A CONTRIBUTION 
TO THE STUDY OF 
Coryza Vasomotoria Periodica, 
OR SO-CALLED “HAY FEVER.” 1 
[Reprint from the N. Y. Medical Record, July 19, 1884.] 
SURGEON TO THE BALTIMORE EYE, EAR, AND THROAT CHARITY HOSPITAL, 
BALTIMORE, MD. 
By JOHN N. MACKENZIE, M.D., 
“ Nunquam it a quisquam bene subducta ratione ad vitam fuit, 
Quin res, atas, usus semper aliquid opportet novi, 
A liquid moneat, ut ilia qua te scire•eredas, nescias, 
Et, qua tibi putans prima, in experiundo ut repudies 
—Terence, in “Adelphis,” Act V. 
When the phenomena of a given disease or unnatural 
condition are'inexplicable by known pathological laws, or 
do not come within the range of that speculation which 
empirical fact and scientific experiment allow, it is cus- 
tomary to seek in the term “idiosyncrasy” a convenient 
refuge for acknowledged ignorance. This applies with 
especial 'force to the affection in question, the peculiar 
features of whose clinical history have been submitted to 
this lazy explanation. The well-recognized, but imper- 
fectly understood personal susceptibility to certain forms 
of local irritation, which is the sad prerogative of the 
sufferers from this disease, has always been the stumbling- 
block in its investigation and the rock upon which the 
various speculations as to its nature have been wrecked. 
Hasty generalizations based on the study of conditions 
external to the organism, to the exclusion of pathological 
agencies within, together with deductions drawn from iso- 
1 A lecture delivered at the Baltimore Eye, Ear, and Throat Hospital, June 14, 
1884. 2 
lated cases, and the uncertain testimony of the laity, have 
given rise to a variety of names indicative of its supposed 
etiology, such as “hay fever” or “asthma,” “pollen 
fever” or “poisoning,” “rose” or “ peach cold,” etc., 
appellations which should be discarded and forgotten, as 
they not only tend to perpetuate erroneous views and to 
introduce elements of confusion into the investigation, 
but also, by a diversion of the mind from more essential 
conditions, have in no small measure contributed to retard 
progress in the therapeutic management of the disease. 
While the term coryza vasomotoria periodica, suggested 
in the title of this communication, does not meet all the 
requirements of a logical definition, it may nevertheless 
be used provisionally until more exact knowledge of the 
affection furnishes data for the construction of a better. 
For, as will be shown below, the disease is essentially a 
coryza, showing, in most cases, a decided tendency to 
periodic recurrence, and dependent upon some functional 
derangement of the nerve-centres as its predisposing 
cause. 
Until within the past few years clinical and experi- 
mental inquiry has been directed to the investigation of 
the most prominent exciting external influences provo- 
cative of the attack, and other and more important agen- 
cies have been entirely overlooked, or set aside as the 
general or special expressions of an idiosyncrasy, an ex- 
planation which is practically meaningless and conveys 
no definite or intelligible idea concerning the essential 
nature of the disease. While it is undoubtedly true that 
the inhalation of certain forms of matter—and pollen is 
only one of them—exercises an unquestionable irritative 
influence in the production of the paroxysm, it is, at the 
same time, equally certain that in a large proportion, if 
not all, careful inquiry will discover this influence to be 
purely secondary or accidental—to be dependent upon 
some local or constitutional condition. 
Although a number of investigators had previously la- 
bored with praiseworthy zeal to establish a definite pathol- 
ogy of the disease, the first to open the way to the rational 
solution of the problem was the late Dr. George M. Beard, 3 
of New York, who, by carefully collected statistics, point- 
ed out the importance of the neurotic element as a factor 
in its production.1 According to Beard, hay fever is a 
neurosis, a functional disease of the nervous system, an 
affection of modern life and of the nineteenth century. 
While he does not explain exactly in what such a neurosis 
consists, while his researches are open to fair criticism, 
and while his conclusions cannot be unreservedly ac- 
cepted, they served, at least, the important purpose of 
lifting medical thought from the grooves to which it had 
been confined by the supporters of the pollen and bacteria 
speculations, and diverting it into newer and more fruitful 
channels. 
Beard, and those who preceded him, not only depre- 
cated the possible etiological importance of catarrhal 
affections of the upper air-passages, but went so far as to 
say that the very opposite state of affairs existed, and 
that the subjects of “hay fever,” so called, were exempt 
from nasal and other forms of catarrh. The first, perhaps, 
to correct this erroneous impression and to point out the 
important role which disease of the naso pharyngeal 
cavities plays in the production of hay fever, was Dr. Daly, 
of Pittsburg, who, in 1881,2 showed that, in a proportion 
at least of cases, there is local disease of the nose or 
naso-pharynx, without which the exciting cause is in- 
nocuous ; and furthermore proved by clinical evidence 
that the cure of the affection may be effected through the 
removal of the local intrinsic condition. 
The following year, Dr. Roe, of Rochester, published 
the favorable results of his treatment of the disease by 
operative procedures directed to the hypertrophied mem- 
brane in the nasal chambers.3 According to Roe, hay 
fever is caused by the contact of the pollen of grasses or 
flowers and other irritating particles in the atmosphere 
with the nasal mucous membrane, which in certain indi- 
1 Hay Fever, etc., New-York, 1876. 
2 Vide Archives of Laryngology, April 1, 1882. Dr. iEdson had previously 
(letter to New York Medical Record, 1878, vol. ii., p. 317) called attention to the 
fact that all cases of the disease presented one or more of certain symptoms 
referable to the nose, as great sensitiveness of the nasal membrane, coryza, per- 
sistent sternutation, naso-pharyngeal catarrh, etc. 
3 N. Y. Medical Journal, May 12, 19, 1883. 4 
viduals is rendered peculiarly susceptible by virtue of 
disease, either active or latent, of the naso-pharynx, 
associated with hypertrophic catarrh of the nasal passages. 
In the course of some experiments made by me on 
the healthy and diseased mucous membrane, with refer- 
ence to nasal cough and the determination of an area in 
the nostril for the production of the various reflex phe- 
nomena associated with nasal disease,1 the following 
facts were ascertained, whose application to the disease 
in question will, I venture to think, throw some addi- 
tional light upon its pathology : i. That in the nose 
there exists a well-defined sensitive area, whose stimula- 
tion through a local pathological process, or through ab 
extra irritation, is capable of producing an excitation 
which finds its expression in a reflex act or in a series of 
reflected phenomena. 2. That this sensitive area corre- 
sponds, in all p/obability, with that portion of the nasal 
mucous membrane covering the turbinated corpora 
cavernosa. 3. That nasal cough is produced only by 
stimulation of this area, and is only exceptionally evoked 
upon irritation of other portions of the mucous mem- 
brane. 4. That all parts of this area are not equally 
capable of generating the reflex, the most sensitive spots 
being probably represented by that portion of the mem- 
brane covering the posterior end of the inferior turbi- 
nated body and the septum immediately opposite. 5. 
That the tendency to evolution of reflex phenomena 
varies in different individuals, and is probably dependent 
upon the varying degree of excitability of the erectile 
tissue. In some the slightest touch is sufficient to excite 
the reflex act, while in others chronic hyperaemia or hy- 
pertrophy of the cavernous bodies seems to evoke it by 
constant irritation of the reflex centres, as occurs in 
similar conditions of other erectile organs, as, for exam- 
ple, the clitoris. 
Apart from experimental proof of such localization— 
\ On Nasal Cough, and the Existence of a Sensitive Reflex Area in the Nose, 
American Journal of the Medical Sciences, July, 1883. The residts of these ex- 
periments were first brought before the Baltimore Medical Association in the early 
part of 1883, and subsequently before the Medico-Chirurgical Vacuity of Mary- 
land (April, 1883, vide Transactions) and the American Laryngological Associa- 
tion (May, 1883, vide Transactions). 5 
viz., to the posterior and inferior portion of the nostril— 
I showed, from my clinical observation, (i) that in cases 
where reflex cough is present, these are the portions 
chiefly, if not solely, involved ; (2) that the act may be 
produced here at will by artificial stimulation of the dis- 
eased area, and (3) dissipated by local applications to, 
or removal of the same; (4) that foreign bodies only 
excite cough when they are impacted in the sensitive 
area ; and (5) that polypi give rise to reflex phenomena only 
when they arise from or impinge upon the sensitive por- 
tions of the area; and lastly, a point of importance 
as bearing on the treatment, (6) that where complete 
atrophy of the turbinated structures exists, as, for exam- 
ple, in certain cases of ozcena, reflex cough is not pres- 
ent, nor can it be induced by artificial stimulation. 
These facts are not alone true of cough and asthma; 
my experience furnishes me with a series of cases where 
they could be demonstrated as true of various other 
reflex phenomena originating in diseased conditions of 
this area, and I have already called attention to the 
reflexes 1 which I have met with (cough, pain in the ear 
and larynx, redness of drum membrane, etc.) in the 
course of operative procedures in this region.2 
Since I first directed attention to the posterior end of 
the inferior turbinated body and septum as the most 
sensitive spots to reflex-producing impressions, I have re- 
ceived several communications comfirmatory of the views 
expressed in my paper, which have also derived support 
from the publications of other writers. Thus, the obser- 
vation that reflex asthma arises from nasal disease only 
when the posterior portions of the sensitive area are in 
some way involved, either directly from a pathological 
condition of the parts or from the irritation of a poly- 
pus,3 has been confirmed by Dr. Roe,4 who explains the 
1 Trans. Med. Chir. Fac. of Maryland, 1883. American J. Med. Sc., loc. cit., 
Trans. Virginia State Society, 1883. 
2 There is one point pertinent to the subject of this paper which should not be 
lost sight of, and that is, that certain reflex phenomena may be awakened by stim- 
ulation of the apparently normal membrane. 
3 Vide a paper by the author on Reflex Cough due to Nasal Polypi, etc. (read 
April 25, 1884), Trans. Med. Chir. Fac. of Maryland, and N. Y. Medical Rec- 
ord, May 3, 1884. 
4 Journal of the American Medical Association, September 15, 1883. 6 
more frequent occurrence of the paroxysms at night 
by the gravitation of blood to the sensitive area. The 
same author, moreover, in his recent paper on “ hay 
fever,” ’ points out the fact that, in the majority of cases, 
the seat of irritation during the attack is the inferior tur- 
binated bone and posterior portion of the septum, thus 
furnishing additional confirmatory clinical evidence in 
favor of localization of the reflex area in the lower and 
posterior portions of the nostril.2 While these observa- 
tions go to show that the most sensitive spots are repre- 
sented by the area indicated above, it is but fair to state 
that a different opinion is entertained by a German con- 
frere, well known from his labors in this special field. 
In August, 1883, there appeared in Germany an inter- 
esting brochure from the pen of Dr. Hack, of Freiburg,3 
in which this writer maintains, as the result of indepen- 
dent experiment, that the anterior extremity of the inferior 
turbinated bone is the point from which all reflexes take 
their origin, and that those arising from stimulation of 
other portions of the nostril only occur, secondarily, 
through congestion of the cavernous tissue of this cir- 
cumscribed locality. 
lake Daly and Roe, Hack holds that morbid con- 
ditions of the nasal membrane play the most important 
part in the etiology of the disease. He also believes 
that there are two factors in the production of the par- 
oxysm, viz., a hypenesthetic condition of the terminal 
filaments of the fifth and olfactory nerves, and an in- 
creased irritability of the cavernous tissue, caused, as a 
rule, by local nasal disease, and inclines to the belief 
(also held by Roe) that the neurasthenic symptoms are 
secondary to the nasal affection, calling attention, at the 
same time, to the fact that the latter may coexist with a 
general neurosis without having any connection with it.4 
1 N. Y. Medical Journal, May 3 and 10, 1884. 
2 In a recent number of L’Union Medicate (January 22, 1884, La toux nasale) 
M. Longuet believes, with me, in the existence of a tussigenicarea (zone iussigene) 
in the posterior end of the inferior turbinated bone and septum, which he com- 
pares to the hystero and epileptogenic zones of Brown-Sdquard. 
8 Ueber eine operative Radicalbehandlung bestimmter Formen von Migrane, 
Asthma, Heufieber, etc. Wiesbaden, 1884. 
4 See also, Wiener Med. Wochenschrift, No. 14, 1883. 7 
Finally, Dr. Harrison Allen advances the view 1 that 
“hay fever” depends solely upon obstruction of the 
nostrils (from deflection of the septum, hypertrophy of soft 
parts and bone, turgescence of nasal mucous membrane), 
and that the cure consists simply in removing the ob- 
struction (or tendency thereto) in the nasal chambers. 
According to his experience, sufferers from hay fever and 
allied disorders have one feature in common—the in- 
ferior turbinated bones lie well above the floor of the 
nostril, an anatomical peculiarity which subjects their 
overlying mucous membrane to additional irritation 
from extraneous substances.2 
It would appear, then, that the truth is irresistibly 
emerging into recognition that certain abnormal con- 
ditions of the nasal passages are necessary to the pro- 
duction of the ensemble of phenomena which form the 
classical picture of so-called hay asthma. Although the 
results arrived at by different observers, working inde- 
pendently of each other, and starting out in some in- 
stances from different standpoints, are not altogether 
harmonious, they present nevertheless a singular unanimity 
in their convergence to a common point—in their recog- 
nition of the importance of remedial measures addressed 
to the nasal chambers as a prime factor in the therapeutic 
management of the disease. While, then, it is probably 
true that certain states of the nasal passages are neces- 
sary to the production of a paroxysm, it is, at the same 
time, equally demonstrable that these are not always de- 
pendent upon well-defined local nasal disease, but that, 
in a number of cases, such conditions are originally 
brought about by abnormal excitability of the vasomotor 
centres from inherited or acquired disease. The prob- 
lem, then, presents for consideration two important con- 
ditions : on the one hand the local nasal phenomena, 
and on the other the etiological relations of the central 
nervous system. In allotting to each its respective 
1 American Journal of the Medical Sciences, January, 1884. 
2 Allen reports several cases successfully treated by removing the obstruction to 
respiration. Cases have also been treated with the cautery by Dr. Sajous ot 
Philadelphia (reported at last meeting of the American Laryngological Associa- 
tion), whose conclusions on the subject do not differ from those of Dr. Roe. 8 
caifsative significance, care should be taken, in avoiding 
the Scylla of the neurologist, not to be too closely attracted 
to the Charybdis of another form of specialism. 
Approaching the question from this standpoint, and 
guided by my personal experience, I believe that our 
definite knowledge of the etiology of the disease may be 
briefly expressed as follows : 
i. The essential distinguishing feature of the paroxysm 
of so-called “ hay asthma ” resides in an exalted con- 
dition (erethism) of the nasal erectile tissue, and especi- 
ally that portion occupying the posterior end of the 
inferior turbinated bone and the septum immediately 
opposite. This latter area corresponds to the distribu- 
tion of the; spheno-palatine branches of the superior 
maxillary nerve, as distinguished from the nasal branch 
of the ophthalmic, which latter supplies the more anterior 
portions of the nasal fossae. The former nerves, derived 
through the ganglion of Meckel, probably therefore con- 
tain the vaso-motor nerves which govern the erection of 
the turbinated tissue, and hence the localization of the 
sensitive area becomes the key to the mechanism of the 
paroxysm and brings us nearer the solution of the path- 
ological process that sets it in motion. 
So far as my observation goes, every attack is attended 
with more or less swelling of the erectile tissue, which is 
more pronounced in the lower and posterior parts of the 
nostril. This swelling, occasionally inconsiderable, is 
often sufficient to produce absolute and complete closure 
of the nasal fossae. I have moreover, so far, never seen, 
nor have I been able to find the record of a single case 
where paroxysms of hay fever occurred where this tissue 
was completely atrophied or destroyed by disease. In 
two cases under my observation, the nasal chambers were 
markedly capacious, but, at the same time, the erectile 
tissue was well developed. Finally, the cure of the 
affection by the artificial destruction of the erectile bodies 
amounts to a demonstration. 
2. This exaggerated irritability of the cavernous tissue 
may be directly due to the constant presence of con- 
gestion or other pathological conditions of that structure, 9 
the result of direct or indirect (reflex) irritation from 
ah extra influences, plus a hypersensitive condition of 
the vasomotor centres begotten of their prolonged ex- 
citation by the irritative influence in the nostril; or it 
may be brought about, in the first instance, by an exalted 
state of the central nervous system, leading eventually 
to disordered functional activity of the vasomotor nerve- 
centres ; or, finally, a hypersensitive condition of the 
latter may be conditioned by other pathological states 
of the system as, a whole, or as the result of reflected 
irritation from its individual parts. 
I am inclined, therefore, to transfer the point of 
greatest excitability from the peripheral ends of the 
nerve-filaments to the nerve-centres themselves. While 
I do not deny the possibility of a hyperaesthetic condi- 
tion, or even organic changes in the terminal filaments 
of the sensitive nerves, as an occasional factor, and 
while fully aware of the want of experimental proof in 
favor of the view advanced, still it seems to me a more 
adequate, a more comprehensive explanation of the 
varied phases of the disease. Upon this theory can be 
best explained, moreover, the occurrence of paroxysms 
from irritation reflected from various parts of the body 
remote from the nasal passages. The weight of clinical 
evidence, too, is in favor of disordered functional activity 
of the nerve-centres, as against organic alteration of the 
peripheral sensitive nerves. Finally, it is probably not 
at the terminal ends of these filaments, but in the centres 
themselves, that the perception is awakened which dif- 
ferentiates one form of irritant from another ; that the 
nerves themselves are but the passive channels through 
which the impression is transmitted, and that the pro- 
duction of a paroxysm by a given irritant will depend, 
other things being equal, upon the, so to speak, dis- 
criminating power or peculiar susceptibility of the centres 
themselves. 
3. There is practically an infinitude of causes, ex- 
ternal and internal, which may precipitate the nasal 
orgasm, such as various forms of matter suspended in 
the atmosphere (pollen, different forms of animal life, etc.), or the erection of the tissue may be conditioned 
by those influences that are commonly productive of 
erection of the nasal corpora cavernosa, such as varying 
meteorological relations, various forms of reflected irrita- 
tion, or, finally, it may be occasioned through psychical 
causes. It follows, therefore, as a corollary to the above, 
that any one irritant is insufficient of itself to provoke 
the attack, the latter being only possible either from 
disordered functional activity of the nerve-centres, or 
local structural disease. 
4. The power of a given local irritant to produce 
such impression, and the violence of the resulting attack, 
in all probability depends upon its physical properties 
and the length of its sojourn in the nasal cavities. Thus, 
the peculiar glutinous nature of some substances, as, for 
example, pollen, the irregular surfaces of others, as the 
golden-rod 1 and similar substances, will give rise to more 
prolonged irritation than substances of smooth contour, 
which are readily swept out of the nostrils. 
5. Apart from its accidental occurrence with the flow- 
ering of certain plants, etc., the marked periodicity of 
the paroxysm in some cases, its regular appearance at 
a certain hour and on a certain day, so far from over- 
throwing its neurotic nature, points to some functional 
derangement as its possible cause. This tendency to 
periodical return of a given state is characteristic of cer- 
tain morbid states of the nervous system, of which the 
so-called functional aphonia is a prominent example. 
It is not, therefore, stepping beyond the bounds of legiti- 
mate speculation to suggest this as the explanation of a 
certain number of cases. 
6. Whatever be the original cause of such special 
tendency to erection and consequent evolution of reflex 
phenomena, the essential part of the mechanism of the 
paroxysm is the orgasm of the erectile area. . This is the 
main-spring of the machinery by which it is set in mo- 
tion, and without which the onset of the attack is im- 
possible. 
1 The golden-rod has also been regarded as the cause of hay fever. See editorial 
article on the Pathology of Hay Fever, by Dr. Frank Woodbury, in the Phila. 
Med. Times, December i, 1883, p. 175. 11 
From what has been said above, it naturally follows 
that the rational treatment will consist (i) in diminishing 
the reflex excitability of the turbinated tissue; or, fail- 
ing in that, (2) the partial, or, if necessary, complete 
destruction of the tissue itself. 
The first indication must be met (1) by tonic remedies 
addressed to the nervous system, and by the exhibition 
of such drugs and methods as experience has shown 
control reflex excitability (the bromides, belladonna, 
chloral, counter-irritation to nape of the neck, etc.) ; (2) 
by the careful search for, and intelligent treatment of 
any pathological condition which may be regarded as a 
source of reflected irritation ; and (3) by simple topical 
treatment of any existing nasal disease or irritation. In 
carrying out the second indication care should be taken 
to sacrifice as little of the erectile tissue as possible. It 
would accordingly be better to commence by removing 
or destroying that portion which covers the posterior 
end of the inferior turbinated bone, and, if necessary, 
that covering the septum immediately opposite ; or, in 
other words, that area which contains the greatest 
number of filaments of the sphenopalatine nerve. Should 
this not accomplish the desired result, any additional 
sensitive spots should be located by means of the probe, 
as has been done by Roe, and appropriate treatment 
adopted. 
The destructive agent used in any given case will vary 
according to circumstances. It may be said, in general, 
that hypertrophic enlargements of the turbinated bodies 
are best removed, if practicable, with the cold wire 
snare ; swelling of the cavernous tissue over the septum 
is best treated with the galvano-cautery, while for com- 
plete destruction of erectile tissue, the latter agent or 
electrolysis is the best agent we possess. 
Reference has been made several times above to re- 
flected irritation of a distant organ as a factor in the 
production of the paroxysm. In order to illustrate this 
point, and at the same time make good the assertion of 
the fact, I will insert the following case : 
Mrs. , aged thirty-seven years, married twenty 12 
years, the mother of one child, now eighteen years of 
age, came in the early part of April of this year to con- 
sult me on account of severe “ hay fever.” She has re- 
sided all her lifetime in a small manufacturing town on 
the banks of one of our Maryland rivers, and in proximity 
to a malarial district. Family history unimportant. Sev- 
eral of the neighbors suffer from paroxysms similar to her 
own. She is herself a woman of average intelligence, of 
spare habit, dark hair and eyes, good disposition, not in- 
clined to be hysterical, nor easily frightened ; is “ dys- 
peptic,” and suffers greatly from inability to digest her 
food. Without possessing a decidedly nervous tempera- 
ment, in the common acceptation of the term, a more 
or less pronounced neurotic tendency expresses itself in 
a certain unnatural acuteness of the senses, and suscepti- 
bility to psychical impressions. Has never suffered from 
any nervous disease, with the exception of occasional 
neuralgic pains in the course of the fifth nerve, which 
have, however, of late, ceased to give her much trouble 
or concern. Has had malarial fever, and for the past 
four years has suffered from constant ovarian trouble. 
The left ovary is probably the only one involved, the 
condition being some chronic inflammatory disease. 
Has suffered for two years from “ hay fever.” Prior 
to her ovarian trouble, enjoyed excellent health and 
exhibited no tendency to catarrhal disease of the nose 
or throat. 
The paroxysms are ushered in, as a rule, by chilly 
sensations, followed by violent and uncontrollable sneez- 
ing, intense redness of the conjunctivas, increased lachry- 
mation and spasm of the lids. During the attack she 
cannot see to read or write, any attempt to use the eyes 
being accompanied by great pain, photophobia, etc. 
The voice soon becomes husky and nasal, a considerable 
amount of mucus is expectorated from the throat, and a 
profuse watery and slightly mucous secretion is discharged 
in abundance from the nostrils. There is generally super- 
added to these symptoms a short barking cough, which 
often continues for several days after the subsidence of 
the attack. During the latter, the nostrils are always 13 
completely closed, so that nasal respiration is impos- 
sible. Pain is felt across the bridge of the nose and in 
the frontal and occipital regions, pain in the ears and 
tinnitus are nearly always experienced, and the meatuses 
feel as if stopped up by a foreign body. The amount of 
asthma accompanying the attack varies greatly, being at 
times more pronounced than at others. During the 
paroxysm pain is always felt in the left ovary, and any 
existing pain of that organ aggravated. The ovarian pain 
comes on after sneezing, and occasionally continues after 
the paroxysm has subsided. The attacks come on at all 
seasons of the year, and bear no definite relation to the 
condition of the atmosphere as regards moisture or dry- 
ness ; but are worse in spring and fall, i.e., in the 
seasons of greatest temperature changes. They come 
on at all hours of the day, and she is often awakened 
from her sleep by the sudden accession of a paroxysm. 
The slightest exposure to draughts of any kind suffices to 
bring on the attack ; the accidental unfastening of her 
night-dress at the neck during sleep, stepping from the 
bed to the floor, going about in her stocking feet, or 
changing her shoes for her slippers, and other equally 
trivial causes have frequently precipitated it. It is also 
brought on by physical or mental over exertion, or by 
emotional excitement.1 The attacks are not modified by 
diet, dust has little or no effect, while gas and smoke of 
various kinds produce a disagreeable, smothering sensa- 
tion with some dyspnoea, but are insufficient to provoke 
the characteristic phenomena of the paroxysm. There 
are some plants that cause slight sneezing; but although 
frequently exposed to a pollen-laden atmosphere, ex- 
posure has never produced a paroxysm. The attacks 
invariably appear and are more severe at the menstrual 
period, appearing sometimes at its commencement, 
sometimes at its close. This latter condition of affairs 
has lasted for one year. They last generally for two days 
atid one night, after which all the discomfort she suffers 
1 The patient attributes a great deal of her trouble to the excitement and mental 
anxiety which she underwent while in constant care of the wounded in her hus- 
band’s factory, where accidents to the hands were constantly occurring. 14 
from them passes gradually away. She averages about 
two attacks a week, during which she is confined to her 
room, and often to bed. They sometimes leave her in 
a state of nervous prostration, from which she slowly 
recovers. 
By the protection of the nasal passages from the con- 
tact of air during the attack, the paroxysms are somewhat 
mitigated in severity, except at the monthly period, 
when this has no effect. Residence at the sea-shore in- 
variably gives relief; except during menstruation, when 
the attack is as severe as when at home. 
During the intervals between the attacks, she does 
not suffer from nasal or throat trouble, beyond the ac- 
cumulation of a slight amount of mucus in the nasal 
passages upon arising in the morning, with occasional 
dryness of the throat and huskiness of the voice. These 
phenomena are, moreover, of quite recent development. 
Physical examination.—Nothing to indicate visceral 
disease, apart from the morbid condition of the ovary. 
No disease of auditory apparatus, larynx, trachea, or 
lungs. Anterior nasal passages apparently perfectly 
healthy. The posterior extremities of the inferior turbi- 
nated bodies, as seen in the rhinoscopic mirror, without 
being notably enlarged, present an ashy gray color often 
seen in hypertrophy of these bodies. The nasal fossae 
are perfectly free and symmetrical. The lower border of 
the inferior turbinated bones cannot be seen in the mir- 
ror, and are not elevated above the nasal floor in front. 
There is no malformation or irregularity in the skeleton 
of the nose or other part of the face. The mucous mem- 
brane of the nasal pharynx is congested, and covered 
here and there with a faint film of transparent secretion. 
The mouths of the Eustachian tubes are normal in ap- 
pearance. The lower pharynx is congested and studded 
here and there with small granules (commencing granu- 
lar pharyngitis). No irregularity in the conformation of 
the pharyngeal cavities. 
The treatment adopted in this case was in accordance 
with the indications laid down above, with special at- 
tention to the diminution of excitability of the erectile 15 
area. The nasal passages were kept thoroughly cleansed 
and protected against local irritation. Anodyne and al- 
terative applications and acetic acid were made to the 
congested surfaces, with the understanding that, should 
they fail to relieve, the galvano-cautery was to be re- 
sorted to. 
At the end of one week little improvement was no- 
ticed ; but at the close of the second marked change for 
the better had occurred, both as regards the number and 
severity of the paroxysms. At the expiration of six 
weeks the attacks had lost their distinguishing characters, 
the only annoyance from which the patient suffered being 
an occasional brief access of sneezing. At the two men- 
strual periods which intervened during this time, how- 
ever, she had attacks resembling the original paroxysm, 
but greatly modified in severity. At the present writing, 
the sneezing has so markedly diminished, that it no long- 
er gives her much concern, and her last monthly period 
was passed without the slightest nasal discomfort, although 
she was convinced that it was inevitable, and had pre- 
pared herself for the attack. What the final result of this 
case will be I am, of course, unable to say, but from the 
present outlook, operative procedures will doubtless be 
unnecessary. 
Remarks.—The above case shows, among other things, 
that the paroxysms of the disease commonly called “ hay 
fever,” may be brought on in the same individual by a va- 
riety of agencies differing entirely in origin, character, 
and mode of operation. At times they are produced by 
causes which are ordinarily provocative of common coryza, 
at others from the increased irritative stimulus given to a 
morbid process in a distant organ, or finally, they are 
occasioned by impressions of a purely psychical nature. 
The attacks at the menstrual epoch are readily explicable 
by the physiological erection of the nasal corpora cavernosa 
which occurs at that period ; for, as I have pointed out 
elsewhere,1 in a certain proportion of women these bod- 
ies become enlarged and engorged during menstruation, 
1 Irritation of the Sexual Apparatus as an Etiological Factor in the Production 
of Nasal Disease. American Journal of the Medical Sciences, April, 1884. 16 
the swelling of the membrane subsiding with the cessa- 
tion of the catamenial How. This turgescence may be bi- 
lateral, or confined to one side, may be inconsiderable and 
give rise to no inconvenience, or, on the other hand, the 
swollen bodies may include the nostrils and give rise to 
various reflex phenomena. In the “ hay fever ” sufferer, 
anything that tends to produce swelling of this tissue 
excites at the same time the tendency to the production 
of the reflex phenomena characteristic of the disease. 
In this particular case the chief, and, under certain cir- 
cumstances, the sole excitant of the paroxysm was the 
utero-ovarian excitement of the menstrual epoch. 
The history would point to a hypersensitive condition 
of the vasomotor nerve-centres, the result, perhaps, of con- 
stant irritation reflected from the diseased ovary, as the 
chief predisposing cause, or so-called ‘‘idiosyncratic” in- 
fluence in this particular case. It is fair, too, to look 
upon the increased excitability of the erectile bodies, and 
the consequent repeated attacks of sneezing, as respon- 
sible for the amount of existing nasal disease. 
The practical outcome of the above conception of the 
disease is simply this : Those who recognize in it the 
foundation of a rational therapeutic, and direct their treat- 
ment accordingly, will relieve all, and cure a large pro- 
portion of their patients ; while those who blindly ac- 
cept the traditional fallacies of the theory of external 
causes must continue to divert themselves with perpet- 
ual palliative experiment, and cling to the gloomy belief 
of the Englishman, that the only cure for the disease is 
patience, if removal from the British Isles is impossible, 
thanking God, at the same time, that there are only thirty 
days in June !1 
1 Vide letter to British Med. Journal,