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 œdema, 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 dyspnœa 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 œdema. And a hive (or urticaria or angioneurotic œdema) 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 homœopathy, 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. Phœbus 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 œdema 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.