it has been known to develop before puberty, and that it is more common in males than in females.

Recall the quotation I made from Kyle about the history of hay fever and see how it agrees with this from Osler in regard to gout. Osler, Anders, and the American Text-Book on Practice give among their lists of symptoms uric acid diathesis, eczema, migraine, despondency, etc.

Alexander Haig was a sufferer from migraine, and he observed that when an attack came on that the uric acid increased in proportion to one to twenty or twenty-five of urea, while previous it was one to thirty-five or forty. He thinks that headache from uric acid is produced by it exciting a vaso-motor contraction of the arterioles of the brain, causing an anemia.

Now, if this is the physiological effect of uric acid, there will be a congestion somewhere else in the system, and where more likely than in the vascular erectile turbinal tissue? With this condition, together with your sensitive areas and your neurotic diathesis, how easy is it for most anything, as dust, odors, obnoxious gases, or unmoist air to excite a "uric acid storm" in the form of hay fever!

Haig also claims that there is an increase in the secretion of uric acid during the warmer months, and hence more in the blood, and this accounts for the fact that hay fever is more common in summer, and why it may appear in winter without assuming that the sufferer must have come in contact with some garment that was put away during the summer, impregnated with pollen.

It is a physiological fact that the blood is more alkaline during the period of repose and in the early morning, and as the person takes exercise the alkalinity decreases. The more alkaline the blood, the more uric acid it will carry, and this explains why hay fever comes on during the night and early morning, and the sufferer gets some relief during the day after taking exercise.

If Ebstein is correct, that the uric acid salts act as exciters of inflammation, we can easily understand how the chilling of the body, by checking the secretion of the skin, which is acid in reaction, will have a tendency to lessen the alkalinity of the blood, and uric acid salts will be deposited and produce rheumatism, gout, tonsillitis, rhinitis, etc.

Leflaine analyzed the urine of some patients previous to an attack of hay fever and found uric acid greatly in excess of its normal ratio to

urea.

Bishop gives "Joal's report of one hundred and twenty-seven cases of hay fever, and out of this number there was a family history pointing to uric acid diathesis in one hundred and seven cases, and in sixty-seven of the seventy-one adult patients the diathesis was marked. There was neurasthenia in one hundred and one of the one hundred and twentyseven cases, and in forty-two of the one hundred and seven the nasal mucous membrane appeared to be normal."

Bishop succeeded in producing and controlling hay fever by diet and treatment the same as migraine or other conditions arising from uric acid diathesis. He gave an acid, and thus lessened the alkalinity of the blood. and cleared it of uric acid and controlled the attack. He then gave an alkali and neutralized the effect of the acid and excited the attack, thus proving the etiology of the trouble.

It is a noticeable fact that the drugs which have some reputation in the treatment of hay fever, as opium, bromide of quinine, blennostasine, antipyrine, etc., are drugs that while they are nerve sedatives are also drugs that decrease the formation of uric acid, and no doubt some of their good effect is due to this fact. This is especially true of antipyrine, which not only decreases the formation of uric acid but also by chemical action aids in the elimination of that already formed. While no one holds that all cases of hay fever are due to the uric acid diathesis, I am satisfied that they are often associated, and the proper treatment of this diathesis would prevent the attack.

Treatment. Examine the nares and see if any sensitive areas or pathological condition in the way of spurs or polyps can be found, and if so they should be removed or destroyed. In that class of cases where you can not discover the sensitive areas, but have found out the excitant of the attack, be it pollen, feathers, ammonia, or what not, isolate the patient from the excitant. Of the different localities where these patients are said to enjoy the greatest freedom from attacks, probably the White and Adirondacks Mountains or a sea voyage have the greatest reputation.

Ingals, basing his treatment on the pollen theory and the ragweed and golden-rod as the most common excitants, has suggested the immunizing of the sufferer by giving these drugs. He makes a report on eighteen cases (see Journal of American Medical Association, June 28th of this year). "Of the twelve patients who believed themselves benefited by the remedy, three, or 25 per cent, attributed the attacks to ragweed, none to golden-rod, and nine, or 75 per cent, to other things, as car smoke, odor of flowers and weeds, night air, dusty weather, dust

from grain and new-mown hay. Of the patients who experienced no relief, three, or 50 per cent, attributed the attacks to ragweed, two, or 33 per cent, to golden-rod, and one, or 17 per cent, to other things, such as damp, warm, or cloudy weather."

Now, with all due respect to Dr. Ingals, "whose shoe-latchets I am not worthy to unlace," I must say that this report is anything but gratifying from the immunizing standpoint. Furthermore, when we study the effect of these drugs we find that they produced diaphoresis, and this effect alone may be sufficient to explain their beneficial effects if we will assume other etiological factors. He promises further investigation of these remedies, and we wait his report with the greatest anxiety.

To that class of patients where the cause is the uric acid, the treatment resolves itself into eliminating the uric acid from the system before the time for the attack. These patients should be urged to drink a large quanty of water, for as a rule they do not drink the proper amount.

This is the main factor for good that comes from the springs that are famous for the treatment of this diathesis, for the amount of uric acid solvent that they receive from the water imbibed is limited. Their diets should be regulated, avoiding sweets, starches, wine, beer, and meats. Let them live principally on vegetables, fruits, milk, and fish. Insist on them taking the proper amount of exercise, and that to the extent of exciting free perspiration, for uric acid is rapidly eliminated through the sudoriferous glands.

If they will not take the proper amount of exercise, I know of nothing better than to prescribe an occasional Turkish bath. From six to eight weeks previous to the time for the attack, put them on anti-uric acid treatment, and lithia in some form is the best. Alkalithia and citrate of

lithia are good.

Wyeth prepares a granular effervescing phospho-lithia, a laxative salt of lithia, that is doubly indicated in this condition.

This is a remedy similar in effects to thalion, prepared by the Vass Chemical Company, which has considerable reputation as a uric acid solvent.

Examinations of urine should be made from time to time to see the relative amount of uric acid to urea, and to find out if the proper amount is being excreted and not stored up in the system. As long as we give lithia preparations and observe instructions in regard to diet and exercise, and the uric acid remains in a normal ratio to urea, we need not have much fear of our patient having hay fever.

During the period for the attack, opposite views are taken as to the proper method of treatment. Some hold (and I think correctly) that the alkaline treatment should be continued and uric acid kept out of the system, and that this is the safest way to prevent an attack, while others hold that during this time an acid should be given and the uric acid kept out of the blood and deposited in the tissues. While this is theoretically true, and an impending attack can be aborted by giving an acid and thus freeing the blood of the excitant, still the acid treatment continued for a few weeks has a tendency to accumulate uric acid in the system and thus finally to excite the very condition that we are trying to prevent. The acid treatment, then, I feel should be held in reserve only to free the blood on the approach of an attack, and then to be followed by the rapid eliminative treatment to free the system of the excitant. In case an acid is used, dilute sulphuric acid twenty to thirty drops is good, but tends to produce diarrhea.

Bishop prefers Horsford's acid phosphate, one to two drachms, when he uses an acid, as in this he gets a nervine, which is always indicated in this condition.

Gleason is partial to fresh concentrated nitro-muriatic acid, in three to five drops, claiming that it limits the formation of uric acid. In making a report on this treatment, which he had used for three years, he found only one case in which it did not give some relief.

During the hay fever season the nares should be sprayed three or four times a day with an oily sedative, and of these menthol in abolene is probably the best. Should an attack come on, nothing can be done for the coryza better than to give a tablet composed of morphia 1⁄2 grain and atropine, as is needed. To give immediate but temporary relief, cocaine in two- to four-per-cent solution, or adrenalin can be applied to the turgescent nares. The effect of these drugs is that of a vaso-motor contractor when applied locally, and has no effect looking toward relieving the trouble longer than their effect lasts. Each of these drugs has a tendency to lose their effect when continuously used, and then are powerless for good in case they should be needed. They can not, therefore, be recommended as a routine treatment, but held in reserve as emergency remedies.

EVANSVILLE, IND.'

H. A. COTTELL, M. D., M. F. COOMES, A. M., M. D., Editors.

No. 11.

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THE WORLD'S FAIR, THE PLAGUE, AND SMALLPOX.

With the plague in San Francisco and at Mazatlan on the Mexican border, and smallpox generally distributed all over this country and its contiguous territory, it behooves the health officers and the commercial public to take radical measures to stamp out these two loathsome and highly infectious diseases.

It is imperative that something radical be done at once, for there is no use denying the fact that the possibility of the United States becoming infected with the plague at many points is very evident. The commercial men of this country should be the most active to insist on positive measures for the prevention and eradication of the plague, as a plague-stricken city is bound to be handicapped from a commercial standpoint. The judiciary of this country has much to do in the enforcement of the sanitary laws, and no judge should hesitate for a single moment to act promptly. Suppose that he does make a mistake in having certain measures enforced and it turns out that there was really no need for such action, there would be little or no harm done save an expenditure of public money unnecessarily, which is not an unpardonable crime when it is done with a good intention.

The example set by many manufacturers and employers of labor in making vaccination a compulsory thing with their employes is one