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 {216} 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]
[Footnote 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
{217} 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.
[Footnote 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 {218} 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 Wyman[15] 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.
[Footnote 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 {219} 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 {220} 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."
[Footnote 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 {221} 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.