SELECTED ARTICLES.

HAY FEVER.

BY H. S. PERSONS, M. D.

Synonyms. The most common synonyms of hay fever are probably hyperesthetic rhinitis, vasomotor rhinitis, rose-cold, and estival catarrh. There have been many others given.

Definition. It is a disease characterized by an acute coryza, coming on suddenly and at stated periods usually, running a certain course and terminating usually as suddenly as its adventgenerally with the first frost. There are two kinds-spring and

autumn.

History. John Bostock first brought this disease into prominence in 1819, although it had been mentioned by writers as early as the sixteenth century. The first complete study of it was made by Phoebus in 1854, who issued circulars to the different medical societies then existant. From the reports he received he issued in 1862 a monograph containing a study of 154 cases. He estimated. that about 300 cases had been under observation at that time. A little later Helmholtz, in a letter to Binz, gave a detailed description of his own sufferings with it and advanced the theory that it was caused by certain vegetable spores which he found in the discharge from his nose. As stated by Bosworth, it is noteworthy that practically all of the early writers based all of their theories as to its origin on the study of the disease on themselves.

Perhaps the most famous of all students of hay fever was Dr. Blackly, who issued his classical monograph in 1873. As so very little authentic knowledge has been discovered concerning this disease since then, I will briefly detail his methods and results.

Blackly was a victim of hay fever and studied the disease in himself. His attacks always began about the 10th of June. He arranged a series of experiments to determine the amount of pollen in the atmosphere at different times and extended his examination over a period of twelve years. The apparatus he devised consisted of a disc of glass, of an inch square, mounted on a central staff, which was surmounted by a weather-vane, the disc itself being protected by a hood. This apparatus was exposed under varying atmospheric conditions, and in different situations, usually in an

open field. The device for collecting the pollen consisted in placing vertically in a slat, on the surface of this glass plate, a microscope slide, one centimeter in diameter, which was coated with a preparation of glycerin, by which the pollen floating in the atmosphere settling on the slide remained adherent to it. This plate was generally exposed day after day for a certain fixed period, usually about twenty-four hours, the object of the vane being to keep the vertical slide directed constantly to windward. From the 30th of May to the 7th of June pollen was found in the air in small quantities. On the 30th of May the number found on the slide was 25, and with this number he began to suffer with perceptible but not troublesome symptoms. On the 8th of June the number rose to 76. On the 11th of June, however, the number of pollen grains found on the small disc rose a little over 280, and it was at this date that the experimenter began to have unmistakable signs of the commencement of his summer attack in troublesome form. From the 11th of June onward, the amount of pollen varied in a notable degree, until on the 28th of June he counted 880 on his disc. He noticed that on rainy days the amount decreased in a very marked degree, while at the same time his symptoms very notably abated, although on warm days following rain, the number increased very markedly. Moreover, he noticed that a few hours' rain made no perceptible difference in his symptoms; whereas, a rain of twenty-four hours or longer gave very striking relief, in connection with notable decrease in the number of grains found. From the 28th of June onward there was a gradual diminution, until the 1st of August, when the pollen disappeared, with complete abatement of all his symptoms. (Bosworth.)

In 1876 Wyman made a geographical study of the disease, establishing the fact that certain sections of America are exempt. However, some portions which he found free of the disease at that time have since had cases. About this time Beard published a theory that the disease was a neurosis, while Daly combated this by denying that it was a pure neurosis but was the result of pathological conditions of the naso-pharynx, such as obstructions. Since then various papers have been issued by different authorities, some upholding one theory and some another. Apparently the subject is no nearer a settlement now than twenty-five years ago.

Etiology. The causes of hay fever may be divided into exciting and predisposing.

Exciting Causes. From almost the beginning of our knowledge of hay fever the generally accepted exciting causes by nearly all authorities has been the pollen of certain plants, notably the grammaciæ, Ambrosia artemisiæfolia (rag-weed) and the Solidago virga aurea (golden rod). From these causes has arisen the name "hay fever." This variety occurs in the late summer. The variety occurring earlier, May or June, is known commonly as "rosecold." There have been cases reported, moreover, which have been due to emanations of certain animals, as cattle, horses, cats, etc.

Predisposing Causes.-Heredity plays an important part in the predisposition to this disease undoubtedly. Baird reports it as high as 33% in the cases under his observation, and Wyman gives it as 20% in his. All other observers have noticed a large per cent in their practice. In my own practice I have three cases occurring among relatives which I will report more fully later.

Many cases are undoubtedly due to neuroses of the nasopharynx, as deflected septums, enlarged turbinals, neoplasms, possibly adenoids, disease of the accessory sinuses (Ballenger), and functional derangement of the nervous system (J. N. Mackensie).

Uric acid has frequently been given as a predisposing cause, but whether this acts directly by making the body fluids acid, or by a general derangement of the chemical functions, has not been settled.

Age plays some part in this disease. The most prolific age is about twenty years, though cases occur among young babies and I have one case which came on after sixty years of age.

Sex. Males are more susceptible than females, though in my opinion, in those cases where neuroses are the causative factor the reverse is the case.

Race also has a bearing. Anglo-Saxons, Germans and French. are the most susceptible. I have seen one case among negroes, a mulatto.

Location plays a very important part in its causation. It is more common in Northern than Southern climates; low, flat countries (particularly those bordering on large bodies of water) than high, dry regions. Until recently it was rarely seen west of the Mississippi River, and the region of the White Mountains, the Adirondacks, the Catskills, were supposed to be entirely free of it, but now cases are found even there.

Social Conditions.-This is called the disease of the rich, for it is rarely found among the very poor-which may account for its scarcity among negroes.

Pathology. The pathological changes, in appearance, vary very little from the condition observed in an attack of acute rhinitis. Ordinarily the nose will secrete from twelve to sixteen ounces of watery serum per day, the amount varying to meet the different atmospheric condition. In this disease there is a very great increase in the watery serum, which at the same time becomes glairy and acrid. It is generally supposed that the pollen, acting on the nerve terminals, causes a vasomotor paralysis, with a dilatation of the venous sinuses, which permits of a freer escape of the serum. The veins, or sinuses, spoken of here, are those composing the turbinal bodies and not those of the mucous membrane lining the interior of the nose. The predisposing neurosis probably weakens the vasomotor control which the sympathetic and trigeminus nerves exercise over the sinuses, making them very susceptible to the action of pollen (Bosworth).

Symptomatology.-The onset is usually sudden, the attack in this region commencing on the 28th of August, as a rule. The first symptoms usually are a feeling of malaise, a slight elevation of temperature, together with attacks of sneezing. Then the nose closes, the eyes become red, and there follows headache more or less severe. About this time itching becomes very severe. It is located either in the roof of the mouth near the soft palate, in the nose, or both places, and frequently the eyes itch and burn. With the congestion and stoppage of the nose the watery secretion increases in amount, becomes glairy, very acrid (so much so that the interior nares and upper lip is soon excoriated), and later contains mucus and maybe a little pus. During sleep there may be a little improvement in the nasal condition. The patient usually complains of dryness and tickling of the throat, possibly tinnitus aurium. In nearly all cases the appetite is markedly impaired and the patient's general condition suffers as a result. An examination of the nose shows the turbinals much congested and the nares closed. This congestion may extend to the soft palate and pharynx. The glairy serum is so free that in making an application to the membrane the medicine is frequently washed out without having any effect. In fact in three cases which I will mention later, the application of any of the supra-renal extracts had no effects unless I first made

an application of a cocaine solution. The symptoms given above are not continuous by any means, but they are usually so severe that a patient is frequently prevented from performing his usual labors.

Geographical Distribution.—It was formerly thought, as set forth by Beard in his treatise on Autumnal Catarrh, that hay fever was limited in its distribution to a portion of the United States east of the Mississippi River and lying between the 35th and 45th parallels of latitude. Not all of this territory had it, however, as Canada, the Adirondacks, the elevated region through the center of New York State and the Appalachian Range were exempt. Also all of the Southern States, except small areas around Milledgeville, Ga., Montgomery, Ala., and Beauford, S. C., were exempt. Later investigations, however, have proven this not quite true. There is now no portion of the United States considered completely exempt, not even the White Mountains. Patients who have the disease will be relieved in nearly all cases when they go to the White Mountains, in spite of the occasional existence of cases there.

Course and Duration.-As I have said before, most cases in this climate commence on August 28th, or a few days later. I have three old cases, who will let no operative work be done in an effort to cure them, who come to my office regularly on August 29th, the disease having commenced on the previous day. This date varies in different sections of the country and in different countries. The kind known as "rose-cold" usually comes in June or possibly May. I have referred previously to three cases which I will take up here, as they are the only unusual cases I have had. Each of these cases has started in January, which is an unusual time for them to commence, but as they showed every symptom of hay fever, I have not hesitated to so classify them. They were a sister, about twenty-two years of age; a brother, about sixteen years of age; and a female, a cousin, fourteen years old. The sister came to me first in January, 1909. I treated her for temporary relief until the disease ceased about the middle of March, and later I removed portions of the inferior turbinals and cauterized the sensitive areas as I found them. The next two years she was exempt, although she gave a history of having had the same symptoms at least two years before coming to me. The brother and the cousin both came in January, 1910, with the same symptoms as the preceding case, ran the same course, and since then have had the same treatment.