GEORGE K. was warned never to call at our office again when summer came. He was an extremely allergic person suffering from severe asthma. Sensitive to grasses and ragweed pollens during each of two previous summers, he was advised to take hyposensitization treatment so that he would be free of this difficulty. Even though hay fever and asthma put him out of action for the entire summer, George was stubborn, and, after he managed to survive his sickness, promptly forgot his experience.
At eight o’clock in the evening on a Fourth of July, with the road slightly wet from a moderate rain, George’s wife telephoned. “George is dead,” she shouted. She was hysterical and wanted us to come at once. It would normally take about 25 minutes to drive to George’s house in good weather, when the streets were dry, and not on a holiday with heavy traffic. But we were lucky, and the traffic, lights and lanes all appeared to open up. We reached his home in less than 25 minutes. (Why such a rush when George was supposed to be dead?)
He looked dead to all intents and purposes. Relatives were present and last rites had been given by a clergyman. He was blue, turning white; he was not breathing; he had no palpable pulse; no heart sounds could be heard.
The training and intuition of a physician keep one trying. We promptly gave George a large injection of adrenalin directly into his heart muscle, then caffeine sodium benzoate and more adrenalin. It seemed like an eternity, but heart beat and pulse started to return, imperceptibly at first, but in a gradually stronger way. Color and breathing began to return.
This very dramatic incident made George a most faithful patient. We have often wondered whether the doctors have fully recovered.
Hay fever is the name given to the symptoms produced by contact of pollen with the allergic, upper respiratory mucous membrane. A more scientific name is pollen disease. It affects about one per cent of the population, and is characterized by attacks of sneezing, watering and itching of the eyes, discharge of watery secretion from the nose and itching of the nose, throat and the roof of the mouth. Hay fever is usually seasonal in nature, recurring annually, beginning and ending about the same time each year. When it is very severe, it may be accompanied by asthma, and may even exist in the form of asthma without nasal or ocular symptoms. This so-called pollen asthma is a rare condition.
Pollen was proved to be the cause of hay fever by Dr. Blackley in 1873. Fortunately, for most of us, only a few pollinating plants satisfy the requirements necessary for the pollen to be significant in the production of hay fever. First, the pollen must contain a precipitating factor in hay fever. Second, the pollen must be windborne. Third, the pollen must be produced in large amounts. Fourth, it must be light in order to be blown large distances. Fifth, it must be a widely distributed pollinating plant. Ragweed is, by far, the greatest offender in this regard.
There are three principal hay-fever seasons in the United States, corresponding to the pollination of three plant groups, trees, grasses and weeds. In some parts of the United States, the tree-pollinating season begins as early as January and, in some, as late as April. It may last two to three months. The early summer or grass-pollinating season begins as early as March or as late as June, and lasts approximately two months. The fall or weed-pollinating season begins as early as June or as late as August, and lasts two or three months. These seasons depend on location. In the Southeast, for example, there may be two grass-pollinating seasons.
Decorative and other flowers, such as the rose, sunflower, chrysanthemum and dahlia, are frequently thought to cause hay fever. Beautiful flowers are insect-pollinated, the pollen being heavy and scant. Close contact may cause an aggravation of symptoms, but, otherwise, it is not a serious factor in the cause of hay fever.
The same special care and thoroughness must be carried out in discovering the cause of hay fever as in asthma. Careful history and a physical examination, with special attention to the eyes, nose, sinuses, throat and lungs, urinalysis, blood count and chest X ray, are musts. Many years ago, we discovered that only 30 out of 100 patients are allergic to one pollen alone; the other 70 patients have other allergens as causes of the hay fever. This explains the many failures in hay fever treatment, whether by the conventional or the more recent “one shot” treatment.
The history of characteristic attacks recurring annually at the same season is sufficient for diagnosis. Although the symptoms of hay fever are nasal, there need be no organic abnormality; and examination between attacks usually shows an entirely normal nose.
Having determined that a patient has hay fever, the physician must find out to what pollens he is sensitive and to which of them he is sufficiently exposed to account for the production of symptoms. To do this intelligently, one must be familiar with the flora of the territory, must know the hay fever-producing plants, their pollinating seasons, the relative amounts of pollen produced by each and their symptomo-logic importance.
Pollen is the male element in the fertilization of plant seeds. All plants may be divided into two groups with respect to their methods of pollination: (a) those pollinated by insects, and (b) those pollinated by the wind. The insect-pollinated plants have inviting flowers and sticky pollen. Because of their odor, color and sweetness, they attract insects which carry pollen on their feet and wings, and fertilization from the male to the female portions of the flowers occurs. These plants produce only small amounts of pollen, and, under natural conditions, their pollen is not found in the air, so that these flowers, in general, do not cause hay fever except when they are cut and used for decorative purposes in homes. Under these conditions, pollens may be scattered as the flowers dry. Treatment here is simply a matter of eliminating such flowers from the home.
The wind-pollinated plants have inconspicuous flowers. Their pollen grains are light in weight and are produced in great abundance.. They depend on gravity and the wind for the proper distribution of the pollen, and, as nature is solicitous for the survival of all plants, she produces excess pollen which the air contains in large amounts during the warm months. The plants most likely to cause hay fever are very abundant, pollen-producers, and their pollen is light enough to be carried long distances by the wind. It has been estimated that a fifteen-mile-an-hour breeze will blow ragweed pollen five miles; and this pollen has been found in the air at a height of 10,000 feet.
Three groups of plants are the chief causes of hay fever: trees, grasses and weeds. Trees pollinate in the early spring, and are likely to cause symptoms of about two weeks’ duration between February and April. The grasses bloom from late April to early July, and cause symptoms during that time. The weeds cause symptoms from mid-August until the first killing frost.
Certain trees, grasses and weeds are found exclusively in certain restricted parts of the country. These may cause symptoms at times other than those specified below.
Spring hay fever: A few warm days in March or April are likely to usher in the pollination of trees. Persons sensitive to some of these pollens will begin to have symptoms. These symptoms are usually mild, and, as the season is short, little treatment is required as a rule. To find the cause, it is necessary to know what trees are found in the patient’s environment, which ones are pollinating at the time, and to which pollen the patient is sensitive.
Summer hay fever: About five per cent of all hay-fever patients have the summer type, often erroneously spoken of as “rose cold.” This condition begins during the last week of May or the first week of June, at the time when the early roses are in bloom. Observing the beautiful rose, we blame it for the symptoms, but this ignores the inconspicuous bloom of the grass which is the real cause. Patients who are sensitive to one grass are likely to be sensitive to all members of the grass family, of which there are several hundred. For this reason, it is imperative that the physician know the names and pollinating seasons of the grasses indigenous to the territory in which the patient lives.
In Cleveland, Ohio, for example, there are four major grasses. The earlier symptoms are due to the pollens of June grass and orchard grass, and the later ones to those of timothy and red top. Sweet vernal grass, which is common in New England, and Bermuda grass, which is common in the South, do not grow in northern and central Ohio and are unimportant as causes, although almost all patients will give positive skin tests to their pollens.
Fall hay fever: Fall hay fever begins in the northern areas about August 15 and is the type from which 90 per cent of patients suffer. It is caused by pollen of plants of the Compoitae group, the chief representatives of which are giant and short ragweed. Cocklebur is also an occasional offender. Goldenrod, sunflower and other decorative plants which are members of the group do not cause hay fever, although they are frequently suspected. The symptoms, which begin about the middle of August, tend to become more and more severe until they reach their height about Labor Day. This peak lasts for a week or two, and then gradually declines until the first hard frost stops further pollination, thus terminating the symptoms. The more pollen in the air, and the more one is exposed to it, the more severe the symptoms. Patients vary considerably in their sensitivity to pollen. For the same exposure, the symptoms will be mild when tolerance is high and severe when tolerance is low.
There are three methods of treating hay fever: (a) by the removal of the patient to an environment which is free or relatively free of the pollen to which he is sensitive, (b) by raising the tolerance to a level which will allow freedom from symptoms in spite of the inhalation of pollen and (c) by a combination of these two methods.
The first method has been in use for many years. It is customary for those who can afford it to go away each year during their season of symptoms to one of the “hay-fever resorts.” These are places in which there is little wind borne pollen of the hay-fever plants, either because these plants do not grow there, or because all grasses and weeds for a number of miles surrounding the resort have been cut to prevent pollination. They are usually primitive places, providing little more than the absolute necessities for living—so that they are seldom places where one would choose to spend a vacation. However, hay fever causes so much distress that sufferers are willing to tolerate inconveniences in order to be symptom-free.
There are certain disadvantages about “hay-fever resorts.” As more and more people go to them, and as the surrounding territory becomes increasingly occupied, land is cultivated and weeds grow in the wake of cultivated plants. Some grass and weed pollens then appear in the air and the resort loses its value for any except mild sufferers. The severely ill must then move on to resorts in still more primeval areas. At most “hay-fever resorts,” for example, only about one-half of the hay-fever sufferers are completely relieved, because there is sufficient ragweed pollen in the air to produce symptoms in patients whose tolerance is low.
Because of the expense and inconvenience of making a long journey, many persons have tried to set up “hay-fever resorts” at home,. One of the methods is to confine the patient to a room in which all doors and windows have been tightly closed in order to reduce the amount of pollen by excluding fresh air. Another method is to transfer the patient to a downtown hotel, where the airborne pollen concentration is less than it is in the residential parts of the city. The first method is unsatisfactory because few persons are willing to forego fresh air for an indefinite period of time to secure only partial relief. Removal to a downtown hotel affords inadequate relief and is as expensive as a trip to a “hay-fever resort.”
Recently, some air filters have been made available which, without interfering with ventilation, effectively remove all of the pollen from the air coming into the room. The patient installs a filter in his bedroom and starts it in operation a few days before the usual onset date of his symptoms. He then sleeps in this room, going about his ordinary business affairs during the daytime. As the season advances and more pollen appears in the air, he will find it necessary to remain for increasing lengths of time in his bedroom. For the very sensitive patient, as many as 22 hours per day may be necessary to afford relief at the peak of the season. Some persons find it convenient to have both their homes and their offices equipped with filters so that they remain in filtered air from 20 to 22 hours a day. Those using this method should curtail their outside activities during the entire hay-fever season; they should avoid automobile and train trips, should not play golf or tennis and should remain in filtered air as much as possible. The principle of this method is to keep the daily dose of pollen below the patient’s tolerance, so that he remains in the balanced allergic state.
The second method depends on increasing the patient’s tolerance. It consists of repeated injections into the patient of increasing doses of pollen extract, in order to teach the body, as it were, to tolerate amounts equal to, or in excess of, doses which will be inhaled on any day during the hay-fever season. There are several difficulties in this method. First, the physician must know with certainty the exact pollen which is producing the patient’s symptoms. Second, the pollen extracts must be potent. Third, the patient must be able to tolerate a sufficiently large amount to produce the desired results. Usually from 20 to 40 injections are required. Treatments are administered daily, every other day or every three or four days over a period of several weeks or months until the patient is able to tolerate sufficiently large doses to insure prevention of symptoms. If the final dose is too small or if the treatment is stopped too early in the season, very little relief will be obtained. The “one shot” treatment is now under careful study, and may be an improvement on the above.
Many physicians administer pollen extract injections supplied by commercial biological laboratories. These extracts are potent, and their routine use protects 25 per cent of cases. Experts, who use larger and more frequent doses, are able to protect a large majority of patients. However, the tolerance obtained by any injection method is evanescent and disappears quickly following the last injection; in some instances, it lasts no more than a week, and ordinarily persists only for from four to six weeks. These injections, therefore, must be repeated every year, as the tolerance acquired one year is likely to be lost before the next hay-fever season. It is for this reason that the year-around method of treatment is employed.
The third method is a combination of these two. Since only 25 per cent of patients receiving pollen allergen injections have their tolerance raised sufficiently to escape all symptoms, it is necessary that 75 per cent of these patients have, in addition, a few hours of filtered air daily in order to remain comfortable. For this group, fewer hours in filtered air will be necessary than for the average patient who has received no treatment directed at raising his tolerance.
Review of all three methods demonstrates again that the treatment of allergic diseases consists in so reducing the dose of the specific exciting cause, or so increasing the tolerance, as to produce in the patient the balanced allergic state. Written By: Jack A. Rudolph, M.D. & Burton M. Rudolph. M.D., Continue Reading, Perennial Allergic Rhinitis
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