A Plea for the Radical Treatment of Hay Fever. BY CHAS. E. CLARK, M. D,, Kansas City, Mo. Professor of Clinical Laryngology Kansas City Medical College. Read before the Jackson County Medical Society, December 9th, 1897. Gentlemen:—While I am aware that a paper would probably be much more appreciated at the onset rather than at the close of the hay fever sea- son, yet I trust that with our mem- ories still fresh regarding the battle which we have just waged against this' most distressing affliction, we may have a full and profitable discus- sion. My only apology in offering a paper upon such an important subject without attempting to offer any new ideas, is that, in judging of the prog- nosis frequently offered to patients by the profession, there must yet be much misapprehension regarding the true status of this disease. Without entering into historical details, I wish to recall to your minds, that the first lucid account of the disease was given by John Bos- tock in 1819, who described “a per- iodical affection of the eyes and chest,” from which he was himself a sufferer. In 1828 he wrote another paper upon the subject, calling the affection “summer catarrh.” In 1862 Phoebus, of Giessen, Ger- many, published a paper reciting one- case; following which he directed cir- cular letters of inquiry to the medical profession of the world, containing a list of questions touching every phase of the disease. As a result of the information thus acquired consid- erable progress was made, and the pollen theory of aetiology was evolved. In 1875 Blackley, of Manchester, contributed the most scientific paper yet written upon the subject, in which he corroborated the pollen the- ory of aetiology and further asserted that the severity of the disease bore a direct relation to the amount of pol- len present in the atmosphere. In 1876 Beard, of New York, published information which he had gathered in the treatment of a considerable num- ber of cases, and by correspondence with over two hundred hay fever suf- ferers. In his statistics he also con- firmed the pollen theory, and elicited the additional information that a very large per cent, of the cases so affect- ed were of a nervous temperament, and that nerve tonics had an import- ant place in treatment. So fixed had Blackley and his followers become in Tf - ~ . I their belief in the pollen theory, that this intrusion of a new aetiological factor, was met with the observation that its author was a member of two neurological societies, and hence his views must be received with a due degree of caution. Illustrative of the one idea zeal with which the pollen advocates ad- here to their theory and seek to log- ically explain its action, might be mentioned the ludicrous theory ad- vanced by Mr. Wright Wilson, viz: “That the pollen granule being only one-tenth the size of the red blood corpuscles, readily passes through the vessel wall and acts as a foreign body in the blood current.” Dr. J. N. McKenzie comments on this theory as follows: “Through ciliated epithelium, base- ment membrane, and vessel wall, the dreadful vitalized amoeboid pest of the summer months is launched into the general circulation. Does it feast on the nuclei of the white corpuscles as its legitimate prey, or does it seek its pabulun in the more organized and nutritious protoplasm of their redder and more numerous companions? Is it carried into the more remote organs on the crest of the serous wave, or is it whirled through the circulation on the back of the red blood cell? Is the dyspnoea of this disorder due to pol- len emboli in the lungs or to granu- lar invasion of the respiratory center ? Are we at last to realize the poetic conception of “Quick effluvia darting through the brain, Die of a rose in aromatic pain?” In 1881 my friend and former as- sociate, Dr. William H. Daly, of Pittsburg, Pa., read a paper before the American Daryngological Asso- ciation in which he showed by the recital of a series of cases, that in at least a very large proportion of the cases affected with hay fever there is a local disease of .the nose or naso- pharynx, varying from a simple hy- perasthesia to pronounced structural changes, such as hypertrophic rhinitis, polypi, &c., without which the excit- ing, or as he designates it, “extrinsic” cause, pollen, is innocuous; and the cure of the affection may be accomp- lished through the removal of the loc- al, or “intrinsic” cause. While the observations of Beard di- recting attention and treatment to the nervous system, thereby enabling constitutional treatment to mitigate to some extent the severity of the dis- ease in certain individuals, and while the previous observations of the pol- len theory suggested immunity from the disease by the removal from their customary place of residence during certain periods of the year, yet to Daly belongs the credit of promulgat- ing the theory of a third aetiological factor and outlining a treatment both practical and efficient. Much has been written since the acceptance of the theory of a local cause, touching on the exact nature of such disturbance, and while it is undoubtedly a fact that almost any portion of the nasal mucous mem- brane may become the site of sensi- tive areas, yet it is also probably true as observed by J. N. McKenzie, “that the area most sensitive to reflex pro- ducing impressions is represented by the portion of the mucous membrane which covers the turbinated corpora cavernosa, the most sensitive spots being in the mucous membrane cov- ering the posterior extremity of the inferior turbinated body, and the sep- tum immediately opposite, a zone cor- responding to the distribution of the spheno-palatine branches of the super- ior maxillary nerve, which derived through the spheno-palatine ganglion, probably contains the vaso-motor fi- bres which govern the erection of the turbinated tissue.” In short to have a paroxysm of hay fever there must be present three aetiological factors as suggested by Sir Andrew Clark in 1887: 1. A neurotic habit. 2. An intra-nasal pathological con- dition. 3. An external exciting cause. The latter expression (an external exciting cause) is preferred rather than “the pollen,” as this classifica- tion includes pollen as well as many other substances which are now rec- ognized as being capable of exciting a paroxysm of hay fever. The ab- sence of any one of these factors breaks the chain requisite for the pro- duction of the paroxysm. The prob- lem which confronts us then in the treatment of this affection is, which factor can be the most readily over- come? All physicians, whether general practitioners or specialists, realize what it is to overcome a decided neu- rotic tendency in the treatment of any disease wherein it furnishes a complication. To remove at all times the exciting cause is likewise difficult, and is gen- erally effected by removing the pa- tient from the cause, rather than the cause from the patient. Social and business duties, as well as circum- stances in life, frequently render this extremely difficult if not im- possible. All things considered then, the most practical method of relief, and the one whose bene- ficent results are within the reach of the most humble walks of life, is the removal of the local pathological con- ditions. Treatment to this end may be commenced either during the in- terval between attacks or during the height of the paroxysm, the result in either instance being almost invari- ably satisfactory and frequently al- most magical. L,ocal treatment may be either palliative or radical. Pal- liative treatment consists in the use of various sedative sprays, powders, or ointments, the chief ingredients of which are generally cocaine, mor- phine, belladonna, &c.,andat most can do no more than furnish tempor- ary relief, and always with the pos- sibility of establishing a drug habit much more terrible than the disease. Radical treatment consists in the complete removal of all abnormal con- ditions found in the nose or naso- pharynx by the use of such methods as may be required for each individu- al case. Polypi should be removed with the cold wire snare, and the pedicle thoroughly destroyed with the galvano-cautery. Marked vaso-pare- sis with distension of the turbinated corpora-cavernosa should be incised with a fine cautery electrode from one extremity to the other and down to the bone, using care to destroy as lit- tle of the mucous surface as the re- quirements of the case will permit. Areas of hyperasthesia with no vaso -motor disturbance may be touched with a moderately warm elec- trode, tincture iodine, or some other suitable counter-irritant. All work must be done by use of reflected light, with skill and preci- sion, and each sensitive spot no mat- ter how small, given proper considera- tion. In offering a prognosis as to the results to be derived from local treatment, I am inclined to think that as a rule, our chances of success diminish just in proportion as ihe neurotic element becomes pronounced. However, as emphasizing the bene- fits to be derived from local treat- ment, even in a case of a most pro- nounced neurotic type, I desire to re- cite the following history of a case coming under my observation: R. B. M., Garden City, Kans., referred to me August 29th, 1897, by Dr. Geo. C. Mosher of this city. Aged twenty-four years; height, five feet, eight inches; weight, one hundred and thirty-five pounds, decided blonde, delicate physique, and marked nervous temperament. Occupa- tion—student in a Commercial College. At the time he was suffering from a well developed and characteristic attack of hay fever. Had had an attack beginning about the latter part of July or first of August each year, for the last eight years, each attack lasting until frosts. At the age of puberty he was quite nervous, and suffer- ed from the belief that every act that he performed (such as picking up an object) should be repeated three times. He has been afflicted in like manner, but to a lesser degree, at various times since, but through mare mature judgment and volition, he has always been able to control the impulse. During the last six years he has suffered much at times from irritable heart action. There is a history of • insanity on the pa- ternal side of the family sevex-al genera- tions back, and his father suffered much from despondency following business re- verses, and finally died of some form of brain disease at the age of fifty-six years. Mother died at the age of forty nine, from some form of liver disease. Has one brother and one sister, both living and in good health. No brother or sister dead. Examination reveals eyes much congest- ed, nares cougenitally small and entirely occluded. Both inferior turbinated bodies swollen, anaemic, and pressing upon the septum. In left nares there was a long horizontal enchondrosis, near the inferior portion of the septum. The entire mucous membrane of both nares was extremely sensitive to the touch. Sneezing was more or less constant, becoming exaggerated upon exertion, and greatly interfering with {rest at night. His previous attacks seemed to have been aggravated most by inhaling dust from alfalfa. Treatment—At the time of referring patient to me, Dr. Mosher was giving him syr. trifolium comp., which was continued; but aside from this he took no internal or constitutional treatment. The local treat- ment consisted in destroying all sensitive areas with the galvano-cautery; selecting each point presenting the characteristic ap- pearance, and thoroughly destroying it. He continued treatment for three weeks, at the close of which time all cauterized surfaces were healed, and the nares pre- sented almost a normal appearance. He stated that after the first week of treat- ment, he was quite comfortable during the day, and able to sleep at night. While this is a case, as above sug- gested, which presented the neurotic element of aetiology to a degree not often encountered, and one in which we would reasonably expect success by directing treatment largely in that direction, yet this was almost en- tirely ignored, and the most happy results obtained were due almost en- tirely to local efforts. Since the recognition of the local factor in aetiology, and the many re- ported cases of success, where the treatment has been directed wholly to that cause, even where the neurotic element would seem to predominate, as in the case just mentioned, I am satisfied that we should no longer treat these patients as incurables with the belief that they are at least suffer- ing from a disease of aristocracy as their only object in living, but assure them that theirs is one of the most curable of diseases, when rationally and scientifically treated. 412-413 Altman Building.