Volume 3 — DISEASES OF THE RESPIRATORY SYSTEM. (continued 8)

Another stimulant highly recommended by Salter is coffee. In stating his objections to the use of opium it will be remembered that one of his reasons for not availing himself of that remedy was that it caused sleep, and that the exaltation of reflex action in that state favored the asthmatic paroxysm. Coffee, being a strong excitant of the nervous and vascular system, has the contrary effect and keeps the patient awake. It should be prepared as a strong infusion without the addition of either sugar or milk and given some time before the expected paroxysm. Administered in this manner, he claims that coffee will relieve two-thirds of all cases of asthma. The relief afforded is, however, very unequal, being in some cases complete, while in others it is only slight and transitory.

Quebracho in the form of an extract has been much used of late years in the treatment of asthma and other affections attended with dyspnoea. It has been found quite useful in mild cases.

The induced electrical current has been recommended by Schaeffer as a means of cutting short the paroxysm. His method is to place one pole on either side of the neck immediately below the angle of the jaw and in front of the sterno-cleido-mastoid, so as to cover the course of the pneumogastric and sympathetic nerves. The current should be sufficiently strong to enable the patient to feel the passage from one side of the throat to the other. It is applied for fifteen minutes twice a day for six days, twelve sittings being usually sufficient to afford relief. When the current is first applied it not infrequently causes dilatation of the pupils, but this is succeeded by contraction when the treatment begins to manifest its beneficent effects.

B. During the Intervals between the Paroxysms.—The diet and daily regimen of the asthmatic should be most carefully regulated, the best and most skilfully directed treatment being of little avail if these important matters are neglected.

The asthmatic patient should be encouraged to pass much of his time in the open air, but the amount of walking he should do will of course depend upon his strength and freedom from secondary affections of the heart and lungs. In a case of simple uncomplicated asthma the more the patient walks the better he will feel; but this is not to be construed to mean that he is to walk until exhausted; on the contrary, his walks should at first be quite short, proportioned to his strength and wind, and then gradually extended, but under no circumstances should he be allowed to overfatigue himself. With a view to keeping the skin in the best possible condition the body should every morning be sponged with water, the temperature of which must be suited to the condition of the patient. If he be feeble and anæmic, the water should be tepid, but whenever admissible cold is to be preferred. After the bath it is essential that the skin be thoroughly rubbed with a coarse towel until it becomes slightly reddened. The cold bath properly used not only invigorates the system generally, but by enabling the body to stand the vicissitudes of temperature diminishes the risk of the patient's taking cold.

The intimate relations existing between the lungs and stomach, and the fact that asthmatics usually suffer at the same time with dyspepsia, make the question of diet an all-important one. Their meals should consist of good, nutritious food, rigidly excluding all heavy, indigestible substances, such as cheese, nuts, dried fruits, etc. The meals should be taken at regular hours, and, as asthma almost always comes on at night, it is important that the principal repast should be in the morning or early part of the afternoon, and that any food taken between that and the hour for retiring should be of the lightest possible description. The more empty the patient's stomach, the better will be the chances of his passing a good night. Alcoholic drinks, coffee, and other stimulants should only be allowed when prescribed as medicines, as they have a tendency to aggravate the hyperæmia of the air-passages, which is one of the prominent features of the disease. Constipation should of course be carefully guarded against.

Aside from the apparently well-established fact that asthmatics do well, and often remain so, in the damp, foggy air of crowded cities, we have no means of determining beforehand what locality will suit a case of asthma. Change of climate in such cases is a mere matter of experiment, but when such change is determined upon the patient should at first try a place which is in every respect the reverse of the one he has previously lived in. If his former residence was in a city, he should remove to the country; if the old place was dry, the new one should be damp; if he has lived in a flat, low country, let him try the mountains; and vice versâ. As already stated, removal from the pure air of the country to the foul, smoky air of a city densely populated often affords complete relief, but so soon as the patient returns to his old home the asthma reappears and is as bad as ever.

As regards its capriciousness as to locality, I quote the following interesting case from Salter's work on asthma: "G. C——, a confirmed asthmatic, a native of a city in Scotland in which he resided, having been a sufferer for many years, came to London in 1838 for the sake of receiving the best medical advice. He took apartments in the centre of the city of London, somewhere near St. Paul's. His intention was to wait for an attack, and as soon as one came on to present himself to his physician, that he might witness it and have a clear idea of the state he was in. He waited six weeks, much to his mortification, not only without experiencing one, but without any difficulty of breathing whatever. His health altogether improved; he slept well and gained flesh. Being tired of waiting, he went back to Scotland without having seen his physician at all, and, to his great disappointment, he had not been in his native city many days when he was attacked in the usual way, and continued to suffer just as before his visit to London. Subsequently, finding it necessary on matters of professional business frequently to visit London, he experienced the same result on all occasions as at his first visit—perfect immunity from his disease. To use his own expression, 'he felt in London like a renewed man.' On his first arrival in town he was in a miserable state: he could not move without feeling his shortness of breath distressingly; he got no rest at night, and was seldom able to lie down in his bed. But in London he could do anything—eat, drink, sleep. The consequence was he gained flesh and strength, and went back to Scotland looking quite a different man. This was the invariable result."

Having once found a place which agrees with him, the asthmatic should remain there, as change of climate when no good is effected often does harm.

Arsenic has long been a favorite remedy in asthma, and is undoubtedly of great value in a number of cases. It was used in the form of a vapor by Dioscorides, and, notwithstanding its poisonous properties, has always occupied a prominent place in the therapeutics of diseases of the air-passages. In Styria and other parts of Lower Austria arsenic is habitually eaten by many of the peasants to enable them to breathe more readily while climbing over their elevated mountains and to endure the fatigue incidental to their long pedestrian journeys. The same habit is said to prevail in China, where, however, it is not taken internally, but is smoked mixed with tobacco. Its physiological effects are thought to be due to the increased oxidation of the blood which it promotes, as is proven by the great increase of urea observed after its administration. The blood thus oxygenized stimulates the vital centre, and thus the nerves and muscles of respiration are incited to increased activity, as a result of which the respirations become freer and more easy. Those who believe in the herpetic diathesis derive an additional indication for its administration from the good effects which it manifests in cutaneous diseases. It is best administered in the form of liquor potassii arsenitis (Fowler's solution), giving at first only three drops in a wine-glassful of water after each meal, and increasing the dose one drop each day until the patient takes thirty drops in twenty-four hours. Should any toxic symptoms supervene—pain in the stomach or diarrhoea, puffiness of the lids or redness of the conjunctiva—the arsenic should be at once suspended, and not resumed until they shall have subsided. Thus given, it is quite safe. Trousseau recommends its use in the form of cigarettes, which are prepared as follows: "Twenty grains of the arsenite of potassium are dissolved in half an ounce of water, and a sheet of bibulous paper soaked in this solution until it is all taken up. The paper is then dried and divided into twenty equal pieces, which therefore contain one grain arsenite of potassium each. Each paper is then rolled in the form of a cigarette. In smoking them the patient should endeavor to inhale the smoke into the bronchi. He should take only four or five whiffs once a day."

Iodide of potassium often affords most satisfactory results in the treatment of asthma, but in many cases it fails entirely. It is a drug which must be given for a long period at a time, occasionally for weeks, before it manifests its effects, and want of perseverance may account for its failure in many cases. It forms one of the chief ingredients in Aubrée's antiasthmatic elixir, the formula for which is somewhat uncertain. According to Trousseau, it is as follows:

Rx. Rad. polygalæ, gr. xl;

Coque c. aqua fervida, ounce iv ad ounce ij;

Filtrat, adde Potass. iodid. drachm iv;

Syrup, opii, ounce iv;

Spts. vin. gallic. ounce ij;

Tr. coccionellæ, q. s. ad coloraud.

Filtra.

Of this Trousseau states three tablespoonfuls are taken "in the morning fasting, at noon, and in the evening, until the asthma disappears." Each dose contains no less than forty-five grains of the iodide of potassium and four-fifths grain of extract of opium. Aubrée himself always insisted that each dose should be followed by a "tablespoonful of chocolate pastille, which neutralizes the irritating action of the iodide of potassium."²⁶

²⁶ Trousseau, op. cit., p. 656.

A remedy resembling in its effects the one just mentioned is nitro-glycerine. It is administered in the form of a one per cent. alcoholic solution, in doses of half a drop, increased to three should the smaller dose prove inefficient. Its effects manifest themselves in from three or four minutes to a quarter of an hour, and disappear within an hour after its administration. The dose should be increased with great caution, as a single drop of the above solution has been known to produce alarming symptoms. The euphorbia pilulifera, much lauded by Australian physicians for its wonderful effects in bronchial asthma, promises to rank as an invaluable remedy in the treatment of that disease. It is best administered in the form of a decoction prepared by steeping one ounce of the fresh, or half that quantity of the dried plant, in two quarts of water, and simmering it down to one quart. The dose of this decoction is three or four wineglassfuls during the day, the last dose preferably in the evening, after supper.²⁷

²⁷ Boston Medical and Surgical Journal, 1885, p. 66.

Leyden, whose theory has been mentioned elsewhere, has proposed a new treatment based upon the solubility of the Charcot crystals in chloride of sodium and carbonate of sodium. A solution of one part of these salts in one hundred parts of water should be inhaled twice daily in the form of a spray.

Oxygen has often been used in asthma, but is now seldom administered except in cases associated with great anæmia.

Sée gives the following statistics of the results of the treatment with compressed air in asthma and its secondary affections. Bertin used it in 15 cases of emphysema, all of which he cured, and in 92 cases of nervous and catarrhal asthma with emphysema, of which 67 were completely and 22 partially cured, while it was only unsuccessful in 3 cases. Of Sandahl's 77 cases of asthma with emphysema and bronchitis, 57 were much relieved, and of 14 uncomplicated cases, all were completely relieved. Compressed air may be applied either by placing the patient in a pneumatic cabinet or by means of the portable apparatus of Waldenburg. It must be remembered, however, that in the cabinet the compressed air acts upon the whole body, while in the portable apparatus only the air-passages and alveolæ are subjected to pressure; hence if the latter is used the amount of pressure must be considerably diminished. Notwithstanding the success claimed for this method of treatment, it should be used with caution, and if the case is complicated with emphysema it should either be regarded as contraindicated, or, if employed, the pneumatic cabinet should be used and not the portable apparatus. In the former, or "air-bath," the exterior pressure of the compressed air acts as an auxiliary to "the elasticity of the thorax and to the abdominal gases in" expiration, and at the same time, by compressing the vessels outside the thorax, aids the venous circulation. The same force exercised on the inner surface of the tubes tends to lessen the hyperæmia of the bronchial mucous membrane (Moeller).²⁸ When the portable apparatus is used, expiration in rarefied air causes retraction of the thorax, and thus in a measure overcomes any tendency to emphysema. A better plan than to use either singly is to combine the two—to expire into rarefied and inspire compressed air—which may be readily accomplished with several of the improved portable apparatuses.

²⁸ Thérapeutique locale des Maladies de l'Appareil respiratoire, Paris, 1882, p. 283.

The inhalation of sulphuretted hydrogen as practised at Eaux Bonnes, Cauterets, Aix-la-Chapelle, and other sulphur baths, is said to have cured some cases, while in many others great benefit is claimed to have been derived from its use; but allowance must be made for exaggeration in many of the reports published.

In giving the treatment of asthma no allusion has been made to Grindelia robusta and other recently-introduced remedies, partly because the writer has had no experience with them, and again where he has tried them they have given negative results.

HAY ASTHMA.

BY W. H. GEDDINGS, M.D.

SYNONYMS.—Hay fever; Hay cold; Summer catarrh; Catarrhus æstivus (Bostock); Freuhsommer katarrh (Phoebus); Autumnal catarrh (Wyman); Rose cold; June cold; Pollen fever; Pollen catarrh (Blackley). Fr. Catarrh de foin; Catarrh d'été; Ger. Roggen Asthma.

DEFINITION.—A form of catarrh caused by some irritant floating in the atmosphere; appearing in the spring, early summer, or autumn; attacking persons predisposed every year at the same time, the patient being at other periods free from the disease; characterized by symptoms resembling those of influenza, the chief of which are sneezing, redness, swelling, and increased secretion of the conjunctivæ and of the mucous membrane of the whole respiratory tract from its commencement in the nostrils down to the finest bronchi; frequently culminating in more or less severe attacks of asthma.

HISTORY.—Bostock, an English physician, is entitled to the credit of having been the first to recognize and describe this peculiar affection, for although, prior to his time, Heberden¹ had alluded to symptoms which are now supposed to be referable to hay asthma, and Cullen had noted the fact that some persons have asthma oftener in summer than in winter, neither of these writers recognized the true nature of the disease.

¹ Commentary on the History and Cure of Diseases, 4th ed., London, 1816, chap. "Destillatio," p. 113.

Bostock's first description of hay asthma appeared in the form of a paper, "Case of a Periodical Affection of the Eyes and Chest," which he read before the Medico-Chirurgical Society in London in 1819.² This was a description of his own case. Nine years later he gave the details of 18 additional cases and mentioned 10 others.³ In the second paper, having noticed that the disease as known to him, the American rose or June cold, prevailed only in the late spring and early summer, he styled it catarrhus æstivus. Rejecting the popular theory, that hay asthma is due to the emanations from hay, flowers, etc., he maintained that heat was the real cause of the disease.

² Medico-Chirurgical Transactions, London, 1819, pp. 161–165.

³ Ibid., London, 1828, pp. 437–446.

It appears singular, in view of its frequency at the present time, that notwithstanding the attention which had been directed to it only 18 cases should have been collected during the nine years which intervened between the publication of the first and second articles by Bostock, and tends to prove that in those days the disease could not have been as common as at present. That this was indeed the case is rendered all the more probable by the indisputable fact that, owing to the more general education of the people and to the requirements of a so-called advanced civilization, other nervous diseases are certainly much more frequent than they were formerly. The great prevalence of hay asthma among the educated is a further proof of the correctness of this conclusion. It must, however, be remembered that diagnosis did not then occupy the position it now does, and it is not unlikely that it was often overlooked or confounded with other diseases.

During the five years which succeeded the publication of Bostock's second paper no less than five treatises on hay asthma appeared in England, some of them by the most prominent medical men of that period. They are remarkable as showing the great diversity of opinion entertained at that early date as to the etiology of the disease. Thus, Macculloch⁴ (1828) attributed it to the air of hot-houses and green-houses, while Gordon⁵ (1829) attributed it to the flowers of grasses, particularly those of the Anthroxanthum odoratum, and suggested that grass asthma would be a more appropriate name than hay asthma.

⁴ An Essay on the Remittent and Intermittent Diseases, London, 1828, vol. i. pp. 394–397.

⁵ London Medical Gazette, 1829, vol. iv. pp. 266–269.

Even as late as 1859 the disease appears to have been scarcely known in Germany, for Phoebus, who has since published a most excellent work on the subject, on being consulted by a colleague suffering from hay asthma frankly confessed that he was unacquainted even with the name of the disease. This incident, and the belief that he had before him a comparatively unworked field, stimulated him to investigate the disease. By addressing circulars to the various medical societies and hospitals, not only in his native country, but also in other parts of Europe, as well as by personal interviews with patients and by publishing requests for information in the various medical journals, he collected a large number of cases and gained much valuable information concerning the disease. The results of his assiduous and painstaking labors were published in 1862 in the form of a valuable work,⁶ which, although over twenty years old, is still regarded the best authority on the spring variety of hay fever.

⁶ P. Phoebus, Der Typische Freuhsommer Katarrh, Geissen, 1862.

Previous to the year 1859, when Phoebus's circulars directed attention to it, hay asthma seems to have been almost unknown in France, as, with the exception of a single case by Cazenave of Bordeaux (1837), who described it as a new disease, we find previous to that date no mention of it in French literature.

The first case of hay asthma published in America, a typical one of the autumnal form of the disease, is recorded by Drake in his work, The Principal Diseases of the Interior Valley of North America, p. 803, published in 1854.

It will be seen by this brief summary of the history of hay asthma that the disease was first recognized in England in 1819, where in 1828 it became generally known, and that at the time of the publication of Phoebus's work (1862), with the exception of one or two isolated cases in France and the United States, England was the only country in which it was generally known and understood. Since the publication of Phoebus's valuable work numerous additions have been made to the literature of the disease, but with the limited space at my disposal I can only refer to a few of the most important that have appeared in the last two decades.

In no country has the subject of hay asthma attracted more attention than in the United States, and in no other has its study been rewarded by the discovery of so many new and interesting facts. To Morrill Wyman of Cambridge, Mass., we are indebted for the first elaborate American work on hay asthma, or rather the autumnal variety of that affection, which Wyman believes to be a distinct disease in no way connected with rose cold, June cold, and other forms which appear in the late spring and early summer.⁷ He had previously described the disease in his lectures as early as 1854, and also in a paper read before the Massachusetts Medical Society in 1866. Being himself a sufferer from it, he naturally devoted much time and attention to its study, and his work may be justly considered the most valuable contribution to the literature of the disease which has appeared since that of Phoebus. Another American work on hay asthma is that of the late Beard of New York.⁸ He elaborates the nervous theory of the disease, and establishes three varieties—the first appearing in the spring, the second in midsummer, and the third in autumn. In 1877, Elias Marsh of Paterson, N.J.,⁹ read an exceedingly valuable paper before the New Jersey State Medical Society, in which he describes a series of experiments which led him to believe that hay asthma is caused by the pollen of plants. In Europe the best treatise on the subject that has been published of late years is undoubtedly that of Blackley of Manchester, who by a series of ingenious and carefully-conducted experiments claims to have found in the pollen of certain plants the true cause of the disease. To all of these works we shall again have occasion to refer in the course of this article.

⁷ Autumnal Catarrh, Cambridge.

⁸ George M. Beard, M.D., Hay Fever and Summer Catarrh, New York, 1876.

⁹ "Hay Fever or Pollen-Poisoning," an essay read before the New Jersey State Medical Society by Elias Marsh, M.D., Paterson, N.J., 1877.

ETIOLOGY.—In scarcely any other disease is there such a diversity of opinion in regard to the cause as in hay asthma. We have seen how Bostock and his contemporaries differed on this point, he attributing it to heat, while of the others one claimed that it was caused by the air of hot-houses and green-houses, and another insisted that it was neither of these, but the flowers of certain grasses. Since that period other theories of causation have been advanced, but the same diversity of opinion as to its origin which marked its early history continues even at the present day.

In treating of the etiology of hay fever the various causes may be divided into two classes—viz.:

Predisposing Causes.—The fact that hay asthma is frequently transmitted from one generation to another, so well established by Wyman, is now very generally admitted, and will become more apparent in the future, as in estimating this feature it must be remembered that we have to deal with an affection which seventy years ago was entirely unknown and which has only recently become generally recognized. That the fact of the hereditary transmission of the predisposition is becoming every year more generally accepted is made apparent by the replies to two sets of circulars addressed to hay-fever patients in different years. Thus, Wyman, whose circular was issued at least eight years ago, received 18 affirmative replies out of 80, a little less than 25 per cent.; while to the writer's circular, issued in 1882, there are 25 affirmative replies out of 66. Numerous instances have been recorded where the disease attacked not only two, but even three, generations of the same family.

Hay asthma appears to be much more prevalent among males than females, the proportion being 3 males to 2 females. There is no apparent reason for this discrepancy other than that males are as a rule more exposed to the vicissitudes of weather, and that the restless energy with which many of them carry on their avocations predisposes to the disease.

The causes which produce hay fever act alike upon many thousands, an infinitesimal percentage of whom are attacked. There must therefore be some individual peculiarity which predisposes certain persons to the affection, but, aside from the facts that those attacked are usually of a nervous temperament, and that the respiratory mucous membrane of many of them is extremely sensitive, and that the vascular erectile tissue over the turbinated bones and lower portion of the septum is often hypertrophied,¹⁰ there are no known peculiarities by which it can be recognized. What races are subject is a question which thus far has received but little attention. To the writer's knowledge, the only well-established fact relative to race susceptibility is that negroes are exempt from the disease, and that in India (Blackley) it does not occur among the natives.

¹⁰ Roe, The Pathology and Radical Cure of Hay Fever, 1883, p. 9.

Statistics show that it is much more common in youth and middle age, and that comparatively few are attacked after forty, as will be seen by referring to the following table:

Age when First Attacked. Wyman's Cases. My Own Cases. Total.

Under 10 10 to 20 20 to 30 30 to 40 40 to 50 After 50 11 11 25 8 11 2 10 17 13 11 5 1 21 28 38 19 16 3

Wyman is of the opinion that females are attacked later in life than males.

Without knowing the numerical proportion which the various professions and occupations bear to each other, it is impossible, even with the aid of statistics, to determine which of them is most subject to hay asthma; but the annexed table shows conclusively that those who do brain-work are much more frequently attacked than those who earn their living by manual labor:

Wyman. My Own. Total.

Statesmen Clergymen Jurists and lawyers Physicians and medical teachers Dentists Pharmacists School-teachers Students Military officers Authors, editors, etc. Mechanical engineers Bankers Bank officers Merchants Brokers Manufacturers Clerks Artisans Farmers and gardeners Butchers Laborers 1 6 6 8 1 0 3 6 3 0 0 3 2 11 0 12 1 1 4 1 0 0 3 2 4 0 1 0 1 0 1 1 1 1 7 1 3 1 1 2¹¹ 0 1 1 9 8 12 1 1 3 7 3 1 1 4 3 18 1 15 2 2 6 1 1

It will be seen by the above that of 100 cases, only 12 were engaged in outdoor pursuits, and that the remaining 88 followed occupations necessitating confinement within doors and entailing more or less intellectual effort; which proves conclusively that the earlier writers on hay asthma were correct in regarding it as a disease of the more cultured classes of society. The writer agrees with Wyman that the large increase in the number of hay-fever sufferers may in a great measure be attributed to the circumstance that many who were formerly pursuing agricultural and mechanical pursuits are now engaged in occupations which require more or less intellectual effort.

¹¹ One of these was an amateur and highly educated.

To determine the value of temperament I have followed Beard's example, and in my circular of inquiry propounded two questions: 1st, the temperament of the patient's family; 2d, his own temperament. To the first query I obtained replies which showed that the nervous temperament predominated in 28 out of 37 cases; or, in other words, the family temperament was more or less nervous in two-thirds of the cases. As regards the patients themselves the temperament was as follows:

My Own. Beard. Total.

Sanguine Nervo-bilious Nervous Nervo-sanguine Nervo-lymphatic Lymphatic Sanguino-bilious Bilious Sanguino-lymphatic Bilio-lymphatic 8 5 23 9 0 3 4 7 0 0 18 23 67 27 3 0 5 29 1 1 26 28 90 36 3 3 9 36 1 1

It thus appears that the nervous element predominates in no less than 157 out of 233 cases.

Other diseases do not appear to predispose to hay asthma, nor, on the other hand, is that affection a cause of any other disease. The question whether naso-pharyngeal catarrh is more common among hay-fever subjects has, after careful investigation, been decided in the negative.

Exciting Causes.—It is generally conceded that the suggestion of a large number of remedies in the treatment of a disease is good evidence that no effective curative agent has as yet been discovered. This observation regarding therapeutics equally applies to etiology, a long array of causes usually developing the fact that great uncertainty exists as to the real causative agent. Hay fever affords a most striking proof of the truth of this remark. The simple enumeration of the various agents which have been accused of causing the attacks would cover several pages. An example of the multiplicity of its supposed causes is afforded by the replies to the question in Beard's circular, "What is the cause of your attacks?" no less than thirty-three agents being accused of causing the disease. Of these I propose to confine myself to a few of the most prominent.

Early in the history of hay asthma heat was considered its chief cause, Bostock, its first describer, having held that view, as have also many of his successors. It is now generally conceded that heat of itself is not a cause, although by promoting vegetable growth and causing dust it may still be regarded as an indirect factor in its etiology. That heat of itself is not a cause is proved by the occurrence of the disease not during the intensely hot weather of midsummer, but in the late spring and early fall. It, however, undoubtedly produces a temporary aggravation of many of the symptoms. This appears to be especially the case in the autumnal variety, as those who have the disease in the spring seldom complain of any ill effects from heat.

"Strong light, sunshine, especially when it falls upon the face, will produce a violent paroxysm of sneezing, and the other symptoms then follow in quick succession; and moving from shade to sunshine, even when not otherwise annoying, will do the same." This is the opinion of Wyman, and coincides with that of Phoebus, Abbott Smith, and others, and is amply confirmed by the experience of the writer. This applies also, though in a less degree, to artificial light, especially gas-light.

Dryness of the atmosphere, by promoting dust, may be regarded as an indirect cause. Hay-fever patients agree almost unanimously that their symptoms are aggravated on clear, bright, dry days, and that they feel most comfortable in damp and cloudy weather.

There is no evidence to show that electricity is in any way connected with the etiology of hay fever.

Ozone is certainly not a cause, as hay-fever patients feel best on the sea-coast and ocean, where ozone is most abundant.

Long before hay fever was recognized by the medical profession hay was supposed by the general public to be the cause of the disease. In England especially, but also in the north of France and in Switzerland, this opinion prevailed very generally. Some suppose that the dust which it contains is the real cause, while others attribute it to its peculiar odor. In those susceptible to its influence it appears to make but little difference how they come in contact with it, whether in an open field where it is mowed, by driving behind a wagon loaded with it, or by entering a stable or loft where it is stowed away. It is not, however, the cause of the autumnal variety, as it is harvested in the temperate regions of North America, where this form of disease is most common, in June or early in July, which is six or eight weeks earlier than the period at which the attacks commence. That hay is a cause of the earlier variety of the disease is evident from the experience of numerous intelligent invalids, who trace it to that agent from the fact that the outbreak coincides with the blooming or harvesting of hay, and that removal from the locality in which they are exposed to its emanations is followed by relief. It must be remembered, however, that hay does not consist of dried grass alone, but that it contains other plants and flowers, as well as a large amount of dust.

The flowers of grass, especially those of the Anthroxanthum odoratum, may be regarded, like hay, as one of the causes of hay fever—a fact that was early recognized by Gordon and others. Blackley¹² cites the case of an Indian medical officer of high rank, whose statement is as follows: "I have suffered from hay fever for about thirty-five years; I have had it both in India and in England. The period at which the attacks come on is not fixed, the date of the attacks depending more on the grass ripening late or early than on any other circumstance. They always begin toward the end of the hay season, when the grass is fully in flower, and cease slowly and gradually—not directly—on gathering in the grass."

¹² Hay Fever, its Causes, Treatment, etc., p. 47, London, 1880.

Rye, oats, and wheat in bloom may also be ranked among the exciting causes of hay fever.

Indian corn in bloom often causes symptoms of hay fever, but that it does so only in certain cases is evident from the fact that the disease does not exist in some places where large quantities of corn are raised (Wyman).

Geraniums, roses, heliotropes, and other sweet-scented flowers often bring on attacks. The bean in bloom and elderflowers are also regarded as causes.

Ragweed, also known as Roman wormwood, Ambrosia artemisiæfolia, a weed which extends almost over the whole of the United States, is a powerful cause of the autumnal variety, but, like all the other agents which have been accused of causing hay fever, is by no means general in its action, many patients being able to inhale the dust shaken from the flowers with perfect impunity even during the critical period. On those susceptible to its influence it will act not only during the hay-fever season, but also at other periods of the year. Wishing to study the plant, I procured during the fall several specimens of it and placed them between the leaves of a large quarto volume. During the winter my wife, who is a sufferer with hay fever, accidentally opened the book, and, seeing the plant, not knowing its nature, picked it up and smelt it. She immediately began to sneeze, the eyes and nose itched intensely, there was profuse lachrymation; in short, all the symptoms of a mild attack of hay fever supervened, the effects of which lasted until the following morning. The case is interesting from the fact that in this instance the experiment was made unconsciously, and the effects could not therefore be attributed to the imagination, the patient being entirely ignorant of the nature of the plant. The prevalence of autumnal hay fever appears to coincide with the blooming of the ragweed, and conforms to the geographical distribution of that plant, which grows wherever the disease prevails, while in exempted localities it is seldom found or never seen. In Bethlehem, N.H., a diligent search was made for it for two days by a botanical friend without his finding a single specimen, although in the neighboring town of Littleton, which is within sight of Bethlehem and is not exempt, the plant is quite abundant. Marsh states that he saw none of it in New Brunswick nor at Moosehead Lake.

Dust of various kinds is more frequently designated by invalids themselves as the cause of their disease than any other agent. Thus, in reply to his question as to the cause of hay fever, Beard received 104 replies assigning dust as the cause, while 540 attributed it to thirty other agents. All kinds of dust, both in and out of doors, are accused, but that of railway-cars is supposed to be the most potent.

There is but one case on record in which animal parasites were the cause of an attack—that of Bastian, who while engaged in the spring investigating the anatomy of the Ascaris megalocephala, one of the parasites of the horse, noted that its emanations not only in the fresh state, but after having been kept in spirits for two years, invariably caused itching about the eyelids, irritation of the conjunctivæ, with continuous sneezing and other symptoms resembling hay fever. These symptoms ceased after two months, and did not return until the following spring. He finally became so sensitive that the wearing of the coat in which he had worked during the examinations was sufficient to bring on the symptoms.¹³

¹³ Salisbury in Infusorial Catarrh and Asthma attributes hay asthma to an animalcular organism, the asthmatos, but his assertions have not as yet been confirmed by other investigators.

Helmholtz, himself a sufferer from hay fever, discovered that the secretion of his nasal mucous membrane contained during the attack a number of vibriones, and, never being able to find them there at other times of the year, concluded that they were the cause of the disease. Binz of Bonn having discovered that quinine was inimical to the vibriones, Helmholtz supposed that that agent would be the proper one to employ in the treatment. He used it with success, injecting a saturated solution into the nostrils, the injection each time affording marked relief.

THE POLLEN THEORY.—Believing from his own experience and that of others that hay fever was due to the pollen of certain plants, Blackley of Manchester instituted a series of ingenious and instructive experiments to prove the correctness of his conclusions. In his first set of experiments a very small quantity of the pollen of various plants was applied to the lining membrane of the nostril. That of the Lolium italicum produced at first a slight feeling of anæsthesia at the point to which the pollen had been applied, followed "by a feeling of heat which gradually diffused itself over the whole cavity of the nostril and was accompanied by a slight itching of the part. After some three or four minutes a discharge of serum came on and continued at intervals for a couple of hours." The mucous membrane became so swollen as to partially occlude the nostrils and impede the entrance of air. When rye was used the symptoms were much more violent, and were attended by violent and long-continued fits of sneezing. With wheat and oats the effect was equally decided. The same experiment was tried with other orders of plants with varied success, some of them being very active, while others were found to be quite inert. One grain of the pollen of Alopecarus pratensis was applied to the fauces, causing itching and diffused redness. That of the Lolium italicum rubbed into the abraded skin of the forearm, as in vaccination, produced itching and swelling.

Marsh,¹⁴ who has repeated Blackley's experiments in America, gives some very interesting facts in regard to the pollen of the Ambrosia artemisiæfolia. On the 5th of August, 1874, he placed a few sprigs of the ambrosia in full bud, but without open flowers, in a glass of water in his office. The next day the flowers were open, and on handling the plant for the purpose of preparing some microscopic specimens from it, the pollen was freely scattered around. This caused in him severe coryza of twenty-four hours' duration, with occlusion of the nostrils and serous discharge. On August 13th he repeated the experiment, this time intentionally applying some of the pollen to the nostrils. This produced such severe symptoms that he had to have recourse to a hypodermic injection of morphia for their relief. These, however, continued into his regular attack, which should have been due a few days later.

¹⁴ Op. cit., p. 14.

Having proved that the pollen of certain plants was capable of producing hay asthma, Blackley next turned his attention to the determination of the amount of that substance floating in the atmosphere of different places and at various periods of the year. The plan which he found best adapted to his purpose was to expose slips of glass to the open air for a given length of time, so as to allow any solid matter the air might contain to deposit upon the glass. On each of these slips a space of one centimeter square was made sticky by covering it with a mixture of water, proof spirit, and glycerin. These were exposed to the atmosphere for twenty-four hours, and then placed under the microscope and the number of pollen-grains adhering to the moistened square counted. These slides were exposed at the height of four feet nine inches above the ground, "the average breathing-level," and were placed in a grass meadow four miles south-west of Manchester. The experiment was begun early in April, 1866, and continued until the 1st of August. Only a small quantity of pollen was found during the first month. On May 30th it appeared in much larger quantities, and continued to appear on most of the days until August 1st. Barometric pressure did not influence the deposit of pollen, but whenever the air was drier the quantity was increased. A fall of rain, especially if attended with lowering of temperature, had the effect of materially lessening the number of grains. The largest quantity of pollen was obtained on June 28th, the day after the highest temperature of the season, showing that a large deposit of pollen coincides with, or follows, a marked rise in temperature. Fully 95 per cent. of the pollen collected belonged to the Graminaceæ, but this would not apply to other localities and countries, in which that of other plants would naturally predominate. These experiments were quite successful in demonstrating that the rise and progress of the disease corresponded with the amount of pollen present in the atmosphere. A third set of experiments was made by attaching the glass slides to kites, to determine the amount of pollen present in the air at different altitudes. These experiments revealed the fact that grass pollen was much more abundant at elevations of 500 to 1500 feet than near the surface of the ground. Marsh also investigated this portion of the subject, only, instead of attaching the slides to kites, they were placed in the attic windows: he arrived at conclusions in regard to the pollen of ambrosia similar to those which Blackley had reached with reference to the Graminaceæ.

The experiments of Blackley justify the belief that the cause of the early form of hay fever, which prevails in England, is to be found in the pollen of a number of plants, especially grasses and grains, which bloom in the late spring and early summer, while those of Marsh prove conclusively that the Ambrosia artemisiæfolia, or Roman wormwood, is certainly one, and probably the chief, cause of the American or autumnal variety of the disease.

GEOGRAPHICAL DISTRIBUTION.—Both varieties of hay fever prevail in the United States, but the late variety is much more frequent, and may be regarded as peculiar to this country. The distribution of the early form of the disease is much more extensive. It is quite frequent in Great Britain, and, according to our present knowledge, it extends over France, Belgium, Holland, Switzerland, Italy, Russia, and in the plains of India (but only among foreign residents). Further investigations will probably show that it also extends over the other temperate regions of Europe. As before stated, the autumnal form is confined to the United States, where it prevails much more extensively than was formerly supposed. Commencing in Florida, where it is quite rare, it extends northward up to Eastport, Maine. Its northern border is defined by Wyman¹⁵ as follows: "From the St. Croix, south of Houlton in Maine, or about the line of 600 feet elevation above the sea-level, the line of exclusion turns eastward, following approximately the border of the elevation just mentioned, excluding the interior lakes of Maine, which are about 1000 feet above the sea, and, descending toward the south, strikes the White Mountain region at its northern portion. Thence, turning toward the St. Lawrence River and running along the height of land which divides the waters falling into the Atlantic from those falling into the St. Lawrence, parallel to the St. Lawrence, it strikes that river north of Lake Champlain." Thence along the southern border of the Great Lakes to the south of the island of Mackinaw, between Lakes Huron and Michigan. "It then crosses the lake and runs north of Lake Winnebago to St. Paul, Minn., leaving the Lake Superior copper-regions beyond its influence." From this point the line is undetermined, but there is evidence to show that the disease occurs in Colorado. The statement of previous authors, that the disease does not prevail in California, is confirmed by a statement recently made to the writer by Hatch, secretary of the Board of Health of that State, who adds that several parties have removed there to avoid the disease. Southward, the line runs along the Mississippi River to New Orleans, where the disease prevails. The southern and eastern borders are the Gulf of Mexico and the Atlantic Ocean.

¹⁵ Op. cit., p. 63.

SYMPTOMS AND COURSE.—No better description of an attack of the autumnal form of hay fever has ever been written than that of Wyman, who, being himself a sufferer from the disease, has had exceptional opportunities for studying it in all its details. I therefore extract the following from his work:¹⁶

"All the cases agree in the time of annual return, about the 20th of August, varying but a few days from this date in different years. By some individuals it is believed to be remarkably punctual, being first noticed on precisely the same day of the month, and, it is even asserted, at the same hour of the day. It is first perceived as a slight itching in the palate and in all parts about the roof of the mouth, soon followed by similar sensations, apparently in the Eustachian tube, extending from the throat into the ears, and inducing the sufferer to attempt relief by swallowing and by rubbing his tongue against the back part of the hard palate, and by pressing and rubbing the external orifice of the ear to give motion to the parts within. There is often a sense of tension about the forehead, especially over the eyes in the region of the frontal sinuses. In a day or two the nostrils are affected; there is irritation of the lining membrane, sneezing, and a stuffing and obstruction of the nostrils. This obstruction is peculiar; it occurs in paroxysms of short duration, one or both nostrils becoming suddenly obstructed, and in two or three minutes as suddenly relieved; at other times the obstruction is more prolonged. But, however complete, it is in many individuals almost immediately relieved by active exercise, rapid walking, leaping, or any movement indeed which gives warmth to the extremities.

"At first these attacks occur only in the morning or on first rising; as the disease advances they occur later in the day, but still in short paroxysms. At this stage the discharge from the nostrils is limpid and almost free from mucus; it is often very copious, especially during or immediately following attacks of sneezing. Holding down the head is often accompanied by a rapid dropping of the same fluid without sneezing. With this trouble in the nostrils come watering of the eyes and itching along the edge of the lids and in the conjunctivæ generally, but most at the inner corners. This irritation occurs also in paroxysms of a few minutes' duration. It is so intense that it is difficult for the sufferer to refrain from rubbing the eyeballs violently, which soon relieves them, notwithstanding that such treatment increases the turgidity of the vessels until the whole conjunctival surface is of a nearly uniform red. The eyelids are swollen, their edges red and inflamed; the small glands are also inflamed, and in some cases pustules or styes form and break, leaving an excoriated surface which heals slowly. The whole face is often red and swollen, especially in the morning. The senses of taste and smell are much impaired, in some cases almost abolished; and at times there is partial deafness, with a sense of obstruction of the internal ear. The lining membrane of the external tube is sometimes much irritated, even to the extent of producing a thin discharge, without evidence of the irritation extending to the tissue beneath. Swallowing is interfered with, especially when the nostrils are so obstructed as to prevent the perfect motion of the parts necessary to this act. The lining membrane of the mouth, tonsils, and pharynx partakes of the general irritation, and becomes red; and sometimes there is soreness of the throat. The lips become dry, cracked, and swollen. The skin is easily irritated and excoriated, and the excoriations are not so readily healed as in health. Many also suffer from itching of the skin, especially of the scalp, back, and chest, at times accompanied by a slight papular eruption. During some portion of this period there is chilliness, or rather sensitiveness to cold; more or less pain or sense of oppression in the head; the appetite diminishes; there is lassitude and weakness, the skin hot and dry, with other signs of a febrile movement.

"Toward the end of the second week to these symptoms are added irritation of the membrane lining the air-tubes; a frequent and dry cough, commencing with a sense of tickling in the upper part of the windpipe, but little relieved by the cough or only after long coughing; and the expectoration of a small quantity of transparent, glairy mucus. The severity of these bronchial symptoms depends much upon the condition of the atmosphere: if dry and dusty, the cough is much worse; dampness and a rainstorm give relief.

"During the third week the affection of the lungs gradually increases; the cough, still with very little expectoration, is more troublesome, especially in the night, sometimes compelling the patient to spend an hour or two sitting up, and not infrequently is spasmodic in its character, producing convulsive retching or even vomiting.

"The disease may now be assumed to be at its height. It is in this stage also that in some cases asthmatic symptoms appear, and, although they are sometimes severe, are not long continued. At the end of the third week the catarrhal symptoms diminish, the tickling of the fauces ceases, the eyes and nose improve; but the cough is apt to continue longer, and the heart's action is easily accelerated by exercise, and the pulse is sometimes intermitting. The skin is dry and warmer than natural.

"During the fourth week in September these symptoms gradually diminish, and by the end of September or the first frost are nearly gone, leaving weakness and a more or less altered state of the mucous membrane of the air-tubes, the effect of the prolonged irritation, from which the patient, if otherwise in good health generally soon recovers."

¹⁶ Op. cit., p. 9.

The spring form of the disease, known as June cold in the United States and as hay fever in England, differs from the late variety in the time of its occurrence, the attack coming on, as its name implies, in the late spring, usually between the 15th of May and the 15th of June, sometimes much earlier; one of my patients reporting that she commences to sneeze as early as the middle of April. The attacks in this variety usually cease during the first or second week in July, although a few continue on into August—a fact which induced Beard to establish a third or middle form of the disease. The symptoms are essentially the same in both varieties, but are much less severe in the early form, which is also of shorter duration. They differ as to cause, the spring variety being usually due to newly-mown hay. It occasionally happens that one person has both forms of the disease, or that a person who has hitherto had the early form fails to have it in the spring and is attacked in autumn.

INDIVIDUAL SYMPTOMS.—There is occasionally a stage of incubation, lasting about a week, during which there is slight feverishness and undue susceptibility to nervous impressions. The patient often experiences a feeling of lassitude and weakness; the digestion is disturbed, as indicated by a coated tongue, want of appetite, and constipation; he is disposed to be wakeful, and when he does sleep his rest is often disturbed by unpleasant dreams.

The first effect of exposure to the irritant is itching of the nose, slight in the beginning, but increasing in severity as the disease advances, until it at last becomes unbearable. The mucous membrane is red and swollen, the swelling being often so great that it interferes with the passage of air; a watery discharge sets in, which, although slight in the early stages, soon becomes copious, and in severe cases is so abundant that it actually streams from the nostrils. Sometimes, when both nostrils are stopped, if the patient changes his position and lies on the side the uppermost nostril will become free. These symptoms are attended with sneezing—not the sneezing of an ordinary coryza, but powerful sternutatory efforts repeated in quick succession and utterly uncontrollable. In one case which has come under my observation the sneezing invariably brought on menstruation in advance of the regular period, and on some occasions caused abortion.

These symptoms just mentioned often appear and disappear with great rapidity, especially in the early stages of the disease, and are usually worse in the morning on awakening.

Itching of the eyes begins at the inner canthus and generally extends over the greater portion of the conjunctiva, slight at first, but becoming more troublesome as the disease progresses. There is also redness of the conjunctiva, sometimes of the lids alone, at others extending over the whole mucous membrane, and giving to the eyes a bright-red appearance. The lids in severe cases are not infrequently oedematous, lachrymation is greatly increased, and the tears, trickling down the face, are liable to cause excoriation of the skin. Pustules and styes often form on the lids. There is more or less photophobia, according to the severity of the attack.

Owing to the occlusion of the nostrils the patient is often compelled to breathe through the mouth, thus causing an uncomfortable drying of the mucous membrane. There is a peculiar itching of the hard palate, which the patient attempts to relieve by rubbing the roof of the mouth with the point of the tongue. This itching sensation extends over the pharynx, posterior nares, and upward through the Eustachian tubes to the ears, causing a disagreeable irritation, which the patient tries to alleviate by thrusting the tip of the finger into the external meatus. The mucous membrane of the pharynx is red and swollen. The dryness observed early in the attack gives place later to increased secretion, which is sometimes quite abundant. On the anterior surface of the velum of one of my female patients I observed a hard papule about the size of a lentil, which she assured me was always coincident with the attack, and never appeared at any other time.

In addition to headache, which is quite common, patients frequently complain of a heaviness and fulness, also of a peculiar sensation as though the head were constricted by a band. This latter symptom I have found present in about one-half of the cases investigated.

Itching of the skin is quite common, especially of the face, between the shoulder-blades, and over the sternum, and is frequently accompanied by a slight vesicular eruption and occasionally by urticaria.

The whole respiratory tract is in a state of catarrh, but there is very rarely any cough during the first week. This usually commences in the second week, and at that time is short and dry, and becomes every day more frequent until the third week, when it changes its type and becomes paroxysmal. During the first three weeks there is little or no expectoration, and what there is consists of small transparent glutinous masses. About the fourth week the irritation reaches the finer bronchi, and in many cases there is more or less asthma, which, like ordinary bronchial asthma, usually comes on at night. The asthma is sometimes quite severe and long-continued. Wyman states that very few escape cough. This does not accord with the writer's experience, as in 65 of his cases 15 had no cough.

Hay-fever patients suffer greatly from mental depression, complain of lassitude, and their capacity for intellectual labor is diminished. They are often troubled with insomnia, and when such patients do sleep it is in a fitful way, and their rest is often broken by unpleasant dreams.

NOMENCLATURE AND CLASSIFICATION.—The various terms used to designate this disease are all misnomers, and up to the present time none has been devised which conveys any idea of the true character of the disease. Hay fever is incorrect, because hay is only a cause in a limited number of cases, and fever is by no means a prominent symptom. Hay asthma should be discarded, for asthma is far from being a constant accompaniment of the affection. Autumnal catarrh or early spring catarrh only serves to designate the time at which the two forms usually appear, but conveys no idea of the disease in its entirety; while the term pollen catarrh or pollen fever is objectionable on the ground that, although the disease is most frequently produced by that agent, there are causes other than pollen which may excite it.

Hay fever is variously classified by different authors, some, like Thorowgood and Beard, regarding it as a neurosis, while others (Bostock, Phoebus, and Wyman) appear to regard catarrh as its distinguishing feature. Zuelzer has recently classed it among the acute infectious diseases, but assigns no reason for placing it in that group.

DIAGNOSIS.—To any one at all familiar with the symptoms of the disease 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 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 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

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 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.

Blackley¹⁸ 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.

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 article¹⁹ directing 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.

¹⁹ Am. Journal of Med. Sciences, January, 1880, Philadelphia.

In April, 1882, William H. Daly of Pittsburgh, Pa., in a paper²⁰ 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.

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 article²¹ 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.

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 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.

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 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.

SYMPTOMATOLOGY.—The general symptoms of bronchial dilatation, as well as the course and duration of the affection, are such as belong to the pulmonary diseases favoring its production, especially chronic bronchitis and fibroid phthisis. The cough and dyspnoea of these diseases are aggravated by bronchial dilatation; but these symptoms, together with the impairment of nutrition, are due rather to the underlying affections than to the mere fact of dilatation. Increased and fetid expectoration, which often occurs in bronchial dilatation from retained and altered secretion, is by no means characteristic of this condition, since it may occur where no sign of dilatation exists.

There is generally some degree of dulness on percussion over a dilated bronchial tube, due to the condensation of the lung-tissue surrounding it, and varying in extent and degree with the amount of that condensation, and also with the amount of secretion retained within the tube. Sometimes, however, increased resonance of a tympanitic character is observed, especially if the dilatation be of the saccular form and near the surface of the lung. Such differences in the percussion sound are analogous to what occurs over a pulmonary vomica, which will generally give a dull sound, though, if the cavity be superficial and thin-walled, it may yield a tympanitic resonance. On auscultation bronchial respiration may be heard along the course of tubes affected with cylindrical dilatation when they are free from secretion; and this is more intense in proportion as the tube is more dilated and the lung-tissue around it more condensed. Bronchophony and increased vocal resonance also occur, and if mucus be present in the dilated tubes coarse moist râles will be heard. In a saccular dilatation there may be true amphoric breathing, with the gurgling sounds heard in a vomica. In some cases there is an alteration in the appearance of the chest-wall, which is retracted by the shrinking of the condensed lung beneath.

Now, of the auscultatory signs that have been mentioned, the bronchophony and increased vocal resonance, together with the percussion dulness, belong also to pneumonia, which, however, at least in its acute form, can be distinguished from bronchial dilatation by the previous history, the febrile movement, and the general phenomena of the case, and by the fact that the tubal breathing of pneumonia, besides being less persistent, is most frequently met with in the lower part of the lung, and that of bronchial dilatation in the upper part.

But the diagnosis between a dilated bronchus and pulmonary phthisis is in some cases a very difficult problem, the signs of the cylindrical form closely simulating those of the stage of deposit in phthisis, because involving the same physical condition, and those of the saccular variety corresponding often with the auscultatory signs of a cavity. In the former case there may be the same localized dulness on percussion, the same bronchial or broncho-vesicular breathing, and the same sinking or contraction of the chest-wall apparent on inspection. In the latter case there may be equally in saccular dilatation and in a vomica amphoric breathing, gurgling, and pectoriloquy. In the establishment of the diagnosis between these two conditions Austin Flint, Sr.,¹ justly attaches importance to the circumstance that there is in general a greater degree of percussion dulness over a cavity than over a dilated bronchus, so that a relatively greater prominence of the auscultatory signs as compared with the degree of dulness makes the diagnosis of dilatation more probable. But the most important evidence on the point is to be gotten from the history of the case. If in a case where the auscultatory signs would leave the examiner in doubt there were found loss of flesh, fever, night-sweats, quickened pulse, and the other general phenomena belonging to phthisis, the existence of this affection would be rendered probable in the highest degree, and the auscultatory signs should be taken as corroborating an opinion founded on the general symptoms.

¹ Dis. of Resp. Organs, p. 353.

Positive evidence, again, may be furnished by a microscopic examination of the sputa; the discovery of particles of lung-tissue or the so-called bacillus tuberculosis pointing clearly to phthisis. Conversely, the absence of the general symptoms of phthisis would, in a case presenting the above auscultatory signs, render it probable that they are due to bronchial dilatation. Long-continued cough and abundant expectoration are the chief symptoms common in both forms of disease. There are, however, some cases in which even with the most careful examination and weighing of evidence the physician will be left in doubt, inasmuch as in some cases of otherwise well-marked phthisis the usual constitutional symptoms are absent or imperfectly declared. In such exceptional cases the estimate of probabilities is to be based on the fact that while bronchial dilatation is comparatively rare, pulmonary phthisis is extremely common.

PATHOLOGY AND MORBID ANATOMY.—Enlargement of the bronchi may be met with throughout almost the entire extent of a lung; when limited to a part of the organ the change most frequently occurs, according to Laennec, Rokitansky, and other observers, in the superior lobe and toward the anterior border. The tubes of the third or fourth order in respect to size are most frequently affected, the primary bronchi being never involved except in association with tracheal dilatation.

In the different forms of dilatation the bronchial walls are found in various states. In the cylindrical variety they are for the most part thickened and hypertrophied, both as to the mucous and the fibrous coats; the mucous membrane being in a catarrhal state, covered often with muco-purulent discharge, and easily broken down and detached, while underneath the white fibrous coat is sensibly thickened.

In the sacculated form, on the other hand, the bronchial wall generally presents a thin and atrophied appearance, the mucous membrane undergoing but little change, except that the stretching to which it has been subjected gives it a smooth and shining look. This difference in the degree of thickening of the bronchial walls in the two forms of dilatation is in part due to the fact that in the saccular variety the enlargement in calibre is far greater than it is in the cylindrical form for a corresponding extent of a tube, so that its wall is much more stretched and attenuated, and thus the tendency to hypertrophy which has play in the cylindrical form is more than overcome in the saccular. But the chief reason of the difference in the state of the walls in the two forms of dilatation is found in the different modes in which they are respectively brought about, as already described.

DIAGNOSIS.—It has been shown that the determination of the existence of bronchial dilatation is at times one of the most difficult problems in diagnosis, from the fact that the auscultatory signs belonging to it may be equally met with in other affections, especially in pulmonary phthisis. The diagnosis is to be established, when this is possible, only by a careful consideration of the physical signs in connection with the general symptoms, so that the sources of doubt arising from the one set of phenomena may be as far as possible corrected by the other. These signs and symptoms, and the various affections to be discriminated by them, have been sufficiently set forth under the head of Symptomatology. While in this way a clear conclusion may be reached in many cases, yet there are others in which, notwithstanding the utmost care, there may still be a doubt as to whether the symptoms and signs indicate a dilated tube or a pulmonary cavity.

PROGNOSIS.—The prognosis of bronchial dilatation is directly connected with that of the affections which chiefly give rise to it—viz. chronic bronchitis and fibroid phthisis. When chronic bronchitis has lasted long enough to cause dilatation, it is seldom if ever cured, and, though improvement may take place from time to time in its symptoms, yet the dilated bronchi can hardly undergo diminution in their size. And in fibroid phthisis, while the progress of the disease is often very slow, yet it is on a downward grade, and the connective-tissue contraction giving rise to the dilatation increases with the advance of the malady.

TREATMENT.—The treatment of cases of bronchial dilatation resolves itself in great degree into that of the underlying and causal diseases on which it depends. As regards methods specially directed to the areas of dilatation, they consist of alterative, astringent, stimulant, and antiseptic remedies, either administered by the stomach or used by the process of inhalation. Cough may be allayed with the syrup of lettuce containing in each dose from ¹/8th to ¼th of a grain of sulphate of codeia or 10 or 12 drops of the spirit of chloroform. If expectoration is very profuse, sulphate of atropia, in the dose of ¹/100th to ¹/80th of a grain, or the extract or tincture of belladonna, may be used. Turpentine and eucalyptol have a controlling influence over this symptom, and are specially beneficial if the bronchial secretion is fetid. They may be given by the mouth in the dose of minim v–xx in emulsion, and applied also by inhalation of their vapor or by spray. Inhalations of solutions of carbolic acid, minim j–x to an ounce of water, are more effective than anything else in checking fetor of the expectoration and the breath. This agent may also be administered by the mouth in the dose of fluidrachm j–iv of a 1 per cent. solution.

EMPHYSEMA.

BY SAMUEL C. CHEW, M.D.

DEFINITION.—The term emphysema is derived from [Greek: emphysaô], to inflate, and signifies an increased amount of air in a part or the whole of one or both lungs. Accordingly as the situation of this excess of air is (a) in the air-vesicles or (b) in the connective tissue between the lobules, emphysema is divided into Vesicular emphysema and Interlobular or extra-vesicular emphysema.

HISTORY.—These two affections are different pathologically and anatomically, vesicular emphysema being a much more common and important affection than the interlobular form. The distinction between the two forms was first drawn by Laennec. Previously to his time the essential difference between them was unknown; and, as the accurate diagnosis of the disease can be made only by auscultation, its existence was no doubt very often entirely overlooked. It has been remarked by Rokitansky¹ that "had Laennec done nothing else for medical science, his discovery of this diseased condition, and of the causes giving rise to it, would have sufficed to render his name immortal."

¹ Path. Anat., vol. iv. p. 53, Am. ed.

VESICULAR EMPHYSEMA.

Vesicular emphysema may be defined as an absolute or relative increase in the amount of air contained in the vesicles of a part or the whole of one or both lungs. As a substantive disease it occurs in two principal forms—hypertrophic and atrophic; but besides these it is met with as a secondary affection due to other diseases and limited to certain areas of the lungs, sometimes acute and sometimes chronic in its production and duration. It will therefore be best to consider the disease under the following different forms:

1st. Acute lobular emphysema; 2d. Chronic lobular emphysema; 3d. Hypertrophic lobar emphysema; 4th. Atrophic lobar emphysema.

1. Acute Lobular Emphysema.

This form of the disease is the result of the rapid distension beyond their natural size of air-vesicles which had previously been healthy. It is most frequently met with in children and as the consequence of bronchitis or whooping cough. The paroxysms of cough occurring in these affections, especially in the latter, are attended by deep inspirations, by which the vesicles are directly distended, and by violent expiratory efforts, with closure of the glottis, so that the air is forced into those portions of the lungs where there is least resistance, particularly at the apex and along the margins. In a large proportion of cases of acute lobular emphysema, when the distending cause is removed by the cessation of the cough, the vesicles return to their normal size through their natural elasticity, which has not been destroyed. But in some cases, when the cough has been of unusual violence or of very long duration, the change may be permanent through loss of this elasticity, and thus a form of chronic lobular emphysema is produced.

SYMPTOMS AND SIGNS.—Unless emphysema of this form is extensive and extreme in degree, it is not attended with symptoms additional to those of the affections giving rise to it. When very great it may occasion increased percussion resonance.

TREATMENT.—The treatment is only what is required by the causal affections.

2. Chronic Lobular Emphysema.

In many cases emphysema is confined to a limited number of lobules, especially at the apices, the anterior borders, or about the base of the lung; and being gradual in development and permanent in duration, it is then termed chronic lobular emphysema. This is the form frequently met with in the different varieties of pulmonary phthisis, in which its development seems supplementary to the incapacitation of other portions of the lung. The lobules nearest to the surface of the lung or immediately beneath the pleura are found to be most distended, so that they often project beyond the adjacent surface.