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Dust Asthma Seasonal Catarrh Hay Fever





Grouped under the term "hay fever" there are probably as many
different affections as there are under the term "chronic rheumatism."
There are people who, in the springtime, as soon as the weather
gets warm, suffer from what is popularly called hay fever. This is
often called "spring catarrh" or "rose cold" and seems often to be
associated with the pollen of flowers. Then there are people whose hay
fever, as it is called, develops about the first of June and continues
to be bothersome until the middle of July, when there is a remission
of symptoms, though in dry prolonged hot periods after that the
affection may recur. It seems as if, at the beginning of the heated
term, the warm, dry dusty air irritates their nostrils very much,
while after some weeks they gradually become used to this and the
reaction is not so violent. Then there are the regular hay-fever
patients whose affection occurs principally in haying time, during
August and September, though most of them have not been near hay
pollen, and the disease is an affection of dwellers in cities rather
than in the country, of indoor livers more than of farming people, who
might be expected to suffer most from the supposed cause, hay pollen.
Even where pollen is directly concerned in its causation it is
probably oftener the pollen of the rag weed rather than that of hay
that is responsible for it.

There are two elements in the disease apparently of equal importance.
One of these is a strictly local condition interfering with
respiration in some way, or with the circulation to the mucous
membrane of the nose and the lachrymal ducts. The other is an
individual over-sensitiveness so that there is an exaggerated reaction
to irritation. Some of this is mental, that is, is due to expectancy,
or to the persuasion that this reaction is sure to occur under certain
circumstances. As a consequence, attacks of hay fever are reported
even after a distant view of a hayfield, or of rose cold due to the
sight of an artificial rose, and of other recurrences that show the
power of the mind to bring about at least a beginning of symptoms.

While the first or physical element in the etiology of dust catarrh
can be treated successfully by various means, it is important to get
the mind of the individual in a favorable state so as to enable him to
obtain better control over his vaso-motor system which is so much
influenced by emotions and thoughts. It is this latter element in the
causation of the disease that has been successfully treated by the
many remedies that for a time have had reported success in the cure of
hay fever yet afterwards proved to be of no benefit because they had
lost their influence over the patients' minds.

In a review of Morell MacKenzie's book "Hay Fever, with an Appendix on
Rose Cold," Dr. J. N. MacKenzie [Footnote 31] has some paragraphs on
hay fever which, though written twenty-five years ago, are worth
recalling for a proper understanding of the disease. He preferred to
call the disease rhinitis sympathetica or coryza vaso-motoria
periodica, names which are much better descriptive terms and have no
unsubstantiated suggestions of etiology in them.

[Footnote 31: American Journal of Medical Sciences, 1886.]

According to our conception, the so-called nasal reflex neuroses,
whether taken singly or collectively, as the cause of the ensemble
of phenomena known as "hay fever," may be regarded as the protean
manifestation of a morbid condition to which we have given the name
rhinitis sympathetica, and which is characterized by a hyperesthetic
condition of the vaso-motor nerve centers linked to a peculiar
excitability of the nasal cavernous tissue. For, if we inquire what
condition or conditions is common to them all, and what morbid
process is capable of producing them, either singly or in
combination; how phenomena apparently so widely different in
character and anatomical sphere of operation may be traced to a
solitary source, we find the answer in certain more or less clearly
defined changes in the nasal apparatus and in a certain exalted
state of the sympathetic nervous system, to which latter we
instinctively turn as the organ most conspicuously concerned in the
evolution of purely reflex acts. In whatever relation the local
nasal affection and the condition of the sympathetic stand to each
other in the matter of cause and effect, they must both be regarded
as inseparable factors in the production of the phenomena under
consideration. It matters not to what hypothesis the path of
speculation may lead. Of this we can be reasonably sure, that in the
production of the characteristic symptoms of this disease, a certain
excitability of the nasal passages is necessary, plus an exalted
state of the central nervous system.

Dr. MacKenzie calls attention particularly to the erectile character
of the tissues mainly involved in all these forms of dust catarrh and
dwells on the role that mental influence always plays in the phenomena
noted in such tissues. This with the vaso-motor elements in the
affection which are so largely also under the control of the emotional
nature make it clear that the pathology of the affection must be
considered from this standpoint and, therefore, its therapy also.

Dr. MacKenzie continues:

From our present knowledge of the disease, it seems difficult to
escape the conclusion that its pathology is intimately interwoven
with a morbid condition of the vaso-motor sympathetic, and probably
a hypersensitive state of the nerve centers themselves. When we
recall the fact that in the famous section of the sympathetic in the
neck by Claude Bernard, symptoms similar to, or closely allied to,
the phenomena of hay fever were produced; when we reflect upon the
results reached by Prevost in his experiments on the spheno-palatine
ganglion, is there not a clue to lead us through the labyrinth of
our difficulties to a rational solution of the question? . . .

. . .In the human body, wherever erectile tissue is found, it is
intimately related to reflex or sympathetic acts; there seems to be
connected with it a certain receptivity to reflex producing
impressions, a certain power of reflex excitability dependent upon
its structure and functions. It is thus peculiarly a tissue of
sympathy in which we may most satisfactorily study the mechanism of
purely reflex or sympathetic acts. Now it seems to us that, as the
nasal corpora cavernosa belong to this class of sympathetic tissues,
there will be little difficulty in explaining the role which they
play in the paroxysms of an affection which is probably connected
with, if not dependent upon, an excitation of the sympathetic nerve
centers, and in more clearly defining the intimate relation which
its erection bears to the reflex manifestations of the disease under
review.

These considerations explain the heredity of the affection in many
cases, since it is dependent on defects that may be family traits, yet
they also enable us to understand how slight lesions of the nasal
mucous membrane may be the center from which radiate the underlying
pathological conditions of the disease.


Railroad Asthma.--There is a form of dust asthma which deserves
special attention here because it is due to modern conditions and
helps to an understanding of the etiology. It occurs in sensitive
persons when they travel on railroad trains in warm weather,
particularly if it has been dry for several days and dust is abundant.
It has been called railroad asthma or railroad catarrh by the English
and the Germans, but the condition has no necessary connection with
the railroad. It occurs as a consequence of the infiltration into
railroad cars of fine dust during the passage of the train. I
have seen it in those who had made long trips over dusty roads in
automobiles, though the dust of the railroad seems finer and more
penetrating. It develops just as much at the end of a long train as if
the passenger spent most of the journey in the car next the engine and
apparently it makes no difference whether the engine burns hard or
soft coal. They use soft coal almost exclusively in England and
Germany, but one sees cases of it here after travel on roads that burn
hard coal and are especially cleanly in this respect. Soft coal adds
somewhat to the amount of dust and therefore this increases the
irritation, but there is nothing specific about coal dust. It is
surprising how severe the symptoms may be. I have seen a patient who
had traveled continuously for four days across the continent who had
so much photophobia when he alighted from the train, that he was
almost unable to open his eyes, and it was not until twelve hours had
passed that he could open his eyes with any comfort, yet at the end of
two days practically all the symptoms had passed off.

Prof. Fraenkel, professor of laryngology and rhinology at the
University of Berlin, who was one of the first to classify the
condition among the affections related to "hay fever," described
certain features of it very well in a clinical lecture reported in
International Clinics, Vol. II, Ninth Series, 1899. As a rhinologist
he insists on the nasal conditions that underlie the affection yet
suggests that the nasal hyperemia may be due to reflexes of one kind
or another. The basis of these is undoubtedly very often an emotional
condition of the patient, a dread of dust, an expectancy of symptoms
and a consequent exaggerated reaction. Unorganized dust produces
asthma, but organic materials bring more severe and lasting effects,
partly because of the mental effect of odors and other sensory
conditions in connection with them.


The Personal Element and Power of Suggestion.--The history of these
asthmas and other symptoms produced by odors and dust make it clear
that the more that is known about the disease the surer it becomes
that there is a large personal element, usually dependent on a certain
frame of mind, in the cases. Some people are affected by one form of
irritant, some by another, some by pollen, others by animal
emanations, and not a few by a persuasion of the likelihood of
suffering from these things, since occasionally the sight of an
artificial product produces a like result. Certain classes suffer much
more than others. Those who are much confined to the house and who are
especially prone to reflection upon themselves and their feelings form
the great majority of the patients. In old days the monks were
favorite victims, in modern times literary folk, students, and those
who have the time and the inclination for reading and introspection
are particularly likely to suffer. How much the mental element may
account for in these cases is not clear, but it stands for much more
than has been thought and there seems no doubt that more relief of
symptoms is afforded by diversion of mind and change of dwelling quite
apart from external conditions than in any other way. It is important
to remember that no specific dust but almost any kind of dust produces
these conditions in sensitive persons.

Dr. MacKenzie describes an interesting case in which all the symptoms
were produced by the presence of an artificial rose. The story is so
striking and he has told it so well that I prefer to tell it in his
own words. I may say, however, that the clinical history of the case
was typical. About the end of May or the beginning of June every
year the patient suffered from a coryza preceded for a few days by an
indefinite sense of general depression with a disagreeable feeling of
heaviness in the head. Sometimes there were chilly feelings and
general malaise. The catarrhal stage commenced with profuse watery
discharge from the nostrils, copious flow of tears with redness of the
conjunctiva, itching of the puncta lacrymalia and photophobia. The
exterior of the nose, especially at the tip, became intensely red and
toward the close of the attack the cuticle desquamated. There was a
short, dry, hacking cough relieved by sneezing, an intense tickling
sensation in the throat, the voice became husky, the pharynx dry, the
ears stopped up and tinnitus occurred. Her attacks continued most of
the summer and were always brought on by the pollen of any plant and
above all by the smell of a rose. It was, indeed, an example and of
the most aggravated form. She was brought to Dr. MacKenzie in
consultation and I leave him to tell the rest of the story.

Decidedly skeptical as to the power of pollen to produce a paroxysm
in her particular case, I practiced the following deception upon
her, which still further confirmed me in that belief. For the
purpose of the experiment I obtained an artificial rose of such
exquisite workmanship that it presented a perfect counterfeit of the
original. To exclude every possible error, each leaf was carefully
wiped, so that not a single particle of foreign matter was secreted
within the convolutions of the artificial flower. When the patient
entered my consultation room, she expressed herself as feeling
unusually well. The evening before she attempted to wear some roses,
but had been obliged to remove them from her dress, as they had
produced a great deal of discomfort. Apart from this incident she
had been perfectly comfortable for several days and nights. Her
conjunctivae were normal, the nasal passages free, and there was
nothing to indicate the presence of her trouble. She conversed with
me for some time about her case and on general topics, speaking in
the most encouraging manner concerning the progress she was
apparently making toward recovery. I proceeded to remove the slight
slough from the cautery operation, which lay loose in the nostril,
and made an application to the mucous membrane, and all without
exciting the slightest tendency to reflex movements. After I felt
sure that such tendency was absent, I produced the artificial rose
from behind a screen, where it had been secreted, and, sitting
before her, held it in my hand, at the same time continuing the
conversation. In the course of a minute she said she must sneeze.
This sensation was followed almost immediately by a tickling and
intense itching in the back of the throat and at the end of the
nose. The nasal passages at the same time became suddenly
obstructed, and the voice assumed a hoarse nasal tone. In less than
two minutes the puncta lacrymalia began to itch violently, the right
and afterward the left conjunctiva became intensely hyperemic and
photophobia and increased lacrymation supervened. To these symptoms
were added, almost immediately, itching in the auditory meatuses and
the secretion of a thin fluid in the previously dry nasal passages.
In a few minutes the feeling of oppression in the chest began with
slight embarrassment of respiration. In other words, in the space of
five minutes she was suffering from a severe coryza, the counterpart
of that which the presence of natural roses invariably produced in
her case. An examination of the throat and nasal passages was then
made. The right nostril was completely obstructed by the swollen,
reddened, irritable, turbinated structures; the left was only
slightly pervious to the air current; both were filled with a
serous-looking fluid. The mucous membrane of the throat was also
injected, but did not exhibit the same amount of redness and
irritability found in the nasal passages. As the discomfort was
rapidly increasing, and as I considered the result of the experiment
sufficiently satisfactory. I removed the rose and placed it in a
distant part of the room. When told that the rose was an artificial
one, her amazement was great, and her incredulity on the subject was
only removed upon personal examination of the counterfeit
flower. She left my office with a severe coryza, but also with the
assurance that her disease was not altogether irremediable. A few
days later she called to see me again, and on that occasion she
buried her nostrils in a large, fragrant specimen of the genuine
article and inhaled its pollen without the slightest tendency to the
production of reflex acts.

There is but one conclusion that can be drawn from this: that
suggestion plays a large role in the relief of the symptoms of the
disease. If patients once become persuaded that something will do them
good, then it surely does. It is true that this good effect will
usually not persist, but that is because after a time conditions
conspire to make the suggestion fail of its purpose. This does not at
all imply that hay fever, or just catarrh as I prefer to call it, is
imaginary. The relief of our most serious and fatal diseases with
profound pathological lesions, such as tuberculosis, may well be
brought about by suggestion. After all, just the same story is told
about consumption and its many remedies as of hay fever and its many
"cures." However, the most important therapeutic element so far
discovered for the treatment of hay fever is evidently suggestion. If
the patient's mind can only be brought to a favorable attitude in
which the discouragement incident to imperfect oxidation can be
greatly lessened, then relief of many of the symptoms will be afforded
and under favorable conditions the patient will deem himself cured.
Undoubtedly the large amount of attention given to hay fever, the
gathering of these patients in particular localities, the repetition
of the story of their symptoms to each other, the body of literature
that has gathered around hay fever and is read with such avidity by
those who are pleased to call themselves its victims, adds to the
unfavorable suggestions and inveterates the symptoms, exaggerates the
nasal hyperemia and makes the general condition worse.

I am the more positive about the influence of suggestion, favorable
and unfavorable, in the affection after having carefully noted the
conditions in certain patients from year to year for a number of
years. I became interested in it because it is a family affection and
several sisters as well as myself are sufferers from it. At the
beginning, when the real nature of the trouble is not recognized,
there is a year or two of considerable general discomfort, though not
much local disturbance. Then comes the realization of what the
recurrent affection is and a period of distinct depression during its
continuance. Eventually it begins to be appreciated that a number of
local applications will lessen the symptoms from day to day and that
there need be no apprehension of serious sleep disturbance, or of any
lasting effect upon the general health, the affection becomes quite
bearable and, while still annoying, is no longer the object of
particular solicitude.





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