CHAPTER I

_THE DIAGNOSIS_

Under the name "hay fever" I include rose-cold and the so-called hyperæsthetic catarrh or vaso-motor rhinitis, all characterized by intense itching of the eyes, nose, and throat, free discharge, sometimes asthma, the attacks being precipitated by strong odors, dust, or pollen. There are many forms of the disease, some occurring in May or June, some as early as March, before the budding of vegetation, some even in the winter; but the large majority of cases occur in August, coincident with the flowering of late summer vegetation, notably the rag-weed and golden-rod. It is not so well known that the California privet, so widely used in hedges and parks, aggravates many patients, especially in June and July, when the scent of the flowers is strong. Others are irritated instantly by the odor of crude oil that is spread so freely on the roads in summer, by metal-dust, and by the cinders of a railway trip. Some patients are sensitive to one irritant, some to many irritants. I knew one man whose itching of the eyes began in March, nose and throat following in April and May, cough in July and August, who was sensitive to each and all of these irritants from March to October every year for thirty years.

If we follow the modern tendency and classify the cases according to the specific irritant, we shall have an endless number of varieties according to the endless number of possible irritants; and where will you classify the man who is subject to them all? In the present state of our knowledge, it seems better to regard the sensitiveness to irritants as the characteristic of these cases and to think of them as different forms of the same disease. In most text-books this idea is expressed by the terms _hyperæsthetic catarrh_ and _vaso-motor rhinitis_; but there are serious pathological objections to the terms _catarrh_ and _rhinitis_. These objections and the reasons for regarding the lesion as an angioneurotic oedema are discussed in Chapter VI, on Hay Fever as Urticaria, to which the reader is referred.

An additional reason for regarding all these varieties as superficially differing forms of the same disease is the fact that all of them are curable by the same methods. I am aware of the danger of error in this argument, the persuasive but misleading _Analogieschluss_, and would not advance it too strongly. However, for all practical purposes except the vaccine treatment, described in Chapter XII, all these hyperæsthetic cases may be regarded as varieties of the same disease.

With a patient suffering from hay fever, as with a patient suffering from any other disease, the first thing to do is to take the history and make an examination. Usually, the nature of the case will be clear from the history, but it is a mistake to rest here without looking into the nose and throat. In the nose, you may find anything from a polyp to a shoe-button, any of which may require mechanical removal before you will make any progress with your medicines, no matter how well selected. Usually, you will find nothing but a swelling of the mucous membrane of the turbinates with free discharge. If you are an adept at examining the nose, you will probably search for the sensitive areas, touching of which causes a spasm of sneezing. These may be found anywhere in the nose, but most commonly at the anterior and posterior ends of the middle and inferior turbinated bones. I apply ichthyol to the naso-pharynx to test the sensitive area described in Chapter III.

What constitutes a gross lesion requiring surgical removal? Competent men differ widely and the practice of the same man has differed widely at different stages of his career. For a time there was enthusiastic cutting of septal spurs and burning of redundant mucosa and cauterizing of sensitive areas. I think that the relation of the nose specialist to hay fever is similar to the relation of the abdominal surgeon to neurasthenics. The more experienced he becomes, the more he advises letting them alone or using gentle measures. Distinct polyps should be removed.

Having finished the examination and found no gross lesion requiring surgical removal, the treatment must be decided. The easiest plan for both patient and physician is to give rosin-weed, as described in