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Title: The Treatment of Hay Fever
By rosin-weed, echthyol and faradic electricity, with a
discussion of the old theory of gout and the new theory
of anaphylaxis
Author: George Frederick Laidlaw
Release Date: July 20, 2012 [EBook #40287]
Language: English
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THE TREATMENT
OF HAY FEVER
BY ROSIN-WEED, ICHTHYOL AND FARADIC
ELECTRICITY, WITH A DISCUSSION OF THE OLD
THEORY OF GOUT AND THE NEW
THEORY OF ANAPHYLAXIS
BY
GEORGE FREDERICK LAIDLAW, M.D.
Consulting Physician to Yonkers Homoeopathic Hospital; to St. Mary's
Hospital, Passaic; and to the Ann Mary Memorial Hospital, Spring
Lake, New Jersey; Consulting Physician to Cumberland Street
Hospital, Brooklyn, Department of Public Charities
Formerly Professor of Practice of Medicine in the New York
Homoeopathic Medical College; formerly Visiting Physician to Flower
Hospital; to Hahnemann Hospital and to the Metropolitan Hospital,
Blackwells Island, Department of Public Charities, New York
BOERICKE & RUNYON
NEW YORK
1917
COPYRIGHT, 1917, BY
BOERICKE & RUNYON
PREFACE
The essentials of this book, rosin-weed, ichthyol, and faradism, were
announced at the Baltimore meeting of the American Institute of
Homoeopathy, in June, 1916, and published simultaneously in the _New
England Medical Gazette_ and in the _Journal of the American Institute
of Homoeopathy_ in December, 1916. They were presented also at the New
York City branch of the United States Hay Fever Association in July,
1916; at the annual meeting of the same Association at Bethlehem, New
Hampshire, in August, 1916; and rather widely printed in the public
press of New York and Boston in the summer of 1916.
As a suggestion to those who may wish to follow the subject of hay
fever in its recent interesting developments, chapters have been added
on the old conception of gout, the new theory of anaphylaxis and
treatment by diet, by pollen extracts and by bacterial vaccines.
CONTENTS
PAGE
I. The Diagnosis 9
II. Rosin-weed 14
III. Ichthyol and the Point in the Naso-pharynx
that Controls the Symptoms 17
IV. Menthol and Eucalyptol 20
V. The Faradic Current and Other Forms
of Electricity 27
VI. Hay Fever as Urticaria 38
VII. Dr. Gueneau de Mussy. Hay Fever as
Urticaria Again 44
VIII. Hay Fever as Gout 51
IX. The Uric Acid Theory 66
X. Hay Fever as Anaphylaxis 76
XI. Immunizing with Pollen Extracts 91
XII. The Bacterial Vaccines 108
XIII. Diet 113
XIV. Rosin-weed Again. Historical and
Pharmacological 123
THE TREATMENT OF HAY FEVER
CHAPTER I
_THE DIAGNOSIS_
Under the name "hay fever" I include rose-cold and the so-called
hyperæsthetic catarrh or vaso-motor rhinitis, all characterized by
intense itching of the eyes, nose, and throat, free discharge, sometimes
asthma, the attacks being precipitated by strong odors, dust, or pollen.
There are many forms of the disease, some occurring in May or June, some
as early as March, before the budding of vegetation, some even in the
winter; but the large majority of cases occur in August, coincident with
the flowering of late summer vegetation, notably the rag-weed and
golden-rod. It is not so well known that the California privet, so
widely used in hedges and parks, aggravates many patients, especially in
June and July, when the scent of the flowers is strong. Others are
irritated instantly by the odor of crude oil that is spread so freely
on the roads in summer, by metal-dust, and by the cinders of a railway
trip. Some patients are sensitive to one irritant, some to many
irritants. I knew one man whose itching of the eyes began in March, nose
and throat following in April and May, cough in July and August, who was
sensitive to each and all of these irritants from March to October every
year for thirty years.
If we follow the modern tendency and classify the cases according to the
specific irritant, we shall have an endless number of varieties
according to the endless number of possible irritants; and where will
you classify the man who is subject to them all? In the present state of
our knowledge, it seems better to regard the sensitiveness to irritants
as the characteristic of these cases and to think of them as different
forms of the same disease. In most text-books this idea is expressed by
the terms _hyperæsthetic catarrh_ and _vaso-motor rhinitis_; but there
are serious pathological objections to the terms _catarrh_ and
_rhinitis_. These objections and the reasons for regarding the lesion as
an angioneurotic oedema are discussed in Chapter VI, on Hay Fever as
Urticaria, to which the reader is referred.
An additional reason for regarding all these varieties as superficially
differing forms of the same disease is the fact that all of them are
curable by the same methods. I am aware of the danger of error in this
argument, the persuasive but misleading _Analogieschluss_, and would not
advance it too strongly. However, for all practical purposes except the
vaccine treatment, described in Chapter XII, all these hyperæsthetic
cases may be regarded as varieties of the same disease.
With a patient suffering from hay fever, as with a patient suffering
from any other disease, the first thing to do is to take the history and
make an examination. Usually, the nature of the case will be clear from
the history, but it is a mistake to rest here without looking into the
nose and throat. In the nose, you may find anything from a polyp to a
shoe-button, any of which may require mechanical removal before you will
make any progress with your medicines, no matter how well selected.
Usually, you will find nothing but a swelling of the mucous membrane of
the turbinates with free discharge. If you are an adept at examining the
nose, you will probably search for the sensitive areas, touching of
which causes a spasm of sneezing. These may be found anywhere in the
nose, but most commonly at the anterior and posterior ends of the middle
and inferior turbinated bones. I apply ichthyol to the naso-pharynx to
test the sensitive area described in Chapter III.
What constitutes a gross lesion requiring surgical removal? Competent
men differ widely and the practice of the same man has differed widely
at different stages of his career. For a time there was enthusiastic
cutting of septal spurs and burning of redundant mucosa and cauterizing
of sensitive areas. I think that the relation of the nose specialist to
hay fever is similar to the relation of the abdominal surgeon to
neurasthenics. The more experienced he becomes, the more he advises
letting them alone or using gentle measures. Distinct polyps should be
removed.
Having finished the examination and found no gross lesion requiring
surgical removal, the treatment must be decided. The easiest plan for
both patient and physician is to give rosin-weed, as described in
Chapter II.
The most painful for the patient but often effective in severe cases is
the application of ichthyol, as described in Chapter III.
If the patient is systematic and will attend to it, the ichthyol may be
replaced by the _frequent_ spraying with menthol and eucalyptol, as
described in Chapter IV.
The best treatment of all, but that which takes the most time of both
patient and physician, is the use of electricity, as described in
Chapter V.
Consider the possible importance of diet in the case, as described in
Chapter XIII.
Finally, ponder on the nature of hay fever, as discussed in Chapters VI
to X, and the advisability of using vaccines or pollen extracts, and you
will have done your whole duty by your patient and by your art.
CHAPTER II
_ROSIN-WEED_
For many years the fluid extract of rosin-weed has been known in my
family as a remedy for rose-cold and hay fever. This use of it was
discovered by my father, Dr. Alexander H. Laidlaw, in the epizoötic days
of 1872, when horses were dying by the thousands all over the United
States and Canada. Though he knew it first as a horse medicine, its use
seems to be forgotten in veterinary practice, for I find no mention of
it in available veterinary books, old or new.
In my father's practice this remedy acquired considerable fame, and I
still receive a letter or two every summer from distant cities from some
one who has heard of the miraculous medicine. For many years it was his
intention to give this remedy to the world in proper form, supported by
competent testimony; but, in a busy life, with many projects
unfulfilled, this was never done. During my own professional life I have
been interested in many things that seemed more important than hay
fever and have not heretofore taken up the matter of publishing our
experiences with the drug. Realizing that there were many hay fever
victims both in this country and in Europe who might just as well be
getting the relief that this drug would give them if they only knew
about it, and having no desire to profit by my possession of the secret
of this remedy, I made the announcement last summer, first to the
American Institute of Homoeopathy and next to the United States Hay
Fever Association. I announced it first to my old society, the
Institute, believing that my friends there, who have known me many
years, would credit my statements as made in good faith and give the
drug a fair trial.
=The Dose.= Beginning ten days before the expected attack, give ten drops
of the fluid extract of rosin-weed in a little water four times daily,
after meals and on retiring. To children, give five drops. If the
symptoms of hay fever appear, increase the dose to twenty and even
thirty drops and continue this dose through the entire hay fever
season.
It is better to begin ten days before the expected attack, for, in hay
fever, as in all periodic diseases, prevention is better than cure,
requires smaller doses, and is more certain. However, few patients are
wise enough to anticipate trouble. Most patients apply for treatment
when, literally, the disease is in full blast, and most of my
observations have been made on the latter class. In case the disease has
already begun, start with the same dose, ten drops. If not relieved in
three days, increase the dose by five drops every third day up to thirty
drops. If the symptoms should be relieved by the smaller dose, it is
unnecessary to increase it.
=Cure Or Palliation?= In regard to the permanence of the cure, most
patients require it for several seasons. Some need it every season for
many years. A few are permanently cured in one season.
For further information about the plant, rosin weed, its preparation and
use in medicine, the reader is referred to Chapter XIV.
CHAPTER III
_ICHTHYOL AND THE POINT IN THE NASO-PHARYNX THAT CONTROLS THE SYMPTOMS_
While the use of rosin-weed was discovered by my father, the value of
ichthyol in the treatment of hay fever and the point in the naso-pharynx
that controls the symptoms are discoveries of my own or, at least, I
fondly think so. In current medical literature, I find no reference to
it. In Merck's _History and Preparation of Ichthyol_, a summary of its
use to 1913, ichthyol is advised in hypertrophic and atrophic rhinitis,
but hay fever is not mentioned. Reference to recent books, as Coakley,
Ballenger, Ivins, Bosworth, Kyle, Grayson, show no knowledge of the use
of ichthyol in hay fever nor of the spot in the naso-pharynx that
controls the symptoms.
The point of the matter is this. In hay fever, the itching and redness
of the eyes, nose, and throat are controlled from a sensitive point in
the naso-pharynx. Local applications to this point will relieve almost
instantly not only the itching of the throat but also the itching of the
eyes and nose and all symptoms of the disease. In some cases such relief
carried out for several seasons makes permanent cures.
My knowledge of it came about in this wise. At about the age of sixteen
I developed a rose-cold that began in June and extended into September.
A few years later it began in April and lasted until October. By one of
those ironical tricks that fate plays on the great ones of the earth,
rosin-weed, the family remedy that cured everybody else, gave me only
partial relief. It is unnecessary to follow in detail the various
experiments made. This was long before the days of Dunbar's pollantin,
Holbrook Curtis' ambrosia, adrenalin, and the modern vaccines. I did not
think cocaine a safe drug and never used it, preferring the hay fever to
the cocaine habit. About this time ichthyol was introduced by Merck for
the treatment of catarrh of all mucous membranes and I found that
ichthyol, used in a certain manner, relieved the symptoms completely. On
swabbing the naso-pharynx with pure ichthyol, there was a severe
burning sensation for a minute or so, but, when the burning subsided,
there was great relief, not only of the itching throat but also of the
itching of the eyes and nose. That is, in the customary swabbing of the
naso-pharynx, we touch a point that controls the whole group of symptoms
of the eyes, nose, and throat.
In those days the laryngeal and pharyngeal tonsils were very much to the
fore in medical discussions, and at first I thought that this point was
probably the pharyngeal tonsil of Luschka. However, judging from the
location of the most severe burning, the controlling point is rather on
the upper surface of the soft palate. The exact location of this point
is not of practical importance. If you swab each side of the
naso-pharynx with plenty of ichthyol, the reflex contraction of the
pharynx while the swab is in it will spread the ichthyol over the right
territory.
CHAPTER IV
_MENTHOL AND EUCALYPTOL_
The ichthyol treatment described in the last Chapter is very effective,
but it burns severely for a few minutes and, for this reason, some
patients will not endure it. With children, it is impossible. Another
disadvantage to the patient and, sometimes, to the doctor, too, is that
it requires the patient to come to the doctor every day for the
application, though Dr. Hollister tells me that he had one patient who
learned to apply the ichthyol to her own naso-pharynx and, what is more
wonderful still, kept up the treatment long enough to get well. In
recent years I have hit on a treatment that is more comfortable than
ichthyol and in many cases equally effective, though a little slower in
giving relief. It can be carried out by the patient with little trouble
and requires no skill in handling nasal swabs, an important matter with
nervous patients and children.
I have found that the ordinary solution of menthol and eucalyptol and
thymol in liquid albolene will relieve hay fever if applied to a certain
spot a certain number of times a day. At this point I can see the
reader's face assuming an expression of pained surprise. What is there
wonderful about that? Is there not a bottle of this solution on the
table of every doctor in the country and does not every modern textbook
on the Nose and Throat advise inhaling vapor of such a solution to
relieve hay fever? True. Note that I did not say that simply spraying
this solution in the nose and throat will cure hay fever. I said that it
must be applied to a certain spot a certain number of times a day. It is
a case of the technique being more important than the remedy; for I have
no doubt that there are other medicines than ichthyol and menthol that
will relieve if put on the right spot. The reason that every doctor has
not discovered for himself the full value of this commonly used solution
is that he did not put it on the right spot and he did not use it often
enough.
=The Right Spot=, as related in the chapter on Ichthyol, is either the
vault of the pharynx or the upper surface of the soft palate.
=Frequency.= Once or twice a day is insignificant. It must be used every
hour or oftener when the symptoms are acute. Here I borrow an idea from
the dermatologist who learned long ago from Unna that when an ointment
rubbed on twice a day fails to cure an eczema, it may be cured by
keeping the same ointment constantly applied to the part, day and night.
The naso-pharynx of the hay fever patient requires the same continual
application of the cure and we come as near as possible to a continual
application by applying the solution every hour or two.
Such frequent applications are impracticable as office treatments, but
must be carried on at home or at business by the patient or a member of
the family. If an expert hand is available to spray the naso-pharynx,
the tip of the atomizer should be pointed forward so that the spray is
directed into the posterior nares and the posterior surface of the soft
palate as well as the vault of the pharynx. An adroit patient may learn
to do this, but even an adroit patient, unfamiliar with the anatomy of
the throat, may spray only the front of the palate and fail to get the
solution correctly applied. To avoid these mistakes and insure the oil
getting on the right spot, the patient should be taught the following
simple technique.
=Method of Application.= Taking an ordinary atomizer full of the oil, the
patient lies on the back with the head low or on one flat pillow. He
must be able to breathe freely through the nostril to be treated.
Usually, one side of the nose is free and he begins with that side,
inhaling the oily spray freely. He then remains lying on the back with
the head low while the oil runs backward into the naso-pharynx,
especially on the upper surface of the soft palate, where it burns a
little but not nearly as much as ichthyol. After two minutes or so, the
other side must be treated, but it must first be opened up so that the
patient can breathe freely through it. This is done by turning on one
side so that the stuffy side is upper-most. In a few minutes this side
will open up and the spray can be inhaled through it freely back into
the throat. To be thorough, the patient treats each side several times.
For the first few days the treatment should be carried out every hour or
so. After a few days or a week mild cases get perfect relief and even
severe cases may drop to four treatments daily. Such a method is far
safer than cocaine, which should never be put in the hands of the
patient for any purpose whatever.
For obstinate cases ichthyol remains the most effective of the local
applications. With those adults who can learn to spray the naso-pharynx
and who are heroic enough to bear the sharp burning for a few minutes
for the sake of ultimate relief, I mix one-tenth ichthyol with the
albolene spray solution. Ichthyol leaves the throat raw and
uncomfortable for a few minutes. For this reason it should not be used
as frequently as the albolene solution.
Ichthyol does not mix well with the albolene, but precipitates quickly.
As it does not mix readily by shaking, the mixture must be stirred
before using. The manufacturers, McKesson and Robbins, were good enough
to experiment in their laboratory with mixtures of ichthyol and
albolene. They report that they were unable to make a satisfactory
combination and that "the only way to get a permanent mixture of the two
would be by a process of emulsion, which would be too thick for spraying
purposes."
It may be objected that my newly discovered point in the naso-pharynx is
merely the posterior end of the inferior turbinated bone, as described
by Mackenzie and Sajous and others long ago, and that the spraying of
the nasal passages simply benumbs the sensitive areas, anterior, middle,
and posterior, that are well known to rhinologists. This may be so. At
any rate, the method just described makes possible a treatment of these
areas in every case, though far from skilled assistance. The treatment
by cautery must always remain a treatment by the skilled specialist in
selected cases. Even if my sensitive spot in the pharynx is nothing new,
this method will at least place in the hands of thousands of hay fever
sufferers a simple method of relief, which thought there is more
satisfaction than in being reputed the discoverer of the resurrection
bone itself.[1]
FOOTNOTES:
[1] Throughout the middle ages, there was a firm belief in the existence
in the human body of an indestructible bone which was thought to be the
necessary nucleus of the resurrection body. With the revival of
dissection and the study of anatomy in the sixteenth century, many
anatomists searched for it eagerly but it was never found.
CHAPTER V
_THE FARADIC CURRENT AND OTHER FORMS OF ELECTRICITY_
The distinguished dermatologist, Dr. Duncan Bulkley, used to argue that
lupus erythematosus was a neurosis because he could cure it with
phosphorus and thought so highly of this _tour d'esprit_ that he made it
the subject of a Presidential Address.
In the same way I might argue for my favorite theory that hay fever is a
neurosis, an angioneurotic oedema, because it is curable by
electricity; or that electricity cures hay fever because it is a
neurosis. These are examples of reasoning by analogy, found so
frequently in medical writings, so plausible and so perilous, leading
more often to error than to truth. So I will not argue the matter at
all, but simply state the result of my observation that faradic
electricity cures hay-fever. This electric treatment takes time and
trouble, but if both physician and patient are willing to take that
time and trouble, more permanent cures may be secured than by any other
treatment known to me.
The use of electricity to cure hay fever is one of those bits of
therapeutic gold that lie long hidden in medical literature, are found
for a moment, and quickly lost again. Back in 1875 Beard and Rockwell
speak of two cases, one cured and the other relieved by descending
galvanism. In 1871, Neftel relieved a case of hay asthma by galvanizing
the vagus; but recent books know nothing of it. Monell, Bigelow, Massey,
and Bartholow know electricity about the nose only as a cautery.
Tousey's big book suggests the local application of the high frequency
current in hay fever, of which more anon at the end of this Chapter.
It was from none of these that I stumbled on the fact that faradic
electricity would cure hay fever. In 1894 there appeared in New York a
patriarchal old gentleman with a queer idea that he could cure
pneumonia, tuberculosis of the lungs, and asthma by manipulation. He was
Dr. Orrick Metcalfe, of Natchez, Mississippi, a brother of Dr. John T.
Metcalfe, long one of the leading physicians of New York and Professor
of Medicine in the College of Physicians and Surgeons. Dr. Metcalfe
visited various hospitals, trying to interest physicians in his method,
demonstrating it freely to whomever would attend. He had a hard time
with the Philistines, who, for his brother's sake, would receive him
politely in their clinics, give him any number of charity patients to
work on, but seldom take the trouble to go personally and see what he
could do. He remained in New York for several years, during which time I
watched his work and was convinced that the principle was sound and the
results good. He made one striking cure of a patient of mine, an old
lady who for many years had a most obstinate cough that she had taken
all over the world, to Egypt and Switzerland and Colorado, without
relief. Dr. Metcalfe treated her by his manipulation in the winter of
1896, cured the cough so thoroughly that it has never returned, now
twenty years, as I know personally, because the old lady still consults
me for minor ills. Let me add this tribute to his memory, that there
never lived a more unselfish, practically benevolent physician than
Orrick Metcalfe, true to the noblest traditions of medicine, working
away at his hobby, not because it was profitable, which it was not, but
because he believed it to be true, constantly seeking with open mind to
improve his methods and to learn better ways.
In regard to asthma and pneumonia and phthisis, his starting point was a
supposed stiffness or rigidity or lameness of the muscles of respiration
as the first step in the chain of events, and his effort was to limber
up at as early a time as possible this stiffness of the muscles. By
manipulating the muscles of the chest, neck, back, and abdomen, he would
find certain points that hurt or where the muscles were plainly tight or
stiff. Continuing the manipulation, he would have the patient take deep
breaths and try to cough. Often, when a certain spot was manipulated,
the patient would begin to cough without prompting. Such a spot was his
delight to find. He would continue to manipulate it, encouraging the
patient to cough and expectorate, holding that free expectoration
brought relief to the lesion. In pneumonia the expectoration was often
bloody, which pleased him mightily. I have seen him thus manipulate a
consumptive only a few hours after a hemorrhage and encourage him to
expectorate, in such direct contradiction to our usual policy of
absolute rest that I trembled inwardly for the patient.
The possible relation between a muscle-bound chest and dyspnoea is
easily understood, but those of us who watched him could not see a clear
connection between the muscle-bound chest and pneumonia or phthisis.
However, in some later paper I will return to this part of Dr.
Metcalfe's work. To return to asthma, Dr. Metcalfe used to say that he
thought there was some way of relieving the tight muscles better than by
manipulation and regretted his unfamiliarity with electricity, which he
thought might be that better way. I gave him a spare battery that we had
around the office, but the old dog cannot easily learn new tricks and
the old doctor stuck to what he knew and had relied on for so many
years, his own fingers. He treated hay fever by manipulating the eyes,
nose, and both the inside and the outside of the throat, wherever the
itching appeared.
About this time a patient applied for relief of attacks of asthma that
were brought on by inhaling dust. Every time he stirred the papers on
his desk--and being an artist, his desk was always dusty--he had a
disagreeable attack of asthma. Here was an opportunity to test the
Metcalfe theory of tight muscles. As I was much more familiar with the
faradic battery than with manipulation and it was more agreeable to use,
I placed one sponge on the back of the neck and with the other twitched
the muscles over the chest. To include all the respiratory muscles, I
exercised those of the neck and throat, the abdomen and back, as well as
the pectorals and the muscles about the scapulæ. Until one stops to
think of it, he does not realize the extent of the respiratory muscles.
Almost every muscle from the base of the skull to the brim of the pelvis
is directly concerned in respiration.
With the faradic current just as with the manipulating fingers, there
are sore spots that the patient describes as bruised. They may be
extremely tender, though the patient is not aware of them until you
find them with the battery sponge or the finger. These sore spots may be
found anywhere over the chest or abdomen, but are particularly common at
the attachment of tendon to bones, the joints between the ribs and the
costal cartilages and the joints of the sternum, especially the joint
between the ensiform and the gladiolus. My idea was that if there were
any stiff or tight muscles restraining the action of the ribs, the
faradic exercise would limber them up.
I treated this patient twice a week for three months and had the
satisfaction of seeing this asthmatic sensitiveness entirely cured; for
he has remained free from it ever since, now twenty years. This case
lead me to try the current on hay fever patients, passing the current
over the eyes and nose and sometimes inside of the throat, wherever
there was itching, just as Dr. Metcalfe had done with his manipulating
finger. If cough or asthma were present, I treated them as in the case
of the artist just described.
=Treatment.= With one sponge on the nape of the neck or between the
scapulæ, pass the other sponge over the eyes, nose, and throat for ten
minutes. Use a gentle current, just enough for the patient to feel it
but not strong enough to cause pain. If cough or asthma are present,
twitch the respiratory muscles for ten minutes more, not forgetting that
the respiratory muscles include the abdominal muscles, those of the
whole length of the spine, and the cervical muscles all around, as well
as the pectorals and the scapular muscles.
In regard to polarity, I do not think it makes any real difference
which pole is used in each place. I am old-fashioned enough to remember
when the polarity of a faradic battery was determined by holding two
sponges of equal size, one in each hand, turning the current on quite
strong and calling the stronger one the negative. In those days I
learned to use this "negative" pole for active treatments and this is
still my habit, putting the positive on the back and twitching the
muscles with the negative. If this exposition seems crude to the modern
electro-therapeutist, I can only say that I am not writing a treatise
on electro-physics, but relating the experiences in actual practice
over a period of nearly thirty years. The customs in which I was
brought up are good enough for me until I see real reason for changing
them. The electro-therapeutist is at liberty to turn the sponges around
and use them the other way if it appeals to him as more fitting.
One of the most brilliant cures of hay fever with faradic electricity
was made by Dr. Thomas P. Birdsall, of Pawling, New York, about fifteen
years ago. The patient was a farmer's daughter of twenty years who had
lived all her life on a farm in Putnam County and had suffered many
years from hay fever. Dr. Birdsall used the faradic current from a small
portable battery three times a week, _while the patient remained on the
farm in the irritating environment_, and in one season made a cure that
has lasted to this day.
=Other Forms of Electricity.= It is probable that all forms of electricity
will relieve or cure hay fever. I have used the faradic current because
it was the most convenient. It is still the most convenient current for
most physicians. The old reports are of the galvanic. Ballenger
recommends the leucodescent light. I have seen several reports of the
use of the high frequency current and Tousey devotes a short paragraph
to it, as follows:
"The author suggests the use of a glass vacuum electrode insulated by a
double wall except at its extremity, which can be applied to all parts
of the nasal mucosa but especially to the inferior and middle turbinated
bones.... A similar application may be made to the outer surface of the
nose at the sides, halfway from the root to the tip." (Second Edition,
page 598.)
From my experience with patients I doubt whether many of them would
submit to the intra-nasal spark. A theoretical objection to using any
form of high frequency or diathermia on the outside of the nose is that,
in some skins, frequent application of these currents causes a permanent
dilatation of the capillaries of the skin, resulting in permanent
redness. I tremble to think of the wrath of the fair lady whom you
should cure of the hay fever by endowing her with a permanently red
nose. I know that these currents are used on the face freely by
dermatologists and have often made a few applications to break up a
catarrhal cold; but I have seen cases enough of capillary dilatation and
its intractability to make me pause and choose for the nose and face the
surely safe faradic current rather than the more spectacular but risky
high-frequency.
CHAPTER VI
_HAY FEVER AS URTICARIA_
The fundamental error in all the literature on hay fever is the teaching
that the lesion is a peculiar kind of catarrhal inflammation; whereas it
is not an inflammation at all, catarrhal or any other kind. The symptoms
of hay fever _resemble_ those of catarrhal inflammation, but the
resemblance is only superficial. The resemblance is striking and must be
so to have deceived so many skilled observers, but it is only
superficial, nevertheless.
When you see a patient with eyes red and swollen, overflowing with tears
and mucus, burning and sensitive to light, you say at once, catarrhal
conjunctivitis. In the nose the sneezing, the discharge, the obstructive
swelling suggest at once catarrhal rhinitis. But stop a moment. Did you
ever cure a catarrhal conjunctivitis or rhinitis in three minutes by
moving the patient from one room to another? You can do that with hay
fever. If you can remove the patient from the irritating atmosphere,
the swelling and redness will subside rapidly, the discharge cease, and
in five or ten minutes you would scarcely know by examining the patient
that there was anything the matter with his eyes and nose. By returning
him to the irritating atmosphere the symptoms will return instantly. By
removing him again, they will rapidly subside. I have watched this many
times in my own eyes. It was in watching the changes in my own eyes and
nose that I realized that this was no catarrhal inflammation but a much
more superficial lesion.
Did you ever see a catarrhal conjunctivitis that acted in this way or a
cold in the head in which the patient could be cured and catch a fresh
cold twenty times a day? I think you never did. A true inflammation
requires time, a few hours, for its development, and when an
inflammatory exudate oozes into the meshes of the tissue, it requires
some days or at least some hours to be absorbed. This one point of rapid
appearance and rapid disappearance would forbid our calling the lesion
of hay fever a catarrhal inflammation.
Next, associate this rapid appearance and disappearance with the chief
symptom of hay fever, the itching, the intolerable itching, of the eyes,
nose, and throat, itching that ceases at once on removal from the
irritating atmosphere and returns instantly when the irritating
atmosphere is reapplied. Turn to the skin, the external mucous membrane.
What is that disorder of the skin that appears abruptly, presents
redness, swelling, and intense itching, and ceases abruptly after a few
minutes or a few hours according to your ability to get rid of the
irritating cause,--that can be reproduced any number of times by
exposure to the same cause? Why, hives, of course, urticaria or
angioneurotic oedema. And a hive (or urticaria or angioneurotic
oedema) is not an inflammation. It is a vascular spasm, a spasm of the
minute vessels that drain small areas of skin, causing a local stoppage
of the circulation in that small area, a turgescence or exudate, the
hive. Just as suddenly as it began, the spasm of the vessels may relax,
the swollen area is drained rapidly, and the hive disappears, leaving a
faint redness. This is exactly the case with hay fever. It is an
urticaria, a vascular spasm. The sudden onset in response to a specific
irritant and the sudden disappearance--this is no catarrhal inflammation
and no rhinitis or inflammation of any kind.
Those cases of hives that appear quickly after chilling the skin are
perfect analogues of hay fever, appearing in response to the local
irritation of odors and dust. There are cases of hay fever that resemble
ordinary hives in being aggravated by certain foods, especially
strawberries, acid foods, and malt liquors. This has a practical bearing
on treatment; for, in such cases, simply excluding these foods from the
diet and the administration of an alkali gives relief. Again, many hay
fever subjects suffer from urticaria, as in the case reported to me by
Dr. Rice of Hawaii, in which the attacks of hay fever alternated with
urticaria.
Sir Morell Mackenzie was wrong when he said that hay fever "had no
pathology because it leaves no permanent structural lesion behind it."
Hay fever "has a pathology" if urticaria has a pathology, for urticaria,
too, subsides and leaves no traces. However, in this statement, we
recognize the effort to state the difference between the evanescent
lesions of hay fever and the more persistent lesions of catarrhal
inflammation; which is just the difference between an urticaria that
comes and goes in half an hour and an eczema (catarrhal dermatitis) that
takes several days to develop and is attended by a real inflammatory
exudate that requires many days for its absorption.
In our text-books, our ablest specialists perpetuate this error by
devising such names as _hyperæsthetic catarrh_, _hyperæsthetic
rhinitis_, _vaso-motor rhinitis_--and then describing a neurosis. The
two ideas will not mix. The very authors who introduce these names feel
that there is something wrong with them, for usually they take several
pages to explain what the name means. It is better to throw overboard
both the name and the idea of catarrhal inflammation or rhinitis and
start afresh.
Recent workers with pollens come near the truth in describing hay fever
as an anaphylaxis. Right here my conception of the lesion of hay fever
as an urticaria fits into the picture and brings us one step nearer to
an understanding of the disease; for where is there a prettier example
of anaphylaxis than those very hives with which long ago I compared the
lesion of hay fever?
Since Bostock first described hay fever in 1816, hundreds of physicians
have looked at thousands of patients, but, as far as I can discover,
there was just one observer besides the modest author of this book who
recognized the urticarial nature of the lesion of hay fever. This was
Dr. Gueneau de Mussy, to whom we will devote the next chapter.
=The Cause Behind the Lesion.= All clinicians agree that there are two
elements in the hay fever problem,--first, the irritant; and secondly,
the abnormal sensitiveness of the patient. All are fairly well agreed as
to the irritants, pollen and dust; but what makes the patient sensitive?
This is still the dark side of the subject. Among the many theories, two
seem to deserve further study and will be considered in the chapters on
Hay Fever as Gout and Hay Fever as Anaphylaxis.
CHAPTER VII
_DR. GUENEAU DE MUSSY HAY FEVER AS URTICARIA AGAIN_
In searching through the early literature of rosin-weed, as related in
Chapter XIV I noted that the article in the _Eclectic Medical Review_
recommending rosin-weed for asthma seemed to have been copied only in
the southern and western medical journals. I was curious to know if the
aristocratic medical editors of the east, the intimates of Bigelow and
Holmes and Warren, had deigned to notice a drug of such lowly parentage,
discovered by the Indians and indorsed by the medical heretics. I began
with the stately row of bound volumes of the Boston _Medical and
Surgical Journal_, running back to 1860, that repose on a dusty back
shelf of the Library of the New York Academy of Medicine. Looking
through the volumes around 1868, when the use of rosin-weed in asthma
was being quoted in the south and west, I found many quaint notes and
comments, but no mention of rosin-weed. To any physician who has a
taste for the history of his art, I would recommend reading a journal of
fifty years ago. So many things have been settled that those old
physicians puzzled and fought over that it gives one the sense of
amusement or lofty detachment of the gods, looking down on struggling,
wriggling humanity, yet knowing all the time how it would come out.
In those old books I noticed abundant quips and sneers at homoeopathy,
now happily taboo in the more courteous journalism of to-day. Besides,
they are not so funny now. The doctrine of like-cures-like and the small
dose has achieved respectability. When armies all over the world are
depending on a minute dose of typhoid poison to prevent and cure typhoid
fever, when articles appear in the most respectable medical journals
advocating doses of tuberculin so small that they have never been
calculated and one-tenth grain doses of calomel instead of the
twenty-grain doses of our grandfathers, most of the merry jests have
lost their flavor to-day. Rather as I expected, in the _Boston Journal_,
I found no notice of the eclectic rosin-weed, but I found something
better, a clinical lecture on hay fever by a man after my own heart,
who, away back in 1868, had recognized the urticarial nature of the
lesion in hay fever. This was a _Clinical Lecture on Spasmodic Coryza or
Periodical Asthma_, delivered at the Hôtel Dieu, by Professor Gueneau de
Mussy, translated from the _Gazette des Hôpitaux_ by W. F. Munroe, M.D.
The lecture runs through several numbers of the _Journal_, beginning in
March, 1869, page 125. It should be read by every rhinologist and by
every physician who is treating hay fever.
When the chemist Woehler, one afternoon in 1828, tried to make up some
ammonium cyanate by mixing ammonium sulphate and potassium sulphate and
found that he had synthesized urea, one of his colleagues said that he
was like Saul, who went out to find his father's asses and found a
kingdom. I felt the same way; only, in my case, I went out among the
asses and found a king.
When Solomon made his despondent remark that there was nothing new under
the sun and that of the making of books there is no end, he must have
been in his library sorting out his collection of old Assyrian bricks
and found that his favorite thoughts had been said already and said
better by some old Hittite scribe a thousand years before. So I, who had
fondly thought myself the discoverer of the urticarial nature of hay
fever because I had searched the books of the specialists and found
nothing about it, was surprised to find my observation anticipated by
the Frenchman.
_Salut!_ Hail to you across the years, Gueneau de Mussy, kindred spirit.
It is not recorded that the gray-headed Dean of a great university ever
stood you on a platform and hurled Latin adjectives at you; but in 1868
you had the sharpest eyes and clearest mind of any of them, M.D.'s or
LL.D.'s, though bespattered with all the letters of the alphabet.
Of all the foolish things that scientific men quarrel about, one of the
most foolish is the question of priority of discovery. A scientist who
will welcome the opinion of another scientist agreeing with him the day
after he announces his discovery will fight like a cat against evidence
that the same man agreed with him the day before. It seems to me that
if another human being confirms your work, it does not make any
difference whether he does it the century before or after your transient
existence. In fact, you should be more pleased to have it "confirmed"
the century before, because then you will have a chance to know about
it.
Besides recognizing the urticarial nature of the lesion, de Mussy sought
the underlying cause of hay fever and thought to find it in the gouty
diathesis. He notes the occurrence of hay fever in gouty families, its
periodicity, its association with urticaria, eczema, granular
pharyngitis and asthma, all characteristics of gout or arthritism.
As de Mussy's lecture is not readily available, I quote from the _Boston
Journal_ some of his conclusions.
"I have dwelt at length on the constitutional condition in order to show
in what diathetic conditions spasmodic catarrh has developed. The direct
and collateral hereditary tendency appears to indicate a diathetic
origin. The two sisters belong to a gouty stock. Chronic urticaria and
granular pharyngitis are not rare in gouty families.
"Periodicity is characteristic of many arthritic affections. The
spring-time periodicity is especially common to them. The periodicity of
this coryza places it in the same category as the arthritic affections
which generally manifest themselves by regular or irregular paroxysms.
"If hay fever has been more often noticed in England than France, can
this be due to the greater frequency of gout in the former country?
"Continuing the study of these analogies which, if not enough to prove a
common origin, are enough to justify further study of the question, I
find in one of my patients a morbid condition due to an arthritic
source, _i.e._, an urticaria alternating with asthmatic coryza (hay
fever), the latter appearing with symptoms such as _injection and
itching and tumefaction of the eyes which recall the cutaneous affection
to which it had succeeded_." (Italics mine. Here is my urticaria theory
expressed in 1868. G. F. L.)
"_Behind a vast number of nervous troubles, behind a vast number of
bizarre functional anomalies stamped with a nervous imprint, we find
arthritism._" (Italics mine. Here is my pet theory of the gouty origin
of neurasthenia and perhaps Beard's _neurotic constitution_, beloved of
rhinologists. G. F. L.)
"As to analogies between summer catarrh and urticaria, I wish to draw no
conclusions from them. If it be admitted that both are due to
arthritism, their succession and the analogy in their local development
can be understood." (My urticarial nature of the lesion again. G. F. L.)
I might add that de Mussy reports success in preventing the appearance
of the symptoms by the use of quinine for seven or eight days before the
expected attack. During the attack he used sulphur and arsenic for the
catarrh.
In the next chapter we will consider the fate of de Mussy's theory of
gout as the underlying cause of hay fever.
CHAPTER VIII
_HAY FEVER AS GOUT_
In the last chapter we read that the theory of a gouty diathesis as the
constitutional basis for hay fever originated with Dr. Gueneau de Mussy,
in 1868, on account of the many resemblances that he found between the
symptoms of gout and the symptoms of hay fever. We have now to consider
the fate of the de Mussy doctrine in those countries where hay fever is
best known and has been most closely studied, Great Britain and America,
Germany and France.
=De Mussy in Great Britain and America.= If any specialist on the nose and
throat in England or America ever heard of de Mussy and his theory that
hay fever is rooted in a gouty diathesis, he is keeping the secret well,
for it does not appear in any of the books that he writes; but in every
book I find the disease attributed to the _neurotic constitution_ first
suggested by Beard. In this statement I do not include several
references to "uric acid poisoning" which is not the same thing as gout,
as will be explained in Chapter IX, on the Uric Acid Theory.
After reading de Mussy's argument for the dependence of hay fever on a
gouty diathesis, I turned first to the English books. For centuries,
England has been famous as the home of gout and, since the Englishman,
Bostock's, account of his own case, hay fever, too, like parliamentary
government and gout, has been recognized as an inheritance of the
Anglo-Saxon race. As British physicians see more gout than any other
physicians in the world and as, for many years, they have had the best
opportunities for the study of hay fever, I turned first to the English
books, thinking that if there was any truth in the gouty theory, the
British physicians would have found it out long ago. To my surprise I
searched book after book by both British and American authors, but in
not one instance did I find hay fever associated with gout. These books
included Allbutt's _System of Medicine_, F. T. Robert's _Practice_,
Lennox Browne, Morell Mackenzie in England and, in this country,
Ballenger, Bosworth, Coakley, Kyle, Solis-Cohen, Ivins and Vehslage and
Hallett.
No one is more saturated with the traditions of British medicine than
Sir William Osler, but, in his _Practice of Medicine_, in discussing the
constitutional causes of hay fever, he seems to know nothing of the
gouty theory.
Besides the article on hay fever in his _Diseases of the Nose and
Throat_, Sir Morell Mackenzie wrote a comprehensive work on _Hay Fever
and Paroxysmal Sneezing_ that ran through five editions and bears on the
flyleaf the admiring comment of the _London Lancet_ that it "must be
regarded as one of the most complete expositions of our knowledge of
this curious complaint in our language." It is a wicked joy to catch
such a scholarly writer as Mackenzie napping. In a footnote he even
refers to the de Mussy lecture in the _Gazette hebdomadaire_, Jan. 5,
1872, as calling the disease spasmodic rhinobronchitis, with which name
the disease is still known in France. One suspects that the learned
Doctor was very busy that day and that the footnotes were looked up by
somebody else; for, though he gives "the most complete exposition in our
language," as the _Lancet_ puts it, of the constitutional causes
underlying hay fever, there is never a word of de Mussy's theory of
gout.
In Osler and McCrae's _Modern Medicine_ the article on Hay Fever is
written by Professor Dunbar, of Hamburg, deviser of pollantin. Here at
last we get away from British insularity, for, in spite of his Scotch
name, Dunbar is a German. On page 863 he writes:
"For a long time it has been believed that the predisposition to hay
fever rests on a gouty diathesis. This view is not on the face of it
inconsistent with the pollen theory. Inquiries, however, have shown that
gouty persons form only a small portion of hay fever patients."
Finally, in the great Edinburgh _Encyclopædia Medica_, 1900, Volume 4,
Greville MacDonald, of London, in the article on Hay Fever, seems to
know nothing of the gouty theory and says innocently at the end of the
article, "No special dietary is indicated, seeing that these patients
present no tendency to lithæmia, etc." He makes the extraordinary
suggestion that, in relieving the attack of hay fever, "rather than give
the patient cocaine, it might be wise to allow the opium pipe." In the
early prescriptions for hay fever, opium sprays and nasal douches were
common enough, but this is the only time I ever heard a reputable
physician and a teacher, at that, advising a patient to "hit the pipe."
I think that, from the evidence examined, we may say that British and
American authors know nothing of de Mussy and his theory.
Next, I looked up the gout authorities, Ewart, Ebstein, Garrod,
Falkenstein, Lancereaux, Lecorche, each of whom wrote a bulky treatise
on Gout, but there is never a word on Hay Fever.
=De Mussy in Germany.= For many years, whenever I have wanted to know
anything from the bottom up, historically, linguistically,
philosophically, I have turned to a German book and have always found
what I was looking for, if it is known to man. Where an American or
British author will skim over or touch a subject carelessly, not seeming
to care where the idea comes from or its relation to other ideas in
different times or countries, a German will plow steadily through the
matter from Hammurabi to Wilhelm III and lay bare all the collateral
tributaries and branches, always with an index at the end.
First I tried Heymann's _Handbuch der Laryngologie und Rhinologie_
(Wien, 1900) and found hay fever described in the article on _Die
Nasalen Reflexneurosen_, by Professor Jurasz in Heidelberg; but there
was no mention of gout. By this, I was truly convinced that nothing was
known on the subject. If a Heidelberg Herr Professor does not know it,
it does not exist. And "Professor Jurasz in Heidelberg" had failed me.
However, looking further in Heymann, my faith in German thoroughness and
all-inclusiveness revived. Hay fever appears also in the article on
Acute Rhinitis, by P. H. Gerber, of Königsberg, and here, on page 371,
we find a complete "Literatur" spread out in true Teutonic style from
Bostock to date. However, Gerber does not discuss the matter of gout in
the text, but says merely, "Recently Bishop asserts that the nervous
disturbances of hay fever are due to an excess of uric acid in the
blood."
The gouty theory of hay fever receives scanty recognition from most
German writers. Strümpell does not mention it. In his _Handbuch der
Specielle Pathologie und Therapie_, Berlin and Wien, 1904, Eichorst says
skeptically, page 326, "It has been stated often that gouty families are
especially apt to develop hay fever," and on page 330 "Grote saw hay
fever patients of gouty families cured (?) by a course of waters at
Neuenahr."
In Eulenberg's _Real-Encyclopædie der gesammten Heilkunde_, 1887, page
509, article Hay Fever, we read:
"Of general diseases, malaria and gout have been advanced as the basis
of hay fever, but without convincing proof."
We may conclude, then, that while British and American physicians know
nothing about the gout theory, German physicians know about it but do
not believe it.
Finally, in my wanderings through German encyclopædias, I came to the
many-volumed Nothnagel and here, at last, found a modern writer who knew
de Mussy and recognized the importance of his observations. At the end
of Volume 4 there is a monograph on Hay Fever by Dr. George Sticker, of
the University of Giessen, the most thorough and satisfactory book on
the subject that I have found. It may be read in English in the American
edition of Nothnagel, Philadelphia, 1902. Sticker resists the impulse to
begin with Galen, though he notes rather wistfully that John Mackenzie
of Baltimore succumbs to it. He gives the most complete statement in any
modern book of the gout theory of hay fever, but, alas, Sticker misses
the pearl in the oyster. He says nothing of de Mussy's recognition of
the urticarial nature of the lesion in hay fever.
As this volume of Nothnagel may not be easily available to the gentle
reader, I copy a paragraph from Sticker for his or her benefit.
Nothnagel's _Specielle Pathologie und Therapie_, Band 4, 1896. Article
_Bostock's Catarrh_, by Dr. George Sticker, page 118. "In the last few
years convincing proofs are accumulating that there is a certain
constitutional disorder on which the individual tendency to hay fever
depends. Though further careful proof is desirable, it can scarcely be
doubted that the pathogenesis of hay fever is based on that constitution
that the English and French describe as arthritic, which expresses
itself in a hereditary or family tendency to rheumatism, gout, diabetes,
obesity, migraine, furunculosis, bronchitis, asthma, etc. Bostock
himself mentioned his gouty tendency. Phoebus found it in many
patients. But it was Gueneau de Mussy who first recognized the
prevalence and necessary basis of the disease in the arthritism of the
hay fever patient; and his teaching has been accepted and enriched with
new material by Herbert, Leflaive, Lermoyez, Ruault, de Dreyfus-Brissac,
Rendu, Molinie.... And so it is probably no coincidence that, like gout,
the _morbus principum_ of Sydenham, so also the aristocratic hay fever
is a prerogative of the Anglo-Saxon race."
Reading this praise of Englishmen and Frenchmen by a German makes one
sad to-day. Hasten the day when the old hearty comradeship in science
will return, the day when German and Frenchman and Englishman will
again praise one another's achievements ungrudgingly and each learn
eagerly as of old what the other had to teach.
=De Mussy in France.= As might be expected, among French rhinologists and
writers on general medicine, de Mussy's teaching is well known and has
many advocates. Note that the writers mentioned by Stickerare all
Frenchmen. The usual view is well expressed by André Castex in his
_Maladies du Larynx, du Nez et des Oreilles_. Paris, 1907, page 425.
"Hay fever attacks especially those who belong to an arthritic stock,
whose parents have had or who themselves have migraine, gravel, eczema.
This explains its frequency in England and America; for the Anglo-Saxon
race is especially subject to arthritic disorders. In France it exists
but is infrequent. In this way also we must explain why hay fever is
rare among the laboring classes who frequent the hospitals and is
observed almost exclusively among wealthy patients, people of sedentary
habits and sluggish digestion (nutrition ralentie)."
In Brouardel and Gilbert's _Traité de Médicine et de Thérapeutique_,
Volume 27, page 66, another André, André Cartaz, expresses mild
skepticism as to the proof offered.
"The presence of an arthritic diathesis is accepted by many authors.
Leflaive thinks it the sole predisposing cause, especially gout. During
the attack he has demonstrated, as I would say, and that is proof for
him, an appreciable decrease in the quantity of urine and percentage of
urea, an increase in uric acid and, in one case, the presence of
indican."
Lermoyez also advises caution in accepting the gouty theory to the
neglect of known remedies for the disease. I abstract his sensible
remarks from his _Thérapeutique des Maladies des Fosses Nasales_, Paris,
1896. Article _Rhinites spasmodiques, rhume des foins_, page 300.
"It would be a mistake to hold with the German school that the nasal
lesions were the only cause of hay fever; for these lesions are
completely absent in many true cases of the disease and, on the other
hand, many people affected with hypertrophic rhinitis breathe air full
of pollen without showing symptoms of hay fever. There is certainly a
general predisposition. In hay fever certain patients present a
peculiar idiosyncrasy, often inherited, almost always neuroarthritic.
But to say with the French school that the arthritic diathesis (trivial
diathesis, commonplace diathesis, _diathèse banale_) is the only cause
of hay fever is to make a mistake that leads to inefficient treatment."
=Conclusion.= How this discussion of the gouty nature of hay fever escaped
English and American authors is a strange thing. British physicians
frequent French hospitals and are familiar with French medical writings.
In 1868 American physicians studied in Paris as they went later to
Vienna and Berlin. It is strange that they never brought back with them
this French theory of the gouty nature of hay fever and that no British
or American author seems to have quoted from their books.
I must make one partial exception to this statement. In his _Diseases of
the Nose, Throat, and Ear_, Philadelphia, 1906, Professor Grayson says
that, in hay fever, there is "some diathetic state that is rooted in
defective nutrition. Whether we term this lithæmia or gout or uric acid
diathesis is immaterial, the central fact being that through intestinal
toxæmia or some disturbance of normal metabolism we have resulting a
persistent poisoning of the blood-current."
Now this is simply substituting one theory for another without proof of
either; for the origin of hay fever in auto-intoxication is as little
proved as its origin in gout or uric acid. Auto-intoxication has simply
replaced uric acid in the Doctor's mental picture gallery; for, like
uric acid, auto-intoxication often exists in the imagination of the
physician and not in the patient. For further discussion of this point,
the reader is referred to the next chapter, on the Uric Acid Theory.
A novel and interesting article in Grayson is the description of
angioneurotic oedema as affecting the nose and throat, page 182. He
writes:
"I have no doubt that in this disease, as in hay fever, the
gastro-intestinal tract is the birthplace of the toxic material.
Although the disease may occur in gouty or rheumatic individuals, there
is scarcely sufficient reason for ascribing any pathological connection
between it and these other affections."
The comment on this is that, until we know what gout is, which we do
not at present, we cannot argue satisfactorily either way. Some day I
shall tell a listening world what I know about gout. I shall elaborate
my favorite theory that the American neurasthenia, now rapidly
increasing in other countries, is a form of gout, a gout of the nervous
system. And here, too, I find that Frenchman, de Mussy, anticipating me
in his remark that "_Behind a vast number of nervous troubles, behind a
vast number of functional anomalies stamped with a nervous imprint, we
find arthritism._" The name _neurasthenia_ was not known in de Mussy's
day, but he hit off the condition neatly as "functional anomalies
stamped with a nervous imprint."
The defect in all these discussions of the gouty or non-gouty nature of
hay fever or of neurasthenia is our lack of a sure diagnostic sign of
the disease gout. Gout occurs in two forms, typical and atypical,
irregular gout. In typical gout, with the deposits of urates in the
joints and cartilages, the diagnosis may be easy. In atypical or
irregular gout we may have a group of inflammations or functional
disturbances in any tissue of the body. From their frequent occurrence
in gouty people, we suspect them to be gouty, but can prove nothing.
When they appear in people who have never had typical gout we can only
say that a gouty origin is probable. There is no sign in the blood or in
the urine or anywhere else by which we can say that gout is or is not
present. It is in this class of atypical gout that hay fever and
neurasthenia belong, if they be gouty at all. Until somebody discovers a
diagnostic sign of gout that is available in these irregular cases, the
evidence of the gouty nature of hay fever and neurasthenia must remain
exactly what it was to de Mussy fifty years ago, analogies of symptom
groups, and not an exact laboratory diagnosis based on physiological or
chemical tests such as we have come to depend upon with such confidence
in recent years.
One matter that should be made clear in the reader's mind is that the
so-called _uric acid poisoning_ or _uricacidæmia_ is not the same thing
as gout by any means, though Grayson confuses it with gout, as do nearly
all American authors. For fuller discussion of this point, we will pass
to the next chapter.
CHAPTER IX
_THE URIC ACID THEORY_
Uric acid is a substance about which more has been written and less
understood than many others in medicine and that is saying a great deal.
As a basis of the suboxidation theory of Bence Jones' day, as the cause
of gout with Garrod, as a step in our knowledge of metabolism and as a
popular fad, uric acid in its time has played many parts.
=Uric Acid in Hay Fever.= In 1893, Dr. Seth Bishop announced before the
American Medical Association that "excess of uric acid in the blood
causes hay fever and nervous catarrh;" and advised elimination and
control of the uric acid as the principle of treatment. The article may
be found in the _Journal of the American Medical Association_, 1893, and
abstracted with an interesting discussion on the treatment of hay fever,
in the _Philadelphia Medical News_, 1894. This position, of course, is
also that of Haig (_Uric Acid_, seventh edition, page 386) and his
followers.
Now, in 1893, the theory of uric acid poisoning flourished like a green
bay tree and all sorts of queer and misunderstood pathological processes
came and roosted in its branches. Patients came to our offices, not
complaining of headache or lumbago or cough, but asking for "something
for that uric acid." As patients will, they had already made the
diagnosis from the newspapers and wished our advice only for the remedy.
As the basis of hay fever, this theory of uric acid poisoning has
apparently made as little impression as de Mussy's theory of gout on the
nose and throat specialists of this country and Great Britain; for I
find no mention of it in their books, except the brief reference of
Professor Grayson quoted in the preceding chapter. In the _Virginia
Medical Monthly_, however, I find an interesting paper by Dr. John Dunn,
Professor of Diseases of the Nose and Throat in the University Medical
College of Richmond, Virginia. Following the suggestions of Dr. Bishop,
Dr. Dunn treated his patients with diet and alkalies according to the
uric acid theory and reports excellent results.
It may be pointed out that the successful results of the treatment by no
means prove that the condition was due to uric acid; for the diet may be
doing many other things besides controlling the movements of the uric
acid and it is probable that the effect of an alkali in the blood is not
a simple neutralizing of an acid but that it sets in motion a train of
chemical changes of great complexity. None the less, Dr. Dunn's paper is
well worth reading by every physician for its practical suggestions in
the treatment of hay fever.
The cardinal error made by the advocates of the _uric acid poisoning_ is
that they _name the poison_. If the theory were stated that an unknown
poison or poisons circulate in the blood and cause many symptoms of
disease, as headache, gouty pains, bilious vomiting, and so on, we would
all agree that this is so. Call it the X-poison, if you will, as
Roentgen did with his unknown ray. But when you name the poison _uric
acid_, you challenge the chemist and the physiologist to test your
doctrine by chemical analysis, and when the uric acid doctrine is
tested in this way it is found sadly wanting.
It is true that uric acid in the form of urates is found in the blood in
varying quantities, but there is no proof that it does any harm there.
In fact, there is good evidence that it does not. In the disease,
leukæmia, there is an enormous amount of uric acid in the blood, far
more than was ever demonstrated in gout or the so-called uric-acid
disorders; yet, in leukæmia, there are no symptoms of gout or any other
symptoms that have been attributed to uric acid poisoning.
A second error of the uric acid advocates, flowing from their first
error of naming the poison, is to pour their acids and alkalies into the
blood with the childlike faith that, like good children, the acids and
alkalies will go in there and do just what they were told to do,
neutralize the uric acid, and get out. They assume that the chemistry of
the acids and alkalies is as simple inside of the body as it is outside
of it and that the blood is simply a passive mixture of chemicals.
A third error of the uricacidites is to talk so glibly of the chemistry
of the blood and the influence of this or that food or medicine on its
chemical changes. The chemistry of blood! A subject of which the ablest
physiological chemists have but touched the fringe,--is that a knot to
be unloosed familiar as his garter by an amateur with a watch-glass and
a thread?
In his _Lehrbuch der Organischen Chemie für Mediciner_, Leipzig, 1906,
Bunge observes slyly that he had "sometimes had occasion to remark in
private that the less a physiologist knew about chemistry, the more
irresistible was his impulse to undertake the most difficult subjects."
When the uric acid amateur chemist comes to study the real poisons of
the blood, he will be confronted with a problem even more intricate than
uric acid, though that one is intricate enough and still unsolved. For
there are "poisons in the blood," though it is improbable that uric acid
is one of them. These poisons are the blood-proteins, so many that the
physiologist has never counted them, so minute in quantity that no
chemist has ever isolated them, so complex in structure that the ablest
chemists of the world stand appalled before a molecule that contains
sixty atoms of carbon,[1] so powerful that an undetermined fraction
smaller than one-third of a grain will kill ten thousand guinea pigs or
one hundred thousand mice, and so perfectly under control that they
circulate harmlessly in the normal blood. The marvel is that any animal
remains alive; and no animal would remain alive were it not for a system
of protection by which these poisons are rendered harmless, usually by a
slight rearrangement of the atoms in their molecule which is one of the
wonders of organic chemistry.
We are far from knowing just what happens when we pour acids and
alkalies and foods into this witches' cauldron of blood. Rather than
impudently announcing the changes that are about to take place in the
blood when we administer a certain food or medicine, we should stand in
reverent awe before one of the most intricate and marvelous puzzles
with which nature ever challenged the chemist and the physiologist.
Shall we therefore stop using acids and alkalies as medicines because we
do not know each step in their mode of action? By no means. We do not
know each step in the mode of action of any medicine or of our foods,
either, for that matter; but we do not for that reason stop eating. We
should still use the acids and alkalies for their effect on the patient
as far as we can see it just as we shall still go on eating food because
it nourishes us; but we shall be wise to stop talking so glibly about
what we cannot see and do not yet know, the effect of those acids and
alkalies on the chemistry of the blood.
=Uricacidæmia and Gout.= Now, why do I speak with respect of de Mussy's
theory of gout as a cause of hay fever and so disrespectfully of the
uric acid doctrine? Are not gout and uric acid poisoning the same thing?
No. They are not; though the two ideas are usually confused by medical
men since Garrod's time and his demonstration of the increase and
decrease of uric acid in the blood of gouty patients. Gout is something
more than a simple accumulation of uric acid in the blood because of its
imperfect elimination by the kidneys. What that something is, we do not
know; but gout is, at least, a clinical entity, a definite group of
symptoms known since Hippocrates' time. Take away the uric acid theory
and you still have the disease, gout, that any of us can recognize, as
the Greeks and Romans recognized it when the word uric acid was unknown.
It is on these symptoms of gout, the clinical picture of disease, not on
any hypothetical uric acid, that de Mussy based his theory and thus far
he is on solid ground. On the other hand, _uric acid poisoning_ is
largely a figment of the imagination. Take away the uric acid, which has
never been satisfactorily proved to be there, and there is nothing left.
In not one one-hundredth part of the cases of so-called uric acid
poisoning is it proved that uric acid has anything to do with the case.
=The Deposits of Uric Acid in Gout.= The deposit of uric acid in the form
of urates in the gouty joint has always been a strong argument for the
theory that gout, at least, is due to an excess of uric acid (urates)
in the blood. At one time, in a humble way, I was a pathologist, and
this theory of a blood overloaded with uric acid as the only thinkable
cause of its deposition in the joints never impressed me as
pathologically sound. I often compared these deposits of urates in the
joints with the deposits of lime salts so often found at autopsies in
caseous glands or small necrotic areas. The superficial observer says:
"See what an excess of lime salts there must have been in the blood." He
is thinking of laboratory glassware and the ground around a mineral
spring that becomes encrusted with salts as the solutions evaporate.
But, in animal pathology, this is a false conclusion. The animal body is
not a test-tube and, in it, the laws of physics are modified by those of
physiology. Lime salts are deposited in the caseous gland or tubercle
not because they are in excess in the blood but because lime salts are
attracted to all caseous material from normal blood. Whether or not this
calcification is an intentional provision of nature to protect the body,
to petrify the necrotic material and make it harmless, is not the
question here, though the calcification has this effect. The point here
is that calcification of caseous glands or necrotic areas does not
presuppose an excess of lime salts in the blood. The first step is not
an excess of lime in the blood but a necrosis, after which the lime
salts will be deposited from normal blood.
So, it has seemed to me that the deposit of urates in and around a joint
is no proof of their excess in the blood. Just as in calcification, so
in gout, the first step may be a minute area of necrosis or other local
degeneration that attracts the urates that are always present in normal
blood; or the secret of the gouty inflammation, like that of urticaria
and hay fever, may at last be found in Anaphylaxis, as described in the
next chapter.
FOOTNOTES:
[1] Wenn mehr als 60 Atome Kohlenstoff im Molekül sind, dann ueberlasse
ich das Object zu andern. Bunge, page 262, quoting "einen hervorragenden
Forscher auf dem Gebiete der organischen Chemie." See Bunge for
authority of these statements.
CHAPTER X
_HAY FEVER AS ANAPHYLAXIS THE GOUTY DIATHESIS REAPPEARS_
Fifty years ago de Mussy pointed to the resemblance between hay fever
and gout and claimed hay fever as a manifestation of the gouty
diathesis. As related in Chapter VII, he based his theory on the
resemblance between the history and symptoms of hay fever patients with
those of gouty patients. In his day he found both hay fever and gout
confined to the Anglo-Saxon race, both hereditary and familial, both
exhibiting urticaria, eczema, and asthma, and he recognized that the
lesion in the eyes and nose of the hay fever patient was not a true
catarrh but an urticaria.
On the other hand, Wolff-Eisner declared that hay fever is an
anaphylaxis and this idea has been developed and confirmed by Koessler
and others so fully that we must accept it as proven. Let us examine
this matter of anaphylaxis to determine whether after all there is any
essential difference between the two views of hay fever.
=Anaphylaxis.= The conception _anaphylaxis_ or _lack of protection_ begins
with the discovery that a harmless protein injected into a dog will so
sensitize him that, after ten days or so, another injection of the same
protein will kill him. The point is that the change has occurred in the
animal, not in the protein injected. The protein is the same as before
and can be injected once into any number of dogs without harm. In this
way we explain the cases in which drugs and foods that are harmless to
most people may be virulent poisons to those who happen to have been
sensitized by a former overdose. The widespread use of antitoxin in
diphtheria gave abundant opportunity to study the phenomena of
sensitizing a human being with one dose and killing him with another
dose of the same thing.
The symptoms of anaphylaxis first observed were urticaria, arthritis,
and dyspnoea. Then Bruck showed that what we used to call
_idiosyncrasy_ to drugs and foods that are harmless to most people is
really an anaphylaxis, attributable to a former overdose of the same
thing. Next, it was learned that anaphylaxis may persist through life
and be transmitted to the offspring of rabbits and guinea-pigs,
illustrating the cases in human families where sensitiveness to a
certain food or drug runs down through several generations. Then the
dermatologist brought in a list of skin eruptions, urticaria in the
lead, as examples of anaphylaxis to certain foods or to poisons
generated within the body, especially in the intestines. Then asthma was
included among the anaphylactic reactions and, finally, Wolff-Eisner
pointed out that the lesion of hay fever is an anaphylaxis. I may add
here that this view of hay fever confirms my observation that the lesion
is not a catarrhal inflammation but an urticaria.
So we have a picture of anaphylaxis as a sensitiveness to bacterial
poisons or to foods or drugs that are harmless to most people expressing
itself as an urticaria, an arthritis, an asthma or hay fever. But this
is the very group of symptoms on which de Mussy based his theory of
gout. When we add that this sensitiveness or anaphylaxis is hereditary
and that it is aggravated by foods, drugs, or pollens that are harmless
to most people, I submit that we have a pretty picture of the gouty
diathesis; for the gouty diathesis, too, is a susceptibility to
arthritis, to urticaria, and to asthma from causes that do not trouble
other people, and in gout, too, this weakness is hereditary. One thinks
of the gouty patient who cannot take iron or digitalis because it
aggravates the gouty pain and of the attack of gout that is brought on
by a glass of champagne or a piece of beef or a few strawberries that
the majority of mankind can take freely without harm. Now, if urticaria,
eczema, arthritis, asthma and hay fever form a picture of anaphylaxis,
and if these symptoms also form the picture of the gouty diathesis, is
it not probable that one of these pictures can be explained in the terms
of the other? If the anaphylaxis to the diphtheria antitoxin, horse
serum, can develop arthritis, is it not probable that the most striking
feature of gout, the inflammation of the joint, is also an anaphylaxis
to poisons yet unknown to us but the same poisons that make the gouty
urticaria and asthma?
What if gout should prove to be a sensitization or anaphylaxis to uric
acid that does not exist in the non-gouty? This would explain the puzzle
of one patient full of gouty pains with very little uric acid in his
blood while another patient, like the leukæmic, has a blood full of uric
acid that does not trouble him.
=The Mechanism of Anaphylaxis in Hay Fever.= The anaphylaxis theory of hay
fever is based on the observation that the epithelial cells of the
mucous membranes of the eyes, nose, and throat have not lost their
primitive power of digesting foreign protein.
Ages ago, when we were amoebæ or little drops of protoplasm, we had no
eyes or nose or separate stomach for digesting food. The one little cell
body did everything. One of the most important powers of that cell body
was its power of digesting and assimilating food, and its most important
food was the nitrogenous food or protein from which it built up its own
body substance. Now, foreign or food protein cannot be simply absorbed
as such. Foreign protein is a poison and never tolerated in the blood.
The foreign protein used as food must first be changed into the special
kind of protein that the body can use. The foreign protein is changed by
splitting its molecule into its simplest parts and then recombining them
in the desired form. The complex protein molecule, containing those
sixty atoms of carbon that gave the Schrecklichkeit to the German
professor of chemistry as related on page 71, is split up again and
again into simpler forms. The end products are harmless, but the early
splittings produce both poisonous and non-poisonous products. The
end-results of these successive splittings, the splinters, as it were,
are then combined by the amoeba to form its own kind of protein or
body substance.
As we rose in the animal scale, instead of being an amoeba of a single
cell, we became constructed of millions of tiny cells and began to set
aside certain groups of cells to do special work, the eyes for seeing,
the ears for hearing, the lungs for breathing, the digestive organs to
prepare our food and a sheath of harder cells over the outside of the
body that we call our skin and mucous membranes. Specialized as those
cells have been for many generations, they have never forgotten that a
foreign protein is a food or, perhaps, an enemy, to be split up and
decomposed at sight. So, the epithelial cells of the mucous membrane of
the nose and eyes, though they have no longer anything to do with
digesting our food, secrete a ferment or enzyme that can split up any
protein that may happen along. This process is called _parenteral
digestion_ or digestion outside of the intestines; and this theory of
the parenteral digestion of protein is the foundation of the anaphylaxis
theory of hay fever.
During the growing months of the year the air is full of pollen that is
blown in everybody's eyes and nose. In that pollen is a proteid that is
digested by the secretion of those mucous membranes, proceeding exactly
as food is digested in the stomach and intestines, splitting up the
complex proteid molecule into simpler groups, and forming both poisonous
and non-poisonous substances. In the normal eyes and nose this splitting
of the protein proceeds slowly, forming only minute amounts of poison.
As absorption from the eyes and nose is slight, no unpleasant effects
are produced.
The first step in the development of hay fever is supposed to be a
disturbance in this digestion of protein in the eyes and nose, by which
larger amounts of poison are formed and absorbed by the mucous membrane,
producing the first poisoning, which, like the first injection into the
dog, sensitizes the mucous membrane to other doses of the same poison.
It is supposed that disturbance in the protein digestion may be caused
by stoppage of the nasal passages, with excessive accumulation of
proteid, inhalation of excessive amounts of pollen, forming excessive
amounts of poison, or, perhaps, insufficient secretion, so that the
splitting-up process is not hastened to its conclusion of harmless
products. The anaphylaxis theory halts a little at this point and is not
exactly clear about the mechanism of that first poisoning.
After the first poisoning, the epithelia are permanently injured and
remain more permeable to protein. They also develop the power of making
large amounts of the digesting enzyme, which is absorbed into the blood
and is supplied to all the tissues of the body, so that all tissues,
including the skin, can decompose the pollen protein. Advantage is
taken of this distribution of the protective enzyme in the skin
reaction, in which a small area of skin denuded of its superficial
epithelia reacts in the form of a hive-like swelling when the pollen
that originally affected the patient is brought in contact with it.
The next time that the pollen reaches the eyes and nose the mucous
membrane is ready for it with an abundant secretion of enzymes to
destroy it. In this intense digestion of the proteid, quantities of the
poisonous substances are formed which irritate the eyes and nose worse
than before, explaining why hay fever becomes worse with successive
attacks.
The inherited form of hay fever is explained by the well-known
transmission of anaphylaxis to the offspring. The first case in the line
of descent must start with a severe poisoning that lays the foundation
of the anaphylactic inheritance.
I would submit to the enthusiastic immunologist that this first
sensitization which he takes for granted but cannot prove is the weak
spot in his hypothesis. This is the point where he needs help, and it
is at just this point that de Mussy's neglected theory of gout completes
the picture. The immunologist has not explained why I, a boy growing up
with other boys, inhaling the same amounts of pollen as they, catching
no more colds than they, and never having any serious illness, became
sensitive to pollen while the others did not. There is no recollection
of any "first poisoning" by pollen that might have started the
anaphylaxis. But, says the immunologist, it was your parents who were
sensitized and you inherited the anaphylaxis. Now, my parents lived to
old age and had no sign of hay fever, though my brother had it and my
children are beginning to sneeze and rub their eyes suspiciously in June
and August. But if you associate hay fever with the gouty diathesis, as
the clinical histories seem to justify, you enlarge immensely your
opportunity to prove ancestral sensitization to whatever unknown poison
originally produced the gouty sensitization. This view does not restrict
you to ancestral hay fever, but extends it to gout or to any equivalent
of gout.
The best work in English on hay fever as an anaphylaxis is the
monograph of Karl K. Koessler in Forchheimer's _Therapeusis of Internal
Disease_, 1914, Volume 5, page 671, to which the reader is referred for
a full discussion of the subject. The same author gives an abstract of
his work in the _Illinois Medical Journal_, 1914, page 120. This article
in Forchheimer is the most complete that has been written since
Sticker's time and covers the ground from Sticker, who knew not
anaphylaxis, to Wolff-Eisner, who is not available in English.
I was gratified to find in Koessler a sympathetic soul. He thinks, as I
did, that the monograph of Sticker in Nothnagel is the best review of
hay fever that we have. He calls it "a remarkable monograph and the
standard work on the subject." But why, oh why, K. K. K., in your own
masterly article in Forchheimer, did you follow Sticker all through his
historical chapter but leave out all that he says of de Mussy's theory
of gout or arthritism as the constitutional basis of hay fever and also
leave de Mussy and every reference to his work out of your list of
_Literature_? The German books are more liberal. While most of them
ignore de Mussy and his theory in their text, they all list his writings
in the _Literatur_. Has the microbe of bacteriology and the laboratory
bitten you so virulently that you can find no place for the gouty
diathesis even in an index?
I know that the gouty diathesis is out of date. In fact, all diatheses
are out of fashion. Nobody speaks of them now. They went out with the
medical philosophies of the eighteenth century. Cellular pathology with
its wonderful revelation of the anatomical seat of disease and
bacteriology, with its still more wonderful revelation of the external
cause of disease, so dazzled the eye and the mind that we forgot that
the sensitive animal body behind the attacking microbe had its changes,
too, its changes in body chemistry that could not be stated in terms of
cells and bacteria. The pendulum is swinging back now to a consideration
of the constitution of the body on which the microbe or poison acts, its
_resistance_ or _immunity_, its _anaphylaxis_ or _allergie_. With these
holiday and lady terms, are we not trying to describe what our ancestors
knew as _diathesis_? For what is the old conception of diathesis but
just such a hereditary weakness or lack of defense or tendency to
disease that our ancestors recognized clinically but could not
demonstrate, elusive, difficult to detect, but nevertheless there; like
the dog who has been sensitized to an otherwise harmless proteid, who
seems well and is well in everything except his susceptibility to that
one special cause of disease?
Bacteriology, which first took away the idea of diathesis, is now giving
it back. The discovery of the tubercle bacillus as the cause of
tuberculosis banished the _tubercular diathesis_ apparently forever;
but, step by step, through bacteria and then toxins and antitoxins and
now through anaphylaxis and allergie, bacteriology is bringing back the
old conception of an inherited or acquired susceptibility to attack.
Call the old tubercular diathesis a _sensitization_ and you have made it
the most modern of modern discoveries. So, also, step by step, through
bacteriology with its toxins and antitoxins and now with anaphylaxis,
from the philosophic ash-heap on which we thought to have thrown it for
good and all, like an old family cat that we thought was dead, comes
creeping back that old conception of a gouty diathesis or arthritism,
not as dead as we thought it, to complete the explanation of the
existence of hay fever.
I am far from saying that calling hay fever a form of gout ends the
subject. I say only that bringing such a common and puzzling disorder as
hay fever in line with such a common and puzzling disorder as gout
brings us a long step nearer to solving the puzzle that lies behind both
of them; and I say also that, in the records of this work, the name of
Gueneau de Mussy, who first recognized this relation clinically,
deserves a place.
Gout as an anaphylaxis, hay fever as an external expression of gout,
what a vista of therapeutic possibilities is opened up by these simple
experiments with pollen extracts and foods. The subject ramifies in
every direction, touching the gouty form of Bright's disease, gouty
heart disease, endocarditis and pericarditis, the popular "hardening of
the arteries," which may prove after all not to be due to meat in all
cases or alcohol in all cases but certain foods in certain cases, the
increase in deaths from heart disease and kidney disease in the fifth
decade of life. The correlation of these gouty problems with this work
in the prevention and cure of hay fever anaphylaxis awaits a Lister or a
Pasteur or a Koch who will have an eye to see and a patient industry to
search and find.
When you have established hay fever as anaphylaxis or lowered resistance
to a specific proteid, you may be sure that the immunologist will seize
the patient as his own, carry him off to the laboratory, and there
attempt to raise his resistance or develop immunity to the attacking
proteid by giving minute doses of the poison gradually increased. The
success of this procedure will be related in the next chapter.
CHAPTER XI
_IMMUNIZING WITH POLLEN EXTRACT_
The idea of preventing disease and poisoning by preparing the body with
minute doses of that poison, gradually increasing until the body is
immune, is an ancient one. The practice is Ur-alt, as my favorite German
history books say; for it has been found among savages and primitive
peoples and is practised in a crude way by every boy who accustoms
himself to that noxious weed, tobacco. Then, there are the Psylli, whom
Lucan tells of, who were by heredity immune to snake poison and who
could make the favored stranger immune by inoculating him with small
doses (_Pharsalia_, Book ix); and old King Mithridates, of Pontus, who
believed in preparedness and kept himself prepared for the attentions of
his faithful subjects by taking small doses of poison every day, keeping
himself immune should by any accident some poison slip into his porridge
(_Pliny_, Book xxv). Old King Mithridates was a good immunologist. He
knew the transient nature of immunity and kept the treatment up. He
knew that, if he stopped taking the poison for a week or so, he would go
into a state of anaphylaxis and the next dose would kill him; so he kept
himself in a state of anti-anaphylaxis by not permitting too long a time
to elapse between doses, after the most approved rules of modern
immunology. That patient whom Goodale immunized against horse-asthma who
objected to a treatment that had to be taken for the rest of her life,
should learn of old King Mithridates the true practice of immunity.
This is still the weak point of artificial immunity; it does not last
very long. You can immunize a guinea-pig or a patient to almost anything
now-a-days by giving him minute doses gradually increased but the
immunity passes off quite rapidly when the treatment is stopped. We have
still something to learn from Nature in this respect. Nature can give us
one dose of yellow-fever or scarlet-fever or small-pox or measles and
make us immune for life but your artificially produced immunity may last
for a few weeks or months only. Our closest imitation of natural
immunity is vaccination against small-pox. Here we produce an actual
disease, cow-pox; yet, even here, we are not at all sure how long
immunity lasts. Even in Jenner's time, the original belief in protection
for life came down to seven years and our modern health boards would
vaccinate every two years or, in the presence of an epidemic, more
frequently.
However, Nature is a wasteful worker, wasteful of her material, and she
kills a great many of her children with measles and scarlet-fever and
small-pox and yellow-fever while immunizing the lucky ones. A Health
Board that would kill so many people while immunizing the rest would be
a public scandal. Yet it is probable that Nature's way is the most
effective and that the best immunizer is the disease itself, as Koch
found with tuberculosis among his guinea-pigs that the best protection
against tuberculosis was inoculation with living tubercle bacilli, not
with dead ones; and the autopsies show that the majority of the human
race that grow up at all have been successfully immunized against
tuberculosis by a mild local attack of the disease.
As yet, no one has had the boldness to inoculate human brings with
living bacteria and to imitate Nature in her manner of killing off all
the sensitive subjects in order to preserve the rest. This was formerly
done by inoculation with small-pox but the unfortunate results of the
practice compelled its abandonment among civilized people. Even Nature's
immunity is not perfect in all diseases, as many a patient with his
sixth attack of grippe or third pneumonia or fortieth year of hay fever
has learned most feelingly; and this irregularity of natural immunity
bears directly on the proposal to immunize patients against hay fever by
small and increasing doses of the offending pollen. If the natural
disease does not confer lasting immunity, you will have some difficulty
in conferring lasting immunity artificially, as the immunologist is just
now discovering. His immunity passes off so rapidly that he is now
searching for a method of immunizing that can be carried on for many
years without tying the patient to a laboratory for life. It is right
here that I believe that homoeopathy has valuable methods that can be
applied to the situation.
But we must not jump to conclusions. Because we can immunize
successfully against one disease, it does not follow that the same
methods will immunize against another disease. Each disease is a problem
in itself and may require its own methods. Nor because we can immunize
the guinea-pig in the laboratory, does it follow that the same methods
are applicable in the human patient. The only proof that we can immunize
against hay fever is to immunize against hay fever. So, to the subject!
=Passive Immunity.= The first man to attempt to apply the methods of
modern immunity to hay fever was Dunbar, of Hamburg, in 1903, with this
_pollantin_. He attempted to duplicate in hay fever the triumph of
antitoxin in diphtheria by injecting a horse with increasing doses of
pollen until the horse became immune to large doses of pollen and his
blood full of antibodies. Dunbar expected to confer passive immunity on
the hay fever patient by transferring to him this horse serum with its
antibodies. There is no better example of the rule that each disease
requires its own methods of immunity. While diphtheria antitoxin is
harmless to the diphtheria patient, the serum of the pollen-immunized
horse nearly killed the first patient Dunbar tried it on, who happened
to be his assistant, a sufferer from hay fever. It is probable that
pollantin is based on the wrong principle, that hay fever is not, like
diphtheria, a poisoning by a toxin to be antidoted by an antitoxin.
However, to Dunbar belongs the credit of first attempting to put the
treatment of hay fever on a scientific basis and he introduced the
method of testing the patient that has been followed by all later
workers, dropping the pollen extract in the eye.
In the _Centralblatt für Bakteriologie, Referate_, xxxvi, s. 453, there
is an account of a most unseemly quarrel between Dunbar and Weichardt,
the latter claiming that before leaving Hamburg, he suggested the idea
of pollantin to Dunbar. Weichardt has since put on the market another
hay fever specific, called _graminol_, which is the blood-serum of
cattle that have fed on the offending grasses during the hay fever
season. The theory is that the blood of the cow contains antibodies to
those grasses and that passive immunity can be conferred on the hay
fever patient by transferring those antibodies to his blood.
This is the old, old experiment that has been tried so many times in
many diseases and has so often failed. It reminds us of the many
attempts to confer on the tuberculosis patient the natural immunity
possessed by the jackass by injecting the patient with the blood serum
of that friend of man. The result of these experiments left some doubt
as to who merited most the name of jackass, the doctor, the patient or
the patient beast. Both pollantin and graminol have been praised highly
in Germany but neither of them have succeeded so well in this country.
Perhaps a shrewd advertising campaign had something to do with it; for
the combination of a German scientist and his manufacturer can give
points to any Yankee in exploiting the public with sure cures for the
sick.
=Active Immunity.= In active immunization, the real pioneers, after
Mithridates, were the homoeopaths, who, for many years, have given
small doses of poison ivy to prevent ivy poisoning and small doses of
the poisons of infectious diseases to prevent and cure those diseases;
but the homoeopath did not realize the transient nature of immunity
and the necessity for continuing the treatment for many months or years,
nor did he adopt the principle of increasing the dose to the point of
toleration.
The first to attempt active immunization and cure of hay fever by
injecting extracts of the pollen that causes the disease appears to have
been Noon, working in Wright's laboratory in London. The work was
continued by Freeman, their work being reported in the _Lancet_, 1911,
i, page 1572 and ii, page 814. They found the English spring form of hay
fever due to the pollen of grasses. By dropping extracts of various
pollens into the patient's eye, after the manner of Dunbar, they
concluded that their patients were most sensitive to timothy grass and
they used timothy extract exclusively in the treatment. Freeman states
explicitly that a patient immunized against timothy grass is immune to
all other grasses of that season; that it is unnecessary to immunize
him to each particular grass, thus differing from some of our American
observers who use the skin reaction to determine the particular pollens
to which the patient is sensitive and inject every one of those pollens
in the treatment.
Independently of these British observers, Karl Koessler, of Chicago, in
1910, attempted to immunize patients against hay fever by injecting
pollen extracts. Like Noon and Freeman, he used the eye reaction to test
his patients and found them most sensitive to rag weed. Just as the
Englishmen had used only timothy grass in their cases, Koessler used rag
weed exclusively. His work is reported in his article on Hay Fever in
Forchheimer's _Therapeusis_, Volume V and also in the _Illinois Medical
Journal_, 1914, page 120.
=Selecting the Pollen. The Skin Reaction.= The next step in the
development of the pollen treatment was to substitute the skin reaction
for the eye reaction in testing the patient's sensitiveness to various
pollens. The advantage of the skin reaction over the eye reaction is
that it permits testing many pollens at the same time and does not
distress the patient as does a sharp eye reaction.
While Noon and Freeman selected the one typical pollen of spring, the
timothy grass pollen, and Koessler selected the typical fall pollen of
the American hay fever, rag weed, for all cases of that season, later
workers, using the skin reaction, go to the extreme of injecting the
patient with each and every pollen to which his skin reacts. Oppenheimer
and Gottlieb carry this individualization to the point of attempting to
discriminate by the skin test the patient's varying resistance to his
different pollens at each treatment. This resistance may rise for some
and fall for other pollens so that six or eight different pollens in
different doses must be injected separately at each treatment. This is
individualizing the case with a vengeance and requires an expenditure of
time and skill (I almost said _skin_) that must be rather expensive for
the patient.
A series of light scratches are made on the skin of the forearm or the
inner side of the arm where the skin is delicate. The scratch must be
only superficial and not draw blood. Really the best method is to make
a round denuded spot by twirling a small brad-awl. A drop of extract of
different pollens or a speck of the pure pollen protein is rubbed into
each scratch and the result awaited for fifteen minutes. Within that
time, a redness and swelling, like a hive or a bite, will appear at some
of the scratches.
This swelling is the skin reaction to that pollen. Its appearance
indicates the presence in the skin of reaction bodies to that pollen. It
is argued, and partially proved by practice, that the pollens to which
the skin reacts are the pollens to which that patient has been
sensitized and these pollens are selected for administration.
=The Dose.= The first dose of pollen extract is the danger dose and
differs for each patient according to his susceptibility for a given
pollen. It is determined by dropping the pollen extract into the eye or
rubbing it on the skin. To avoid anaphylactic shock, this dose must be
incredibly small. Noon and Freeman's first dose was one-third c. c. of
the weakest dilution of which one drop in the eye would cause
hyperaemia. This was usually four drops of a millionfold dilution in
water. Later doses were never more than 1 c. c. of a 1 to 100,000
dilution "to avoid unpleasant reactions."
Goodale begins with five drops of that dilution that just fails to cause
a skin reaction. Later, to avoid the risk of shock, he advises one-tenth
of this dose.
Koessler's theoretical initial dose of rag weed extract is one drop of
the weakest dilution that will just redden the conjunctiva. As he finds
rag weed more toxic than the English timothy, his actual first dose is
one-half of this theoretical dose. The actual first dose will vary from
one drop of a 1 to 1,000,000 to one drop of a 1 to 20,000 dilution, the
smaller of which he estimates to contain of pollen protein one
one-hundredth part of a millionth of a gramme or .000,000,01 gramme.
Shade of Samuel Hahnemann, the first and greatest homoeopath! And they
drove you out of Leipzig into poverty and exile for teaching that in
using drugs that are similar to the disease there is serious danger of
aggravating the disease; that the dose must be extremely small; and that
disease so sensitized the patient that a dose so small as to be
inappreciable in health becomes active in disease!
The smaller doses of pollen extract are given every three or four days
and increased as rapidly as possible, judging the increasing tolerance
or resistance by a diminishing eye or skin reaction. With larger doses,
the interval is longer, a week or ten days. The pioneer, Noon, and all
workers since, warn against increasing the dose too fast, for the
reactive power of the patient is easily exhausted, his resistance
lowered and he may be left more sensitive than before.
=Dangers of Pollen Injections.= Treatment by pollen injection is beset
with dangers for the unlucky patient. It has been noted how Dunbar
nearly killed his first patient by injecting the serum of the horse that
had been immunized to pollen. All experimenters, without exception, say
that the injection of pollen extract is attended with danger to the
patient, danger of anaphylactic shock, and warn against the use of any
but the most infinitesimal doses. The hay fever patient is a human being
who, in some way, has been sensitized to pollen. He is in a state of
exquisite anaphylaxis and a dose of pollen injected into his blood may
kill him in twenty minutes. Goodale reports shock (faintness, nausea,
vomiting) in two patients following the mere rubbing of a drop of pollen
extract into a scratch on the skin. Evidently the scratch was too deep
and the pollen poison was absorbed rapidly into the blood instead of
being stopped by the deep epithelia. I have seen a similar absorption
and general reaction in children after a skin test with tuberculin, when
the tuberculin entered the blood through too deep a scratch.
Another danger lies in the instability of the pollen extracts. Koessler
expressly warns against commercial preparations of pollen protein
because of the danger of decomposition. His extracts do not keep more
than three weeks and are dangerous to use after that time. On the other
hand, Goodale, making his extracts with 15% alcohol, reports them as
active and fit for use after more than one year. Oppenheimer and
Gottlieb object to commercial preparations on different grounds. The
commercial preparations contain many different pollens so as to be sure
to include those to which the patient is sensitive. They point out that
in these mixtures, the dose of the individual pollens cannot be adjusted
to the changing conditions of the patient and, in addition, injecting
into the blood of the patient pollens to which he is not already
sensitive may sensitize him to these pollens also and leave him worse
than before.
There is the lesser danger that the patient will not be immunized by the
injections but become more sensitive to his old pollens than he was
before, as Noon pointed out in his first paper; for artificial immunity
is a difficult thing to control and is by no means as easy as it looks
in the book. Nor is it as easy to immunize a human being over many years
of life, subject to so many conflicting influences, as it is to immunize
a guinea-pig living in a cage.
To lessen the dangers and enable the patient to keep up his immunization
for many months and years, Goodale borrowed an idea from Schloss, who
fed his egg-oat-meal-almond anaphylaxis patient minute doses of these
foods until he so raised his resistance that he was able to eat them in
ordinary quantities without harm. Such artificial resistance must be
kept up by eating a small quantity of the food each day or it will be
lost (old King Mithridates again). As most of the pollens are not edible
and as patients react to botanically allied plants, Goodale tried
feeding the patient over long periods of time with vegetables and edible
plants that were allied to the offending pollens, expecting that, as in
Schloss's patient, some minute part of the protein would pass unto the
blood unchanged and maintain the protection. So far, these feeding
experiments have failed. Trial with homoeopathically potentized
pollens over long periods of time has not been made.
=Conclusions on Pollen Extracts.= My conclusions on the pollen treatment
are that it is in line with our best practice of immunity but that it is
still in an experimental stage, the pollens are possibly dangerous even
in the hands of a skilled immunologist. In a disease that is usually so
easily controlled by rosin-weed, faradism and ichthyol, I would not
expose a hay fever patient to the very real danger of anaphylactic
shock. The conditions governing immunity stated in the beginning of this
chapter still hold good. It is transient. Already some of the early
workers have discontinued the practice. The despair of Goodale has been
quoted. Scheppegrell, probably the first in this country to use the
pollens, has given them up and advises the patient to keep away from his
irritant and to have the weeds cut in all cities as the best treatment
obtainable (_Journal of the A. M. A._, March 4, 1916, page 710). The
most hopeful aspect of the pollen extracts seems to me to be their
administration all around the year in high dilutions, _more
homoeopathico_, and to this practice I believe the immunologist will
eventually come.
=Pollen Extracts not Vaccines.= Some manufacturers and all British writers
speak of pollen extracts as _vaccines_ and of immunizing the patient as
_vaccination_. This seems an unnecessary confusion. We have two kinds of
vaccines already, the cow-pox vaccine and the killed cultures of
bacteria introduced by Wright. For an account of the use of these
vaccines in hay fever, we will pass to the next chapter.
CHAPTER XII
_THE BACTERIAL VACCINES_
In his paper in _The Lancet_, the pioneer in the use of pollen extracts,
Freeman, observed that "many cases of supposed hay fever" were simply
acute bacterial catarrhs. He excluded hay fever by the lack of any
reaction when timothy extract was dropped into the eye. The bacterial
infection was proved by culture from the eyes and nose, usually yielding
the staphylococcus. The final proof was the cure of the patient by an
autogenous vaccine made of the offending microbe. In the past few years,
this observation has been confirmed and many cases of cure of "hay
fever" by bacterial vaccines have been reported in the journals. The
bacteria were chiefly staphylococci, rarely the pneumococcus or the
micrococcus catarrhalis.
Oppenheimer and Gottlieb report cases of mixed hay fever where the skin
reacts to pollen but the pollen extract failed to cure. In these cases,
they found a bacterial catarrh of the eyes and nose. They suppose a
vicious circle, the catarrhal inflammation and the hay fever
sensitiveness mutually interfering with each other's recovery and they
succeeded in curing the patient by using the appropriate pollen extract
and the bacterial vaccine at the same time, believing that while the
pollen extract was raising resistance to the pollen poisoning, the
bacterial vaccine was raising resistance to the bacterial catarrh.
While hay fever is not strictly a catarrhal inflammation, the cure of
hay fever by curing a coexisting catarrhal rhinitis or conjunctivitis
seems easily possible. The surgeons taught us long ago that some cases
of "hay fever" need nothing but good drainage of the nose, which they
secured by freeing the nose from obstruction. Every physician sees mild
cases of hay fever recover on various popular catarrh treatments. The
tablets sold by homoeopathic pharmacies, containing iodide of arsenic,
naphthalin and quillaya, cure many cases of hay fever and these are the
same drugs that cure catarrhal rhinitis. It is easily possible that my
old inheritance, rosin weed, cures hay fever by curing the coexisting
catarrh; for it was a famous remedy among the eclectics for catarrhal
inflammation of the nose, throat and bronchial tubes.
If, then, operations or remedies that cure catarrhal rhinitis cure also
some cases of hay fever, there is nothing inherently improbable in
expecting the bacterial vaccines to cure some cases of hay fever, for
the vaccines have made many cures of catarrhal inflammation. However,
the physician using them should understand that they are not specific
drugs against the pollen anaphylaxis but against a supposed catarrh or
bacterial infection. He will be well advised to control the treatment by
taking cultures from the nose to make sure that the bacteria are there,
determine the variety present and, if possible, have an autogenous
vaccine made up for treatment.
I have no personal experience with the vaccines in the treatment of hay
fever, though I know their value in ordinary catarrhal conditions. As
remarked in the chapter on Pollens, I have succeeded with the milder
methods of rosin-weed, faradism and ichthyol. However, bacterial
vaccines are much safer than pollen extracts, the technique of their
use is not as complicated and they are well worthy of trial in
refractory cases if bacteria are demonstrated in the eyes and nose. I
might remark here that this demonstration will seldom fail; for you can
get a culture of the staphylococcus from almost any nose.
=The Word Vaccine.= Used in connection with the treatment of hay fever,
the word _vaccine_ is confusing, for it has been applied to two totally
different kinds of medicine, the bacterial vaccines and the pollen
extracts. Physicians intending to use _vaccines_ in the treatment of hay
fever should make sure which they are using; for the methods and dosage
of the one are quite different from those of the other. Sir Almroth
Wright, to whom the whole world is indebted for his work in preventive
medicine, started the trouble by calling his killed bacteria _vaccines_,
having in mind the prevention of bacterial diseases as the familiar
vaccine prevented small-pox. Now, _vacca_ is Latin for cow, _vaccinia_
is properly cow-pox and the virus of cow-pox that we use in vaccination
against small-pox is properly called _vaccine_. With a paucity of
vocabulary unexpected in an Irishman, Wright called his killed bacteria
_vaccines_ because he used them to prevent disease, using the word as
synonymous with _preventive_. As cow-pox vaccine is the greatest
preventive we know, the word _vaccine_ might be justified when applied
to the bacterial cultures or to the pollens or to any preventative of
disease. But when you leave pure prevention and apply these remedies to
the _cure_ of disease, the word _vaccine_ loses even this shadow of
justification and the present confusion results. One American house
makes a laudable attempt at a more exact terminology by calling the
killed cultures of bacteria _bacterins_. Still, the word _vaccine_ for
killed bacterial cultures has been advertised so deeply into the medical
mind that it is firmly rooted there and not likely to be disturbed by
mere considerations of etymology. As for the pollen extracts, they are
yet young and impressionable. It would be better to leave off the word
_vaccine_ as applied to them and call them what they are, _pollen
extracts_.
CHAPTER XIII
_DIET_
Until recently, diet in hay fever was a matter of avoiding meat and
strawberries and the result was usually unsatisfactory. With the
conception of hay fever as an anaphylaxis and the recent studies in food
anaphylaxis, the subject of diet in hay fever assumes a new and inviting
aspect.
This new view of diet in hay fever begins with Schloss's masterly study
of a case of food anaphylaxis reported in the _American Journal on
Diseases of Children_, 1912, No. 6. A good review of the subject with
references to the literature will be found in the special Hay Fever and
Anaphylaxis number of the _Boston Medical and Surgical Journal_, August
10, 1916, especially the article by Talbot.
Some physicians have long insisted that they could relieve hay fever by
diet. For instance, I once asked a physician of large general practice
what he did for hay fever. He smiled in an incredulous way that I have
noticed before among people who never had hay fever and replied, "I find
that if people will stop eating strawberries and not eat too much meat,
they soon get rid of their hay fever." This answer surprised me for I
knew that in his long practice, he must have seen many cases of hay
fever and my experience had been that diet had no influence on the
symptoms.
Then, there is Professor Dunn, already quoted in Chapter IX, who
believes in the uric acid theory and says that, in his opinion, "hay
fever is the result of improper eating and living." He has been able to
prevent the annual attacks by using cold baths and excluding meat, tea,
coffee and alcohol from the diet.
Any patient who can get rid of the annoying symptoms of hay fever by
such simple means of diet and bathing should be urged to try it, whether
he believes or disbelieves in the "uric acid poisoning" on which the
treatment is based. My own experience leads me to believe that most hay
fever patients require something more than dietary regulation to control
the disease. For instance, in my own case, the disease appeared at an
age when I had never taken tea, coffee or alcohol, during the summer
vacation when I was living a hygienic out-door life, playing ball,
cycling and swimming every day in the salt water. I remember one summer
in camp by a lake among the pines, in which I lived Dr. Dunn's hygienic
life for many weeks, drinking no tea, coffee or alcohol, eating chiefly
fresh fish and green vegetables and swimming daily. My experience can be
paralleled by many hay fever patients that as long as I remained among
the pines, I was in perfect health but on going down into the valley,
one breath of fragrant wind blowing over the fields would cause instant
itching and swelling of eyes and nose and all the previous hygienic life
up at the lake was no protection against the disorder. I have seen the
hereditary form develop in three children of one family while they were
at the seashore, bathing daily in salt water and living a care-free,
active, out-door life, never taking tea, coffee or alcohol and not much
meat.
So, I concluded long ago that there must be two kinds of hay fever, one
kind curable by diet, bathing and exercise and another kind in which
habits of living and eating made no difference; and I had seen mostly
the other kind.
Now, there may well be cases of hay fever as there are known to be cases
of that other anaphylaxis, asthma, that are pure examples of food
anaphylaxis. In such a case, detecting the irritating food and removing
it from the diet is the proper path to cure. The error in our former
practice was to divide foods into good and bad for certain diseases. We
should rather think of foods as good or bad for a particular patient.
The plain people long ago crystallized their experience in diet in the
maxim that what is one man's meat is another man's poison, but your
scientist will never believe anything until he sees it in a test-tube
and physicians have kept on a few centuries behind the rest of the world
prescribing _diet_ for all cases of the same disease irrespective of
whether or not it agreed with the patient. Witness the rigid _diets_ for
tuberculosis and Bright's disease. So, inevitably, there had to be a
_diet_ for hay fever and equally inevitably, the same diet did not agree
with everybody.
Scientific men are fond of stating in scientific terms what everybody
else knows already. While we have known for a long time that some foods
did not agree with everybody, science is just now demonstrating that one
man's meat is literally another man's poison by testing the different
food proteins on the skin and calling the condition _food anaphylaxis_
or _food allergie_.
As the patient reader of the chapter on Pollens will remember, the
anaphylaxis or sensitiveness of the patient to particular pollens is
tested by rubbing a speck of different pollens into scratches on the
skin. This skin reaction as a test of anaphylaxis was used by Schloss
with different foods before it was adopted in hay fever; and it has been
taken up by the dermatologist also. The dermatologist has long suspected
that certain skin diseases, as urticaria, and eczema, are aggravated or
produced by certain foods but he has been unable to demonstrate just
what foods were at fault. The problem was confused by the fact that he
had found no guiding principle. Food that one patient could eat with
impunity brought out a beautiful eczema or urticaria on another
patient. The uric acid theory was one effort to solve this problem but
it was not comprehensive enough and it was not true. Forbidding
_nitrogenous foods_ has been a favorite formula with some and they
straightway advised milk, which is highly nitrogenous. The recent
recognition that food sensitiveness is an anaphylaxis and the detection
of the foods at fault by the skin reaction may supply the missing
guiding principle that was needed to adjust a diet to the individual
needs.
The poisonous element in food is the protein. The food itself will serve
for the skin test but it is better to use the pure food protein, which
gives clearer reactions and avoids contamination. Proteins of all our
common foods are now obtainable in the drug trade put up in tiny
capsules ready for the test.
The skin is cleansed with soap and water and dried. A number of little
spots are denuded of their superficial epithelia by twirling a small
brad-awl, which should not scrape deeply enough to draw blood. Most
workers speak of scratching the skin but the brad-awl scrapes to the
proper depth more quickly and easily. The spots are marked with the
names of the foods to be tested, as milk, beef, potato, oats, etc., and
a drop of a five per cent solution in water of the respective proteins
is rubbed into the spots. One spot is left as a control, into which
normal saline or 3% solution of milk sugar is rubbed, as the proteins of
commerce are made up with milk sugar. Within five or ten minutes, there
appears a redness and swelling, as with the pollens. As with the
pollens, a patient who at any time has been poisoned or, as we now say,
_sensitized_ by any of these foods, still has circulating in his blood
or fixed in his skin the reactive bodies to that food. These reaction
bodies react to that food on the skin by redness and swelling. Food
proteins that cause no redness and swelling are thought harmless for
that patient. Foods that cause the reaction are thought to be those to
which the patient has been sensitized and to which he has not developed
or maintained an efficient defence. There is a contradiction here; for
the reaction merely shows the presence of defense bodies in the blood
and does not tell us whether that defence is or is not efficient.
However, even if the argument limps, the results reported are
encouraging. Some striking cures have been reported by simply excluding
these foods from the diet. The test is simple and harmless if the
scratch is not too deep and _if the protein is not injected beneath the
skin_. If injected beneath the skin or rubbed into a deep scratch, the
food proteins, like the pollen proteins, may be dangerous. If they are
absorbed rapidly into the circulation of a patient who happens to have
been sensitized to any of them, there is serious danger of anaphylactic
shock.
If these observations prove reliable, here is a method of selecting a
diet for the individual patient that surpasses in accuracy anything that
we have ever known. If hay fever is ever a food anaphylaxis, this method
of testing the food sensitiveness of the individual patient promises
much; but these observations are still too new and unconfirmed and the
skin reaction too uncertain to rely on it implicitly yet. There was a
time, back in 1908 to 1910, when the skin reaction for tuberculosis too
was highly valued. Enthusiasts proposed to test all the school children
and all the soldiers and all the factory workers and segregate the
tubercular by the skin test. The diagnosis of tuberculosis was to be put
in words of one syllable.
That dream is over. Tuberculin skin reactions have now been made by the
million and we know that a positive reaction means nothing but that, at
some time, the patient has been infected with tuberculosis. The skin
test does not tell us whether he has recovered long ago and built up a
good defense or whether he is still sick with tuberculosis and will die
of it. It reacts equally well in the healthy, vigorous subject who at
one time has had a mild tuberculosis and recovered, in the patient with
early phthisis and in the advanced case. In Kraus and Levaditi's
_Handbuch der Technik und Methodik der Immunitätslehre_, 1911, page 205,
von Pirquet himself, the grandfather of all the skin tests, says, "A
positive skin reaction indicates with certainty that the organism has
been infected with tuberculosis. Of the localization, extent and
prognosis of tubercular infection, a positive skin reaction gives no
conclusion." Yet hundreds of physicians to-day are making diagnoses of
tuberculosis by the skin test; for if there is one thing more difficult
than to get a new idea into a doctor's head, it is getting it out again
when the idea proves fallacious. So, I view these skin reactions for
food and pollens with some suspicion of their real value in diagnosis
and prognosis and as guides to treatment. Still, Talbot says,
"Experience has shown that when a positive skin test is obtained for a
food and that food is then excluded from the diet, the general condition
of the patient almost invariably improves and in many instances a cure
results." May his words prove true.
CHAPTER XIV
_ROSIN-WEED AGAIN HISTORICAL AND PHARMACOLOGICAL_
When we wish to learn anything about American medical literature, we
turn to the big Index Catalogue of the Library of the Surgeon-General.
The botanical name of rosin-weed is _silphium_. In the Index Catalogue,
the word _rosin-weed_ does not appear, but, in the first series, under
_silphium_, there are ten references, and thereby hangs a tale.
=Ancient Silphium.= In ancient Greek and Roman medicine there was a famous
gum called _silphion_ (Latin _silphium_) which, like all popular
medicines, was the better for being brought from a far country and for
being a little mysterious; for it was brought across the Mediterranean
from Cyrene, where it had been originally presented to the inhabitants
of that favored place by the gods. Learned botanists have discussed at
length what plant produced this gum and have concluded that, like its
neighbor in Egypt, the papyrus plant, it has disappeared from the
earth. Even in Dioscorides' time the plant was getting scarce and there
came a day when in all Cyrene there remained only a single silphium
plant, which was piously presented to that worthy representative of the
gods, the emperor Nero.
In the year 1817, an Italian, Della Cella, returning from an expedition
of the Egyptian Pasha against the neighboring Arab tribes, reported that
he had discovered the ancient silphion growing on the site of old
Cyrene. He brought back specimens of the plant which were identified as
a species of thapsia. Several expeditions brought back more specimens
but there was little general interest until Laval, in 1859, saw the
commercial possibilities in a revival of this wonder-medicine and put
the famous old cure-all on the market as a specific for consumption,
under the name of _silphium Cyrenaicum_, backed by the endorsement of
all the ancients from Hippocrates to Pliny. Seldom has even a French or
German drug house found so distinguished a company of medical
authorities to endorse its wares. Whereat, there began a brisk
discussion in the European journals, first, whether the ancient
silphion had been found and, secondly, whether, if found, it was worth
anything. Both questions being finally decided in the negative, the
ancient silphion passes again into the twilight of tradition; all of
which entertaining tale may be read at great length in the _Dictionnaire
Encyclopædique des Sciences Médicales_, Paris, 1881, Volume 9.
Now, with one exception, all the references to _silphium_ in the Index
Catalogue refer to this _silphion_ controversy and have nothing to do
with our American _silphium_ or _rosin-weed_. The exception is the
reference to Dr. Goss, to be related presently.
=The American Silphium.= On the American prairies from Ohio south and west
to Texas, as far north as Wisconsin and south to Florida, there grows
abundantly a plant unknown in Europe and better known here to botanists
than to physicians. From the gummy juice that exudes from the leaves and
stem, Linnæus himself named the genus _silphium_ in memory of the
ancient silphion of Cyrene and the plain people called it _rosin-weed_.
There are more than twenty species of rosin-weed or silphium, all
probably similar in their medicinal virtues. The species that we have
used in hay fever is the _silphium laciniatum (Silphium gummiferum,
Ell.)_ This species is known also as the compass-plant or pilot-weed
because the large lower leaves present their faces north and south, as
we may remember from our boyhood tales of the plains where the trapper
never lost his way because he had simply to look down at his feet and
there was the compass-plant pointing faithfully to the north.
=Rosin-Weed among the Indians.= This rosin-weed is not a poisonous plant.
Children all over the west gather the resin for chewing-gum as the
Indians did before them and horses eat it freely, being thereby
protected from the heaves, as the frontier tradition goes. Rosin-weed
was valued highly by the Indian. He chewed the gum to make his breath
sweet and drank a decoction of the root to make him live forever. The
rosin-weed of the Indian is the parallel of the ancient silphion, the
opoponax or _all-healing juice_ of southern Europe, the spruce gum and
pine tar of rural America and the more valued resins of the East where,
in Othello's time, the trees dropped down their medicinal gum; for we
find the native gums used all over the world for the same diseases,
cough and consumption and urinary distress, always with a dash of
mystery and the idea of prolonging life.
=Rosin-Weed among the Eclectics.= One would have thought that the early
American botanic physicians who worked so industriously to introduce
American plants and who learned the use of many native plants from the
Indians, would have adopted such a popular remedy but I find no mention
of it in their books. The learned writer in the _Dictionnaire des
Sciences Médicales_ was correct in writing, in 1821, Volume 51, page
312, that there were several varieties of silphium, all growing in
America, but that none of them as yet had been used as medicines.
It was reserved for a successor of the old botanic school, an eclectic
physician, Dr. H. B. Garrison, to introduce rosin-weed into medical
practice as a specific for asthma in an article in the _Eclectic Medical
Review_ in 1868. This article was abstracted in the _Pacific Medical and
Surgical Journal_, in the _Nashville Journal of Medicine and Surgery_
and in Francis Porcher's _Medical Botany of the Southern States_, second
edition, 1869 (not in the first edition of 1863). Dr. Garrison noted
also the popular belief that heaves or asthma did not exist in horses on
the prairies where this plant grew.
For a few years, rosin-weed became popular and was widely commented on
in the eclectic journals; but it soon dropped out of sight and is not to
be found in any eclectic text books to-day.
ROSIN-WEED AMONG THE HOMOEOPATHS. Rosin-weed comes into the
homoeopathic school through "the indefatigable Dr. Hale," as Richard
Hughes calls him. The homoeopathic school owes much to Dr. E. M. Hale,
who enriched our materia medica with many American plants, most of them
drawn from the eclectic school and, be it noted, Dr. Hale gives full
credit to that school from which the new medicines came. Dr. Hale did
masterly work in proving the new remedies and verifying the observations
of the eclectic physicians and published his _Characteristics of New
Remedies_ in 1864. In 1868, Dr. Garrison published his paper on the use
of rosin-weed in asthma and Dr. Hale, in his third edition of 1873,
included rosin-weed under the name _silphium laciniatum_, as follows:
SILPHIUM LACINIATUM
_ROSIN-WEED_
Syn. (page 544) Compass-plant, Polar-plant, Rosin-weed.
Analogues, Cubeba, Copaiva, Terebinthina.
Officinal preparations.--Tincture of leaves: dilutions.
Catarrhal affections and diseases of the mucous
membranes.--Eclectic.
Chronic catarrh of the nasal passages.
Chronic laryngitis and bronchitis.
_Asthma_, hurried (breathing?) with concomitant catarrhal
affections of the bronchial mucous surfaces.
(It is a popular domestic remedy in _asthma_. Eclectic physicians
value it highly in throat affections. Some homoeopathic
physicians, Drs. Small, Kendall and others have used it with
gratifying results.--Hale.)
_Horses_ that eat of the leaves mixed in hay are cured or relieved
of the _heaves_ and chronic loose cough.
Catarrh of the bladder.
Dr. Hale did not prove this remedy. All symptoms except the last one are
clinical, that is, they disappeared while the patient was taking the
remedy but they have not been produced on the healthy. The last symptom
is a pathogenetic symptom verified by cure. There is, however, a proving
of silphium but it is buried deep in the dust that covers old reports
and has not seen the light of day for many a year. I reprint it here
from the _Hahnemannian Monthly_, Volume 8, June, 1873, page 536, from
the report of a meeting of the Philadelphia County Homoeopathic
Society.
"Silphium lac.--Dr. G. A. Hall, in the April number of the Medical
Investigator gives a summary of a proving. (The first decimal
trituration was given in doses of two grains gradually increased to
ten grains every two hours.)
"It produces a scraping, tickling and irritation of the fauces and
throat; nausea, sick, faint feeling and a sense of goneness in the
epigastrium; a desire to hawk and scrape the throat, throwing off a
thin viscid mucus. The irritation extends up the posterior nares,
involving the mucous membrane of the nasal passages, producing
sneezing, followed by a discharge of limpid, acrid mucus from the
nose, attended with constriction and pressure in the supra-orbital
region. Engorgement and thickening of the mucous membrane of the
throat as far down as could be seen; rough cough, attended with
the expectoration of yellow mucus; contraction and tightness of
lungs, constant disposition to raise; hacking, spasmodic cough;
tongue covered with whitish slimy coat attended with dry sensation
as if burned with hot soup; urine high colored and scant, frequent
passages with sense of heat at the meatus urinarius during passage
of urine; stools natural in form but covered with whitish, slimy
mucus. An internal feverish sensation; pulse not accelerated; want
of appetite.
"=Clinical Observation.= For ten years, I have used silphium in
asthma with large quantities of stringy mucus, in influenza,
coryza, catarrh, and believe it to be the best remedy we have in
phthisis when gray or yellow mucus is expectorated copiously,
causing rapid exhaustion. I use the second decimal trituration in
one or two-grain doses every two hours until expectoration is
diminished perceptibly and then at intervals of four or six hours
until expectoration is diminished to a degree consistent with other
symptoms of the case."
In spite of this good start, rosin-weed did not have any better fortune
with the homoeopaths than with the eclectics. It never got into the
text books. After transient popularity in the journals, it sank back
into obscurity and has remained as a remedy for asthma in the memory of
a few of the older practitioners from whom it is occasionally handed on
by oral tradition.
It was in 1872 when rosin-weed was enjoying its brief publicity and when
the epidemic of epizoötic among the horses created a public interest in
veterinary medicines, that my father, Dr. Alexander H. Laidlaw,
discovered its remarkable curative power in hay fever, as related in
Chapter II.
=Rosin-Weed among the "Allopaths."= Rosin-weed never got into the
Pharmacopoeia but it is none the worse for that. More people have been
poisoned by the drugs inside of the Pharmacopoeia than by those
outside of it. Except the few comments by western and southern medical
journals, it was practically unknown in the dominant school, as shown by
there being only one reference to it in the Index Catalogue. This is an
article by Dr. Q. J. M. Goss, of Marietta, Georgia, in the _Nashville
Journal of Medicine_, 1887, xx, page 60, in which Dr. Goss praises
rosin-weed highly for its power to cure catarrh of the mucous membranes,
comparing it to the balsams, cubeb and turpentine, and relating the cure
of two cases of asthma.
In the Library of the New York Academy of Medicine, there is a thin
pamphlet by Dr. Goss, entitled _New Medicines_, which I suspect to be
taken chiefly from Dr. Hale's _New Remedies_, in which he says of
silphium laciniatum, "It has proved for me one of the best remedies in
humid asthma. I have made several brilliant cures with the tincture of
this plant and the tincture of ptelea trifoliata in doses of 30 drops
each four times a day in simple elixir.... In acute diseases of the
mucous membranes, the dose should be small, 5 to 10 drops; but in
chronic inflammation, the dose may be 30 drops of the saturated
tincture. It is a valuable remedy in chronic bronchitis and tracheitis.
It will soon become a popular remedy in mucous diseases."
This prophecy of popularity was scarcely borne out; for, with the
exception of the article by him in 1887, rosin-weed drops out of sight
and is found in no books published in the last forty years.
=Pharmacology.= For the following information, I am indebted to the
Botanical Department of Parke, Davis & Co., whom I wish to thank for
their unfailing courtesy in replying to my inquiries about this little
known plant:
"Rosin weed is a general name for all species of the genus
_silphium_ of which there are more than twenty species; some of
these species, however, have special names. Three species are
usually mentioned as being used for medicinal purpose. We list them
with their synonyms as follows:
Silphium perfoliatum, Lin. Indian cup, ragged cup, cup plant, rosin
weed.
Silphium terebinthinaceum, Lin. rosin weed (true), prairie dock.
Silphium laciniatum, Lin. Syn. S. gummiferum, Ell. compass-plant,
polar plant, pilot plant, rosin weed.
It is more than probable that all the species of the genus are
equally effective from a therapeutic point of view."
We have always used the fluid extract of the herb. Goss and Hale used
the tincture of the fresh leaves and so the homoeopaths have always
used it. Since looking into the history of the plant, I recall a remark
of that wise old physician, Rademacher, in regard to chelidonium. _Ich
bin kein Freund von Extrakten._ He preferred the tincture of the fresh
plant. Tinctures of the fresh plant were Hahnemann's preference too, and
it may well be that with rosin-weed also, the tincture preserves the
medicinal power better than the extract.
=Mode of Action.= If the proving of rosin-weed made by Dr. Hall is
reliable, we must conclude that rosin-weed cures the symptoms that it
produces in the healthy and it must be regarded as acting on the
homoeopathic principle. I must own that I am a little suspicious of
provings that match so closely the long established popular use of a
drug and, in this case, believe that we must wait for confirmation of
this proving before accepting it as sound. Rosin-weed has always seemed
to me to be a harmless herb, which is shown also by its use among
children as chewing gum. I have never noticed the "tonic, diaphoretic or
diuretic effects" attributed to it in eclectic medicine and believe that
they must be feeble. The only unpleasant effect that I have noted is
nausea after large doses, sixty drops or more, and this in very few
patients. Vomiting is rare, is never serious and ceases spontaneously
when the stomach is empty of the drug.
At the Baltimore meeting of the American Institute of Homoeopathy,
where the use of rosin-weed in hay fever was first reported, Dr. John
Sutherland, of Boston, made the proper criticism that if rosin-weed was
harmless and could not produce any effect on the healthy body, he could
not understand how it had any power to cure. To this, I had no answer
except that I had both taken and given large doses for many years to
patients of all ages and had never seen any symptoms develop. Another
speaker suggested that, like calcarea and silica, potentization would
develop pathogenetic powers that were not evident in the crude drug.
This I have never tried. As related in the chapter on Bacterial
Vaccines, I suspect that the curative power of rosin-weed in hay fever
lies in its power of relieving a coexisting catarrh, of which theory we
have the confirming evidence that other methods that cure catarrh, nasal
operations, bacterial vaccines, homoeopathic remedies, have often
cured a coexisting hay fever. Since that discussion, I have found Dr.
Hall's proving. It would be a pleasure to find that our old family
remedy for hay fever really acts on the homoeopathic principle but I
believe that the question needs the verification of further proving.
Transcriber's Notes:
Footnotes have been placed at the end of chapters.
Obvious punctuation errors repaired.
All oe ligatures have been replaced with "oe" (eg: "homoeopathic")
page 52 "posioning" changed to "poisoning" (uric acid poisoning)
page 57 "familes" changed to "families" (gouty familes are especially)
page 69 "urid" changed to "uric" (so-called uric-acid disorders)
page 95 "Immutiny" changed to "Immunity" (Passive Immunity)
page 97 "Inthe" changed to "In the" (In the Centralblatt für)
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