the diagnosis of hay fever is quite easy. Its distinctive features are:
It appears at the same time every year (the early form about the 1st of
June and the later about the 20th of August); the severity of the local
symptoms which usher in the disease--sneezing, stoppage of the
nostrils, the inflamed condition of the eyes, and above all the itching
of the nose, eyes, skin, and mucous membrane of the root of the mouth.
A detailed differential diagnosis {222} is not as important now as it
was formerly, when, as in the days of one of its early describers,
Phoebus, "Man sah sie nicht, wo sie war, und sie sah, wo sie nicht
war."
PROGNOSIS.--The number of elderly persons with hay fever, many of whom
have passed the allotted threescore years and ten, and the fact that no
one has ever been known to die from the disease, affords conclusive
evidence that it does not shorten life. On the other hand, when once
affected, except in those cases relieved by operative procedure, the
patient remains subject to it during the remainder of his life. A few
isolated cases are said to have recovered, but such a result is
extremely rare. It is thought by some that a prolonged residence in the
South may mitigate the disease, and eventually cure it, but this
assertion lacks confirmation. It does not, like bronchial asthma, lead
to secondary affections, the interval between the attacks giving the
organs time to recuperate, nor does it predispose to other diseases.
TREATMENT.--Aside from its surgical treatment, to which I shall refer
farther on, the only effectual remedy for hay fever consists in removal
to a region which is exempt from the disease. By going to such a
locality before the attack occurs, and remaining there throughout the
critical period, complete immunity from the disease may be secured. The
time of departure and return must be determined by the previous
experience of the invalid in regard to the date upon which his former
attacks have commenced. As the disease seldom comes on exactly on the
same day every year, but often varies three or four days, he should be
in his place of refuge at least a week before the usual time for the
attack, and should remain until he can return with perfect safety. This
is usually about the middle of July in the early variety, and after the
first frost severe enough to kill vegetation in the autumnal form.
In the milder form which occurs in the spring the seashore affords
considerable relief, except when the wind is from the land. It is
therefore uncertain, and is only indicated when the circumstances of
the patient prevent his visiting one of the exempt localities. On the
eastern coast of the United States there are several places of this
character, such as the Isles of Shoals, a group of rocky islands with
little or no vegetation off the coast of New Hampshire, the climate of
which is very like that of the ocean; and Fire Island, near New York.
Similar to the above, but much more exposed to land influences, are
Mount Desert and Nantucket.
The ocean itself affords complete exemption, and a sea-voyage is the
surest means of avoiding the disease. It is true that persons have been
known to be affected with hay fever even in mid-ocean, but in such
cases it is more than probable that the cause of the attack could have
been traced to the cargo. A case of this character came under the
writer's observation during a voyage from New York to Charleston during
the month of September, and was evidently caused by hay, a number of
bales of which were stowed on the forward deck of the vessel. It makes
comparatively little difference what particular voyage is undertaken,
provided the vessel's course does not bring her too near land; but for
most hay-fever patients a trip to Europe is to be preferred, especially
for those suffering with the autumnal form, as by going to that
country, where this variety does not exist, they avoid the necessity of
remaining nearly two months on the water. A voyage to California is
almost as good, and for the same reasons.
Whether this applies to the so-called June or rose cold, which is quite
common in Great Britain and prevails to some extent on the Continent,
has not as yet been definitely determined, but it is more than
probable. Whether patients who have contracted the disease in Europe
would escape in America is exceedingly doubtful. Two of the cases
reported to the writer, who were first attacked (with the early form)
in Europe--the one in Switzerland and the other at Florence--continued
to have the disease after their return to {223} this country; while, on
the other hand, an English lady who was subject to the disease at home
escaped entirely during her residence of three years in the Southern
States. Of the exempt regions in the United States, the one most
frequently resorted to, and which at the same time affords the surest
relief, is that of the White Mountains of New Hampshire--not the whole
of it, but a certain portion, which is bounded on the west by a line
drawn from Littleton to Lancaster (but not including the former place,
which is only partially exempt), on the north by Canada, on the south
by Franconia, Crawford House, and Jackson, while to the east it extends
as far as Bethel in Maine. Of the various places contained within this
territory, Bethlehem and Jefferson, Whitefield, White Mountain House,
Fabian's, Twin Mountain House, Crawford House, Glen, Gorham, and Mount
Washington, may be regarded as entirely exempt; Franconia Notch almost
equally so; while Dalton, Lancaster, and Bethel must be ranked as
uncertain. Another exempt region extends to the north and east of the
one just described, and comprises the lake region of Maine. Petoskey in
Northern Michigan, at the head of Little Traverse Bay, is said to
afford almost entire relief, and is resorted to by a large number of
patients from the Western and South-western States. There are also
several places in Vermont which offer more or less immunity, such as
Mounts Mansfield and Stow, both of which, however, are inferior to
those first mentioned. Canada, with the exception of a few cases
reported at Toronto, St. Catherine's, and at a few places near its
southern border, appears to be exempt. The same may be said of the
Adirondack Mountains and Pottersville on Schroon Lake and Marquette.
The Catskill Mountains and several places high up on the Alleghanies,
such as Cresson, Pa., Oakland and Deer Park in Maryland, afford relief
in many cases. Colorado is said to be exempt, but several patients who
have gone there failed to obtain relief. California is free from the
disease, and many hay-fever patients have escaped their attacks by
removal to that State. I know of no place in the Southern States which
affords relief except Florida, where the disease is rare; several cases
have been entirely relieved during their residence there. In others,
however, the experiment was unsuccessful.[17]
[Footnote 17: Two patients in their replies to the writer's circular
claimed to have been entirely exempt--the one (early form) at Beaufort,
and the other (autumnal) at Mount Airy, Habersham county, Ga. Wyman
mentions four cases that were relieved at or near Beaufort.]
The relief obtained by resorting to an exempt locality after the attack
has begun is very prompt, all symptoms of the disease disappearing
within a few days after the arrival of the patient. While residing at
Bethlehem, N.H., I was called one evening to see a German who had just
arrived on the train from Fall River. His condition was most pitiable:
his eyes were fiery red, the nose and face were terribly swollen, while
the water streamed from both eyes and nose. The asthma was at its
height, and his struggles for breath were fearful in the extreme. A
quarter of a grain of morphia was injected into the arm, and after
providing other means for his comfort I left him for the night. The
next morning, while preparing to pay him an early visit, the patient
himself appeared at my office, bright and cheerful, and so much changed
that I at first failed to recognize him. A single night had served to
dissipate all traces of his hay fever.
Unfortunately, a journey to the mountains, and a residence there of six
or eight weeks, are not within the reach of every one afflicted with
the disease; and for these unfortunates something must be done to
relieve, or at least mitigate, their sufferings. If unable to visit any
of the exempt localities, a sufferer may secure a certain degree of
comfort by exposing himself as little as possible to the exciting
causes of hay fever. As it is well known that heat and dust aggravate
the symptoms, the windows of the apartment occupied {224} by the
patient should be so arranged as to exclude the sunlight and every
precaution taken to avoid the presence of dust. He should eat good,
nutritious food, avoiding the use of all stimulants, except perhaps a
little light wine at dinner. Anything which induces dyspepsia must be
carefully guarded against, and care taken to keep the bowels regular.
Blackley[18] advises as a surer method of excluding the irritant
(pollen) the hanging of a curtain of thin calico before the door and
fitting into the lower portion of one of the windows a screen made of
two layers of thin black muslin enclosed in a square frame. When in use
both curtain and screen should be moistened with a solution of carbolic
acid, ten grains of the acid to one pint of water. For those who are
compelled to go out he has devised a very ingenious respirator. Having
taken an exact cast of the nasal passages from the margins of the alæ
and septum to the inferior turbinated bones, he constructed with the
aid of these, by means of the galvano-plastic process, cases of silver
fitting exactly all the folds and depressions of the cavity. Several
layers of platinum wire, 0.001" to 0.007", were arranged in the cases.
The sieve thus formed was moistened before using with a 1/10 per cent.
solution of carbolic acid. To prevent the pollen from coming in contact
with the eyes, they were protected with spectacles provided with
accurately-fitting gauze guards. The result of wearing this apparatus
was an almost perfect freedom from unpleasant symptoms.
[Footnote 18: _Op. cit._, p. 267.]
In the absence of any specific, the medicinal treatment of hay fever is
necessarily confined to palliative measures. Debility being one of the
prominent symptoms, tonics are indicated, and in this way quinine, at
times regarded almost as a specific, may be of use. It should be given
in doses of one or two grains three times a day before and during the
attack. Thus administered, it is undoubtedly of great utility in many
cases. Arsenic, whether in the form of Fowler's solution or the iodide
of arsenic, as suggested by Blackley, may also be used with advantage.
Galvanism, which was used successfully by Hutchinson of Rhode Island,
is strongly recommended by the late Beard. He advises that the negative
pole be placed at the epigastrium "and the positive applied a moment
over the forehead and on top of the moistened head, then over the front
and back of the neck, and down the upper and middle of the spine." The
current used should be mild and the sittings short. The writer has had
no personal experience with this method of treatment, nor has it been
generally adopted.
The injection into the nostrils of a saturated solution of quinine by
Helmholtz, although apparently useful in his case, has not met with
like success in the hands of others.
The troublesome itching and burning of the eyes and face are most
readily relieved by bathing the parts at first in tepid and then in
cold water, repeated several times a day, and with mild astringent
collyria, such as a strong infusion of tea or of one or two grains of
sulphate of zinc to an ounce of rosewater. If the lids be much inflamed
and the skin excoriated, the following ointment may be applied:
Rx. Bismuth. subnit. drachm ss;
Ungt. simpl. ounce j.
M. Ft. ungt.
The pharyngeal symptoms are best controlled by chlorate of potassium as
a gargle, or, better still, in the form of the compressed tablets now
prepared by many of our druggists. The treatment of the asthmatic
symptoms differs in no way from that which we have recommended for the
paroxysms of BRONCHIAL ASTHMA, the details of which were fully
described in the preceding article.
In 1880, Harrison Allen of Philadelphia published an article[19]
directing {225} the attention of the profession to the fact that many
cases of chronic nasal catarrh which had resisted the ordinary methods
of treatment could be readily cured by restoring the permeability of
the nasal passages.
[Footnote 19: _Am. Journal of Med. Sciences_, January, 1880,
Philadelphia.]
In April, 1882, William H. Daly of Pittsburgh, Pa., in a paper[20] read
before the American Laryngological Association, gave the histories of
three cases of hay fever which he had succeeded in curing by means of
operative procedure. In each of these cases the tissue over the
inferior and middle turbinated bones was hypertrophied, and in one case
it was so extremely sensitive that the slightest touch with the probe
was sufficient to excite a violent paroxysm of sneezing. In these the
diseased tissue was removed with the galvano-cautery or by the
application of glacial acetic acid.
[Footnote 20: "On the Relation of Hay Asthma and Chronic
Naso-pharyngeal Catarrh," _Archives of Laryngology_, vol. iii. No. 2.]
The following year (1883) a much more elaborate article[21] on the same
subject was published by John O. Roe of Rochester, N.Y. After
describing the highly vascular and somewhat erectile tissue covering
the inferior turbinated bones and lower portion of the septum, the
turbinated corpora cavernosa of Bigelow, he calls attention to its
great susceptibility to the action of irritants, whether applied
locally or to some remote portion of the body, citing as an example of
the latter the swelling, and sometimes almost complete closure, of the
nostrils supervening after exposure of the body to the action of a
current of cold air. In this situation the tissue is liable to become
hypertrophied, and in that state its susceptibility is greatly
increased. If, when in this condition, it is exposed to the action of
pollen, dust, or any other irritant, the substance produces a local
irritation which is reflected through the sympathetic nerves to other
parts of the respiratory tract; and it is to this reflected irritation
that Roe attributes most of the phenomena of hay fever. He regards it
as analogous to certain forms of laryngeal catarrh which, according to
the recent testimony of many distinguished laryngologists, are clearly
traceable to disease of the nasal cavity. Applying this theory to the
treatment of hay fever, he removed the hypertrophied tissue in five
cases, and in every instance succeeded in preventing a recurrence of
all symptoms of the disease. His operation consists in the removal of
the diseased tissue by means of Jarvis's wire écraseur and the
galvano-cautery, caustics having proved less effective. The wire snare
is best adapted for the removal of the tissue over the posterior
portion of the turbinated bone, where, owing to its being pedunculated,
it is readily caught in the wire loop. Over the anterior portion of the
turbinated bone, as well as over the septum, the growth is more
sessile, and is best destroyed by means of the galvano-cautery. To
avoid inflammatory reaction and to guard against other unpleasant
symptoms it is advisable to remove only a small portion of the growth
at a time. After each operation the part should be sprayed with warmed
vaseline to allay the irritation occasioned by the burning, and this
should be continued until the surface is sufficiently healed over to
admit of a repetition of the operation. The cauterization should be
repeated until every trace of the diseased tissue is removed.
[Footnote 21: _The Pathology and Radical Cure of Hay Fever_, New York,
1883.]
Prior to the publication of Roe's article Harrison Allen had operated
successfully on two cases, the histories of which he has not as yet
published, but has kindly communicated by letter to the writer,
together with a description of his method of operating. This latter
differs but little from that of Roe, except as regards the time at
which the operation should be performed, Roe maintaining that the
operation should never be performed when the patient is suffering from
an attack of hay fever, while Allen considers this immaterial, and does
not hesitate to operate even when the symptoms are at their height. If
symptoms of hay fever recur after the operation, the nares should be
{226} carefully examined, and if, as is usual in such cases, any
remnants of hypertrophied tissue be discovered, these should be at once
removed. The operation is not regarded as a very painful one, and a
patient of Allen's upon whom he had operated during an attack assures
me that he left the doctor's office feeling much better than when he
entered it. This is mentioned because hay-fever patients are
excessively nervous, and timidity on their part has hitherto prevented
many of them from availing themselves of this form of treatment.
It will be seen that, thus far, the operation has been performed in but
ten cases, but the results have been so uniformly successful as to
justify the belief that it is capable of relieving many cases of this
hitherto intractable disease. Whether this hypertrophied condition is
present in every case, as claimed by many, or in even the majority of
cases of hay fever, has not as yet been determined; and until further
observation shall have decided this question it will be impossible to
form an opinion in regard to the general application of this method of
treatment.
{227}
DILATATION OF THE BRONCHIAL TUBES, CIRCUMSCRIBED AND DIFFUSED.
BY SAMUEL C. CHEW, M.D.
DEFINITION.--Enlargement of the calibre of a bronchial tube or tubes,
whether confined to a limited portion of one tube, or reaching
throughout a great part of its extent, or involving several or many
tubes.
SYNONYM.--Bronchiectasis, from [Greek: bronchos], a bronchial tube, and
[Greek: echtasis], an expansion.
HISTORY.--The change in the physical condition and size of a bronchial
tube, designated as bronchial dilatation, never occurs as a primary
affection, but is always the result of some preceding disease,
especially of chronic bronchitis or fibroid phthisis. The full
consideration of its pathological origin belongs, therefore, to the
natural history of those causative affections.
Later writers have in general followed Laennec's description of the
different varieties of bronchial dilatation; which, indeed, can hardly
be improved upon, for such was the accuracy of that great clinician and
pathologist as an observer that nothing was likely to escape him as
regards physical conditions, though he may sometimes have been in error
as to the theoretical explanation of what he saw. Previously to
Laennec's observations dilatation of the bronchial tubes was, as he
remarked himself, almost entirely overlooked both by pathologists and
practitioners. The reason of this is evident from the considerations
that a smaller tube when dilated would, except to the most careful
examination, closely resemble a larger tube of normal size, and that a
large dilatation might be mistaken by the ear at the bedside and by the
eye at the necropsy for a pulmonary vomica.
Two principal forms of bronchial dilatation are met with. In the first,
or diffused bronchial dilatation, known also as the cylindrical form,
the tube is uniformly enlarged in calibre, so that, whereas in the
normal state it would have admitted only a fine probe, in its enlarged
condition it may be of the size of a goosequill. In this state it may
be readily mistaken, when seen by itself, for a larger tube; but the
alteration is conspicuous when the tube is seen to be larger than the
branch from which it is given off. In the second or circumscribed form,
which is also termed sacculated dilatation, a pouch-like or fusiform
distension occurs in the continuity of a tube. In a third form, which
is far less common, several successive enlargements are met with in the
course of one tube, which thus presents a beaded appearance. It happens
at times that all of these different varieties of dilatation may be
encountered in the bronchial tubes of the same lung. The second, or
sacculated, form is the most common, especially in young persons.
ETIOLOGY.--In both of the more common forms of bronchial dilatation the
previous existence of bronchitis is to be regarded as the chief
causative agency, though other conditions may serve to increase the
dilatation when it has once been established. Laennec's observations
led him to connect the {228} occurrence of bronchitis with the
production of dilatation of the bronchial tubes, though his explanation
of the mechanism of this production was erroneous, inasmuch as he
considered the accumulation of secretion in the affected tubes, and the
forcible inspiratory efforts made in coughing to dislodge this
accumulation, to be the direct causes of the enlargement. The part
played by bronchitis in producing dilatation is, however, less
immediate and mechanical than Laennec held it to be. It may, in a
general way, be considered the direct cause of the cylindrical and the
indirect cause of the saccular form of dilatation.
The long continuance of chronic bronchitis gives rise to weakness and
atony of the bronchial walls, so that they yield to the pressure
brought to bear upon them in the violent or protracted and repeated
respiratory efforts that are made in coughing. In such cases the tubes
which are themselves affected by the inflammatory process may yield
throughout a greater or less extent of their continuity, and thus the
cylindrical form of dilatation may be established. The same mechanism
may be supposed to give rise to the beaded variety of the disease if
the inflammatory action should be greater at several points along the
course of a tube, with intervals of tissue in a healthier or less
atonic state.
In the saccular form, on the other hand, the dilatation does not occur
in the portion of the tube which is chiefly affected with the
inflammatory process, but is the consequence of a local capillary
bronchitis involving the ultimate ramifications of the affected tube
and occasioning collapse of a portion of the lung. This collapse
operates in two ways in causing a pouch-like dilatation of an adjacent
bronchus--partly through the atmospheric pressure within the affected
tube, tending to fill the space created by the collapsed portion, and
partly by the traction of this collapsed lung-tissue outside of the
tube.
In addition to the part played by bronchitis and atelectasis of the
lung in occasioning bronchial dilatation, another important factor in
its production is to be found in the condition described by Corrigan in
1838 as cirrhosis of the lung, and since recognized as interstitial
pneumonia or fibroid phthisis. In this affection there is formed around
the blood-vessels and terminal bronchi, as well as around the
air-vesicles, a hyperplasia of the connective tissue, which, as is the
case with connective-tissue formations in other situations, ultimately
contracts, obliterating the air-cells, smaller bronchi, and
blood-vessels, and thus converts the lung-tissue into a tough, fibrous
mass. By the contraction thus produced the bronchial tubes of a larger
size, which have been previously weakened by bronchitis and have lost
their elasticity, are subjected to traction on all sides, and thus
become dilated. Dilatations of all forms may thus be produced,
cylindrical, sacculated, or beaded, according to the amount of lung
involved in the contracting process and to the degree and situation of
the bronchitis which favors the dilating action.
The determining causes, then, of bronchial dilatation are--1st, chronic
bronchitis; 2d, atelectasis; and, 3d, fibroid phthisis or cirrhosis of
the lung.