Grouped under the term "hay fever" there are probably as many different affections as there are under the term "chronic rheumatism." There are {369} 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 {370} 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 rÔle 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 rÔle 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. {371} 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 {372} 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 {373} 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 rÔle 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.