nervous disturbance not dependent upon demonstrable change in the nervous system, and not the necessary consequence of some peripheral lesion, this name is applicable. We may thus call hay fever a neurosis due to a certain irritation of the respiratory mucous membrane by an unknown irritant in predisposed subjects.

The predisposition depends partly upon the existence of other nasal anomalies. This is shown by their frequent coexistence, as well as by the beneficial influence of their elimination. The successful removal of septum deformities, of circumscribed hypertrophies of mucous membrane, and enlargement of the pharyngeal and faucial tonsils or of foci of suppuration relieves some patients markedly and occasionally cures one completely.

188. Hay fever victims escape the disease by spending the fatal season in an immune locality. Some stand the distress as long as possible until the increasing heat forces them to flee for relief. The sufferers have formed a hayfever association with headquarters at Bethlehem, which, while it serves to spread useful information, exerts, on the other hand, a bad psychic influence.

Most writers speak of the valuable influence of nerve tonics, arsenic, zinc phosphid, or valerianate strychnin, etc., upon the disease, but I cannot find a single record. of any permanent cure obtained thereby. The latest reports of the Hay Fever Association claim emphatically that there are no cures on record. On the other hand, more can be expected of intranasal surgery upon proper indications. The full restoration of nasal patency relieves the suffering to a great extent, even if it does not prevent the attack. In medical literature a number of apparent cures are on record, but they have mostly not been followed for a sufficient number of successive seasons to be fully convincing. I may say the same of several instances. in my own limited experience with this disease. Some years ago galvanocaustic destruction of the turgescent cavernous tissue was extensively practised, apparently with some relief during the following season. But the

records of the Hay Fever Association disclaim any permanent cures obtained thereby. During the attack itself any operative treatment, except a clean incision resulting in free patency of the nose, gives rise to very unpleasant reaction.

Decided temporary relief is obtained by the use of a spray of suprarenal solution. This agent has also been recommended for internal use, but on questionable theoretic grounds and with very questionable results. In several instances in which hay fever coexisted with and seemed dependent upon purulent rhinitis I have obtained an apparent cure for the season by the use of this spray, followed by the douche, and the spray of watery solutions of the essential oils (¶ 25). The use of cocain is too transient to be serviceable, and the danger of cocain habit too great to sanction its employment by patients. The asthmatic attacks can sometimes be greatly relieved by antipyrin internally.

189. It is instructive to compare the pathology of hay fever with that of another disease of similar seasonal and geographic distribution-viz., spring catarrh of the conjunctiva of the eye. This affection is not directly related to hay fever. In about 15 instances of it which I have seen I have known only one patient to suffer at the same time from hay fever. Its lesions are the striking but not constant grayish tumefactions of the ocular conjunctiva around the cornea, while absolutely constant, but less noticeable, are the lesions of the conjunctiva of the upper lid. The disease begins during the warm season and ends with frost, but returns annually. Its symptoms are irritation of the eyes, watering, sensitiveness to light, and discomfort on use. The symptoms cease during the cold season at first, but in some patients persist in a very mild degree during winter after a duration of many years. The first summer the conjunctiva of the upper lid shows merely a mild degree of catarrhal inflammation with stringy mucous secretion. The second season the surface is slightly follicular. Later on the follicles en

large and assume the appearance of papillæ. During winter the conjunctiva is again normal, but after a number of years the lesions diminish, but do not disappear entirely during cold weather, producing, however, very little annoyance. Like hay fever, spring catarrh returns with fatal regularity every year. As the writer was the

first to point out, a sufferer gets absolute relief by going to a locality immune against hay fever. The resemblance to hay fever is, unfortunately, completed by the rebelliousness of the disease to all treatment.

CHAPTER XXIV.

DIPHTHERIA.1

190. Diphtheria may be defined clinically as an inflammation with the formation of false membranes, and etiologically as the reaction of the tissues to infection by the diphtheria bacillus. These two definitions do not coincide fully. A pseudomembranous inflammation is sometimes caused by other germs, while the reaction to the diphtheria bacillus may be limited to a superficial inflammation without membranes. Diphtheria is essentially a disease of childhood. Uncommon within the first few months of life, its maximum frequency and mortality occur in the first five to seven years of infancy, becoming less frequent and less fatal after that period. It is not frequently seen after adolescence and very rarely after middle life.

The disease begins with fever, usually increasing for a day and of variable height, rarely excessive, sometimes remittent or even absent. The fever lasts usually as long as the local lesion. With it there are marked general disturbance, lassitude, malaise, want of appetite, furred tongue, and often more or less albuminuria. The cervical glands are generally swollen, and remain so until after recovery. From the start there is pain on swallowing and sore throat. The affection begins most often on the tonsils, generally on both sides, sometimes on the posterior pharyngeal wall, rarely on the soft palate. The invaded spots show a whitish coating, in the form of a membrane, which from the start cannot be detached without leaving a bleeding abraded surface. In severe cases

1 It is not within the province of this work to include a complete description of diphtheria, as this disease is fully treated in all text-books on general medicine. Hence details will only be given regarding its localization in the upper air-passages.

the color of the membrane may turn to a dark brown, being stained by blood extravasation. Around the membrane is an area of considerable redness and swelling. When the tonsils are involved, they swell. Except in mild or in properly treated cases the membranous inflammation extends so as to involve the larger part of the visible throat. It may spread upward into the nasopharynx, which is rare, or even into the nasal passages. Much more common is the involvement of the larynx in the form of croup. The extension may continue from two to five or seven days, rarely longer. After this period the membranes gradually detach themselves, and the abraded surfaces heal. When the membranes are detached artificially, they form again in a few hours. Occasionally a relapse or rather an exacerbation occurs when the disease seems nearly ended. In exceptional cases the persistence of the disease for a number of weeks has been observed. In rare instances deep ulceration may follow after detachment of the membrane and cause cicatricial shrinkage and adhesions in the pharynx.

191. The disease varies in severity with the epidemic and with the individual. We can distinguish between abortive, mild, average, and severe or septic cases, but with transitions between these forms. The systemic disturbances are more or less pronounced, somewhat in proportion to the intensity of the local process. But sequels, especially the different forms of paralysis, are nearly as apt to occur in the mildest cases as in the severe. The contagiousness, also, does not depend on the severity of the case. In abortive cases nothing is seen beyond an apparently slight pharyngitis or tonsillitis. The diagnosis suggested by known exposure can be verified only by the bacteriologic test or the subsequent occurrence of paralysis. In mild cases the typical membranes are seen, but they do not spread in extent after the first or the second day. In the severe or septic form, the severity of which depends perhaps on concomitant infection by other germs, especially streptococci, or on want of re