Chapter XIV: Part 14

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 {207} 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: {208}

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]

[Footnote 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]

[Footnote 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 {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.

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 {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.