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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