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Dr, Grant oelfrldge
HAY-FEVER, HAY-ASTHMA
ITS CAUSES, DIAGNOSIS, AND
TREATMENT
BY
WILLIAM LLOYD
surgeon-in-chargb of the nose, bar and throat department, kensington
general hospital ; surgeon to the nose and throat department,
st. pancras and northern dispensary ; fellow of the royal
college of surgeons; fellow of the british
laryngological. rhinological, and otological
association; member of the laryngo-
logical society op london.
W. T. KEENER & CO.
90, WABASH AVENUE.
London: Henry J. Glaisher, 57, Wigmore Street, Cavendish Square, W.
1907.
/ I
PREFACE.
The author does not for a moment delude himself
with the idea that this little work will supply a " long-
felt want." The chief reason for writing it is to
record certain opinions which the author holds
upon the causes and effective treatment of hay-fever.
These opinions, although not exactly in accordance
with those generally current in this country, he is
convinced, from a considerable experience, are substan-
tially correct. This little work, which does not pretend
to be an exhaustive treatise, of necessity deals with
the subject in a more or less sketchy manner. The
author nevertheless hopes that it will be found to
contribute something of service to those interested.
William Lloyd.
15, Harley Street, W.
May, 1907.
* ■ '^^ *
CONTENTS.
CHAPTER I.
PAGE
A REVIEW OF THE OPINIONS HELD ON
THE EXCITING CAUSES OF HAY-FEVER - I
CHAPTER n.
PREDISPOSING CAUSES - - - - 23
CHAPTER HI.
SYMPTOMS OF HAY-FEVER - - "37
CHAPTER IV.
TREATMENT OF HAY-FEVER - - '47
CHAPTER V.
ILLUSTRATIVE CASES - - - - 75
CHAPTER I.
A Review of the Opinions held on the
EXCITING Causes of Hay-fever.
Hay - fever, hay - asthma, was first described by
Bostock, in the year 1819. In a paper read before
the Royal Medico-Chirurgical Society of London, he
gave an account of what he termed " A Case of the
Periodical Affection of the Eyes and Chest." This was
followed in 1828 by a second paper on this subject
before the above-named Society, in which he gave a
more lengthened and exact account of the symptoms
of the disease, and endeavoured to prove that the
symptoms in his case were due to heat. In the latter
communication the disorder was designated " catarrhus
aestivus " or " summer catarrh," showing that Dr.
Bostock was quite aware of the circumstance that it
commonly came on during the hay season, and must be
credited with having first appreciated this connection.
About 1850 the subject excited increased interest
amongst the laity and also amongst the members of the
medical profession, which showed itself not only in
the publication of numerous articles in the Medical
Journals, but also in the works of various writers on
systematic medicine on the Continent, in America, and
B
2 Hay-Fever,
in this country. There were also several treatises
published in a separate form between 1865 and 1875,
among the principal being those of Abbots Smith,
Pirrie and Moore.
In America Morrill Wyman wrote an excellent
monograph upon the subject, whilst in England Blagkley
studied its connection with the pollen of various grasses
and flowers, the result of his experiments showing the
important role they played in the production of the
disease. The opinions which have been entertained
on the causes of hay-fever have been very varied and in
some cases conflicting. The most opposite conditions
have, by both writers and patients, been thought
capable of producing the disorder, on the one hand,
high temperature with dryness of the air, on the other,
excess of moisture with high temperature.
By some writers ozone is named as a possible
exciting cause of the disease ; and by others odours of
various kinds, especially those given off by plants. In
some cases common dust has been thought to have had
a considerable share in bringing on the disorder, whilst
in a comparatively large number of instances the agent
which has given the popular name to the malady has
been taken to be the principal exciting cause.
Blackley, and later, Dunbar, made experiments which
proved beyond doubt that there is only one exciting
cause, namely, the pollen of grass. All observers are,
however, agreed on the existence of some peculiarity
ExcitiriQ Causes,
v>
of the constitution which predisposes to the disease,
but exactly what it is, is not yet decided. It has,
however, for all practical purposes, been demonstrated
that there is always present a hypersensitive con-
dition of the nasal mucous membrane.
Bostock, who, as we have already said, was the
first writer to give a full description of the ailment,
believed that in his case it was due to heat, and not
caused by the effluvium of grass or hay.
Elliotson, who was a contemporary of Bostock's,
agreed with him in believing that the disorder was not
caused by hay, but believed it to " depend upon the
flower of grass and probably upon the pollen."
Elliotson also contended that this view of the case was
supported by the circumstances that the disease does
not usually appear " till the grass comes into flower ;
and as long as there is any flower remaining on the
grass the disease continues."
Dr. G. T. Gream, who was also affected with the
disorder, believed that the dust from beaten carpets,
from the roads, and from other sources, produces the
same distressing symptoms. He also remarks that
from the end of May to the end of July, at which time
hay-fever generally ceases, a quantity of fine dust
floats in the atmosphere, finer than any which is in
the air at other seasons, increased probably, by the
farina of the mass of flowers at that period in bloom,
but that during the later and earlier months, the more
B 2
4 Hay-Fever,
frequent rains, and the dews at night, prevent these
particles from leaving the ground. He hit upon
one very important feature in the phenomena of hay-
fever, namely, the influence which rain has in diminishing
the intensity of the symptoms.
Kirkman seems to have been the first patient who
tested, by an experiment upon himself, one of the
supposed causes of hay- fever — the pollen of grass.*
He tells us that a day or two before Christmas he
noticed, in his hot-house for flowers, one single plant of
the anthoxanthum odoratum in blossom, loaded well
with pollen. He thought it would .be a capital oppor-
tunity for trying this particular grass, so he plucked
it, rubbed off the pollen with his hand, and sniffed it
up his nose ; almost immediately it brought on
sneezing, etc., and all the symptoms of hay-fever, which
continued for an hour and then left him.
Dr. Abbots Smithf gives numerous cases in which
the exciting cause of the attack seems to have been the
emanations from grass and other flowering plants. He
also states '' that strong light as well as great heat will
induce or aggravate the symptoms."
The work of Dr. Morrill WymanJ deals with the
hereditary character of the disease. The disease is said
to commence in America at two different periods — in
* Quoted from Dr. Phoebus' Typische Fruhsommer-Katarrh^ p. 137.
f On Hay-fever, Hay-asthma, by William Abbots Smith, M.D.,
4th edition, London, 1866.
X Autumnal Catarrh (^Hay-fever), by Murrill Wyman, M.D.
Exciting Causes. 5
the month of June, as rose cold, hay cold, or June cold,
and in the month of August as autumnal catarrh. The
symptoms are essentially the same in their character at
these different periods.
Like other writers on hay- fever he makes in-
dividual predisposition the starting point. Dr. Wyman
holds that American autumnal catarrh is not in any
case produced by hay or by grass in flower, inasmuch
as the hay is generally made one or two months before
the catarrh comes on.
In speaking of the causes of the paroxysms of the
catarrh, he mentions the following : the dust and smoke
of a railway train ; the dust of the highways ; strong
light and sunshine ; the odour of flowers, especially that
of a full-blown rose ; the smelling at, or the eating of
fruits of various kinds.
With some patients Indian corn (maize), when in
flower, produces sneezing and other signs of hay-fever,
but the plant that brings on the most decided symptoms
of the disease is the Roman wormwood. This plant
commences to flower about the middle of August, or a
little later, and continues to flower till late in
September.
" An approach to it," Dr. Wyman says, " will,
during the critical period, produce a paroxysm with
a very large number of persons. It grows very sparingly
in mountainous regions, and is there generally short
and feeble."
6 Hay-Fever,
Dr. Beard* seemed to think it quite correct to
place hay- fever among the neuroses. In treating of this
part of the subject, he says " Hay-fever is essentially a
neurosis — that is, a functional disease of the nervous
system. . . . The debilitating influence of heat
and the external irritation of a large number of
vegetable and other substances, are exciting causes
merely, widely varying in their effects with different
individuals, and of themselves are powerless to induce,
or at least to sustain, an attack As the
disease is not due to any single specific cause, animal
or vegetable, as has been supposed, no specific will
ever be found for it." He names twenty-five agents
as the exciting causes of the malady. In the United
States the more prominent exciting causes appear to be
Roman wormwood and the pollen of corn, both of
which flower about the middle of August, and both of
which, without doubt, excite the paroxysms in some
persons, even when applied in the non-catarrhal regions
of the mountains. Other irritants "as cinders, dust,
smoke, bright sunlight, gaslight, etc., are common to
the whole summer season ; but they are not sufficiently
powerful to induce protracted attacks of the disease,
unless stronger vegetable irritants start the malady and
co-operate with them in maintaining it."
Blackley'sf experiments have proved that the
* Hay -fever, or Summer Catarrh, by Dr. Beard,
■f Hay-fever, by C. Harrison Hinckley, M.D,
Exciting Causes. 7
exciting cause of hay-fever is the presence of the pollen
of flowering grasses and cereals in the atmosphere
during the time the disorder prevails, and, moreover,
that the mildness or severity of the malady correspond
with the varying amount of pollen in the air.
He made experiments with the following presumed
causes of hay- fever : viz., benzoic acid, coumarin
(odoriferous principle found m some of the grasses,
etc.) ; odours of various kinds ; dust, pollen, the
influence of light and heat. I shall only deal with
the experiments that were made with dust, pollen
and heat.
Dust as a Factor of Hay-fever.
In speaking of dust as a cause of hay-fever most
authors have used the term " common dust." As
Blackley points out, .the dust of any district will
show that, in addition to those matters which may
with propriety have the name "common" applied to
them, it contains ingredients to which this cannot be
applied, and the nature of which will to a large extent
depend upon the season, upon the geological character
of the district and upon the nature of its botanical
productions. The number as well as the kind of
germs and other organic bodies found in the dust of
any district will also largely depend upon its
meteorological conditions which prevail in that district.
I have myself noticed that dust could at certain
8 Hay-Fever,
times of the year produce some of the milder and less
marked symptoms of hay-fever, but there was this
peculiarity about these attacks, that generally they
came on only during the time that hay-fever prevailed
or immediately after the hay season was over, but
rarely, if ever, during winter or early spring.
There was also another peculiarity which these
attacks had, namely, that they were more fitful, coming
and going in a more irregular and transitory manner
than the ordinary attacks of the disease ever do when
they have once set in. Also that the attacks were
more frequent whenever one had to pass through any
dusty lane in the country, when the hay had been
recently all gathered in. As a matter of fact it is
practically certain that dust per se will not induce true
hay-fever even in susceptible patients. In these, it is
true that dust from roads will apparently bring on an
attack, but we can easily demonstrate by micro-
scopical examination that during the summer the upper
layer of dust from any road contains a large proportion
of pollen. It is however more than probable that
the irritating action of the pollen is intensified by the
presence of the sharp siliceous spicules of which dust
upon country roads is composed.
Experiments with Pollen.
As far as I am aware Blackley was the first to
put this agent to the test by means of a systematic and
Exciting Causes 9
continuous course of experiments. The first investiga-
tio.ns were made with the pollen of grasses, but the
pollen of plants belonging to thirty-five other
natural orders were also tried. These experiments
were made at all times and seasons of the year. In
some cases the dried pollen was used after it had been
kept some months, but as a general rule fresh pollen
was used, collected during the period in which the
plants indigenous to this country were in flower.
The effect of pollen was tried in five different
ways, viz., 1st, by applying it to the mucous
membrane of the nares ; 2nd, by inhaling it, and
thus bringing it into contact with the mucous
membrane of the larynx, trachea, and bronchial
tubes ; 3rd, by applying a decoction of the pollen to the
conjunctiva ; 4th, by applying the fresh pollen to the
tongue, lips, and fauces ; and 5th, by inoculating the
upper and lower limbs with the fresh moistened pollen.
The pollen of a number of the grasses was first tried,
and it is stated that in almost every instance it gave
distinct and unmistakable evidence of its power to
disturb the healthy action of the respiratory mucous
membrane. When a small portion of pollen, just
sufficient to tinge the tip of the finger yellow, was
applied to the mucous membrane of the nares, some 01
the symptoms of hay-fever were invariably developed,
the severity and continuance of which varied directly
with the quantity and the number of times it was used.
lO Hay-Fever.
The action of the pollen of the order graminaceae
was, on the whole, very distinct and well marked. .In
some cases it was comparatively mild, and in other
cases somewhat severe. In the case of plants of some
of the other natural orders the action was quite as well
marked as in any of the grasses.
Blackley applied a quantity of pollen from two
anthers of the lolium italicum to the anterior surface of
one forearni after the skin had been abraded. In a few
minutes after the pollen had been applied the abraded
spot began to itch intensely, and the parts immediately
around began to swell, this effect seeming to be entirely
due to effusion into the subcutaneous cellular tissue.
There was no heat or redness ; although the swelling
had the appearance of oedema, it located itself at first
exactly around the abrasion to which the pollen had
been applied, and gradually spread from this point and
formed a flattened tumour, which had its centre at
the abraded spot. There was no tenderness and the
swelling was easily made to pit on pressure. The
swelling increased in size until it measured two and a
half inches in length by one inch and a half in breadth,
and was raised above the ordinary level of the surface
nearly three-quarters of an inch. Experiments of a
similar character were performed by applying pollen to
the integument covering the tibia — results were the same.
Dr. Wyman, in speaking of his experiments, says :
** Early in September, 1870, I gathered in my grounds
Exciting Causes. 1 1
at Cambridge, Mass , some Roman wormwood in full
flower, covered with pollen, taking the whole plant,
stalk and roots. This was carried to the White
Mountain Glen, about 1,200 feet above tide, where we
remained till September 23rd in the afternoon. The
parcel containing it was then opened and freely sniffed
by myself and my son. We were both seized with
sneezing and itching of the nose, eyes and throat, with
limpid discharge. My nostrils were stuffed and my
uvula swollen, without cough, but with the other usual
symptoms of autumnal catarrh. These troubles
continued through the night and did not disappear till
the afternoon following. K portion of the same plant,"
Dr. Wyman says, " was sent to friends. The results
of the experiments tried were as follows : Eight persons
sniffed the plant. One was seized with asthma, and did
not entirely recover from the effects until the next
day ; one was attacked with catarrh as he would have
been at the same period at home, and the eyes were
irritated for several hours ; one had sneezing and
coughing for some little time ; two had sneezing only ;
one had sneezing and watering of the eyes ; one had
only irritation of the eyes for some time ; and one
experienced no effects whatever. Eight other persons
were in the house at the time who are subjects of the
disease, but did not sniff the plant, and were not
similarly affected."
Temperature exercises an important influence
12 Hay 'Fever.
upon the production as well as upon the activity of
pollen. A high temperature is in itself favourable to
the generation of pollen, but a high temperature with
severe drought, will, in the case of the grasses, check
their growth, and thus prevent the formation of pollen.
Under such circumstances, hay-fever patients may have
a short season of attack, but the symptoms may be
very severe whilst they last.
Low temperature operates in quite another manner
with the majority of the grasses. Some of the cereals,
however, will arrive at maturity and maintain a vigorous
and healthy condition during their period of growth
with a much drier state of the atmosphere and soil than
is borne by many of the grasses. Thus it happens
that in cold and wet summers hay-fever patients will
suffer much less than in better seasons ; whilst in a
very hot summer with continued drought, patients may
almost escape the disease even if they reside in a part of
the country where hay grass is largely cultivated. But
when the cereals come to be in flower they may suffer
very severely for a time.
The pollen grains of different orders of plants vary
from about O'OI to oooi of an inch in diameter. They
also vary in shape and in the roughness or smoothness
of their outer coat. In the state in which the pollen
comes to be when in contact with the mucous membrane
of the nares, the outer coat will in some cases be perfectly
smooth and even, such as, for instance, in the cereals
Exciting Causes. 1 3
or the grasses. In others the surface is studded over
with sharp points, and whatever may be the varying
conditions such pollen is. placed under, with regard to
excess or deficiency of moisture, this roughness is never
entirely got rid of. Between these two extreme
characters of surface there are all degrees. In com-
mencing the enquiry into the question as to what
constituent of pollen is the exciting cause of hay-
fever, we encounter some difficulties which are not easily
removed. Pollen is, in its recent state, a living structure,
and any mode of manipulation which alters the relation
of its separate parts, may change its character and lessen
its vitality. It will no longer be the active and living
organism it was before our examination began.*
Examined under the microscope the pollen consists of
microscopic cells, which possess two coats, known as
the extine and intine. In rare cases the outer coat
appears to consist of two or even three layers.
The intine is the innermost layer, and appears to
be of the same nature and appearance in all pollen-
grains. It is usually smooth, very delicate and trans-
parent, and is composed of pure cellulose.
The extine is a hard thick resisting layer, and is liable
to great variation ; thus it is sometimes smooth, at others
marked with granular processes or spiny protuberances.
The nature of these markings is always the same for the
pollen of any particular species or variety of plant, but
* Manual of Botany, J. Reynolds Green, F.R.S.
14 Hay-Fever,
varies much in that of different plants. The extine
is often covered by a viscid or oily secretion. The
colour of pollen-grains also resides in the extine. In by
far the majority of cases the pollen-grains are yellow,
but various other colours are also occasionally found.
Besides the various markings just described as
existing on the extine, we find also either pores or
slits which vary in number and arrangement in different
plants. Thus we commonly find one pore in mono-
cotyledons, as in the grasses ; and three in dicotyledons.
Pollen-grains are found of various shapes, the most
common forms appear to be the spherical and oval ;
in other cases they are polyhedral or triangular, etc.
It should also be noticed that the form of the pollen is
materially influenced according as it is dry or moist, the
size of the grains being liable to vary according as they
are examined in a dry state or in water.
The Cell Contents.* — Besides the protoplasm
or living material present in the cell, very many other
substances are found which are extremely variable in
nature and amount. The bodies included in the cell
contents — using the term in this restricted sense — may
be divided into two groups : Those soluble and those
insoluble in the cell-sap. In the former are included
constructive materials for the protoplasm, such as freshly
absorbed inorganic salts, and more highly elaborated
bodies destined either for immediate use, or temporary
"^ Manual of Botany. Vol. I, p.290. By J. Reynolds Green, F. R.S.
Exciting Causes. 15
storage, or possibly merely on their way through the cell.
Various carbo-hydrates, chiefly sugars, vegetable acids
and their salts, nitrogen containing bodies in the form of
amides, belong to this category. Other substances,
possibly nutritive, possibly only the bye-products of
nutrition, such as tannin, various glucosides, alkaloids,
and other complex bodies are also to be met with.
The bodies which form the second or insoluble
group include starch grains^ fats, proteid reserve
materials, either in amorphous, granular, or crystalline
form, and crystals of inorganic salts.
We have in plants a large number of secretions
(peculiar bodies which the protoplasm forms or secretes)
which are known as enzymes or unorganised ferments.
The action of these bodies is not at all completely
understood, but they evidently carry out many changes
in the substances deposited in the cells. Many of
these exist in the cell-sap in a state of solution ; others,
however, in a solid form.
When water is allowed to come into contact with
the dried pollen, this quickly swells and assumes its
normal shape. If moisture continues to be supplied it
loses its form, and, whatever may have been its shape
previously, it tends to become more or less spherical.
Carried still further, the granular contents of the cells
are seen to protrude more or less through the pores, and
to form, in this way, minute mastoid processes, in some
cases bulging very considerably beyond the outer coat.
1 6 Hay 'Fever.
The granular contents will, in the case of the pollen of
the grasses, move to the end to which the single pore,
in this pollen, is situated, leaving one-third or one-half
of the cell comparatively empty. After a short time,
varying according to the condition of the pollen when
placed in contact with water, the portion of the granular
contents of the cell is expelled, and diffuses itself
gradually in the surrounding fluid. If, instead of
bringing the pollen grain into direct contact with water,
we allow the vapour of water to act upon it, the
changes described above occur much more slowly.
We reproduce the condition in which pollen is placed
when it is brought into contact with the respiratory
mucous membrane by being inhaled. In the one case,
we have mucous and watery vapour acting upon the
pollen, whilst in the other we have only watery vapour
present.
Blackley came to the conclusion, from the results
of his experiments, that the disturbance caused by
pollen is due partly to its mechanical and partly to its
physiological action.
The mechanical changes which I have briefly
described Blackley considers quite sufficient to account
for some of the earlier symptoms of hay-fever, sneezing
and discharge of serum, and that the swelling caused
by the effusion of fluid into the submucous cellular
tissue is due to the presence of some substance or quality
in the granular matter, the exact nature of which is at
Exciting Causes. ly
present unknown. He considers that it is highly
probable that the finer particles of this matter do, in
some cases, pass through the mucous membrane of
the respiratory passages, and by getting into the
circulation in this way, give rise to the constitutional
symptoms we see developed in some cases.
There is another supposed cause of a form of hay-
asthma, namely, the odour given off by certain animals.
The presence of cats, rabbits, or guinea-pigs, will, in
some cases, cause a form of asthma which cannot be
distinguished from hay-asthma. In the case of the
two species last-named, it is well-known that they are
often kept almost constantly amongst hay, and it
may, therefore, with very great propriety be suggested
that the fur of these animals may be simply the carrier
of the granular matter and of the pollen.
Blackley also made experiments upon the
* quantity of pollen found floating in the atmosphere
during the prevalence of hay- fever, and in its relation
to the intensity of the symptoms."
From observations he found that fully 95 per
cent, of all the pollens that were collected in this
country belonged to the graminaceae. Pollen may
be carried from flower to flower by wind or water,
or by the agency of insects or other animals. From
this point of view plants have been classed as
anemophilous, or wind pollinated, that is, fertilised
by the agency of the wind, hydrophilous or
1 8 Hay-Fever.
water-pollinated, entomophilous or insect-pollinated,
and zoophilous or those pollinated by other animals.
Of these methods of pollination the anemophilous
and the entomophilous are the most wide spread ; in
the former case certain structural features are asso-
ciated with the mode of transference of the pollen.
It is produced in such flowers in great abundance, is
extremely light and dry, and in some cases furnished
with bladders to aid its transport. The receptive organ
is sometimes a bulky cone, the leaves of which are
separated from each other and from the common axis
by spaces into which the pollen may drop ; sometimes
it is a much divided or plumose stigma, often furnished
with hairs, so that pollen falling on it may be readily
retained.
On the other hand, anemophilous flowers are
always inconspicuous and of a comparatively humble
type. Flowers which are pollinated by insects are
usually much larger and more showy, and are often
very highly coloured and provided with characteristic
odours. Their perianths and sometimes their sporo-
phylls are highly modified to adapt them to the habits
of their insect visitors. As a further attraction to the
latter they usually produce honey in some part of the
flower, in such a situation as will lead to the removal
of pollen by the insect in its search for the attractive
liquid. The pollen itself also is often the subject of the
insect's visit. The grasses are examples of anemo-
Exciting Causes. 19
philous plants, and the orchids of entomophilous plants.
The pollen of the latter is seldom found floating in
the atmosphere, and cannot, therefore, be a cause of
hay-fever. The grains of the former are almost always
found floating in the atmosphere singly. In no case
did Blackley in his experiments find a number of
grass pollen-grains massed together on the exposed
slides. He therefore contends that pollen will be
distributed in the same manner on the mucous
membranes. From his experimental enquiry he claims
to have shown that pollen of all kinds will give rise
to some of the symptoms of hay-fever; and that the
progress and fluctuations in the severity of the malady
during the hay-fever period, correspond with the varying
amount of pollen which floats in the atmosphere at the
time. Moreover, that all the other so-called causes have
little or nothing to do with generating the disease. Also,
that pollen rises to high altitudes and is carried very
long distances by atmospheric currents ; at times it will
descend to the lower part of the atmosphere and be
deposited on board any ship that comes in its way.
In this manner some of those anomalous cases of hay-
fever, which are said to have occurred out at sea, may
be reasonably accounted for.
In November, 1902, Professor Dunbar published a
pamphlet on the ** Cause and Treatment of Hay- Fever."
In this he has shown conclusively by experiments
that there is but one cause for hay-fever — the pollen of
C2
20 Hay-Fever.
grasses and certain plants. The pollen of about 130
different plants were examined by him, of which that
of 25 grasses and of only 7 other kinds of plants were
found to exert a definite action. The pollen of rye was
the most active.
He succeeded in isolating from the pollen of certain
grasses a peculiar toxic substance of an albuminous
nature which was very powerful, and when applied in
very small quantities to the conjunctiva or nostrils of
people predisposed to hay-fever, within a few minutes
produced in a more or less marked degree the local
symptoms characteristic of that disease, whilst the
same quantity of the toxin when applied to the eyes
and nostrils of persons not predisposed remained without
any effect.
Dunbar obtained from the pollen three different
products : (i) the toxic substance, (2) a starchy matter,
(3) the ethereal oils. Only the first-named — which he
isolated in the form of a, white powder — produced the
typical symptoms. He also confirmed by his experi-
ments the conclusions arrived at by Blackley and others,
that the severity of hay-fever is in direct proportion to
the quantity of pollen present in the atmosphere.
Observations on the Influence of Light and Heat.
Both light and heat have been thought by some
authors, and also by some patients, to give rise to
exacerbations of the disorder, when once it has been
Exciting Causes, 2i
established. Blackley refused to accept the statements,
as no evidence had been brought forward to show
that the actual exciting cause of the disease had not
been present when these exacerbations have come on
apparently through exposure to light.
Dr. Abbots Smith agrees with Phoebus and
Bostock in believing that great heat and strong light
will induce or aggravate the symptoms of hay-fever.
One case, however, is given in which the attack came
on whilst the patient was engaged in unfurling the sails
of a yacht a short distance out at sea. Blackley con-
siders it highly probable that the sails had become the
receptacles for pollen, which had been blown on to
them from the land, and that the unfurling of the sails
had disturbed the pollen and caused it to be inhaled
during the period of exertion. He turns to the
evidence furnished by medical men and by patients in
India, that whilst sufferers have mostly escaped attacks
on the plains, they have often had them when they
have ascended into the cooler atmosphere of the hills ;
and, when patients have been attacked in both situations,
the general testimony is that they have suffered less
severely in the former than in the latter place.
Then, again, it has not been proved that the period
at which we have the greatest average intensity of light
is the period at which hay-fever prevails.
The powerful influence which heat has in deranging
the whole economy of the body has been recognised
22 Hay- Fever,
from very early times, but, in searching the works of
writers on medicine, we look in vain for any description
of symptoms resembling those of hay-fever.
Bostock was, as we have seen, the first to ascribe
the malady to the influence of heat. He believed that
the cooler air of the sea coast was the cause of the
comparative immunity he enjoyed during hot summers.
CHAPTER II.
Predisposing Causes.
General. Beyond the circumstance that the pre-
disposition to hay-fever is more common amongst the
educated, the brain-workers, and town-dwellers than it
is amongst the working-class, we have scarcely anything
to guide us in forming an opinion as to the class or
kind of individuals most likely to be affected by the
malady. I myself have never seen a case of true hay-
fever among the working part of the population. It is
certainly true that I have met with cases suffering from
similar symptoms among the working classes, but upon
examination hypertrophic rhinitis with catarrh was
invariably discovered, and these patients, when
questioned, tell you that . they are liable to similar
symptoms during any period of the year and not only
during the hay-fever season. The disease seems to
affect persons of all temperaments and all kinds of
constitutions, but the nervous temperament is credited
as predisposing to attacks of hay-fever.
Many instances have been quoted to show the
neurotic element. For example, the case of J. N.
Mackenzie. An attack came on in a susceptible
person by offering her an artificial rose to smell.
Another case has been quoted where the patient had
24 Hay-Fever,
an attack of sneezing, with other symptoms of hay-
fever, whilst looking at a beautiful picture of a hay-
field. Another patient in thinking of the disease, and
seeing his swollen face in the glass, had all the
symptoms. I myself have never seen a patient with
such extreme susceptibility of the nervous system as
is here described, and can, therefore, only give these
cases on the authority of the writers.
Age undoubtedly exercises some influence upon
the commencement of the attacks, and the sexes appear
to be about equally affected. Dr. Wyman* gives a
table showing the age of 72 patients at the time the
disorder first commenced.
Of these : —
II had their first attack when under 10 yearsof age.
15 » » 20 „
30
25
8
II
2
»
>>
>>
i»
40
50
60
>>
>>
>>
>>
Dr. Reardf also gives a table containing a total
of 188 patients. Of these : —
34 had theirfirst attack when under 30years of age.
56 „ „ 40
65 „ „ 50
33 » M 60
* Autumnal Catarrh^ by Dr. Wyman, p. 81.
t Hay Fever, by Dr. Beard, p. 45.
>>
»
Predisposing Causes 25
In May of last year I treated a little girl, 6 J years,
suffering from the typical symptoms of hay-fever. On
examination of the child I found adenoids ; I advised
immediate removal, after which, the symptoms dis-
appeared and did not recur throughout the season.
Hay-fever is strongly hereditary in its character.
Dr. Wyman states, six members of his own family were
sufferers from the malady. In another family, consisting
of six individuals, five had either autumnal catarrh or
June cold. Sajous has been able to show that, in
35 per cent, of his cases, near relatives were similarly
affected, and in 42 per cent, the patients had asthmatic
relations. Dr. Beard states, one-third of the patients
had relatives who suffered from some form of the
malady. No information that can be relied on has yet
been obtained as to the effect which severe illnesses have
upon hay-fever.
Local. Hay- fever is classed among the nasal reflex
neuroses for the reason that its principal manifestations
are the result of a temporary arrest of vaso-motor
control over the vessels of the nasal mucous mem-
brane. Hack, in 1882, directed general attention to
the subject of nasal reflexes, making it include such
affections as neuralgia, headache, etc., and initiated a
discussion which has to this day continued and remains
unsettled.
The frequent association of asthma with intra-nasal
disease was recognised by Trosseau long before it
26 Hay-Fever.
was realised that asthma might be caused by patho-
logical irritation in the nose or that it might be
benefited or cured by treating the existing diseased
condition.
It is only since Voltolini's classical case of asthma,
which he cured by the removal of a nasal polypus, that
serious attention has been directed to intra-nasal
abnormalities suggesting a causative relationship.
The observations of Frankel, Daly, Roe, Harrison,
Allen, J. N. Mackenzie, Francis and many others, have
demonstrated the association of asthmatic attacks with
intra-nasal disease. Daly pointed out that in a large
proportion of the cases of hay-asthma, there was local
disease of the mucous membrane, the cure of which
rendered the patient insusceptible to conditions pre-
viously exciting the attacks. Bosworth stated that
asthma was invariably caused by some form or other of
nasal obstruction. This relationship has not only been
abundantly confirmed but is now generally recognised
by all rhinologists.
In hay-fever there is always present a hypersensitive
condition of the nasal mucosa. The affection must be
differentiated from nervous coryza and paroxysmal
sneezing excited reflexly by the action of bright sunlight
(sensorimotor) or by the imagination (ideomotor), as,
for instance, the occurrence of sneezing and other
symptoms of hay-fever induced by the sight of an
artificial rose or the harmless house cat.
Predisposing Causes. 27
Fran9ois-Franck performed an interesting series of
experiments on animals with a view of demonstrating
the occurrence of various nasal reflexes. It was shown
by these experiments that irritation of the inflamed
nasal mucous membrane produced various phenomena
in the respiratory and circulatory systems, such as
laryngeal and bronchial spasm, spasmodic movements
of the respiratory muscles, slowing of the heart's action,
and distension of the blood-vessels of the head on one
or both sides.
One part of the effect produced by pollen is due to
its direct action, and another to its indirect or reflex
action. The discharge of serum in the nares is an
example of the first kind. In the congestion of the
vessels of the conjunctiva we may have both kinds of
action. The reflex mode of action may be exhibited
by any irritant applied to the mucous membrane of
the nostrils. Every aurist knows that the introduction
of the catheter to the eustachian tube will ^w^ rise to
a flow of tears and to congestion of the conjunctival
vessels. Another way in which reflex action may
manifest itself is when the irritation in the nostril is
transferred to the bronchial tubes and produces
asthmatic symptoms. Most writers on hay-fever have
attributed the dyspnoea which occurs in the asthmatic
form of the disorder to spasm of the circular muscles
of the bronchial tubes. Weber and many others believe
it to be due simply to tumefaction of the bronchial
28 Hay Fever,
mucous membrane. It is possible that hay-asthma
is a spasmodic contraction of the bronchial muscles.
This theory corresponds best with the sudden onset
and disappearance of the asthmatic seizure. It explains
the instant relief afforded by anti-spasmodic remedies,
such as atropine, morphia, chloroform and lobelia.
The application of cocaine to the nasal mucous
membrane will often immediately relieve an asthmatic
spasm ; this, to my mind, definitely shows that hay-
asthma is a nasal reflex.
In the preceding paragraphs I have endeavoured
to lay before my readers a resume of the opinions by
various authors of the causes of this troublesome
disease, and to keep my individual opinion in the
background. For my own part, as the result of a
careful study of a very large number of cases of
hay-fever, I feel convinced that we have conclusive
evidence that in this country there is but one primary
exciting cause of the malady as it occurs in summer,
and that is the pollen of the grasses ; and that where
pollen of any kind is thrown into the atmosphere
in large quantities, it will give rise to hay-fever in
those predisposed to it.
I am quite aware that other agents may be found
to produce symptoms not unlike those of hay-fever,
but these should be classed as secondary causes.
The main predisposing cause is a hypersensitive
condition or susceptibility of the nasal mucous
Predisposing Causes. 29
membrane. ' There are three factors in the etiology
of an attack of hay-fever, viz.: First, the presence
of hypersensitive areas in the nasal mucous mem-
branes ; if accompanied by asthma similar areas are
detected in the pharynx. Second, a diseased, or at
least an irritable condition of certain nerve centres,
giving rise to symptoms in the nose itself or in more
or less distant parts by reflex action. Third, the
presence of pollen. The absence of any one of these
factors is sufficient to prevent an attack.
In order to understand the physiological associa-
tions existing between the various portions of the
respiratory tract, it is necessary to glance at the nerve
supply of the nose.
The nerves of the nasal fossae are of two kinds —
those of special and those of common sensation. The
filaments of the olfactory nerve enter the nose through
the foramina in the cribriform plate.
The nerves of ordinary sensation supplying the
nose come chiefly from the first and second divisions
of the fifth nerve and form the spheno-palatine or
nasal ganglion. Of the branches derived from the
ophthalmic divisions of the fifth nerve the largest
and most important is the nasal ; and the fact that
it supplies the anterior part of nasal septum, the outer
wall, and the floor of the nose will explain the more or
less profuse lachrymation occurring during operations
upon or irritation of these parts. It is the several
30 Hay-Fever,
branches of the superior maxillary nervfe and those
coming from the spheno-palatine ganglion, however,
that supply by far the greater portion of the nasal
chambers.
The arterial supply to the mucous membrane and
to the erectile tissue of the turbinated bodies is
controlled by vasomotor nerves from Meckel's ganglion,
and is under control of the vasomotor centres in the
medulla, where there is probably a connection with
the nuclei of the vagus through association fibres, a
physiological connection which has an important bearing
on the pathology of various neuroses, as for instance
the cases of asthma associated with nasal disease.
The subjects of hay-fever form two distinct
clinical types — the predisposing pathological cause
present in the nose varying sufficiently to justify this
classification.
(a) On examination of the nose no structural
abnormalty is discovered, but certain, areas of the
mucous membrane are hypersensitive.
(b) Some pathological condition or abnormality is
present, plus hypersensitive areas. In some patients,
especially the subjects of asthma, identical areas are
present in the posterior wall of the pharynx. They may
be situated opposite the oral cavity, above and behind the
soft palate, but most commonly opposite the larynx.
Amongst the intra-nasal diseases present may be
mentioned (i) simple chronic catarrhal or hypertrophic
Predisposing Causes. 31
rhinitis, (2) polypi, (3) sinus disease, (4) ethmoiditis,
(5) adenoids, (6) deflected septum, spines and crests, (7)
foreign bodies, or rhinoliths.
Group (a) form the true type of hay-fever, and the
symptoms are only produced by pollen.
Group (b) should be termed pseudo hay-fever ; the
symptoms are much the same, may come on during any
period of the year, and the primary or secondary are
equally as exciting.
In the true type of hay- fever, it is at present
impossible to explain the presence of sensitive areas.
Why one or two members of a family should be so
susceptible to the action of pollen, while the others
remain free, is one of the problems to be solved.
In the pseudo form, the nerve-endings may be
rendered sensitive in various ways. First, there must
be more or less hyperaemia, and this, of course, involves
a proportionate amount of hyperaesthesia. Second,
by friction or pressure, a polypus, and especially
one which can change its place, may rub against the
nasal mucous membrane, or induce pressure by the
transitory swelling which so frequently occurs, and in
this way displace the epithelium, leaving the nerve
endings exposed. Third, synechiae resulting from the
accidental use of the electro-cautery may exert tension
in the sensory nerve endings. Fourth, it is probable
that the contact of a spur with the turbinated bodies
has a decided influence in setting up reflex symptoms.
32 Hay 'Fever,
They may promote a tendency to catarrh, and
thus render the nerve endings more sensitive. On the
other hand, hypertrophy or congestion of the nasal
mucous membrane may be the consequence and not
the cause of hay-fever.
Examination of the True Type of Hay-fever.
The appearance of the nasal-mucous membrane
will vary with the period of the year at which the nose
is examined : —
Before or sometimes after the periodic fever
is over, the mucous membrane usually appears normal,
but to one who has had experience in this class of
cases, the presence of hypersensitive areas are readily
distinguishable by their heightened colour and slight
elevation above the surrounding mucous membrane.
In most of my patients there was nothing wrong
pathologically ; a small spur, or slight deviation of the
septum might have been present, but from the fact
that it gave rise to no trouble fequiring treatment, I
should consider these noses as normal.
During the critical period the turbinates are
considerably swollen. The mucous membrane presents
an extremely red, congested appearance, and as a
whole is sensitive to the touch of a probe, but certain
areas can be discovered by careful search, which show
peculiarly hypersensitive reflexes. The extreme sensi-
tiveness is due probably to the fact that the mucous
Predisposing Causes, 33
membrane is practically denuded of its epithelium,
and also may itself become swollen and inflamed.
Where is the site of origin for reflex disturbances ?
In the pseudoform of hay-fever, no particular nasal
area can be described in connection with the disease.
In fact, almost every part of the mucous membrane has
been stated to be hypersensitive.
Hack considered that reflex disturbances originated
in the anterior and posterior end of the inferior and
middle turbinate.
Heryng states that most reflex phenomena are set
up in the posterior part of the septum.
Francis and Torstennon claim that in most cases
they have demonstrated an area in the upper and
posterior region of the septum, above the centre of the
middle turbinate, which is closely related to asthm-a.
Lewy is said to have discovered a number of thick
nerve branches on the under surface of enlarged inferior
turbinates.
In my experience there is always more than one
hypersensitive area present in various parts of the nose.
The mucous membrane, as a whole, is sensitive to
the touch of a probe, but certain areas can be discovered
by careful search, which shows peculiarly hypersensitive
reflexes, such as cough or sneezing.
Careful examination of my cases leads me to locate
these areas in the upper and anterior half of the nasal
D
34 Hay-Fever,
cavity. For instance, the middle meatus, the region
of the ethmoidal cells, the anterior half of the septum,
and especially where the septum meets the nasal
cartilages. The hypersensitive area may be only one
small spot or several, and may even be a fusion of
several areas to comprise one relatively large one.
The methods of detecting the hypersensitive areas :
1 need hardly mention that this procedure should
be carried out before the hay-fever season commences.
The whole interior of the nose should be thoroughly
examined, and the slightly "elevated areas" looked for
and tested.
Most authors advise that the various parts of the
mucous membrane should be touched with the end of
a nasal probe, and if it produces irritation, a tendency
to sneeze, burning, and lachrymation, such a spot
should be cauterized. This method of detection will
suffice in some cases, but not in all.
The method I have employed is the following : —
A small piece of cotton wool is twisted round the end
of a probe and is dipped into a weak solution of nitrate
of silver, or a weak solution of iodine. My idea is to
imitate the chemical action of the granular matter of the
pollen, and the touch will be the mechanical cause. If
in this way certain areas, when irritated, bring on an
attack of hay-fever, then our diagnosis is confirmed
and this area should be thoroughly destroyed.
Predisposing Causes. 35
This is a valuable experiment, proving that hay-
fever is a reflex disturbance. It is invariably successful
in producing asthma, which, however, can immediately
be cut short by applying 20 per cent, of cocaine to the
nose.
D 2
CHAPTER III.
Symptoms.
First attacks of hay-fever are often milder and less
persistent than they are after a patient has suffered for
some years ; this is no doubt due to the fact that the
susceptibility to the action of pollen is not so marked
on its first appearance as it is at a subsequent time.
There is also, in some cases, a tendency for the disorder
to take on the asthmatic form in later years.
This, to my mind, is due to chronic swelling or
hypertrophy of the nasal mucous membrane, as a con-
sequence of the repeated attacks, which causes the
susceptibility to become more marked in each suc-
ceeding year.
The symptoms, have been divided into six groups,
viz., into the head group, the nose group, the throat
and mouth group, the chest group, and the general
symptoms. For all practical purposes the simple
division into the catarrhal and the asthmatic forms of
the disorder will answer quite as well as the classification
given above. A patient may suffer from one or from
all the phases of the disorder, but whatever difference
there may be in the symptoms, the malady is one and
the same, and due to the same cause.
38 Hay-Fever.
In most cases, and especially in the early years,
the larynx, trachea and bronchial tubes are unaffected.
The first symptom of the presence of pollen is
generally itching of the parts, — the nostrils, fauces and
eustachian tubes ; then in a severer form in the eyes ;
and, lastly, in the bronchial tubes, in those who are
liable to the asthmatic form of the malady. When
the dose of pollen increases, the attack passes from the
mild form to the true catarrhal stage. This is
characterised by the discharge of thin watery serum
from the nostrils, by violent attacks of sneezing, and
in many cases by swelling of the eyelids and severe
lachrymation. Generally the violent attacks of sneezing
precede the discharge from the nostrils, but the coryza
in a mild form may be the first symptom of an attack.
In the earliest stage of the disorder the fits of
sneezing are neither very long nor very severe, but when
the malady has become fully developed they become
so violent and seem to take such entire possession of
the patient, when they do come on, that, for the time
being, he loses all control of himself. In some cases
the patient will sneeze twenty or thirty and even
approaching a hundred times in succession, and what-
ever he may be occupied with when the fit comes on
he is obliged to set it aside and resign himself to the
paroxysm until it is over. Occasionally the patient
will break out into a cold sweat at the termination of
an attack of sneezing. After the attack has lasted for
Symptoms, 39
a short time, the sub-mucous tissue in the nasal
passages begins to swell, and this goes on increasing
until finally no air whatever can be drawn through the
nostrils.
This " stuffiness " of the nose often varies in a very
curious manner. After both passages have been
equally closed for a time, if the patient gets into a
recumbent position, so as to lie on one side, the nasal
passage which is uppermost becomes after a short time
quite open, whilst the lower one becomes still more
completely occluded. This change is caused by the
fluid in the submucous tissue gravitating towards the
lowest part, and as often as the position is changed
this alteration in the condition of the two passages
will take place. During the hay season, most patients
have paroxysms of sneezing, not only in the day, but
frequently also during the night, and especially when
the disorder is just arriving at its highest point of
intensity.
So long as the supply of pollen is kept up, the
sneezing and discharge of serum continue. If the
quantity is large, however, the swelling of the sub-
mucous tissue continues, and the alae nasi, as well as
the mucous membrane of the nose, become tender and
inflamed, and have a tendency to bleed if rubbed.
Under these circumstances the patient is only able
to breathe through the mouth, and on awaking in the
morning the tongue and mouth are more or less parched.
40 Hay-Fever,
As the disease progresses, the nasal discharge becomes
more inspissated and puriform.
In the eyes, as in other regions, the first symptoms
of a commencing attack is itching. At first it is very
mild, but as the hay season progresses it becomes very
troublesome, and is frequently attended by a slight
burning sensation, which extends to the deeper parts
of the eye-ball.
When the disease is fully developed the lachrymal
canals and nasal ducts become almost entirely closed by
the swelling of the submucous tissue. A short time
after pollen first comes in contact with the eye the
conjunctival vessels become injected, and generally the
larger capillaries show the first. After a time the
itching and burning become so troublesome that
the patient finds it difficult to resist the temptation to
be constantly rubbing the eyes, and in the end adds
much to the irritation. Occasionally shooting neuralgic
pains are felt in the back part of the orbit and in the
eyeball. In severe attacks the eyelids become oedema-
tons, and in some patients a considerable amount of
photophobia, and the patient is glad to seek the shade
rather than the broad sunlight. The discharge which
comes from the eye is at first thin and watery, after a
time, however, it becomes more inspissated. Taking
the eye symptoms as a whole, they disappear rather
sooner than the nasal symptoms. With some patients
who are extremely sensitive to the action of pollen the
Symptoms. 41
skin of the face and neck will occasionally show signs
of irritation. There is no doubt that all the subjects
of hay-fever are liable to have the normal condition
of the skin disturbed, but it is only under some
circumstances that this disturbance is severe enough
to attract notice.
In the summer, 1903, 1, myself, on several occasions
after a cycle ride in the country, suffered from
intolerable itching of the skin of the face and body.
The mucous membranes of the fauces and buccal
cavity do not seem to be as sensitive to the action of
pollen as the eyes. Nevertheless, some degree of
congestion of the mucous membrane and swelling of
submucous tissue does occur. The symptoms caused
by the action of pollen upon the lining membrane of
the pharynx are itching and slight burning or pricking.
Occasionally there is a little hoarseness. The itching
is generally felt to be very severe in the hard palate,
in the upper part of the pharynx, and in the eustachian
tubes. Sometimes there is slight dulness of hearing,
owing to the extension of congestion in the eustachian
tubes. The throat symptoms, like those of the buccal
cavity — to which, indeed, they really belong — vary much
in intensity in different individuals ; they may, in a few
cases, be somewhat severe, but generally they will be
very mild.
The asthmatic symptoms of hay-fever are by far
the most important of any of the groups, because
42 Hay-Fever,
they are the most troublesome and the most dangerous.
They vary in intensity in different individuals and in
different seasons. In some cases there is only a very
slight sense of obstruction in the breathing ; in others
the derangement may cause great suffering, and at
times may seem to endanger life. The symptoms are
thought to be due either to the obstruction caused
by the altered condition of the submucous cellular
tissue of the trachea and bronchial tubes, or more
probably to spasm of the bronchial muscles.
In many of its symptoms hay-asthma closely resem-
bles ordinary asthma. In both there is the same sense
of tightness across the chest at the commencement,
and as the disease advances there is the same loud
wheezing with slow inspiration and expiration. There is
also at first a dry cough, that is to say, a cough with
scanty expectoration, in both forms of the disorder, and
as the breathing becomes more and more difficult the face
may be pale and anxious looking. If the dyspnoea still
increases, the face will become livid and turgid, the
patient will seem to be threatened with suffocation, and
will try to fix himself in such a position that the
respiratory muscles can act with the greatest vigour.
This will invariably be in the upright position, with
the arms and hands firmly fixed on some article ot
furniture. In both cases too the voiding of a thin
frothy sputum may be one of the first signs of approach-
ing relief, but not so frequently in hay-asthma as it
Symptoms. 43
is in ordinary asthma. There are, however, some
points in which the two disorders differ, and these it is
important for us to notice.
In ordinary asthma the attack usually comes on
in the night, and is often preceded by a long-continued
fit of dyspepsia.
In hay-asthma the first attack of the season
generally comes on in the daytime after the patient
has been exposed to the influence of pollen and is
usually quite independent of dyspepsia. In hay-asthma
the first attack of the season may, and often does, come
on in the open air, but in ordinary asthma it generally
comes on in the house. Another very important
point of distinction is that unless the patient is brought
accidently into contact with pollen, hay-asthma only
comes on during the hay-season, whilst ordinary asthma
may come on at any time of the year, and is most
common in winter.
In ordinary asthma there are paroxysms with
intervals of perfect freedom, at least in the early and
less confirmed state. In hay-asthma this scarcely ever
occurs in so marked a degree as in ordinary asthma ;
there may be remissions and sometim.es even distinct
intermissions for short periods, but the tendency is
for the disease to continue with more or less severity
during the whole of the hay-season. And, lastly,
if coryza does accompany an attack of common asthma
it is rarely as severe as it is in hay-asthma, and we
44 Hay-Fever,
scarcely ever see the conjunctivae affected as they are
in the latter disorder.
In the early stage of the disorder the difficulty of
breathing is not very great, and if the patient lives in
the centre of a large town he will often escape with
comparatively little suffering. In cases where the
patient is extremely susceptible to the action of pollen,
he may have the symptoms pretty fully developed
even in a large town, but this is not often the case.
Coming to the head group of symptoms, these are
a fulness of the head, with heaviness and pains behind
the ears and a feeling as of a band passing round the
head above the eyes. There are occasionally shooting
pains in the head, and in some cases a considerable
amount of tinnitus aurium, due to the congestion and
inflammation of the lining membrane of the eustachian
tube and middle ear. The tinnitus may remain for
some weeks, or even months, if untreated.
The constitutional symptoms of hay-fever are
differently stated by different authors. In some cases
they are almost entirely wanting. Amongst these are
low spirits, a dislike to mental and physical exertion,
and palpitation of the heart on making violent exertion.
In some cases there are pains of a neuralgic or rheu-
matic character in various parts of the body.
After the disease has lasted some three or four
weeks — varying in time according to the kind of season
and the susceptibility of the patient — it begins to
Symptoms, 45
decline. If the season is a very favourable one for hay-
making, that is to say, if the weather is fine and hot,
it will decline rapidly, and vice versa.
When any of the cereals happen to be in bloom at
the time hay-making is about finishing in any
district, patients residing there, will find their attacks
to be prolonged. And if it should happen that a
second crop of grass comes into flower before the
harvest is over the attack may seem almost con-
tinuous from May to September. When once the
stage of convalescence has set in, if the patient keeps
free from the influence of pollen, the recovery is very
rapid. This may, however, appear to set in two or
three times in the course of a season. If there is a
fall of rain for three or four days in succession, and
especially if this is tolerably continuous, the symptoms
subside so quickly that the patient may think
recovery has commenced. Generally, however,
convalescence is slow, for the reason that in most
seasons the quantity of pollen diminishes comparatively
slowly. Exercise influences the severity of the attacks
considerably, for if it be taken when the disorder
has become fully established, the irritation in the
hard palate, nostrils, and fauces will become very
marked. The fits of sneezing also will become more
violent and prolonged, and if the patient suffers
from the asthmatic form of the complaint the breathing
will become very laboured.
46 Hay-Fever.
When we remember that the quantity of air inhaled
in violent exercise, is three or four times the amount
we take in in a state of rest, it is easy to see that
exercise must make a wide difference in the severity
of the symptoms. One of my cases, an officer in the
volunteers, suffering from a mild attack of hay-fever
whilst in the camp grounds, gradually got worse when
marching out with the regiment, until at last the
symptoms became so severe that he was compelled to
fall out and return to camp.
Almost all authors are agreed upon the fact that
hay-fever leaves no perceptible effects behind. The
eye recovers its healthy condition almost as quickly
as it became affected, and never, as far as I am
aware, exhibits any trace of organic change in any
of its structures as regards the lungs. Even in those
cases where the asthmatic attacks have been very
severe, and have occurred periodically for years,
emphysema, which is so apt to complicate the course
of long continued attacks of ordinary asthma, is rarely
seen to follow.
CHAPTER IV.
Treatment of Hay-Fever.
We come now to discuss what will be considered by
sufferers from hay-fever, the most interesting and im-
portant part of the subject, namely, the treatment and
prevention of the malady. No doubt the most
desirable mode of dealing with a patient who suffers
from hay-fever is to rid him of the susceptibility
altogether, and the means to accomplish this I shall
describe under CURATIVE measures. When these are
for any reason contra-indicated, we must content our-
selves with measures giving temporary relief. These
may be said to divide themselves naturally into the
prophylactic and the palliative.
Prophylactic. — When one reads the literature of
hay-fever, even up to a comparatively recent date,
one is struck by the many different modes of treatment
advised.
Amongst these, baths of various kinds occupied a
prominent place. The daily use of the cold plunge
or cold shower-bath, is recommended, also the hot-air
and the vapour baths. Some authors have advised
the Turkish bath during the hay- fever period. As
regards results, in no case do baths of any kind
48 Hay-Fever.
seem to have any beneficial effect upon the attacks of
hay-fever in the early part of the season ; nor do they
in any way lessen the susceptibility that exists in the
nasal mucous membrane to the action of pollen. On
the other hand, many of my patients have said that
the Turkish bath is serviceable in lessening the
prostration which most hay-fever patients complain
of at one part of the season or another.
A large number of drugs have been tried in doses,
varying from the purely infinitesimal to the toleration
point. Amongst these may be mentioned : arsenic,
aconite, ammonium carbonate, belladonna, camphor,
mercury (in various forms), ipecacuanha, nux vomica,
iodide of potassium, bichromate of potassium, chlorate
of potassium, quinine, senega, stramonium, sulphur,
strychnine, etc.
This list by no means makes up a full record of
the drugs tested, but it will serve to show that a fair
number of remedies have been tried. In some cases
they seemed to do good, but often a relap.se came on
whilst the drug was still in use, and in some instances
when a full dose was taken, especially with quinine,
the unpleasant effects were worse to bear than the
disease itself None of the drugs possessed any
perceptible control over the severity of the symptoms.
On the whole then, the treatment by medicines has been
very unsatisfactory.
In the hands of some practitioners, who are but
Treatment. 49
imperfectly acquainted with the cause and natural
history of hay-fever, remedies have been credited with
effects which were due simply to the diminution of the
quantity of pollen in the atmosphere during the latter
half of the critical season.
Experiments have been made with numerous drugs
with a view of delaying the commencement of the
attacks. If one remedy failed, the use of another was
immediately commenced. In using the drug, the plan
adopted by various physicians was to commence using
it some two or three weeks before the hay season
began, and to discontinue its use if it had no beneficial
effect. The drugs tried were : arsenic, arsenite of
quinine, iodide of arsenic, bromide of potassium, iodide
of potassium, quinine, salicine, and sulphur.
Quinine proved an entire failure. It was used by
injecting a saturated solution of the drug into the nostrils
several times a day, as well as by the mouth. Salicylic
acid and soda salicylate were also found to be failures.
Potassium bromide has been said to have some influence
in delaying the attacks, but it is very feeble. Potassium
iodide possessed some control at the commencement, but
in attempting to push its use beyond a moderate dose,
the disturbance produced by the drug is as bad to bear
as a mild degree of hay-tever. Arsenic and sulphur may
also be said to have no prophylactic action. Iodide of
arsenic is credited with useful properties in the early
stage of the disease.
E
50 Hay-Fever,
Of all the methods of prevention, the removal of the
patient to some place beyond the reach of pollen is the
most effective ; and the open ocean is the most free from
the presence of this agent. Where a patient can spare
the time, a sea voyage during the early summer months
is an unfailing remedy in ninety-nine cases out of a
hundred. Failing this a residence at the seaside is the
next best thing, if the place is well selected. A place
situated on the extreme point of a peninsula will in
some instances be almost as efficacious as a voyage.
Where the land is used principally for grazing (as in
some parts of the Western Highlands), the liability
to the disease will be correspondingly diminished. In
America the patients obtain great relief, if not complete
immunity for the time being, by having a sojourn in the
mountainous districts during the critical season.
Patients who live in the centre of a large town, may
almost entirely escape the most troublesome symptoms
of hay-fever by removing indoors during a few of
the most critical days. For those patients who live in
the outskirts of a town, or in the country, the following
additional precautions will be necessary in order to
escape any considerable amount of suffering. In the
first place, a patient must make up his mind to remain
in one room during fourteen or eighteen days of the
worst part of the season, and this room must be
protected from the ingress of pollen in the following
ways : —
Treatment, 5 1
Outside the room door a curtain of thin calico
should be hung, so as to cover the door completely ;
ingress and egress to and from the room being had by
turning the curtain aside. When in use the curtain
should be kept sprinkled with water which has
had lo grains of carbolic acid dissolved in each pint.
• In addition to this, it is well to have a frame of thin
wood mnde to fit the upper or the lower part of the
window of the room. This, when covered with two
folds of black muslin, acts as a ventilator and
percolator, and keeps out the pollen whilst it lets in the
air. Wherever the patient is, it is of the.highest import-
ance that he should not, whilst the grasses or cereals
are in flower, have a constant current of air passing
through his room without some means of intercepting
the pollen. Pollen in a still atmosphere indoors will fall
to the floor, but if the air is constantly renewed the
supply of pollen is kept up, and a certain amount of it
must be inhaled by those who come in contact with it.
Another important point is the avoidance of sudden
changes of temperature. This is very apt to occur if
the patient allows himself to get into a profuse perspira-
tion, and then remain still in the open air or where
there is a draught. In such circumstances the already
irritated mucous membranes of the air passages are
very apt to take on some degree of inflammatory
action, and in this way to render the patient an easier
prey to the floating pollen. For a similar reason, a
E2
$2 Hay 'Fever.
patient should, as much as possible avoid the inhalation
of dust or irritating vapours. The action of pollen
really is to clear away a portion of the natural protector
of the mucous membrane — the epithelium — thus expos-
ing the sensory nerve-endings, and so rendering the
nasal mucous membrane exceedingly sensitive to the
contact of foreign bodies. Under such circumstances
the inhalation of matters that are at other times quite
innocent, will often give rise to violent attacks of
sneezing and to difficulty of breathing. The occurrence
of such attacks has led some writers, and also some
patients, to believe that these secondary causes of
paroxysms are the primary causes of the disease in
many cases. They are, however, easily distinguished
by the fact that they have no disturbing influence at
other seasons.
Another important precaution, if the patient has to
go out of doors, is to protect the eyes by close-fitting
coloured goggles. To the nostrils, a piece of fine
surgical sponge should be fitted. It serves to filter the
inspired air, and may be worn without discomfort by
day and, if necessary, during the night.
Palliative.
Nothing more than a palliative treatment should
be undertaken while the attack lasts.
This cannot be satisfactorily carried out so long
as the nostrils are blocked with the swollen and
(edematous inferior turbinates.
Treatment. 53
These engorged bodies must, therefore, be first
reduced by spraying a 5 per cent, solution of cocaine
upon the anterior ends of the turbinates, and when
these bodies have contracted the same solution may
be applied by means of a piece of cotton wool into both
nostrils. In a few minutes the nasal mucous membrane
will have become less sensitive, and a warm alkaline
solution, consisting of boracic acid grains v, sodium
bicarbonate grains v, and sodium chloride grains iii,
aqua ad. §i, should, by means of a nasal syringe,
thoroughly wash the nasal cavities, and thus free them
from all secretion. The mucous membrane is dried in
the gentlest way with absorbent cotton. Adrenalin
extract, in i to 5,000 strength may be sprayed, but 1
prefer to smear the nasal mucous membrane over with
the solution by means of a small tuft of wool on a
forceps. In a few minutes a considerable amount of
shrinkage of the inferior turbinates will have occurred,
and the patient experiences the pleasure of free nasal
breathing. Once again is the warm alkaline solution
used, the nose is dried with pledgets of cotton wool,
and then one, two or more of the offending turbinates
are lightly touched in two or three spots with chromic
acid. Dr. Grayson,* who employs this method of local
treatment says : " This may seem a rather startling
therapeutic measure, but there are several reasons for its
employment. In the first place, although it is seemingly
* Diseases of the Nose^ Ear, and Throat, by C. P. Grayson, M.D.,
Philadelphia, 1907.
54 Hay- Fever.
an additional irritant to the already incensed mem-
brane, yet it is to be remembered that the condition
present is not one of simple coryza, but is wholly the
result of suspended vasomotor inhibition, brought about
through the specific influence exerted by some variety
of pollen. It is not an ordinary irritation ; its effects
being dependent upon an idiosyncrasy afforded by the
patient. The condition then is one of complete vascular
relaxation, and the action of chromic acid at this juncture
is that of a tonic stimulant rather than an irritant.
Within a few hours a material contraction of the
distended turbinate will have occurred, the secretion
will be less profuse, and the paroxysms of sneezing will
be neither as frequent nor violent. This pin-point
application of chromic acid occasions no destruction of
tissue, and it may be repeated, therefore, at intervals
of a few days without hesitation and with increasing
benefit to the patient. It is not unlikely that its
stimulating and indeed tonic effect may be central as
well as peripheral."
A great variety of local remedies have been from
time to time recommended for the relief of hay-fever.
Snuffs, lotions used in the form of a spray, and, what is
more pernicious, the prescription of proprietary com-
pounds. It seems only necessary to advertise these
proprietary articles sufficiently long enough in order to
popularise their employment. They mostly consist of
cocaine, adrenalin, or its equivalent under other names.
Treatment. 5 5
Since these particular drugs possess such useful qualities
for surgical purposes, it is necessary to say a word of
caution against its indiscriminate use. The fact that it
possesses the property of blanching mucous membranes
has seduced people into prescribing it for use by the
patient in inflammatory cases, especially acute and
chronic rhinitis. A moment's thought will show us that
this very inflammation which so annoys the patient is
nothing more or less than the reaction of the tissues to
bacterial invasion, and is, in fact, the very means
whereby that invasion is repelled.
The effect of cocaine, in whichever way it is applied
to the nasal mucous membrane, is only transitory, and
as the drug gradually loses its effect, stronger and
stronger solutions are required. The danger to cocaine
poisoning is very great, and besides the risk of the
patient, especially in nervous individuals, acquiring the
cocaine habit for its stimulating effects. Moreover,
such frequent use of the drugs lead to a greater
tendency to vascular dilation, and increased irritability
of the nasal mucous membrane. The internal adminis-
tration of atropine, belladonna and morphia has the
same objections. These remedies may undoubtedly
give relief to all the symptoms, but it must be evident
that they lend themselves to grave objections to allow
patients to use such dangerous remedies. Menthol,
which has a somewhat similar action to cocaine, without
its dangers, can be readily recommended. A lo to 20
per cent, solution in liquid paraffin, or olive oil, may
56 Hay-Fever.
be applied by means of a camel hair brush or sprayed
into the nose.
Carbolic acid in fluid vaseline (grs. v ad. §i) may
also be used. Its application causes a little smarting,
but soon passes off*.
ft
A method of relieving the irritation in the eyes and
face, is to bathe these first in tepid, then in cold water
several times a day, taking care to include in the
process those parts of the hair that are exposed to the
atmosphere. The hair forms a very efficient gathering
ground for pollen, and there is no doubt that when this
is disturbed it will ^wo, rise to irritation if it comes in
contact with the eyeball.
The use of one of the various forms of collyrium
will be found to be beneficial in allaying the irritation
of the eyes. They are to be bathed with it three or
four times a day.
The asthmatic form of hay-fever is a much more
distressing phase of the malady than the catarrhal form,
it is not more amenable to treatment by drugs than the
latter. Nevertheless something may be done to lessen
the force of the attacks by the aid of drugs. The
administration of lo grains of iodide of potassium with
five drops of liquor sodii arsenalis three times a day,
will sometimes give speedy relief.
In that form of hay- fever in which asthma is the
leading symptom from the commencement of the
attack, the early administration of sulphur is stated to
Treatment. 57
be very valuable. It is most useful where the patient
is troubled with occasional attacks of urticaria at other
times of the year, and when the sneezing in his hay-
fever attacks is apt to be most troublesome on first
awakening in the morning, or on first lying down in
the evening. All the other asthmatic palliatives, such
as medicated cigarettes, Himrod's powder, nitre fumes,
etc., will be found of good service in hay-asthma.
Stramonium is also useful when given internally in
the later stages of the disease.
For the prostration which is present in many cases
of hay-fever, and especially in the middle and later
periods of the disease, the arsenite of quinine or phos-
phate of quinine will be found most useful.
Curative.
In treating true cases of hay-fever and asthma, our
success must depend, in the first place, on the correct-
ness of our diagnosis — that is to say, the recognition
of the presence and exact location of sensitive areas or
other pathological conditions ; and, in the second place,
in the judgment, patience and thoroughness with which
we carry out the local treatment that we adopt.
The treatment may be required under the following
conditions, viz. : —
A. Where some definite pathological con-
dition or deformity is present.
B. Where no disease or abnormality exists in
the nose.
58 Hay- Fever.
Where some Disease or Deformity is present.
In these cases, most surgeons would advise treat-
ment independent of the existence of hay-fever or
asthma.
Adenoids, ii present, should be removed. Nasal
polypi should be treated with the snare ; but better
results are obtained by freely curetting the diseased
bone and mucous membrane in the ethmoidal region.
Some writers have declared that many cases, especially
of asthma, have been made worse after the removal of
polypi. The only explanation 1 can suggest is that
the hyperaesthetic areas present have been overlooked,
and consequently left untreated. Marked erectile
swellings are to be reduced by means of the galvano-
cautery, etc. Anterior or posterior hypertrophy of
inferior turbinates should either be removed with the
snare or scissors. A polypoid, or oedematous enlarge-
ment of the middle turbinate, should be removed with a
spokeshave or snared with the aid of Grunwald's forceps.
Deflections, spurs or ridges, especially those which
impinge on the structures of the outer wall of the nasal
passage, and so cause obstruction, should be treated
the usual manner.
Where no Disease is present on inspection.
This class of patient has been said to be the
most difficult to treat. Personally, it has not been
my experience. After making up our minds, as to the
Treatment. 59
exact location of the sensory areas, the cautery should
be applied.
If for any reason — and occasionally the nervous
state of the patient will not permit of a scientific
examination — we are unable to ascertain the exact
position of the sensitive areas, then the various nasal
reflex areas which have been pointed out by authors as
causes of hay-fever, must be cauterized, one by one, at
several sittings, until improvement is effected.
As I have previously mentioned, the position of
areas in the true form of the disease is more or less
constant, but in the " pseudo " form and especially in
asthma, it is possible that any part of the nasal mucous
membrane may be the pathological reflex spot.
Hack cauterizes the inferior turbinate. Francis,
MacDonald and other rhinologists advise the application
of the cautery to the septum in every case. Others
have secured the best results by cauterizing, or the
removal of the tubercle of the septum.
Francis, in describing his method, advises that a
line be drawn from a spot opposite the middle turbinate
body, forwards and slightly downwards for a distance of
half an inch. In a few days' time this is repeated on
the other side of the septum, and he subsequently
cauterizes alternate sides at intervals of a week or two
according to the results. At each sitting he selects a
fresh area, and sometimes the posterior portion of the
septum is also cauterized.
6o Hay-Fever.
My own procedure in a case of hay-asthma is
briefly as follows : — Firstly, the anterior ends of the
inferior turbinate are cauterized ; after an interval of a
fortnight the tubercle of the septum or the septal
mucous membrane situated opposite the anterior
extremity of the middle turbinate is dealt with in a
similar way, and lastly, in some cases the posterior
end of the inferior turbinate and the posterior and
upper part of the septum are treated by means of
application of astringent lotions. I certainly do not
advise the electro-cautery to be applied to the posterior
nares, as such a manipulation is in the nature of a
step in the dark. Hyperaesthetic areas in the pharynx,
if present, must also be cauterized.
Technique for the Application of the
Electro-Cautery.
The chief difficulty experienced by the student or
practitioner who is desirous of using the electro-cautery
in the treatment of affections of the nasal passages
is the absence of minute and detailed instruction.
In the text-books, these arc conspicuous by their
absence, and in default of an efficient instructor the
operator runs the serious risk of acquiring a faulty
technique which subsequent experience will only
confirm.
I shall here endeavour to supply in a measure this
deficiency, and to inculcate certain main first principles
Treatment. 6i
essential to the proper use of the instrument. With
these well assimilated, the student can proceed to
learn by experience the refinem.ents of cautery technique
with satisfaction to himself and safety to his patient.
Any galvano-cautery battery that is capable of
heating the platinum point or cautery-knife to a cherry-
red heat will answer.
The instrument should be kept at a dull cherry-
red when operating on hypertrophied turbinates.
The cautery knife is placed upon the thickest part of
the hypertrophy, and by means of gentle to-and-fro
movements is made to cut through to the bone, when
it is carefully withdrawn, so as not to detach the
eschar which it has formed. The operator should be
careful to cut down to the periosteum before with
drawing his cautery knife. The edge of the cautery
knife and not its flat surface, should be applied to the
hypertrophy, because the object is not to destroy the
nasal mucous membrane, but to produce a firm and
permanent eschar that shall anchor the mucous
membrane to the bone beneath, and prevent the
turbinated tissues from swelling with each '' cold " to
an extent sufficient to occlude the nasal chambers.
The less mucous membrane destroyed the better.
A white heat is to be used for the destruction of
" hypersensitive areas," the galvano-cautery knife
being so introduced that its flat surface will rest upon
the sensitive areas and make a superficial burn.
62 Hay-Fever,
In cautery work it is always advisable to operate
upon one side of the nose at a time and allow an
interval of a week or two to elapse before attacking the
other.
Before applying the local anaesthetic to the part, it
should be properly cleansed with a mild alkaline
solution ; it should be dried before the local anaesthetic
is used and afterwards dried again.
To apply the anaesthetic a thin piece of cotton wool
is saturated with the solution used, wrung nearly dry
and nicely adjusted to the part to be operated on. The
length of time to produce anaesthesia varies, averaging,
ten to fifteen minutes for a lO or 20 per cent, solution
of cocaine or cocaine and adrenalin solution. Cocaine
spray should be avoided as the spray is usually very
coarse and consequently there is danger of cocaine
poisoning.
Although as a rule the shrinking of the tissues
caused by the drug facilitates the operation, sometimes
insensibility to pain is all that is required. Too much
shrinking may be an actual hindrance to operation on
the inferior turbinates, as one may be at a loss to know
how far to go.
Many surgeons are in the habit of treating the
nose repeatedly with the cautery, instead of making
a thorough destruction of the hypertrophic tissues at
a single application. This I believe, as a rule, to be
injudicious, not because the cautery is an uncertain
Treatment. 63
instrument, but from the fact that the tissue upon
which it is used is uncertain. I have the notes of two
cases of my own where the electro-cautery was frequently
used and produced a condition resembling ozaena. The
cautery is not to be recommended upon the septum in
tuberculous and syphilitic subjects, both diseases having
a predilection for that part when in a weakened con-
dition from the excessive irritation set up. It should
rarely be applied to the middle turbinate. The mucous
membrane in this region is intimately blended with
the periosteum : periostitis and osteitis are very liable
to follow its use and to aggravate the disease for which
it was applied. Owing to the proximity of the structure
to the intracranial contents, and in view of the free
venous and lymphatic communication between them,
the use of the galvano-cautery is prohibited.
The cautery electrode should either be applied to
the part at a dull cherry-red or applied cold and
then kept at a dull cherry-red — not a white heat.
After as much tissue as desired has been destroyed,
the platinum point should be quickly removed before
the heat is turned off*.
If this precaution is not taken, it will stick, and
requires to be pulled away, in doing which the tissue
will be torn, and later accompanied with pain and
bleeding.
To try to reduce enlarged posterior ends of
the inferior turbinates by an anterior introduction of
64 ' Hay-Fever,
an electrode is in the nature of a step in the dark.
The platinum point must always be kept in sight,
otherwise the liability arises of damaging the eustachian
orifices. I frequently observe that after the dense
anterior end of the inferior turbinate has been reduced,
the soft hypertrophied posterior end will atrophy and
allow free breathing through the nasal passage. The
exact method in which the cautery produces its
effect when applied is difficult to explain, but never-
theless the shrinking in some conditions is out of all
proportion to the actual burning. It is very striking in
cases of simple erectile swelling of the inferior turbinate.
The subsequent care of a surface when the nose
has been cauterized is important. As a rule, the tissue
may be allowed to take care of itself as far as possible.
After the operation, a good deal of reactionary
s.welling follows, with profuse discharge of mucus, the
patient feeling as if he had caught cold in that nostril ;
but this quickly subsides if the necessary precautions
are taken.
In very vascular cases, also, considerable haemor-
rhage may be induced if the tissue is torn.
It is very desirable that the patient, during the
periods of sloughing, should adopt every care in
sanitation and avoid exposure to septic influences.
The superficial sloughs produced by the cautery
tend to fall off in a period varying from a few days
to a fortnight. As well for surgical reasons as for
Treatment. 65
the patient's comfort, accumulated discharge should
be cleared away by carefully syringing or douching the
nose with a mild antiseptic or alkaline lotion.
When a crust has nearly separated, great care must
be taken in removing it with the forceps lest the
cauterized tissue be damaged. The use of peroxide of
hydrogen (vols, xx) is very serviceable to detach the
crusts. A very excellent method, which has been
described is the following : — The flat surface of the cold
electrode is firmly laid against the crust, a dull red heat
is turned on and shut off* at once. The crust is thus
made adherent to the electrode, and will come away
with it ; there is thus rarely any damage done.
Especial care must be taken when a cauterized
surface is in close proximity to another part. If the
septum nasi opposite the turbinal be burnt too, a
synechial band will certainly form, which is a most
troublesome condition and difficult to get rid of. The
two surfaces, therefore, should be mechanically
separated.
For this I use a piece of sterilized unmedicated
gauze, dipped in a mild antiseptic oily preparation,
which is replaced daily after the nasal cavities have
been cleansed in the usual manner. On no consideration
should this precaution be omitted until the heating is
complete, otherwise adhesions readily form across the
ulcerating surfaces.
In severe cases one author has advised the complete
66 Hay- Fever.
removal of the inferior turbinates, of the middle
turbinates, or even of both.
In defence of such a colossal procedure he claims
that " these operations in hay fever are apparently never
followed by the dryness of the nose and throat which
follows them when performed in other affections."
The author qualifies his statement and tells us
" he has performed the operation on several patients,
but, of course, as a last resort and only when the
application of the cautery had been tried and entirely
failed."
In order to understand the illogical and unscientific
character of the operation, we will consider briefly
the physiological functions of the middle and inferior
turbinated bodies.
The nose is a perspiratory organ, and if the
function of perspiration is interfered with, various
deleterious results are certain to be brought about.
Its most important function is to warm, moisten,
and free from dust the inspired air. The venous
plexuses of the mucous membrane lined with ciliated
epithelium are peculiarly adapted to the carrying out
of this function. The more watery portion of the secre-
tion which is largely elaborated by the glands of the
mucous membranes, saturates the inspired air with
moisture, whilst the moist condition of the mucous
membrane itself serves to catch and retain micro-
organisms and particles of dust which might otherwise
Treatment. 67
enter. The large vascular sinuses which form a peculiar
feature of the nasal mucous membrane, together with
the bulk of the secreting glands are collected in the
inferior turbinate. These structures play the chief
part in cleansing, warming and moistening the inspired
air. When dust or any' other irritating particles gain
entrance into the nose, the vascular sinuses dilate, the
secretion of the glands is increased, and abundant fluid
is poured out to wash the irritant away.
What happens, then, when the turbinates are
removed ?
The nose will become merely a hollow cavern
divided into two by the bony septum, the orifices of
the eustachian tube, the upper surface of the soft palate,
and the posterior wall of the pharynx being plainly
visible.
There will thus be a great tendency to a dry con-
dition of the pharynx, larynx, and trachea, and a liability
to catarrh of these regions, and probably also pulmonary
diseases.
As a matter of fact, the upper air passages will
suffer less from respiration through the healthy mouth
than from breathing through a nose when the inferior
turbinates have been removed.
We are all aware, too, of the important part the
ciliated epithelium plays to the well-being of the
nose and, in consequence, to the general health. Their
removal does away with these important functions, the
F2
68 Hay-Fever.
air containing its organic matter is admitted unfiltercd
and in consequence the mucous membrane of the
pharynx, larynx, and trachea will eventually become
dry, catarrhal, and later or* even pulmonary disease
may supervene. I need hardly point out to my
readers that hay-fever usually lasts but a few weeks in
the year, whereas the condition of atrophy and catarrh
of the mucous membrane is an affection of every week
in the year for the remainder of life.
Caustics.
When the galvano-cautery is not at hand, chemical
caustics, such as chromic acid, trichlor-acetic acid,
nitrate of silver, or nitric acid, may be employed.
Solutions of the two former caustics may be applied
with small pledgets of wool on a probe ; nitric acid
must be used with small wooden sticks, as the end
of a wooden match.
Chromic acid is more frequently employed than
any of the others in the treatment of hypertrophied
mucous membrane. It should be used in the following
manner: — The end of a silver or aluminium probe is
heated and plunged into a bottle containing crystals of
chromic acid, some of which will stick to the probe and
be withdrawn with it from the bottle. A further
application of heat will fuse these crystals, which are
now ready for use. The probe may also be prepared
for use as a cautery by wrapping a few fibres of cotton
Treatment, 69
about its end and rubbing into it moist powdered
crystals of chromic acid until the cotton is saturated
with the paste. A little cocaine may be first applied,
but the applications are not painful as a rule. The
part is thoroughly dried, and then the end of the probe
covered with chromic acid is pressed firmly into the
hypertrophy, and pushed backward and forward over
the line to be cauterized, and finally withdrawn. After
the lapse of a few moments the nasal cavity is thoroughly
mopped out with pledgets of cotton wool soaked in a
solution of bicarbonate of soda, care being taken that
none of the resulting chromic acid reaches the pharynx
and is swallowed.
Chromic acid is more uncertain in its action than
the cautery. It is difficult to limit the depth to which
the cauterization will extend ; and it is apt to spread
over its surface and produce a somewhat superficial
destruction of the mucous membrane by no means
desirable. For this reason the cautery is always pre-
ferable except when it is necessary to destroy sensitive
areas in the neighbourhood of the ethmoidal cells where
the electro-cautery is contra-indicated.
The Application of Astringent Lotions.
There are certain regions of the nose, e,g.^ ethmoid,
middle meatus, the superior and posterior part of the
septum, and the point where the septum meets the
nasal cartilages, to which the application of the cautery
JO Hay-Fever.
is impossible, owing to the close anatomical relation of
the parts, and any attempt to introduce it would
injure neighbouring surfaces.
As a substitute, the frequent application of
astringent lotions have been very successful in my
hands, speaking roughly, these having for their object
the hardening of the mucous membrane, in the sense
of making it less irritable.
The late Sir Andrew Clarke advised spraying the
mucous membrane with a mixture of glycerine of
carbolic acid, small quantities of quinine (3i ad. §i) and
perchloride of mercury (pt. i in i,ooo). Protargol has
been advocated by Alexander. Others have had good
results from using biniodide of mercury (strength i in
50 to I in 20). When the nose is extremely sensitive,
only a small amount of cotton wool should be wrapped
round the end of a nasal probe, so as to form a brush
capable of absorbing but a small amount of the solution,
which should be carefully applied to those portions of
the nasal mucous membrane which seem hypersensitive.
A 5 per cent, solution of cocaine may be used
beforehand, but it is not usually necessary.
The mucous membrane of the nose becomes
immediately congested and swollen, accompanied with
sneezing, lachrymation and all the symptoms of hay-
fever, and these symptoms are followed by a nasal
catarrh lasting from one to three days.
The application should be repeated on the opposite
Treatment. 7 1
side at an interval of a week. In many cases, if this
is efficiently done, the patient will remain perfectly free
from the malady throughout the season.
POLLANTIN. — Owing to the great publicity given
to Dunbar's theory that hay-fever is to be regarded
as a toxic affection, and as such, should be treated with
the corresponding serum antitoxin, Sir Felix Semon*
undertook to investigate upon a large amount ot
clinical material, Professor Dunbar's researches by ex-
perimenting with the toxin and antitoxin provided for
the occasion by Dr. Prausnitz (^Dunbar's assistant).
Sir Felix Semonf published a second paper entitled
" Impressions of the Efficiency of Professor Dunbar's
Antitoxin in Hay-Fever." In this paper Semon states
the results of his experiments and I shall quote here his
own words : " With regard to the cutting short of fully-
established attacks, I cannot say that I have observed
any marked effects, with the exception that so far as
the irritation of the eyes is concerned all my eight
patients immediately after the application of the
remedy experienced a sense of relief, the duration oi
which was very variable.
" To sum up : I can unfortunately not say that the
remedy (pollantin) has in any sense acted as a panacea
in any of my cases. It has given relief in some, and
appears to have acted beneficially certainly in post-
♦ Brit. Med. Jour n.^ 1903* i> P* 7.^*
t Ibidem^ 1903, "", p. 123.
72 Hay-Fever.
poning the occurrence of the attack in others of my
patients. Possibly these effects might have been even
more marked had the applications been made with
even greater frequency. I ought also to say here that
according to the spontaneous statements of at least a
few of my patients it appears to have had the effect of
making the present hay-fever period altogether a good
deal more tolerable thati on previous occasions. The
main applicability of the serum would certainly seem to
lie in the direction of its postponing for several hours
the occurrence of the regular attack. If further
experiences should show that prolonged and frequent
application neither diminishes its efficiency nor causes
unpleasant by-effects, even the limited results above
described will not have inconsiderably added to our
therapeutic power of combating this troublesome
affection ; but whether this will be so I do not dare to
say at present. I am quite willing to modify my
impressions with further and more extensive experience.
The statements, made in this paper, however, represent
the impressions I have so far gained."
Wolff- Eisner* also undertook to test upon a large
amount of patients both pollantin and a similar serum
called graminol. Objectively speaking, the results of
these experiments tend to show that these serums are
altogether devoid of any reliable therapeutic activity,
*Hay-Fever, its Nature and Treatment, by Alfred Wolff-Eisner,
Munich, 1906.
Treatment. 73
and that even when employed prophylactically they
are quite powerless in preventing the onset of an
attack of hay- fever. In 47 per cent, of the cases pollantin
was without any action whatsoever, and in 50 per cent,
some alleviation was observed. Only in one single mild
case could a really favourable result be observed,
although the symptoms persisted lor four weeks in spite
of pollantin treatment.
CHAPTER V.
Illustrative Cases.
In the present chapter I have selected a few cases
from my note book, which, I think, illustrate certain
points in the symptomatology, and show the effects
which may be expected to follow well directed
treatment.
Case I. — A lady residing at Maidenhead consulted
me in May, 1905. In giving particulars of her case,
she says the attacks generally commenced some time in
May, and from the commencement of the disease her
life is a perfect misery until the end of summer.
Bright sunshine and dust of any kind will bring
on an attack of hay- fever.
Immediately on leaving her bed in the morning
she sneezes some thirty times, accompanied with profuse
discharge from the nose and eyes. During the hay-
fever season the patient is unable to take exercise or
even drive in her trap during the day time owing to
violent paroxysms of sneezing, lachrymation and
intense itching of the eyelids. She suff'ers from
considerable mental depression, headache, loss of
appetite and decreases in bodily weight to the extent
^6 Hay-Fevir.
of a couple of stone. PoUantin has no effect in
allaying the symptoms.
Examination : The nasal mucous membrane
extremely sensitive, and the inferior turbinates in
contact with the septum.
Treatment : A solution of cocaine and adrenalin
was applied to the nose, and, so rendering a free
passage, a nasal douche was used, and the mucous
membrane dried by mopping and with cotton wool.
Chromic acid was applied to several areas of the
turbinate bodies.
Result : The patient has passed through two
seasons without any symptoms of the disease.
Case 2. — Mrs. M., aged 27, resides a few miles
from London. In her case the disease first came on
about eight years ago ; at that time she resided near
Gloucester, and was assisting her father in the hay-fields
and got buried under the hay. A few minutes later she
was seized with a violent cold in the head and had to
be taken home ; her eyes being extremely painful had
to be bathed with warm water. She never remem-
bered having hay-fever before, but has suffered every
year since. When once the malady sets in she is
completely incapacitated from taking any pleasure or
attending to the duties of the house.
The attacks of sneezing are so violent and long,
that on one occasion her husband counted fifty times,
at the end of which she is completely prostrate.
Illustrative Cases. 77
The patient believes that the smell of roses will
induce an attack more severe than one following any
of the other causes already enumerated.
The patient has a right inguinal hernia which
occurred during a bout of sneezing while out driving
in the month of June, 1904.
Examination : Hypertrophic rhinitis, spur on
either side of the septum.
Treatment : Electro-cautery and removal of
spurs. Several hypersensitive areas were cauterized at
the same time.
Result : Cure.
Case 3. — Mrs. W., aged 27. Has suffered from
hay-fever since she was sixteen years of age. The
first time she ever remembered it troubling her was on
one occasion when walking through the fields gathering
wild flowers in the month of June. She thought at
the time she must have taken a violent cold. She
had terrible attacks of sneezing, accompanied with a
watery discharge from the nostrils, but the eyes were not
so much affected as they have been for the last three or
four years. She has had the attacks every year since
the one mentioned above.
Slight itching of the eyes and nose are
amongst the earliest symptoms of the disease,
but as it progresses, attacks of sneezing come on, and
these become severe and prolonged whenever she
ventures out of doors in the country. The eyes itch
yS Hay -Fever.
intensely and become much inflamed, especially if she
rubs them. The patient has always noticed that she is
worse during the bright hot sunny days ; at the seaside
she is always better, however high the temperature
may be.
Examination : The nose perfectly normal as
regards the structures. One large hypersensitive area
on the septum opposite the middle turbinate.
Treatment : Application of the cautery on four
occasions, a week intervening between each sitting,
followed with swabbing the nasal mucous membrane
with astringent lotions.
Result : Cure. .
Case 4. — Miss H., aged 23. Has suffered from
hay-fever for years. So far as she can recollect the
symptoms commenced about the end of May, and the
disease continues until July. During this time she is
unable to drive or motor into the country owing to the
violent sneezings and a profuse discharge from the
nostrils. The attack of sneezing is frequently followed
by severe headache, which compels her to remain in a
dark room.
Examination : Adenoids, enlarged turbinates with
nasal catarrh. The mucous membrane extremely
sensitive to any form of touch, which is followed by
attacks of sneezing, lachrymation, etc.
Treatment : Removal of adenoids and the appli-
cation of the electro-cautery.
Illustrative Cases. 79
Result : Cure.
Case 5. — Mr. M., aged 40, a gentleman residing
in the County of Berks. At the age of twenty he began
to be affected whenever he entered a greenhouse when
certain flowers were in bloom. The attack is charac-
terised by the discharge of thin watery serum from
the nostrils, by violent attacks of sneezing, swelling
of the eyelids and severe lachrymation. When the
disease has become fully developed, the fits of sneezing
are so severe, that for the time being he loses all control
over himself. Occasionally he will sneeze for ten
minutes without stopping, and whatever he may be
occupied with when the fit comes on he is obliged to
set it aside and resign himself to' the paroxysm until
it is over. A profuse cold sweat will break out at
the termination of each of the violent attacks of
sneezing. During the course of the disease his nights
are often disturbed by fits of coughing and sneezing.
There is loss of appetite, mental depression, and by
the end of the season, which now extends until the
latter end of August, he loses between one and two
stone in weight. He also complains of deafness and
ringing in the ears, while the stuffiness of the nose
lasts.
Examination : The turbinates completely blocked
the nostrils when I saw him in the second week in
June of last year. The posterior ends were the largest
I have ever seen, and appeared to block the posterior
8o Hay-Fever,
nasal space completely. He states that up to twenty
years of age his nose was free of any obstruction.
Treatment : Under an anaesthetic the posterior ends
were removed, and the rest of the body freely cauterized.
He remained free from the disease after he returned home.
Result : Cure.
Case 6. — A lady, residing in one of the London
suburbs, suffered from hay-fever fourteen years. The
attacks generally commence about the third week in
May ; but they come on earlier in a warm season
than a cold one. The attacks sometimes cease before
the hay is all gathered in ; the symptoms are less
severe after rain.
Examination : Partial deviation of septum to
right side with a fair amount of obstruction.
Treatment : Submucous resection of septum and
destruction of the hypersensitive areas on the septum,
middle meatus, and the ethmoidal region by the appli-
cation of chromic acid and astringent lotions.
Result : The patient has passed through two
seasons without any signs of the malady.
Case 7- — I^^ this case, a lady, who has suffered
from hay-fever since she was 1 5 years of age.
During the hay season, smoke affects her sooner
than the smell of hay, but at other seasons of the
year smoke has no effect.
A trip to the seaside during the hay-season is sure
to bring relief if a sea breeze is blowing.
Illustrative Cases. 8i
Examination : Hypertrophic rhinitis with nasal
catarrh.
Treatment : Posterior ends of the inferior turbi-
nates removed and the application of the electro-cautery
with the subsequent use of an alkaline lotion.
Result : Cure.
Case 8. — Dr. S., aged 38. In this case the patient
is a medical man in practice in London, who has
suffered from hay-fever since he was 14 years of age.
The attack usually comes on in June, and lasts from
three to five weeks. Since he has resided in London,
now three years, the malady is much less severe.
Examination : Septum deviated to right side and
almost in contact with the inferior turbinate. The
mucous membrane, in the upper and anterior half of
the nose, is sensitive to the touch of a probe.
Treatment : The septum was not operated on.
The inferior turbinate was freely cauterized.
Result : Free from attacks last summer.
Case 9. — Captain S., an officer in the Royal Army
Medical Corps consulted me in September, 1905. In
answer to my questions, he says : I was in India for
three years, and during the last year suffered from hay-
fever, but more severely whilst in parts of the hills,
which really correspond with the heat and climate of
England, where grain crops were nearly ripe. Long
grass was growing in places on the hills. He feels quite
certain that if he is in any way worried the attacks are
more severe.
82 Hay-Fever.
Examination : No disease or abnormality present.
The nasal mucous membrane is extremely sensitive to
mechanical irritation.
Treatment : The application of caustic lotions to
the whole of the lining membrane of the nose.
Result : No attacks last season.
Case 10. — Miss F., aged 24. Has suffered from
hay-fever four years. The first time she remembers it
troubling her was on one occasion when walking through
the fields in May, near Ilford. She thought for some
time it was a cold of unusual severity, and remained
quiet at home taking ordinary remedies, but with no
result. She had severe attacks of sneezing, and the
running from the nose was so profuse that a dozen hand-
kerchiefs were used. After the disease has lasted a
month, her general nervous system is much impaired.
Examination : Nasal cavities normal ; mucous
membrane hypersensitive.
Treatment : Electric-cautery and the use of astrin-
gent lotions to the nasal mucosa.
Result : No attacks last three summers.
Case II.— Miss S., aged 28. For four months in
the year this patient may be said to be an invalid
through hay-fever.
Dust of any kind, whether in or out of doors, will
induce the symptoms. Sudden exposure to bright sun-
light invariably brings on an attack. Roses affect her
so severely that if she handles them a very severe
Illustrative Cases. 83
attack instantly supervenes, worse than from any other
flower. Violent paroxysms of sneezing repeat them-
selves again and again throughout the day
Fcft- the last two seasons, that is, from the end of
May to the middle of August, she carefully avoids
taking exercise during the day time. When I saw her
she was anaemic, very low spirited, and complaining
of marked disturbances of the digestive functions.
Asthma developed for the first time about June, 1904.
Both affections persist alternately all through the
summer months.
Examination : Turbinates pale and oedematous
and absolutely packed up against the septum. The
mucous membrane of the tonsils, pharynx and larynx
much congested and inflamed. Irritation of the
pharynx brings on an attack of asthma.
Treatment : The turbinates were reduced by
means of the cautery, and the sensitive areas existing
in the nose and pharynx were also destroyed.
Result : Free from hay-fever last season.
Case 12. — A clergyman, residing in Wales, con-
sulted me for hay-fever, he says : " I have suffered
for years, but was unaware of the nature of the disease
until the summer, 1902 I was staying at the time in
Devonshire, and there I met a gentleman suffering
from the same malady." The patient does not
find the symptoms worse in the country than in
the town, unless he walks through or near a
G2
84 Hay-Fever.
field of ripe grass or hay, and then they become
very violent.
He had an uncle who was very sensitive to dust of
any kind, and a niece who suffers more than himself,
though she lives at the seaside.
Examination : The nose appears perfectly normal,
but the mucous membrane presents a bright red
appearance and is extremely sensitive to the probe, with
areas of sneezing, etc.
Treatment : Chromic acid to sensitive areas.
Result : Cure.
Case 13. — Mr. B., aged 50. Suffers from hay-
fever and asthma. The attacks first came on when he
was about twenty-one years of age, and in speaking of
the disease he says : ** I well remember the commence-
ment of those symptom which I now recognise as my
annual hay-fever torment. I was at the time in the
midst of newly-mown grass, when I was suddenly
seized with profuse running from the nose, lachrymation,
swelling of the conjunctivae and eyelids, well-nigh
blinding me, and ceaseless sneezing. I remember that
I was taken into a farm house by my friends, and
speedily recovered. From that time to the present the
disease has manifested itself every year, and has always
governed my habits and residence during June and
July, and part of May and August. The warmer the
weather, and the more advanced the vegetation, the
earlier does my malady show itself. It usually lasts till
Illustrative Cases, 85
the end of the first week in August (when it leaves me
very suddenly), though this also is dependent on the
shortness of the haymaking season, for in a hot, dry
season (last summer for example), in which the hay is
rapidly made and carried, my immunity occurs two or
three weeks earlier."
Examination : No pathological or abnormality
present, the nasal mucous membrane, as in all these
cases, extremely sensitive to any form of irritation.
Chronic pharyngitis.
Treatment : Cauterization.
Result : Cure.
Case 14: Mr. L., aged 45. Has suffered from
attacks of hay-fever and asthma since he took up
motoring five years ago. He says : " The early part
of June I was motoring to Brighton ; in front of me
were two other motors which had caused a cloud of
dust. Suddenly I was seized with intense and violent
sneezing, and had to stop the car ; my eyes burnt
intensely, and later every joint ached. I was unable
to proceed on my journey, and drove to the nearest
station and returned to London. The disease persisted
more or less for five weeks, and suddenly disappeared."
The patient tells me he is unable to do any motoring in
the summer, although in the winter it does not
affect him. Every severe bout of asthma which he has
suffered occurred during the hay-season.
Last year he had, whilst walking in Hyde Park, on
S6 Hay-Fever.
the isth of May, a good deal of the heat and nose-
running accompanying hay-fever, but nothing more
until early in June, when, in company with his wife,
he started to motor to Eastbourne.
Examination : Hypertrophic rhinitis, with deviation
of the septum to the left. Chronic pharyngitis.
Treatment : Galvano-cautery, astringent lotions
applied to the hyperaesthetic mucous membrane.
Result : No symptoms since treatment.
Case 15. — Mr. A., aged 39. Has suflFered from
hay-fever and asthma for nearly twenty years.
The attacks generally begin about the end of May
and cease about the middle of July, according as the
hay season is early or late. As long as the grass is in
flower the hay-fever persists ; afterwards, it ceases. It
is not constant throughout this time as one attack but
comes and goes with those other symptoms of irritation
of the respiratory mucous mem b raneof which it is a
part. The patient says, "the neighbourhood of hay,
bright, hot, dusty sunshine, a full meal, &c., suffice at
any time to bring on an attack of hay-fever. It is
generally worse at night,'* while the disease lasts the
asthma is often so severe as to deprive the sufferer of
sleep for nights together, and he leaves his bed in the
morning, pallid, and worn out. When the hay season
is over the malady vanishes, and for ten months in
the year he may calculate on a perfect immunity from
even the slightest sensation.
Illustrative Cases. Sy
Examination : Partial deviation of septum. An-
terior ends of middle turbinates in contact with septum.
The nasal and pharyngeal mucous membrane exceed-
ingly sensitive to any form of chemical or mechanical
irritation.
Treatment : A 20 per cent, solution of cocaine was
applied to the nose and pharynx. The anterior ends
of the middle turbinates were removed. Hypersensitive
areas cauterized.
Result : The patient has remained free from the
attacks since the summer, 1904.
Case 16. — Mrs. H., aged 37, who says : " I have
always enjoyed excellent health during the winter and
early spring, with the exception of an occasional cold in
the head, which, however, was never attended with any
difficulty of respiration, or any of the symptoms of
asthma. As soon, however, as the warm weather set
in, I always began to suffer from colds, and after a
short time my breathing would become difficult, and as
long as the warm weather continued I suffered severely
from hay- fever and asthma; and in spite of all the
means recommended to me by my friends to prevent
these attacks, or to lessen their severity when once
developed, the malady returned regularly every
summer."
Examination : The nose quite normal as regards
the structures. The whole of the upper and anterior
half of the nasal mucous membrane hyperaesthetic.
88 Kay-Fever,
Treatment : Electro-cautery and the application of
astringent lotions.
Result : The patient wrote to me last August
stating she was in perfect health, and that she had
not suffered from hay-fever during the season.
Case 17. — Mr. S., aged 40. Hay-fever came on
after the patient had suffered from ordinary asthma for
many years. In commencing to describe the hay-fever
symptoms, he says : " It seems reasonable to suppose
that I must have been liable to hay-fever, at the ordinary
season, during the whole course of my life, but till
within the last few years I was never aware of its
presence, or of the existence of such a malady."
The patient suffers most from paroxysms whilst
taking country walks or walking through grass
meadows.
Examination : Hypertrophic rhinitis and nasal
catarrh. Pharynx congested and granular.
Treatment : Pharynx and inferior turbinates
cauterized, and the use of nasal alkaline lotions.
Result : The patient has written to say that he
feels cured, having remained free from symptoms
for two years.
Case 18. — Mr. A. has suffered from hay-fever as
far as he can recollect, since he was fourteen years of
age. The attacks usually commence the first week in
June and continue for four or five weeks. The first
symptom is itching of the nose and throat, followed by
Illustrative Cases, 89
the discharge of thin watery secretion from the nostrils,
violent attacks of sneezing, not only in the day, but
frequently also during the night.
The patient thinks that dust of any kind, strong
light as well as great heat will induce the symptoms.
Examination : The pathological condition present,
the nasal mucous membrane sensitive to any form of
irritation.
Treatment : The hypersensitive areas cauterized.
Result : Free from the symptoms of hay-fever last
year.
Case 19. — Mr. M., aged 40. Has suffered from
hay-fever twelve years. The first time he ever remembers
it troubling him was on one occasion when out fishing
in June. He had terrible attacks of sneezing, discharge
from the nostrils, the eyes itched intensely, and became
much inflamed and swollen.
The patient states that he is always worse on the
bright, hot sunny days if out driving in the country.
During the latter years he has attacks of sneezing in
the winter when driving facing the horse.
Examination : Hypertrophic rhinitis.
Treatment : Electro-cautery and the applications
of astringent lotions.
Result : I treated the patient three years ago ; no
symptoms of the disease since.
Case 20. — Mrs. R., aged 46, consulted me in 1904,
has suffered from hay-fever for more than twenty-five
go Hay-Fever.
years, but the exact time at which the disorder first
commenced the patient cannot remember. The attacks
at first only lasted a week or ten days and then
disappeared.
During the last six years the duration of the
attack has increased, beginning in May and terminating
the end of September. With regard to the question of
the cause the patient is unable to decide, but thinks the
grasses affect her most. The seaside has not given
her much relief this three years. Rainy weather and
also sitting quietly indoors with all the windows closed
are both very comforting to the patient when suffering
from the malady. When once the hay-fever has
developed she is completely prostrate, suffering agonies
from stuffiness of the nose, severe attacks of sneezing,
and these become prolonged whenever she ventures
out. There is at the same time a copious discharge of
thin serum from the nostrils, often bloodstained, the
eyes itch intensely and become much inflamed,
especially if she rubs them, which is impossible to
resist doing so. Suffers from severe headache and
mental depression. During the summer, 1904, she lost
two stone in weight.
Examination : The nasal cavities small and narrow
and all the room taken up by the turbinated bodies.
The nasal mucous membrane was so sensitive that the
mere touch with a probe induced a severe attcick
lasting the whole day.
Illustrative Cases. 91
Treatment : The inferior turbinates were partly
removed with a spoke-shave, of course leaving the bone
untouched, followed by subsequent applications of
astringent lotions.
Result : The symptoms of hay-fever completely
absent during the last two summers.
I may state several of my patients have been
treated with pollantin. In none of them did the n
act, although some thought it gave relief at first.
Printed by George Pulman & Sons, Ltd., London, W.
(93)
INDEX.
PAGE
Aconite ... ... ... . ••• ... ... 48, 55
Adrenalin ... ... ... ... ... ... 55> ^^
Age, influence of, in the production of hay-fever ... ... 24
Animal emanations ... ... ... ... ... 17
Areas hypersensitive, methods of detection ... ... 34
Baths, use of ... ... ... ... ... ... 47> 4^
Beard, Dr. ... ... ... 6, 24, 25
Belladonna ... ... ... ... ... ... 4^> 55
Blackley's, Dr., experiments with the presumed causes of hay-
fever ... ... ... ... ... 6-10, 16-19
Bostock, Dr., on the cause of hay-fever ... ... ••• i, 3
Cases of hay-fever ... ... ... ... 75-91
Causes, local ... ... ... .. ... ... 23-35
Caustics ... ... ... ... .. 68, 69
Cautery -electro, application of ... ... ... ... 60-65
Cocame, application of ... ... ... ... 54, 55, 62
Curative measures ... ... ... ... ... 57-73
Daly, observations of ... ... ... ... ... 26
Diseases, intra-nasal ... ... ... ... 30, 31
Dunbar, Professor ... ... ... ... 19, 20, 71
Dust, as a supposed cause of hay-fever ... ... ... 7, 8
Dyspnoea of hay-asthma ... ... ... ,. 27,42,44
Elliotson, on the cause of hay-fever .. .. ... 3
Exercise, influence of, in increasing the severity of hay -fever . . 45, 46
Experiments on the action of pollen on the skin ... ... 10
MmjJ^ LAUw ••• ••• ••• ••• ••• *.. ••• ^ J
Eyes, symptoms of ... ... ... ... ... 40
Fauces, action of pollen on the ... ... ... ... 38, 41
Francis ... ... ... ... ... 59
Francois-Franck, experiments of ... ... ... ... 27
94
INDEX.
PAGE
Granular matter of pollen
• ■ •
I6
Grass in flower, a cause of hay-fever
• ■ • ■ •
45
Grayson, Dr., local treatment by ...
• ■ • ■ ■
•• 53, 54
Green, Reynolds J.
■ • • • 1
... 14, 15
H ack, on nasal reflexes ...
• • • • •
25
Hay-fever : a supposed neurosis . . .
• • • • <
6
American forms of ...
• • •
4,5
Animal emanations ...
• • • ■ •
17
Catarrhal form of
• • • •
37
Classiflcation of
• •
... 30, 31
Constitutional symptoms of ...
...
44
Coumarin
a ■ • •
7
Duration of
• • • • •
44, 45
Hereditary character of
• • • • •
25
Odours
■ • • •
2
Ozone
> ■ • •
2
Prevention of
M • • •
50, 51
Symptoms of
• • ■ •
39-46
Treatment of
• • • • •
••• 47-73
Hay season, a supposed cause of hay-fever
...
... 39, 45
Head symptoms, in hay-fever
• • ■ •
44
Heat, a supposed cause of hay-fever
• ■ • •
20-22
India, hay-fever in
■ • ■
21
Intine...
• ■ ■ •
*3
Kirkman, experiment with pollen
Light, influence of
Lotions, application of astringent
20-22
69-71
Mackenzie, J. N., case of
23
Nerves of nasal fossae
Neuroses, nasal
Nose, functions of
... 29, 30
.. 25-29
... 66, 67
Odours
2,7
INDEX. 95
Palliative treatment
Pharynx, action of pollen on the ...
Phoebus, Dr., on hay -fever
Plants : Anemophilous
Entomophilous
Hydrophilous
Zoophilous ...
Pollen : action of granular matter ...
Average size of
Cell contents of
Experiments with
Examined under the microscope
In a dwelling house ...
Pollantin
Predisposition, causes of ...
Prophylactic remedies
Quinine in hay -fever
Rain, influence of
Reflexes, nasal, site of origin
Sea-air, influence of
Semon, Sir Felix, experiments with antitoxin
Smith, on hay -fever
Spectacles, use of, in hay-fever
Sulphur in the asthmatic form of hay-fever
Symptoms, grouping of
Temperature
Trosseau, association of asthma with nasal disease
Turbinated bodies, removal of, in hay-fever
Types of hay -fever
Voltolini*s, case of asthma ... ... ... .. 26
Wyman, on autumnal catarrh ... ... ... ... 2, 4, 5
Wolff"- Eisner, on pollantin ... ... ... ... 72
PAGE
... 52-57
• • •
41
• • •
4
17,
18
... lo.
19
• • •
18
• ■ •
18
... 15,
16
• » •
12
... 14,
15
... 8
-20
... 12,
13
• • •
51
12, 13,
14
... 71
-73
- 23-35
... 47-52
... 49,
70
• ■ •
45
■ • •
27
• ■ ■
50
... 71,
72
... 4,
21
...
52
... 56,
57
■ • ■
37
II,
12
... 25,
26
... 65,
67
... 30-32
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