necessarily take part in the 
 production of an access; in some, only one 
 of the three will be the "sensitive spot;" in 
 another, the posterior and middle areas will 
 be involved, etc., etc. Again, a difference of, 
 intensity may exist in the degree of hyper- 
 8Bsthesia; while one area may be but slightly 
 sensitive, the next may be extremely so. In 
 cases complicated with asthma, for instance, 
 I have noticed that both anterior and pos- 
 terior areas are sensitive, the latter being 
 principally so, both giving rise to more or 
 less reflex manifestations, but that when the 
 paroxysms are uncomplicated, the anterior 
 area is much more sensitive than the posterior. 
 An explanation of the origin of this local 
 hyper^esthesia would not be difficult did it 
 involve the middle and posterior areas of the 
 
 s* 
 
30 HAY FEVEK. 
 
 nasal cavity only. Here it may be caused by 
 most of the affections of the anterior nasal 
 cavity, from simple chronic rhinitis down to 
 nasal polypi. But how can we explain its 
 origin in the anterior portion of the cavity, 
 which seldom takes part in the diseases to 
 which the other portions are liable ? This 
 leads us to the discussion of another question : 
 Can hypersesthesia of the nasal mucous mem- 
 brane occur idiopathically or is a pathological 
 process necessary as a primar}" cause ? 
 
 In three of the cases which have so far 
 come under my care, examination some weeks 
 before the access appeared, not only presented 
 the cavities in their normal state, but I could 
 not obtain from the patient any indication 
 of the presence during the period intervening 
 between the accesses of any, even temporary, 
 local trouble. Artifi(ual stimulation with the 
 probe to ascertain the location of the hyper- 
 aisthetic spots, as first suggested l_iy Roe,* 
 however, demonstrated clearly the presence 
 
 *Vide New York Medical Journal, j\Iav 3d and 10th, 1S84. 
 
HAY FEVER. 31 
 
 of several of them, and in one case gave rise 
 to a number of reflex symptons. It tlius ap- 
 pears evident that a healthy membrane, in 
 the ordinary sense of the word, can become 
 hypertesthetic without having undergone a 
 local pathological process, and this be due to 
 implication of the nasal nerve-supply in the 
 general neurtesthenia. But the small number 
 of hay fever sufferers among the large num- 
 ber of neurasthenic people, makes this theory 
 hypothetical, and the more plausible and less 
 critieisable one of local chronic disease as a 
 cause of the hypersesthesia must be accepted. 
 In the three cases in which no disease could 
 be discovered, then, a pathological process, 
 not sufficiently marked to be appreciated by 
 ocular inspection, must have been present. 
 As far as the anterior sensitive area is con- 
 cerned, it is not unlikely that the proximity 
 of an active pathological process maintained, 
 by continuity of tissue, a latent inflammatory 
 state which caused the hypersesthesia. 
 
 As to the differentiation of one irritant 
 
32 HAY FEVEE. 
 
 from another, I believe, with. Dr. J. N. Mac- 
 kenzie,* that it resides in the nerve-centres 
 themselves. Their abnormal state renders 
 them much more susceptible to the effects of 
 external influences, and their discriminating 
 power is increased in proportion. Let there 
 be in a certain subject any unusual suscep- 
 tibility to any particular substance or sub- 
 stances, this will be increased in proportion 
 to the degree of disturbance in the nerve- 
 centres, the result being an exalted reflex 
 manifestation. This peculiar susceptibility to 
 certain substances is well exemplified by the 
 violent coryza brought on in some persons by 
 ipecacuanha. So sensitive are some to its 
 effects, that a few moments spent in a drug 
 store are sufficient to cause an attack. 
 
 A number of secondary circumstances seem 
 to exert some influence in the production of 
 the affection, the principal of which is nation- 
 ality. It is a strange fact that the Americans 
 and the English are the principal sufferers. 
 
 * Op. cit. Page 8. 
 
HAY FEVEE. 33 
 
 It might not be amiss to suggest that these 
 are the only two great tea-(hinking nations, 
 and that this beverage may exert a depressing 
 influence on the nerve-centres, and aggravate 
 an inherited or acquired neursesthenia. 
 
 The affection seems to be most frequent 
 among people of education and thos(- in com- 
 fortable circumstances, or whose occupation 
 is sedentary. This may be due to a lack of 
 wholesome exercise in the open air, a fact 
 which I have been able to appreciate in the 
 great majority of cases. 
 
 Heredity has l^een shown to exert great 
 influence in the etiology of the affection, 
 thirty-seven per cent, of the forty cases alluded 
 to in the first part of this essay, having rela- 
 tives who are sufferers of either rose cold or 
 hay fever, while asthma, which is, as shown, 
 a predisposing cause, is present in eighteen 
 per cent. more. 
 
 The affection seems to be somewhat more 
 frequent in men than women, the use of 
 tobacco and other pernicious habits in the 
 
34 HAY FEVER. 
 
 former being possibly accountable for the 
 difference. 
 
 Pathologij. — Having considered the essential 
 etiological factors of the affection, we will now 
 enter into the pathological considerations bear- 
 ing directly upon the production of a paroxysm. 
 Before doing so, however, it might be advisable 
 to review briefly the anatomy of the Schnei- 
 derian membrane, the turgescence of which 
 constitutes the main feature of the affection. 
 
 An important point in connection with 
 the curative measures to be adopted, is a 
 proper recognition of the fact that each nasal 
 cavity is divided into two regions which have 
 distinct physiological functions, — the olfactor^r 
 region, in which the sense of smell is located, 
 and the respiratory region, the function of 
 which is to purify the air of foreign sub- 
 stances, besides furnishing it with the neces- 
 sary moisture and warmth before it reaches 
 the lungs. As can be seen in Fig. 1, the fila- 
 ments of the olfactory nerve cover the superior 
 turbinated and the upper third of the middle 
 
HAY FEVEE. 35 
 
 turbinated bone. They also cover the corres- 
 ponding portion of the septum. The upper 
 part of the nasal cavity is thus devoted 
 entirely to the sense of smell and not involved 
 in the pathological etiology of hay fever. 
 
 The respiratory region, which includes all 
 the surfaces below the olfactory, is covered 
 by a highly vascular membrane, especially 
 thick over the inferior and middle turbinated 
 bones, which possesses to a marked degree, 
 the power of becoming turgid or erect, suffi- 
 ciently so, sometimes, to completely occlude the 
 nasal cavity. This membrane, termed by Bige- 
 low, of Boston, the turbinated corpora cavernosa, 
 on account of the large venous sinuses or cav- 
 erns which it contains, and which, by becoming 
 suddenly filled with blood, cause its turgescence, 
 is under the control of vaso-motor nerves of the 
 sympathetic system, and is exceedingly sensi- 
 tive to local or peripheral irritating causes. 
 This sensitiveness, however, does not reside 
 in the vaso-motor supply, which is only a 
 secondary factor in the production of the tur- 
 
36 HAY FEVEK. 
 
 gesceiice, but in tlie terminal filaments of the 
 sensory nerves distributed over the surface of 
 the membrane. A brief allusion has already 
 been made to these, when speaking of the 
 different hyperaisthetic areas, but they were 
 not sufficiently described to render a clear 
 outline of the pathological process possible. 
 Commencing with the posterior area, we find 
 that the membrane of that location is sup- 
 plied by several branches of the spheno-pala- 
 tine ganglion, which enter the back part of 
 the nasal fossa by the spheno-palatine fora- 
 men. Besides its motor and sensory roots, 
 the spheno-palatine ganglion possesses a sym- 
 pathetic root, which is derived from the carotid 
 plexus through the vidian, thus forming a 
 well-defined connecting link between the nasal 
 membrane and the sympathetic system. 
 
 In the production of the reflex symptoms 
 peculiar to the posterior area, cough and 
 asthma, the impression is eonsecjuently trans- 
 mitted from the posterior end of the inferior 
 turbinated bone or the corresponding portion 
 
HAY FEVEE. ot 
 
 of the septum, to tlie splieno-palatine gang- 
 lion ; fi'oni that to the carotid plexus, ■which 
 is closely cpuuected with the posterior pulmo- 
 nary plexus, formed not only by the branches 
 of the symi^athetic but also by some from 
 the pneumogastric, and finally to the rami- 
 fications of the air-tubes through the ultimate 
 filaments of the formei', which are lost in the 
 bronchial mucous lining. In many eases, 
 however, the asthma is not due to refiex 
 action, but to the gradual extension of the 
 catari'hal inflammation from the nasal mem- 
 brane, down along the pharynx, trachea and 
 bronchi. In these cases, the asthmatic symp- 
 toms only manifest themselves some time 
 after the onset of the paroxysm. In both 
 varieties the exciting cause and the ultimate 
 results are the same, but in the one the link 
 between them is the nervous system, while in 
 the other it is the mere continuity of tissue. 
 The frequently complained of symptom, itching 
 at the roof of the mouth, is readily explained 
 by the presence of a large number of branches 
 
 4 
 
38 HAY FEVEK. 
 
 wliich emanate directly from the spheno-pala- 
 tine ganglion and are distributed throughout 
 the membrane covering the inferior surface 
 of the hard and soft palate. 
 
 The middle area Ijeing formed by the ter- 
 minal fibres of the branches constituting the 
 posterior and anterior areas, irritation over it 
 may give rise to any of the reflex symptoms 
 which the two former occasion. 
 
 The anterior area includes the nasal 
 ner^'e, one of the principal branches of the 
 first division of the fifth pair, the ophthal- 
 mic, which supplies the eyeljall, the lach- 
 rymal gland, the muc<^us lining of the eye and 
 nose, and the integument and muscles of the 
 eyebrow and forehead. This distribution, and 
 the fact that the ophthalmic is a sensory 
 nerve, explains readily how a pathological 
 condition involving the nasal nerve may pro- 
 duce so many varied sjinptoms. In the pro- 
 duction of lachrjaiiation and palpebral pru- 
 ritus, we have the lachrymal branch, which 
 supplies not only the lachrJ^nal sac, but also 
 
HAY FEVER. 39 
 
 the conjunctiva. In addition to this cause, 
 however, closure of the tear duct certainly 
 contributes greatly to the profuse laehryma- 
 tion. The photophobia also finds an easy ex- 
 planation, if we consider the communication 
 existing between the first division of the fifth 
 pair and the ophthalmic or ciliary ganglion, 
 the filaments of which are distributed to the 
 ciliary muscle and the iris. If we couple this 
 with the fact that the pupil is dilated when 
 the eyes are implicated in the paroxysm, we 
 can understand how exposure to sunlight can 
 aggravate the symptoms of the affection, and 
 appreciate the pathological verification which 
 it furnishes. 
 
 In accordance with these views, the produc- 
 tion of a paroxysm may be briefly described as 
 follows : A given irritant coming in contact 
 with the hypersesthetic nasal membrane in a 
 neursesthenic subject, the impression made on 
 the former is transmitted through the afferent 
 fibrillae of the nearest set of sympathetic ganglia 
 to those ganglia, and returned by them to the 
 
40 HAY FEVEK. 
 
 vaso-motor nerves of the membrane. Tlie 
 result is the same as in acute rhinitis — a pri- 
 mary contraction of the vessels followed by 
 dilatation, the venous sinuses or corpora cav- 
 ernosa becoming filled with venous blood and 
 remaining distended. Violent sneezing occurs 
 as soon as the membrane of the septum and 
 that over the turbinated bones touch, and reflex 
 asthma presents itself if the distention is suf- 
 ficiently great iu the posterior area to cause 
 pressure against the septum. In the anterior 
 area, the inanifestations are not local, but occur 
 in the parts which are in direct nervous commu- 
 nication with it. We thus have lachrjination, 
 photophobia, headache, facial and palpebral 
 pruritus, and so forth. If the distention is 
 great in the middle area and nowhere else, 
 we may have the whole train of sjTuptoms, 
 both anterior and posterior areas being in- 
 volved, while implication of the posterior area 
 will give rise to astlima if there is sufficient 
 tiu'gescence to cause pressure against the sep- 
 tum, and if the asthmatic tendency exists in 
 
HAY PEVEE. 41 
 
 the patient. As to the general systemic dis- 
 turbances present in connection with the head 
 symptoms, they are easily accounted for by 
 the momentary increase of the abnormal ex- 
 citability of the nerve-centres. 
 
 In my opinion, a paroxysm brought on by 
 peripheral irritation, exposure to draughts, 
 wind, dampness, etc., or occurring as a reflex 
 manifestation from other i:)arts of the body in 
 an abnormal state at other times than in the 
 hay fever season, cannot be considered as hay 
 fever. It is an attack of acute coryza, due to 
 the fact that the nasal mucous membrane re- 
 ceives its vaso-motor innervation from a gan- 
 glion which is the part of least resistance in 
 the patient's economy,* and which does not 
 require a special agent to become influenced. 
 
 Treatment. — The first indication in the treat- 
 ment of hay fever is to ascertain hj careful 
 examination of the nasal chambers, whether 
 the condition which gave rise to the hyper- 
 SBsthesia is sufficiently marked to receive 
 
 ^'Woakes' "Post-Nasal Catarrh," p. 43, 1884. 
 4* 
 
42 HAY FEVER. 
 
 special attention. In the great majority of 
 cases, a simple chronic rhinitis exists with a 
 tendency to frequent or permanent turges- 
 cence of the mucous membrane. In others 
 we have true hypertrophy, involving either 
 the anterior or posterior portions of the nasal 
 cavities, or both. Occasionally we find polypi, 
 which occlude more or less one or both cavi- 
 ties, while a deviated or thickened septum 
 may keep up a marked irritation and con- 
 stitute a serious obstacle to a subsequent 
 thorough treatment. When these, or any 
 other abnormal condition compromising me- 
 chanically the lumen of the cavities, are present, 
 they should first receive attention, and the 
 nasal cavities returned as nearly as possible 
 to their normal state. If the treatment em- 
 ployed be one of a destructive nature, the 
 organic changes induced by it in the mucous 
 membrane proper, will often be sufficient to 
 annul its hypenTesthesia. This was exempli- 
 fied by the cases reported by Daly,* Eoe,t 
 
 * Op: cit. p. 6. t Op- <^t- P- 6. 
 
HAY FEVER. 4d 
 
 (first paper), in two of the first reported by 
 me, and in several reported by Dr. Harrison 
 Allen.* In a large proportion of patients, 
 however, it does not suffice, and immunity 
 from the disease can only be expected after 
 each sensitive spot has been thoroughly cauter- 
 ized. 
 
 The condition most frequently met with, 
 a simple chronic rhinitis with tendency to 
 frequent or permanent turgescence of the 
 membrane, often mistaken for hypertrophic 
 rhinitis and treated as such, can be differ- 
 entiated from the latter by noting the sluggish 
 recoil of the turgescent membrane when pres- 
 sure upon it with a probe is suddenly discon- 
 tinued, and the completeness of its collapse 
 under the influence of a four per cent, solu- 
 tion of hydrochlorate of cocaine. Such a 
 condition having been recognized, the appli- 
 cation of an escharotic over a limited area is 
 indicated. One application of nitric acid gen- 
 erally suffices for each nostril. The small 
 
 * 0/). cit. p. 7. 
 
44 HAY FEVER. 
 
 cotton-carrier shown in Fig. 2 is the most 
 desirable instrument for the pui'pose, the 
 diminutive thickness of the blade enaljling 
 the operator to wrap a thin film of cotton- 
 wool around its tip, and still form a very 
 small volume. The nostril being well dilated 
 and illuminated, the end of the cotton-carrier 
 is dipped into the acid and pressed against 
 a piece of blotting-paper, so as to part with 
 any excess of acid and prevent dripping. It 
 is then introduced into the nose and applied 
 to the most prominent portion of the inferior 
 or middle turbinated bone, or both, as the 
 case may be, taking care not to touch the 
 septum. A sharp pain follows if the acid is 
 applied pure, which will be avoided if hydro- 
 chlorate of cocaine has previously been dis- 
 solved in it to saturation.* An eschar is the 
 result, which upon healing forms a cicatrix 
 which prevents future distention, this being 
 
 *The experiments with such a mixture for cutaneous applica- 
 tions by Dr. N. A. Randolph and i\Ir. S. G. Dixon, reported in their 
 "Notes from the Physiological Laboratory, etc.," Philadelphia, 1SS5, 
 suggested its use in the nose to me. 
 
HAY FEVER. 45 
 
 assisted by the consolidation induced in the 
 deeper layers of the membrane by the acute 
 inflammatory process following the cauteriza- 
 tion. Galvano-cautery can be used with 
 advantage in the manner described below 
 instead of the acid, the edge of the knife, at 
 cherry heat, being introduced into the most 
 prominent portions of the membrane. 
 
 Fig. ■^. 
 
 fi^w!fS":r!W''iMMiS>^^ — ■ — =^ — g sdZIZZIS^ 
 
 Harrison Allen's cotton-carrier. 
 
 In all applications of this character, there 
 is danger of inflammatory adhesion with the 
 septum, when the parts are in close apposi- 
 tion. To guard against this, the patient 
 should be seen in a couple of days, and if 
 any tendency to adhesion should show itself, 
 i.e., bands of soft tissue connecting the burnt 
 area with the opposite surface, they should be 
 torn by passing a probe through them, and 
 a cotton wad anointed with cosmoline inter- 
 posed. 
 
46 HAY FEVEK. 
 
 Hypertrophies of the membrane can be 
 recognized by the resistance which they offer 
 to the pressure of the probe, and the sudden- 
 ness with which they reassume their confor- 
 mation under the application of the cocaine. 
 The membrane, completely emptied of its 
 fluids, cannot contract m<jre than the organ- 
 ized elements in its layers will allow, and its 
 actual thickness can then easily be deter- 
 mined. In uncomplicated chronic rhinitis the 
 contraction is almost complete, the thicken- 
 ing in the sub-epithelial layer not being 
 sufficient to cause any appreciable differ- 
 ence in its appearance. Its surface is smooth 
 and uniform, the conformation of the bone 
 beneath being often descernible. As soon as 
 sufficient hypertrophic tissue has formed to 
 become noticeable, however, the smoothness 
 and uniformity are lost, and irregular promi- 
 nences appear, indicating the localities in 
 which the hypertrophic process is most ad- 
 vanced, and where surgical measures will 
 be most effective. 
 
HAY FEVER. 47 
 
 The presence of hypertrophic rhinitis hav- 
 ing been recognized, a successful result can 
 only be obtained by resorting to a treatment 
 calculated to destroy a sufficient quantity of 
 the redundant tissue to insure, with the assist- 
 ance of the resulting inflammation and the 
 subsequent cicatricial contraction, its com- 
 plete reduction. 
 
 The means at our disposal for the reduction 
 of hypertrophied mucous membrane differ ac- 
 cording to the degree of hypertrophy, and con- 
 sist in the use of caustic acids, galvano-cautery, 
 the galvano-eaustie snare, and the cold wire 
 snare. 
 
 The three acids usually employed are the 
 nitric, chromic, and glacial acetic. The first is 
 by far the most powerful, and its action can 
 only be limited by using it in very small quan- 
 tities at a time. If too much is applied to the 
 membrane, deep-seated ulceration may ensue, 
 and give rise to much annoyance. 
 
 As already explained, a very thin probe 
 should be used, with a film of cotton wrapped 
 
48 HAY FEVEE. 
 
 around the tip. Being dipped in the acid, and 
 applied against a blotter to prevent dripping, 
 the cotton pledget is applied to the most 
 prominent portion of the membrane, limiting 
 the application to an area about the size of a 
 small pea. A sharp pain is felt, unless the 
 meml:)rane be previously anesthetized with 
 cocaine, or the acid contain a sufficient quan- 
 tity of the latter in solution. When the co- 
 caine is not used, howcn-er, the pain can be 
 quickly arrested by applying with the atomizer, 
 a saturated solution of bicai'bonate of sodium, 
 which will also limit the penetration of the 
 acid. During the day, the patient experiences 
 a sensation of fullness in the nostril cauterized. 
 This, however, only lasts a few hours, and in 
 some cases does not occur at all. The next 
 day, shreds of the destroyed mucous mem- 
 brane are discharged, and a feeling of relief 
 is at once experienced. This continues until 
 all the cauterized tissue has been thrown off, 
 leaving a groove to mark the seat of the ex- 
 foliation. This groove gradually fills up, not 
 
HAY FEVER. 49 
 
 by reproduction of tissue, but by a displace- 
 ment, as it were, of the surrounding superficial 
 stratum, wliicb contracts, thereby constricting 
 the parts beneath. This process requires for 
 its completion about a week. A great advan- 
 tage possessed by nitric acid is that it requires 
 but one or two applications to contract mark- 
 edly the hypertrophied membrane. At least 
 two weeks should elapse between each appli- 
 
 Bosworth's probe. 
 
 cation. An earlier renewal of the caiiterization 
 on the same spot might give rise, to serious 
 inflammation, and perhaps erysipelas. 
 
 In inexperienced hands, glacial acetic acid 
 is a much safer agent, but requires a greater 
 number of applications to produce the same 
 effect. The instrument shown above, devised 
 by Dr. Bosworth, of New York, is very conve- 
 nient for its application. Its end is flattened, 
 and when wrapped with cotton, presents a 
 
 5 
 
50 HAY FEVEE. 
 
 comparatively wide surface, while at the same 
 time it can be introduced into the narrowest 
 cavity. It is dipped into the acid if both sides 
 of the cavity are to be treated, that is, if there 
 is septal hypertrophy besides the turbinate, 
 or dropped on one side if the hypertrophy be 
 limited to the latter. The vestibule being di- 
 lated and illuminated, the charged end is passed 
 into the nasal cavity along the free edge of the 
 hypertrophied turbinated body or applied to 
 the septal growth, as the case may be. The 
 pain induced is much less severe than when 
 nitric acid is used, but again the amount of 
 tissue destroyed is much more limited. Seven 
 or eight applications at a week's interval are 
 necessary to produce the effect of one appli- 
 cation of nitric acid, but the im2:)rovement is 
 gradual and steady, and if care be taken to 
 touch the same spot each time, in order to as 
 much as possible avoid the destruction of the 
 ciliated epithelium, not only will the stenosis be 
 remedied, but the physiological functions of the 
 membrane proper will be preserved. 
 
HAY FEVEB. 51 
 
 Chromic acid is highly recommended by- 
 several eminent specialists. The most conve- 
 nient method for its employment is to heat 
 the tip of an ordinary probe and to apply it 
 against one of the acicular crystals of the acid. 
 Care should be taken not to overheat the in- 
 strument, lest decomposition of the acid occur. 
 Enough adheres for two applications. Chromic 
 acid gives rise to little or no pain, and is very 
 effective, but systemic intoxication is liable to 
 occur if too great a quantity is used at one 
 sitting. Its application should consequently 
 be limited to a small area, and renewed from 
 two to five times as the case may be. As 
 with nitric and glacial acetic acid, any excess 
 can be neutralized by applying over the cauter- 
 ized surface, a saturated solution of bicarbonate 
 of sodium. 
 
 Gal vano -cautery possesses many advantages 
 over any method employed for the reduction 
 of hypertrophies. Its application gives rise to 
 but Uttle pain, and the local inflammation fol- 
 lowing its use is so limited, that it is hardly 
 
52 HAY FEVER. 
 
 perceived by the patient in the great majority 
 of cases. A number of excellent batteries are 
 at our disposal, among wbicli may be mentioned 
 Seller's, of Philadelphia, and Piffard's, of New 
 York. The former is the more convenient of 
 the two instruments, and was used by me until 
 lately, when, having replaced cold wire snaring 
 by galvano-caustic snaring in my practice, I 
 found it necessary to devise an apparatus ca- 
 pable of furnishing a greater quantity of elec- 
 tricity when this was required, without in- 
 creasing the bulk of the instrument. 
 
 When the hypertrophy is situated anteri- 
 orly and is not very large, a linear incision, 
 made with the edge-knife, is sometimes suffi- 
 cient to reduce it completely. In order to 
 obtain the best effect from the cauterization, 
 the platinum loop must be introduced glowing, 
 and the margin of the nostril must therefore 
 be protected. Dr. Harrison Allen's nasal 
 speculum is very efficient for the purpose, 
 and several sizes being procurable, a suitable 
 instrument can be employed in each case. It 
 
HAY FEVEE. 53 
 
 should be inserted and held with the left 
 hand in such a manner that the prominence 
 to be treated will appear opposite the small 
 opening. The knife is then entered into the 
 speculum, and the circuit closed just as the 
 platinum loop has reached beyond its external 
 or wide opening. Holding it there an instant, 
 until the proper heat is attained, the instru- 
 
 Allen's nasal speculum. 
 
 ment is pushed forward so as to cause its 
 sharp edge to penetrate the centre of the 
 prominence, and advanced until an incision 
 of the desired length has been made. The 
 circuit is then broken, and the instrument 
 withdrawn cold. As a result, the different 
 layers of the membrane are severed, includ- 
 ing the dilated blood-vessels and sinuses, and 
 
54 HAY FEVER. 
 
 cicatrical bands are formed which cause the 
 contraction to involve its entire thickness. 
 
 An important matter in connection with 
 this operation, is the proper regulation of the 
 heat. When the platinum point is not suffi- 
 ciently hot — hlach heat — it causes great pain. 
 When it is too hot — ivhife heat — it causes pro- 
 fuse hemorrhage. Cherry heat is hardly felt 
 by the patient, causes no bleeding, and is 
 more effective than either of the two others. 
 
 Some specialists employ a shield to pro- 
 tect the membrane of the septum; I have 
 never found such an instrument necessary, 
 and merely apply a little vaseline over its 
 surface, to avoid the sensation of heat which 
 the radiation from the hot metal might occa- 
 sion. Should the septal membrane be acci- 
 dentally touched, the burn heals without 
 trouble. Such is not the case, however, if 
 the skin around the margin of the nostril is 
 singed; the pain is not only very severe, but 
 lasting. 
 
 The after-effects of an application of gal- 
 
HAY FEVEE. 55 
 
 vano-cautery, performed in this manner, are 
 almost nil. Occasionally, slight inflammation 
 occurs, the membrane swells, and slight shoot- 
 ing pains are felt along the distribution of 
 the fifth pair, especially the superior maxillary 
 branches. After a few hours, however, these 
 symptoms disappear and the membrane returns 
 to its former state. Some cases have been 
 reported in which violent inflammation oc- 
 curred after galvano-caustie applications. I 
 have never met with such a misfortune, the 
 only untoward effect noticed being a momen- 
 tary polypoid swelling of the membrane of 
 the middle turbinated bone, occurring, strange 
 to say, in the same locality in three patients. 
 The slight inflammation induced by galvano- 
 caustie or acid applications, may cause, as 
 already stated, adhesion of the cauterized area 
 to the membrane of the septum, and thus 
 obstruct the cavity. This should be guarded 
 against by seeing the patient every other day 
 while the inflammatory process is progressing, 
 pledgets of cotton being interposed between 
 
56 HAY FEVEK. 
 
 the surfaces to prevent their agglutination, if 
 necessary. If a second application should be 
 deemed advisable, a week, at least, should 
 elapse before making it, in order to aUow the 
 local inflammation to subside. 
 
 When the hypertrophies are very large, 
 the contraction resulting from simple applica- 
 tions is not sufficiently effective. A portion 
 
 Fig 5- 
 
 Jarvis' transfixing needles. 
 
 of the membrane must be removed. For this 
 purpose, Dr. Jarvis' transfixing needles are very 
 useful. One of these being passed through 
 the growth as shown in Fig. 6, the cautery 
 loop is passed into the nasal cavity over the 
 handle of the needle, and over its point as it 
 protrudes from the surface. The wire being 
 
HAY PTEVEK. 
 
 57 
 
 then tightened around the growth, by de- 
 pressing the finger-lever of such an instrument 
 as that shown in Fig. 11 (page 69), the circuit 
 is closed, and a few turns of the milled nut at 
 the end of the handle will cause separation of 
 
 Fig. 6. 
 
 The needle and loop in position. 
 
 the transfixed portion of the hypertrophied 
 membrane from its base. The pain experi- 
 enced is usually very slight, and the wound 
 heals without trouble. 
 
58 
 
 HAY FEVEB. 
 
 This operation may also be performed m 
 the manner suggested by Dr. Harrison Allen, 
 which consists in applying the heated loop 
 against the side of the gi'owth, and allowing 
 it to burn its way into it, until a portion of 
 the mass can be grasped, when the loop may 
 be narrowed and the portion removed. Dr. 
 Allen employs for this and his other galvano- 
 
 Fig- 7- 
 
 Allen's galvano-cautery snare. 
 
 caustic snaring operations, the ingenious in- 
 strument shown in Fig. 7. 
 
 The body of the instrument consists of a 
 slotted aluminum barrel containing a screw of 
 equal length. The latter is connected with a 
 vulcanite "carriage" which moves freely over 
 the barrel, and serves for the attachment of 
 the wires and battery cords. A milled nut at 
 
HAY FEVEE. 59 
 
 r~\ Fig. 8. 
 
 the end of the screw, -working on\ \ 
 the same principle as that shown in \ \ 
 Fig. 8, causes the latter to descend \ \ 
 when turned, and the loop is thus 
 drawn home. A novel feature intro- 
 duced by this instrument, is that the 
 platinum wire is covered with a uni- 
 form coat of copper, excepting alone 
 the portion forming the loop, which 
 is bare. The current can in this 
 manner be transmitted along the 
 wires by means of the copper layer. 
 When the surgeon is not possessed 
 of galvano-cautery instruments, the 
 same operation can be performed 
 with the cold-wire snare shown in 
 Fig. 8, a modification of an in- 
 strument invented by Dr. Jarvis. 
 To arm it for use, a small piece 
 of wire two or three inches in 
 length, according to the size of 
 the tumor, is doubled into a loop, 
 and the ends are passed through 
 
 Author's modifica- 
 tion of Jarvis' snare. 
 
60 HAT FEVEK. 
 
 the eye of the rod until they protrude a 
 quarter of an inch. Traction being then 
 caused by turning the milled nut, the end 
 of the rod, which otherwise projects beyond 
 the end of the tube a short distance, dis- 
 appears in the latter, doubling the wire 
 ends on the loop. The loop is then firmly 
 held and ready for use. Being passed over 
 needle transfixing the membrane, the nut is 
 turned until the tumor is firmly held in the 
 grasp of the wire. Care must now be taken 
 not to cause it to cut through too hastily, lest 
 severe hemorrhage occur. Twenty to thirty 
 minutes, at least, should be employed to gradu- 
 ally penetrate the growth, turning the nut once 
 in a while. If performed in this way the oper- 
 ation is hardly painful ; but little blood is lost, 
 and the wound heals readily. 
 
 The diagnosis of posterior hypertrophies is 
 not difficult when a good view of the posterior 
 nares can be obtained with the rhinoscope. 
 The peculiar ashy color of the white growth, 
 its rugous surface and its situation are so 
 
HAY FEVEK. 61 
 
 characteristic, that a mistake can hardly be 
 made. Polypi, however, often resemble them, 
 but their smooth surface and the history of 
 the case are generally sufficient to indicate their 
 nature. The red growths are by no means as 
 common as the white. Their violet hue is also 
 characteristic, while their soft consistence and 
 their tendency to bleed when touched, serve to 
 differentiate them from fibrous polypi or osteo- 
 mata, with which they might be confounded. 
 When examination of the parts cannot be con- 
 ducted satisfactorily with the mirror, much in- 
 formation can be obtained by introducing the 
 index finger behind the soft palate, and gently 
 advancing it until its palmar surface comes in 
 contact with the posterior border of the sep- 
 tum. The posterior nares can then be easily 
 made out, and the conformation and density 
 of the parts ascertained. 
 
 Repeated observation has demonstrated, con- 
 clusively in my opinion, that local medicinal 
 treatment does not influence posterior hyper- 
 trophies, and that in all cases, some active 
 
 6 
 
62 HAY FEVEK. 
 
 measure must be resorted to which will affect 
 the growth mechanically. The means at our 
 disposal are the same as for anterior hyper- 
 trophies: — acids, galvano-cautery, and the gal- 
 vano-caustic, or cold-wire snare. 
 
 Before selecting any of these, however, it 
 is of great importance to determine whether 
 the growth is principally apparent through ex- 
 tensive distention of the venous sinuses — soft 
 hypertrophies — as is the case in the majority of 
 the white and in all the red hypertrophies, or 
 whether the fibrous tissue, which predominates 
 in posterior growths, forms the greater portion 
 of its bulk — hard hypertrophies — the venous sin- 
 uses, in that case, being much smaller and fewer 
 in number. A four per cent, solution of hy- 
 drochlorate of cocaine can be used for the pur- 
 pose, as for anterior hypertrophies. ^Iien dis- 
 tended sinuses are the principal cause of the 
 turgescence, immediate contraction will follow 
 and the tumor will almost disappear, whereas 
 if true hypertrophy of all the layers be present, 
 the influence of the drug wiU hardly be notice- 
 
HAY FEVEE. 
 
 63 
 
 able. In tlie first condition, acids 
 or galvano-cantery are indicated, 
 because the snare, by cutting 
 througli the enlarged and en- 
 gorged sinuses, would expose the 
 patient to serious hemorrhage, 
 while in the second, the snare 
 can alone be effective, the acids 
 and galvano-cautery being com- 
 paratively powerless to remove 
 the mass of exuberant tissue, 
 which, when cut, bleeds but 
 slightly, if at all. 
 
 The position of the growth 
 rendering a view through the 
 anterior nares impossible, the 
 direction and proper location 
 of the acid, cautery knife, or 
 wire loop employed, necessitates 
 the use of the rhinoscope. But 
 as the hand which should hold 
 the tongue-depressor is needed 
 for the operating instrument, the J 
 
 Fig. 9. 
 
 arvis' combined rhi- 
 noscope and tongue- 
 depressor. 
 
64 
 
 HAY FEVEB. 
 
 former must either be held by the patient, or 
 an instrument such as that shown in Fig. 9, 
 a combined tongue-depressor and rhinoscope 
 invented by Dr. Jarvis, has to be employed. 
 
 For the application of acids, the little in- 
 strument represented in Fig. 10, will be found 
 very convenient. It consists of a plated tube 
 
 Fig. lo. 
 
 Author's acid applicator. 
 
 mounted on an ebony handle, and containing 
 a thin rod, which is flattened near the end 
 and curved, the bent portion being hardened 
 so as to possess enough spring to reassume 
 its shape after being straightened out. A slot 
 about one inch in length, cut through the 
 upper surface of the tube, at its point of at- 
 tachment to the handle, exposes the near end 
 of the rod, which is here furnished with a 
 
HAY FEVEK. 65 
 
 knob. This knob is perforated horizontally 
 and perpendicularly, the holes thus formed ac- 
 commodating a pin ^Yhic•h is attached to a flat- 
 tened spring, which, in turn, is bent in the 
 shape of an arc, and is screwed to the handle. 
 The pin fitting loosely in either of the holes, 
 the sx^ring and rod (/an be easily disconnected, 
 and the latter's curved tip can thus be pointed 
 in any dii'ection, after which the pin can be 
 inserted in the hole neai'est its point. When 
 pressed upon, the spring drives the rod before 
 it, causing its end to f)rotrude beyond that of 
 the instrument, and draws it in again when 
 the pressure is released. 
 
 Of the three acids mentioned, chromic acid 
 is by far the most satisfactory for posterior 
 applications. Nitric acid is not sufficiently 
 safe, while glacial acetic acid requires too 
 many applications. 
 
 When an application is to be made, the 
 instrument is adjusted so that the curved tip 
 will take the proper direction on emerging, 
 and the end of the rod is protruded. The tip 
 
 6* 
 
66 HAY FEYEE. 
 
 is heated slightly to the fire of a match, and 
 dipped among the crystals of the acid, then 
 allowed to re-enter the tube. Enough of chro- 
 mic acid will have adhered to the rod for the 
 application. The tube being passed through 
 the nasal cavity as far as the hypertrophy, 
 the rhinoscope, held with the left hand, is 
 placed in position, and the parts are illumi- 
 nated. The location of the tube Ijoing ascer- 
 tained, its point is placed against the side of 
 the growth, and the spring is pressed upon. 
 This forces the acid-covered tip to emerge, 
 the bend causing it to apply itself against the 
 growth. By now drawing the instrument out 
 a short distance, the application can be made 
 more effective, the point thus parting with all 
 its acid on the hypertrophied membrane as it 
 rubs against it. The pressure on the spring 
 being then released, the tip disappears in the 
 tube, and the instrument can be withdi'awn. 
 A solution of bicarbonate of soda, used pos- 
 teriorly with the atomizer, is always indicated 
 after this operation, to neutralize any excess 
 
» HAY FEVEE. ^ 67 
 
 of the acid that might have remained on the 
 membrane, and to limit absorption. Four or 
 five applications of this kind generally cause 
 marked shrinkage of a moderate-sized growth. 
 
 Galvano-cautery can also l)e used in the 
 same manner bj introducing the (nxutei'y knife 
 instead of the acid applicator. Its use, how- 
 ever, should be limited to septal growths, the 
 close proximity of the turljinate hypertrophies 
 to the mouth of the Eustachian tubes render- 
 ing inflammation of the latter liable to occur 
 from the effects of radiation. 
 
 Wlien the hypertrophy is of the hard 
 variety, and the use of the snare becomes 
 necessary, preference should he given to the 
 galvanic snare, if that can be obtained. The 
 operation can be performed much more rap- 
 idly, and the danger of seeondai'v hemorrhage 
 is avoided. The rhinoscope must of course be 
 employed as for the application of acids, the 
 snare being held and guided with the right 
 hand. In some cases it is necessary to retract 
 the soft palate, in order to avoid its tendency 
 
68 HAY FEVEE. 
 
 to adapt itself against ttie pharynx and inter- 
 fere with the view during the application of 
 the loop. An easy manner of accomplishing 
 this, is to tie a piece of white tape, a foot 
 long, to the broad end of a small-sized ure- 
 thral rubber bougie, and to pass the latter 
 through the nasal cavity until its end is seen 
 protruding below the soft palate. Being seized 
 with a pair of forceps, it is drawn out through 
 the mouth, until the tape, which has, of course, 
 followed the catheter, jirotrudes about as much 
 out of the mouth as its other end protrudes 
 through the nose. The two ends are tied sufd- 
 ciently tight to leave a satisfactory space at 
 the isthmus, and the catheter is detached and 
 withdrawn. It should, if possible, be applied 
 on the same side as the tumor, but when this 
 cannot l)e done, and the other nasal cavity is 
 alone perniealjle, the tape can be passed across 
 the posterior surface of the uvula and caused 
 to emerge through the arch on the side of the 
 hypertrophy when drawn out. 
 
 An estimate of the size of the growth hav- 
 
HAY FEYEE. 
 
 69 
 
 ing been formed, the wire loop should be 
 made sufficiently large to slip over it with 
 
 Fig. II. 
 
 I Author's galvano-cautery snare in position.* 2. Rhinoscopic view. 
 
 ease. In tlie majority of cases, the growth 
 
 * This instrument is a modification of Shurly's handle. 
 
70 HAY FEVEE. 
 
 protrudes sufficiently beyond the outline of 
 the turbinated body to be easily caught in 
 the loop, but at times it does not, and the 
 wire slips over its surface without engaging 
 it. When such is the case, the loop should be 
 bent on the tube at an angle of about fifty 
 degrees, before introducing it. When traction 
 is produced, the loop will first straighten 
 itself, then lean over to the opposite side, and, 
 if properly adjusted, encircle the tumor. If 
 the galvano-cautery snare is em})loyed, pres- 
 sure is exerted on the finger-lever as shown in 
 Fig. 10, without, however, closing the circuit. 
 This will cause the wire to tighten itself 
 around the growth until a pedicle is formed. 
 Leaving it in this position for a few moments, 
 the rhinoscope is withdrawn, and the left hand 
 is used to turn the milled nut at the end of 
 the instrument. The circuit being now closed, 
 a quarter revolution of the nut will cause the 
 glowing wire to bury itself in the tissues, 
 coagulating the blood in the severed vessels 
 and preventing what hemorrhage might occiu'. 
 
HAY FEVEB. 71 
 
 As soon as the nut stops turning, the circuit 
 is broken, and after waiting a couple of min- 
 utes the same process is repeated, to be again 
 arrested and renewed until complete separation 
 of the growth occurs. With the cold snare, 
 the procedure is the same, only that much 
 more time should be employed, to accomplish 
 the operation safely. Although the chances of 
 hemorrhage are very small in hard hyper- 
 trophies, one moderately large sinus would 
 be sufficient to cause copious bleeding, this 
 usually occurring some time after the opera- 
 tion, when the physician is not on hand to 
 arrest it. 
 
 The wire generally employed- for these 
 operations is what is known as the No. 5 
 piano wire, which possesses more elasticity 
 and tensile strength than ordinary annealed 
 wire. When the loop has engaged the mass 
 firmly, which can be ascertained by with- 
 drawing the instrument until its progress be- 
 comes arrested by the tumor, a few turns 
 of the milled nut will secure it. The exact 
 
i2 HAY FEVEB. 
 
 position of the wire sliould now be deter- 
 mined with the rhinoscope, and if satisfac- 
 tory, the nut is turned slowly until firm 
 resistan(_'e is felt. After a few minutes 
 another turn is given, repeating the periods of 
 rest and traction, until the growth has been 
 complet(4y severed. The mass usually comes 
 out with the snare, but when it does not the 
 latter should be used as a prolx' to push it 
 inti:) the posterior nasal cavity, and cause it 
 to drop through the isthnn;s into the mouth ; 
 or, the })atient can lie dir<_'cted to inhale vio- 
 lently through the cavity operated in, the nos- 
 tril of the other sidi.' being closed with the 
 finger. An insufflation of pure tannin will 
 greatly lessen the chances of secondary hem- 
 orrhage, and the patient should be ordered a 
 small quantity to use as snuff, should bleeding 
 occur. 
 
 Having described the treatment of the ab- 
 normal conditions of the nasal cavities which 
 are most frequently found in connection with 
 the hay fever dyscrasia, we must refer the 
 
HAY PEVEE. 73 
 
 reader to general works on nasal diseases for in- 
 formation as to the curative measures to be em- 
 ployed when other affections are encountered, 
 such as polypi, deviations of the septum, 
 etc., and proceed to the description of the 
 method employed to annul the hyperaesthesia 
 in the other portions of the nasal cavities. 
 
 Organic alteration of the surface of the 
 membrane can be inducecl by the application 
 of galvano-cautery, or of caustic acids. Each 
 sensitive spot must be ascertained and treated 
 with the agent used until the exaggerated sen- 
 sitiveness is replaced by the normal sensation 
 of contact. When the galvano-cautery is to 
 be used, it is very essential to have a battery 
 powerful enough to cause the platinum loop to 
 suddenly attain white heat, so as to avoid the 
 pain caused by the gradual in(/rease of tem- 
 perature, and prevent prolonged radiation. 
 This condition being fulfilled, we require a 
 loop which, upon lieiug entered into the nasal 
 cavity, will be sufficiently blunt at the point 
 and edges, not to scratch or cut the mucous 
 
 7 
 
74 
 
 HAY FEVEE. 
 
 membrane, when gently passed over it. I have 
 
 Fig. 12. 
 
 The cautery knife applied to the anterior area, c, middle area; a, posterior area; 
 d and e, sensitive surface of middle turbinated body. 
 
 found the tip shown in Fig. 12, which re- 
 sembles an ordinary cautery knife, but is more 
 
HAY FEVEK. 75 
 
 rounded at the point and somewhat broader, 
 most satisfactory. It can be easily introduced 
 in all the sinuosities of the fossae. 
 
 The nasal cavity being properly dilated and 
 illuminated, the cautery knife is introduced 
 gently and applied flatwise to the anterior 
 area as indicated in the cut. If the part is 
 not sensitive, the patient will not wince, the 
 sensation being hardly more than a slight itch- 
 ing. If it is hyperfesthetic, a feeling of intense 
 itching or burning will be ('omplained of, fol- 
 lowed, in some cases, by profuse lachrymation. 
 As soon as the evidences of abnormal sensi- 
 tiveness appear, care should be taken not to 
 move the platinum tip, and the circuit being 
 closed, the metal singes the s})ot, destroying 
 the superficial nervous filaments. If the plati- 
 num becomes white hot immediately, compara- 
 tively little if any pain will be experienced, 
 but the contrary will certainly be the case, 
 if a weak current, or a knife so thin that the 
 nasal mucus will prevent it from becoming 
 heated rapidly, is used. 
 
76 HAY FEVER. 
 
 One spot being cauterized, another sensitive 
 spot is searched for by gently passing the loop 
 over the surface until the patient complains of 
 the sensations experienced before, when the 
 current is again applied. In this manner 
 the entire respiratory area should be gone 
 over, until the instrument can be applied to 
 any part of the membrane without exciting 
 reflex symptoms or causing the violent itching 
 or burning, which the patient soon learns to 
 recognize. 
 
 The pain accompanying these applications 
 varies according to the degree of heat em- 
 ployed. White heat, which cauterizes in an 
 instant, destroys the nerve filaments before they 
 have time to convey the sensation of pain to the 
 nerve centres. Cherry heat causes some pain, 
 while black heat is exceedingly painful. White 
 heat, therefore, should always be employed for 
 superficial applications. 
 
 The cauterizations should always be begun 
 in the anterior portions of the nasal cavity, 
 (except when reflex asthma is present, as a com- 
 
HAY PEVEK. 77 
 
 plication of tlie affection, for reasons wMch will 
 be explained later on), so that the anterior hy- 
 pergesthesia will not be present when the poste- 
 rior parts are examined, and thus conceal the 
 sensitiveness, or convey a wrong idea as to 
 its location. The septum should be as care- 
 fully examined as the turbinated bones, and any 
 spot of even doubtful hypersesthesia cauterized. 
 Three or four spots can be cauterized at 
 one sitting, and it is best to locate them some 
 distance apart. A sensitive spot being found 
 in the upper part of the anterior area, for in- 
 stance, and cauterized, the next spot should 
 be looked for in the lower part of the septum, 
 etc. In short, the object should be to avoid 
 large superficial abrasions, numerous small 
 ones healing much faster and producing no dis- 
 agreeable after-effects. In the great majority 
 of cases, a few minutes after the applications 
 are made, all annoying sensations are passed, 
 and the patient can return to his business 
 without fear of being in the least troubled. 
 In some few, however, the membrane swells 
 
 7* 
 
78 HAY FEVEK. 
 
 for awhile, and the patient may experience 
 difficulty in breathing through the nose. When 
 such is the case, one nostiil should be treated 
 at each visit, so as to preservi,^ for the patient 
 the patency of the other, and thus insure him 
 comparative!}' free respiration. 
 
 In two eases, so far, tlie applications were 
 followed l)y an attack of eoryza, accompanied 
 by reflex symptoms. In one case it lasted ten 
 hours, in the other it continued about twenty- 
 four. 
 
 The membrane covering the middle turbi- 
 nated bone does not seem to enter the i^roeess 
 of resolution after galvano-cauteiT applications, 
 as readily as the other portions of the respira- 
 ratory n/gion. In three eases in my practice, 
 osdeniatous inflammation took place, which 
 caused me to mistake the overhanging, grape- 
 like protuberance for a pohiiiis. In one ease 
 I snared it off, causing immediate recovery; 
 the two others were left to themselves, and 
 disai)peared after a few weeks. Fortunately, 
 the limited innervation of the sui-face of the 
 
HAY PEVEK. 79 
 
 middle turbinated membrane, renders but few 
 applications necessary, and tliey should be 
 made sufficiently far apart to insure complete 
 resolution after eacli sitting. 
 
 Important in this connection is the projiei' 
 topographical recognition of the oKactory 
 membrane, which includes the ui)per third oi 
 the middle turbinated l^ody. Care should of 
 course be taken not to cauterize it, and to 
 limit the applications over the turbinated 
 bone to its lower half. With this precaution, 
 no danger to the sense of smell need be api)re- 
 hended. 
 
 The number of applications required to 
 render immunity positive, depends of course, 
 upon the number of sensitive spots. With 
 some, five sittings are sufficient, while in the 
 majority of patients from fifteen to • twenty 
 are required, each from three days to one 
 week apart, the length of the interval depend- 
 ing upon the rapidity with which resolution 
 of each cauterized spot takes place. 
 
 When the physician is not possessed of 
 
80 HAY FEVER. 
 
 galvano-cautery instruments, acids may be 
 used instead. Chromic acid would be the best 
 of any, were it not for the danger of general 
 toxaemia following its application over com- 
 paratively large surfaces. Grlacial- acetic acid, 
 with which I treated my first cases in the 
 spring of 1881, is the most satisfactory in 
 every way exco]^;)t one — the pain its applica- 
 tion gives rise to, on account of the quantity 
 which has to be used. This fact, however, 
 can in a great measure be corrected by dis- 
 solving in it hydroehlorate of cocaine to satu- 
 ration. Another feature characterizing its 
 use, is the turgescence which takes place 
 after each application, as stated when speak- 
 ing of the treatment of anterior hypertro- 
 phies. The hydroehlorate of cocaine seems 
 also to influence this result, by limiting the 
 inflammation markedly and advancing resolu- 
 tion. Dr. Beverly Eobinson, of New York,* 
 has reported good results with applications of 
 pure carl^olic acid. Unlike when it is applied 
 
 * Archives of Am, Laryngol. Association for 1884, p. 111. 
 
HAY FEVEK. 81 
 
 to other parts I found that this acid caused 
 much pain, besides imparting its well-known 
 odor, and I therefore discontinued its use. 
 Nitric acid should never be used, except for 
 the reduction of hypertrophies as described. 
 
 Fig. 13. 
 
 Author's glacial acetic acid applicator. 
 
 For the application of glacial acetic acid, 
 the instrument shown in Fig. 13 will be found 
 very satisfactory. It consists of two probes, 
 shaped like Bosworth's (Fig. 3), in close appo- 
 sition, their surfaces being so' flattened as to 
 render their contact perfect. One of the 
 
82 HAY FEVEE. 
 
 probes is fastened to the handle and is fur- 
 nished with a number of shallow holes, a dis- 
 tance of one-half inch along the inner sui'face 
 of its extremity, so that a drop of acid will 
 be retained when the other probe is placed 
 over it. The latter having free longitudinal 
 motion, can be moved freely along the other 
 by means of a finger lever, thus uncovering 
 at will the acid-covered surface.* The two 
 probes are so arranged that they can be 
 rotated together on their axis, so that the 
 acid-covered surface can be made to face any 
 direction. Their broad ends being of silver, 
 the acid does not affect them. 
 
 The manipulation of this instrument is 
 precisely the same as that of the galvano- 
 caustic knife. Being introduced into the 
 cavity, a sensitive spot is searched for with 
 both probes in apposition, and as soon as it 
 is found, the finger lever is depressed and 
 
 *The priority of the uncovering mechanism belongs to Dr. 
 Alex. McCoy, of this city, who first applied it to u, laryngeal 
 applicator of his invention, to be soon published. 
 
HAY FEVEB, 83 
 
 the acid probe being uncovered, the spot is 
 cauterized. The finger lever is then allowed 
 to raise, and the instriTment can be with- 
 drawn without cauterizing any other surface. 
 Care should be taken to cleanse the instrument 
 carefully before entering it into the nose, lest 
 some acid remain over its surface. 
 
 As to the effectiveness of this procedure, 
 I will cite the case of — 
 
 Miss M., who was treated in 1881, and whose 
 accesses had appeared regularly for several years. 
 The application of glacial acetic acid not only pre- 
 vented the S3'niptoms that year and ever since, but 
 made her mucous membrane absolutely invulnerable 
 to the effects of pollen. As a test, she exposed her- 
 self as much as possible to the emanations of the 
 plants which she knew to be the most liable to occa- 
 sion a manifestation of the disease, and went even 
 so far as to place bouquets in her bed-room and to 
 approach a field of clover, her most dangerous enemy. 
 
 As to the period when the applications 
 should be made, I am of the opinion that 
 the treatment should be begun at least two 
 
84 HAY FEVEK. 
 
 months before tlie expected attack. There 
 is sufficient time left then, to annul all the 
 hypergesthetic spots (in the great majority 
 of cases) without having to crowd the appli- 
 cations together, an unsatisfactory procedure, 
 since the inflammation is likely to impair the 
 abnormal hypersesthesia and prevent proper 
 recognition of the sensitive spots. 
 
 In three cases so far, however, I have 
 been able to arrest the paroxysm from one 
 to three weeks after it had begun, and when 
 it was at its height. 
 
 Mr. S., of this city, was sufTering intensely, and 
 notwithstanding the irritable condition of his nose, 
 allowed me to make four applications in each nos- 
 tril. A few days later he returned, feeling consid- 
 erably relieved, and the operation was repeated with 
 the same number of applications. A week later, I 
 received a postal card from him, stating that he had 
 had no hay fever since the last application. These 
 were all made in the anterior portion of the cavities. 
 This gentleman being a member of a cricket club, 
 was enabled at once to resume his position in the 
 
HAY FEVEK. 85 
 
 field without suffering the least inconvenience. He 
 continued with the treatment, coming regularly until 
 all the hypemesthetic spots had been cauterized. The 
 following season Mr. S. returned, stating that his 
 hay fever had appeared on the usual day. Exam- 
 ining the nasal cavities very carefully, I found no 
 hyperajsthesia except at the anterior area, on both 
 sides, limited to a spot about as large as a small pea. 
 One cauterization on each side arrested the paroxjsm, 
 and no recurrence took place. 
 
 Mr. B., of Chicago, 111., placed himself under treat- 
 ment five days after the onset of the paroxj'sm. Hav- 
 ing come to Philadelphia expecting that the treat- 
 ment would only require one week, and being obliged 
 to return home at the end of that time, the appli- 
 cations were made every day to each nostril. The 
 attack ceased after the third ajiplication, and did 
 not return, notwithstanding the railroad travelling, 
 which, before, caused great suffering. 
 
 This result, however, cannot be expected 
 in every case, but the applications are bene- 
 ficial in all, and reduce in a marked manner 
 the intensity of the paroxysm and its dura- 
 tion. Of seven cases treated last season in 
 
 8 
 
86 HAY FEVEB. 
 
 the midst of the hay fever, three were entirely 
 relieved, three were very much benefited, and 
 the seventh was enabled to return to his busi- 
 ness, from an imprisonment in a dark room. 
 Although his sufferings were much abated, 
 they continued until the end of his usual 
 six weeks. 
 
 When the treatment is begun at the proper 
 time, i.e., several weeks before the paroxysm, 
 its success depends entirely upon the thorough- 
 ness with which both nasal cavities have been 
 relieved of their sensitive spots. An insuf- 
 ficient number of applications, or a timid pa- 
 tient, are as likely to prevent a radical cure, 
 as a thorough treatment in a plucky patient 
 is certain to be rewarded with permanent im- 
 munity. 
 
 Mr. M., of this city, had been subject to hay fever 
 fortjr-two years. The intensit}^ of the attacks was so 
 great, that unless he absented himself from the city 
 to spend a season in a region where he enjoyed im- 
 munity, he was obliged to remain in. a dark room the 
 greater part of the period of suffering. The appli- 
 
HAY PEVEE. 87 
 
 cations, begun three weeks before the expected attack, 
 were continued twice a week until the 15th of August, 
 the usual date of the onset. No symptoms of hay 
 fever appeared. The patient being desirous of having 
 all the sensitive areas cauterized, this v/as accomplished 
 in ten more sittings, in the midst of the hay fever 
 period, without the least manifestation of the disease. 
 Mr. M. at that time finding it necessary to make a 
 trip to the Western States, feared greatly the neces- 
 sary railroad travelling, which had always, during the 
 pollen season, caused intense suffering. He, never- 
 theless, bravely undertook the journey, and notwith- 
 standing the presence of much dust, returned, after 
 having ridden over two thousand miles without having 
 experienced the least manifestation of the disease. 
 The treatment had been limited to superficial cauteri- 
 zations, no abnormal condition of the membrane ex- 
 isting other than the hyperaesthesia. 
 
 Master L., aged eight, had sufi'ered severely for 
 several years, his paroxysms being accompanied with 
 violent asthma. The treatment was begun- five weeks 
 before the date of the onset, the applications being 
 made twice a week. A few days after the usual 
 time for the attack of hay fever to begin, slight pal- 
 pebral pruritus and lachrymation occurred, but stopped 
 
88 HAY FEVEE. 
 
 after a couple of days. The treatment was continued 
 for some time during the hay fever season, notwith- 
 standing which, complete freedom from all symptoms 
 of the affection (incUiding asthma) was enjoyed. In 
 this case the hyperaestliesia was greatest over the 
 posterior and anterior areas, superficial cauterizations 
 bei)ig alone used during the entire treatment. 
 
 As an evidence of the influence of imperfect 
 cauterization on the results of the treatment, 
 I will cite the case of — 
 
 Mr. T., in whom great hj'peraesthesia of the entire 
 mucous tract rendered the least contact with any 
 object painful. He suffered greatly every year, and 
 his attacks were complicated with asthma and general 
 systemic disturbance. Owing to the great sensitive- 
 ness of the membrane, which caused the patient to 
 spring back as soon as the cautery had penetrated 
 the nasal cavity, the applications could only be made 
 at random, and were all limited to the anterior and 
 middle areas, cauterization of the posterior area being 
 impossible. The nasal symptoms were almost entirely 
 prevented, but the asthma occurred with unusual in- 
 tensity. 
 
HAY FEVEH. 89 
 
 In another case of tliis kind, however, the 
 result was entirely different: — 
 
 Miss S., of Bridgeport, bad had liay fever since her 
 childhood, marked asthma accompanying each attack. 
 The timidity of the patient rendering limitation of 
 the eanterizations to the sensitive spots impossible, 
 I concluded to singe the entire respiratory region on 
 each side, by drawing the glowing loop along the sur- 
 face of the membrane from front to back, involving 
 the three sensitive areas. No symptom of hay fever 
 (including the asthma) appeared. 
 
 An important point in connection with the 
 results of imperfect cauterization is that how- 
 ever limited the number of applications may 
 be, the benefit produced, as far as the nasal 
 symptoms are concerned, is proportionate with 
 that number, and with the thoroughness with 
 which they are performed. When but a limited 
 number of applications are made before the 
 period of attack, the onset of the paroxysm 
 is retarded, which naturally curtails the dura- 
 tion of the disease, while its intensity is re- 
 duced. 
 
90 HAY FEVEK. 
 
 Mr. C. applied for treatment two months before 
 the expected attack. Two applications were made at 
 ten days' interval, but, the patient being obliged to 
 absent himself on business, the treatment could not 
 be continvied. Some months later a letter from him 
 announced that the attack had been delayed several 
 weeks, and that it had been milder, continuing, as 
 usual, throughout the greater part of October. 
 
 Mrs. B., who had been a sufferer eleven years, ap- 
 plied for treatment three days before the usual date of 
 her attack. An application was made at once, and the 
 cauterizations were continued at four days' interval 
 until two weeks after the time her paroxysm was to 
 begin, but which had not appeared. Mrs. B., desiring 
 to attend a wedding in Connecticut, stood the six 
 hours' railway trip without inconvenience, but three 
 days after her arrival there, the hay fever appeared, 
 and, although in milder form, continued unabated 
 until the time at which it usually ceased. 
 
 Again, when reflex asthma is a complica- 
 tion of the affection, and an insufficient number 
 of applications have been made, this symptom 
 is likely to appear as the sole expression of 
 the paroxysm, the head symptoms being ab- 
 
HAY FEVEK. 91 
 
 sent, or if present, exceedingly mild. This is 
 doubtless due to the fact that the first applica- 
 tions being made anteriorly, the sensitive spots 
 in the anterior and middle areas are more or 
 less deprived of their hyperesthesia (the pres- 
 ence and intensity of the head symi)toms de- 
 pending upon the thoroughness with which this 
 is done), and the posterior area being only 
 cauterized towards the end of the treatment, 
 the symptoms which are secondary to its irri- 
 tation present themselves. This is well exem- 
 plified in the following case: 
 
 Mrs. P., who had been afflicted since her child- 
 hood, and in whom asthma was a prominent symptom, 
 placed herself under treatment four weeks before the 
 expected attack. The applications were made twice 
 a week. The first two weeks of the annual access 
 seemed rather discouraging, as the asthma appeared 
 as usual, although the head sj-mptoms were very 
 slight. The treatment was continued, however, until 
 all the hyperffisthetic spots, including the posterior, 
 had been cauterized. The symptoms of the afl"ection 
 subsided, although in the midst of the annual period 
 
92 HAY FEVER. 
 
 of suffering Mrs. P., wishing to call on some relatives 
 some distance from Philadelphia, undertook the trip, 
 notwithstanding the amount of suffering which rail- 
 road travelling usually occasioned. 
 
 Some time later, I received a letter from 
 the lady's husband, a professional colleague, 
 who wrote as follows: 
 
 " Mrs. P. and myself came directly here, a distance 
 of about two hundred miles from Philadelphia. Beyond 
 a little fatigue incident to the journey in the hottest of 
 hot weather, Mrs. P. experienced no discomfort what- 
 ever. Since she came here, her health has been excel- 
 lent, and whatever symptoms she had of the presence 
 of the ' tormentor' rapidly subsided. In fact, I may 
 say that the month of September, thus far, has found 
 her completely free from the trouble, and that too 
 in a locality where in other j-ears she has spent the 
 larger part of the month in bed. Her health has been 
 as good as at any other time of the year, notwith- 
 standing the intense heat of the earlier dajs of the 
 present month. * * *." 
 
 A conclusion which I have come to lately, 
 and which is borne out in the above cases and 
 
HAY FEVEK. 93 
 
 by close observation in all the others, is that 
 when reflex asthma exists as a complication of 
 the head symptoms, a greater number of appli- 
 cations are required than when it does not, and 
 that immunity from all the symptoms can only 
 be obtained when all three of the sensitive 
 areas have been thoroughly treated, the treat- 
 ment of the posterior area being such as to 
 limit the inordinate power of turgescence, 
 which is alwa7y"s present when true hyper- 
 trophy does not exist. In accordance with 
 this view, I now direct my attention first to 
 the posterior area, ivhen reflex asthma exists^ 
 employing chromic acid, galvano-cautery, or 
 the snare ecraseur as needs be. This is 
 greatly facilitated by annulling the hyperses- 
 thesia of the anterior and middds areas with a 
 four per cent, solution of cocaine. 
 
 In the cases in which asthma is the only 
 symptom, this procedure, when thoroughly con- 
 ducted, will often sufiice to cure the affection, 
 even, sometimes, when mild head symptoms 
 are present (these being due to implication of 
 
94 HAY FEVEE. 
 
 what terminal filaments of the nasal nerve may 
 extend in the sensitive region), but, as these 
 cases are rare, applications to the anterior and 
 middle areas are nearly always necessary. 
 
 Again, a mild case of hay fever, compli- 
 cated with reflex asthma, may be due solely 
 to hypergesthesia of the middle area, and be 
 cured by a treatment limited to it. Here, the 
 asthma is due to the turgeseence of the posterior 
 area occurring as a result of the inflammatory 
 process, while the head symptoms are induced, 
 as just stated, through implication of the nasal 
 nerve in the hyperaesthetic region. I am of 
 the opinion, however, that it is always best to 
 include the posterior ends of the turbinated 
 bodies in the treatment. 
 
 As stated under the heading of Pathology^ 
 catarrhal asthma, which occurs late in 
 the history of the affection, is much more 
 frequently met with than the reflex variety, 
 which comes on as soon as the Schneiderian 
 membrane has become sufficiently turgid, 
 through the local inflammation, to induce 
 
HAY FEVEK. 95 
 
 pressure against that of tlie septum. Being 
 due to extension of the- inflammation by con- 
 tinuity of tissue, it can only present itself, 
 provided the nasal symptoms take place, and 
 prevention of ihe latter will obviously deprive 
 the asthma of its primary cause and prevent 
 it. When the membrane is free from hyper- 
 trophies, etc., cauterization of the sensitive 
 spots, whether these be situated in the anterior, 
 middle or posterior areas, will therefore be suffi- 
 cient to prevent both head symptoms and 
 asthma, a fact so far demonstrated in six cases. 
 
 When the head symptoms solely charac- 
 terize the accesses, the greatest hypersesthesia 
 will be found in the anterior area, which will 
 of course require the brunt of the treatment. 
 Any other sensitive spot, however, should also 
 be effectively cauterized. 
 
 The internal administration of nerve-tonics 
 such as strychnia, nux vomica, etc., and ehaly- 
 beates where anaemia exists, is a valuable 
 adjuvant to the local treatment. Quinia seems 
 to exert a beneficial influence in preventing 
 
96 HAY FEVEK. 
 
 what premonitory symptoms the patient may 
 be liable to, two grains being administered 
 three times daily. When the patient applies 
 for treatment dm-ing a paroxysm or just before 
 it, a four per cent, solution of hydrochlorate 
 of cocaine applied with a cotton pledget every 
 two hours, will doubtless furnish much relief, 
 judging from its effects in acute coryza. It 
 should not be used, however, at least three 
 hours before the cauterizations, so as to avoid 
 the interference with the discernment of sensi- 
 tive spots, which its anaesthetic property might 
 occasion. 
 
 After-effects of the local treatment. — ^Although 
 the number of cases treated so far has been 
 rather large, I have not had to regret any ill- 
 effect occurring as a result of the treatment. 
 The sense of smell instead of being obtunded, 
 is frequently improved, especially when an- 
 terior hypertrophies are reduced in the course 
 of the treatment. This is easily explained by 
 the fact that the olfactory membrane is not 
 involved in the treatment, and that by faeHi- 
 
HAY FEVEE. 97 
 
 tating tlie passage of air by tlie reduction, of 
 tlie tumefactions, the odoriferous particles can 
 reach the olfactory area in greater number 
 and Avith more freedom. 
 
 The permanent nasal hypertesthesia which 
 exists in the majority of hay fever cases, 
 through which irritating substances cause 
 much annoyance, itching, sneezing, etc., is 
 naturally obviated in every instance. The 
 following abstract, which alludes to a patient 
 already mentioned, will illustrate the truth 
 of this assertion: 
 
 '• We came directly to W. to find the cit}' suffer- 
 ing from a drought wliich was protracted to the end 
 of tlie month. The duwt and heat were intolerable. 
 We had some of the very hottest weather in October. 
 Mrs. P. did not experience the least annoyance, not- 
 withstanding these nnfavorable conditions. Besides, 
 she returned to W. earlier by five weeks than she 
 had ever dared to for years. Indeed, her return some 
 j'ears had been protracted as late as now (Dec. I'lth), 
 depending, of course, upon the early or late fall. She 
 could not have selected a more unhappj' period, had 
 
 9 
 
98 HAY FEVEE. 
 
 she been still a sufferer from hay fever, than the time 
 mentioned ; and it continued, with here and there a 
 cool daj', all through October and part of November. 
 The dust was dreadful. She did not experience the 
 slightest discomfort from any of these untoward con- 
 ditions. As she told J'ou, heretofore, in winter even, 
 the least amount of dust, from cloth, for instance, 
 would irritate her very much. This susceptibility is 
 entirely removed, etc." 
 
 As to the permanenc}^ of tlie immunity, it 
 depends, of course, upon the thoroughness with 
 which the treatment is conducted. A spot as 
 large as a small pea, left in its hyper^sthetic 
 state may not be active during the period of 
 the first paroxysm, owing to the proximity 
 of the curative treatment and the temporary 
 local inflammation set up ]jy it, while the fol- 
 lowing year, having reassumed its hyperses- 
 thesia, it may occasion unmistakable, although 
 shght symptoms of the disease. This was illus- 
 trated in the case of Mr. S., page 84, in whom 
 one application in each anterior area, however, 
 sufficed to arrest all manifestations. In all 
 
HAY FEVEK. 99 
 
 cases in whieli a satisfactory treatment could 
 be carried out, the patient possessing enougli 
 self-control to allow me to make tlie applica- 
 tions in a thorough manner, the symptoms 
 did not recur; and as two cases treated in 
 1881 are included in the number, the radical 
 character of the cure becomes evident. This 
 is further corroborated by the cases reported 
 by Daly,* Eoe,t and Shurly.| 
 
 The conclusions to be drawn can be sum- 
 marized as follows : 
 
 1. That, as a result of heredity or of dis- 
 eases implicating markedly the nervous sys- 
 tem, the nerve centres become abnormally 
 sensitive, and are, therefore, inordinately in- 
 fluenced by the extei^nal elements to which 
 they are naturally susceptible. 
 
 2. That, as a result of local disease, the 
 portions of the nasal mucous membrane over 
 which the .branches of the spheno-palatine 
 
 * Op. cit. t Op. cit. i Archives Am. Laryng. Assoc, for 1884. 
 
100 HAY FEVEE. 
 
 ganglion and those of the nasal branches of 
 the ophthalmic nerves are distributed become 
 hypersesthetic, and capable of acting as media 
 for the transmission of impressions made 
 upon their surface to the nerve centres. 
 
 3. That when these two conditions co- 
 exist and when the external elements to which 
 the nerve centres are inordinately sensitive 
 are present in the atmosphere, a paroxysm 
 termed "hay fever" is excited. 
 
 4. That the paroxysm cannot take place 
 unless the inordinate susceptibility of the 
 nerve centres, the intra-nasal hyperaesthesia 
 and the external irritating cause are present 
 simultaneously. 
 
 5. That since one of the necessary ele- 
 ments, the external irritating cause, is only 
 present at a certain time each year, the par- 
 oxysm can only occur at that certain time. 
 
 6. That as a consequence of the above, 
 elimination one of the three elements neces- 
 sary to the production of a paroxysm will 
 prevent its occurrence. 
 
HAY FEVEK.' 101 
 
 7. That by cauterizing by means of gal- 
 vano-cautery or acids the bypersesthetic por- 
 tions of the membrane, their hypergesthesia 
 can be permanently annulled. 
 
 8. That the medium between the external 
 irritating cause and the systemic dyscrasia 
 being thus obliterated, the periodical parox- 
 ysms termed "hay fever" become impossible. 
 
 9. That there are in the nose three hyper- 
 festhetic areas, for which the terms posterior, 
 middle and anterior areas are proposed, and 
 which are individually or conjointly the prin- 
 cipal seats of the hyperfesthesia in hay fever 
 subjects. 
 
 10. That the posterior area is principally 
 implicated when reflex asthma is the most 
 prominent symptom of the affection. 
 
 11. That the anterior area is principally 
 implicated when head symptoms are alone 
 present. 
 
 12. That when head symptoms and reflex 
 asthma are present both anterior and pos- 
 terior areas are implicated. 
 
 9* 
 
102 HAT FEVER. 
 
 13. That the middle area may alone be 
 the starting point of all the symptoms com- 
 bined. 
 
 14. That catarrhal asthma has no re- 
 lation with the nasal hypersesthesia, being 
 merely a result of the local inflammation oc- 
 curring during a paroxysm. 
 
 As bearing directly upon the treatment, I 
 would suggest the following : — 
 
 1. That all abnormal conditions of the 
 nasal cavities, such as marked hypertrophies, 
 polypi, exostoses, etc., must be eradicated be- 
 fore instituting the superficial cauterizations. 
 
 2. That the latter are productive of best 
 results when begun six weeks at least before 
 the onset of the paroxysm. 
 
 3. That the treatment can be conducted 
 duriiifi a paroxysm, the latter being arrested 
 in some and beneficially modified in others. 
 
 4. That the immunity against hay fever 
 depends upon the thoroughness with which 
 the treatment is conducted. 
 
HAY FEVEK. 103 
 
 In a paper i-ead before the American 
 Laryngological Association, on tlie 12tli of 
 May, 1884, I inadvertently o-^'eiiooked the fact 
 that Dr. W. H. Daly, of Pittsburgh, Pa., had 
 been the first to demonstrate to the profession 
 the relation of hay fever and disease of the 
 nasal cavities, and accorded the credit to Dr. 
 J. O. Roe, of Rochester, N. Y., who subse- 
 quently developed the same ^•ie^v in the ad- 
 mirable paper cited. I, therefore, take ad- 
 vantage of this opportunit>' to rectify my 
 error. In justice to myself, however, I must 
 also state that my paper, entitled "Notes on 
 Hay Fever," published December 22, 1883, was 
 the first to demonstrate tlic practical value 
 of superficial oi'ganic alteration of the nasal 
 mucous membrane as a radical remedy for 
 the disease, and that I am, therefore, entitled 
 to the priority of this method of treatment. 
 
In Peess — Will Appear Oct. 1, 1885. 
 
 OS 
 
 DISEASES 
 
 or THE 
 
 Nose and Throat. 
 
 CHARLES E. SAJOIIS, M.D., 
 
 Instructor in Rhinology and Laryngology in the Post-Graduate 
 Course of Jefferson Medical College; President of the Phila- 
 delphia Laryngological Society; Fellow of the American 
 Laryngological Association, of the Royal Society 
 of Belgium, of the Medical Society of 
 Warsaw (Russia), etc., etc. 
 
 In one handsome octavo volume of about ^00 pages, with 
 
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 From Oil Paintings by the Author, and 
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 1317 Filbert Street, 
 
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 THE OLEATES. 
 
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 It gives in concise form the nature and uses of the 
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