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 {209} 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.
[Footnote 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.
{210}
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, Heberden[1] 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.
[Footnote 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.
[Footnote 2: _Medico-Chirurgical Transactions_, London, 1819, pp.
161-165.]
[Footnote 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 {211} 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,
Macculloch[4] (1828) attributed it to the air of hot-houses and
green-houses, while Gordon[5] (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.
[Footnote 4: _An Essay on the Remittent and Intermittent Diseases_,
London, 1828, vol. i. pp. 394-397.]
[Footnote 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.
[Footnote 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 {212} 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.
[Footnote 7: _Autumnal Catarrh_, Cambridge.]
[Footnote 8: George M. Beard, M.D., _Hay Fever and Summer Catarrh_, New
York, 1876.]
[Footnote 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 {213} 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.
[Footnote 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 | 11 | 10 | 21
10 to 20 | 11 | 17 | 28
20 to 30 | 25 | 13 | 38
30 to 40 | 8 | 11 | 19
40 to 50 | 11 | 5 | 16
After 50 | 2 | 1 | 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 | 1 | 0 | 1
Clergymen | 6 | 3 | 9
Jurists and lawyers | 6 | 2 | 8
Physicians and medical teachers | 8 | 4 | 12
Dentists | 1 | 0 | 1
Pharmacists | 0 | 1 | 1
School-teachers | 3 | 0 | 3
Students | 6 | 1 | 7
Military officers | 3 | 0 | 3
Authors, editors, etc. | 0 | 1 | 1
Mechanical engineers | 0 | 1 | 1
Bankers | 3 | 1 | 4
Bank officers | 2 | 1 | 3
Merchants | 11 | 7 | 18
Brokers | 0 | 1 | 1
Manufacturers | 12 | 3 | 15
Clerks | 1 | 1 | 2
Artisans | 1 | 1 | 2
Farmers and gardeners | 4 | 2[11]| 6
Butchers | 1 | 0 | 1
Laborers | 0 | 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 {214} who were
formerly pursuing agricultural and mechanical pursuits are now engaged
in occupations which require more or less intellectual effort.
[Footnote 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 | 8 | 18 | 26
Nervo-bilious | 5 | 23 | 28
Nervous | 23 | 67 | 90
Nervo-sanguine | 9 | 27 | 36
Nervo-lymphatic | 0 | 3 | 3
Lymphatic | 3 | 0 | 3
Sanguino-bilious | 4 | 5 | 9
Bilious | 7 | 29 | 36
Sanguino-lymphatic | 0 | 1 | 1
Bilio-lymphatic | 0 | 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 {215} 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. Blackley[12] 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."
[Footnote 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.