Tuesday, June 17, 2014

1898: How to diagnose hay fever

So a patient presents with itchy, water eyes, scratchy throat, sneezes, wheezes and shortness of breath.  How does a physician in 1898 diagnose this as hay fever as compared with asthma, bronchitis or some other ailment?  The answer is: it isn't easy.

William Hollopeter states that "Hay-fever may be distinguished from asthma, common catarrh, bronchitis, acute rhinitis, remittent fever, and catarrhal conjunctivitis. The salient feature of hay-fever is its periodicity or annual recurrence. This is part of its very nature, is the central point of diagnosis, is its chief characteristic, and to its elucidation, Holmes says, all existing theories tend."

According to Hollopeter, Beard lists the following as similarities between hay fever and asthma:

1. It is hereditary;
2. It is more or less periodic;
3. It is paroxysmal;
4. It is correlated to other functional nervous affections;
5. The paroxysms are excited by great variety of irritants; persons being differently affected;
6. It is singularly obstinate and is relieved by the same remedies.
Likewise, Hollopeter quotes Bosworth as considering "hay-fever dependent upon":
1. A neurotic habit;
2. Pollen in the atmosphere;
3. A disordered condition of the nasal passages.
While asthma is dependent upon:
1. A general neurotic condition;
2. Obscure conditions of the atmosphere;
3. Diseased bronchial (not nasal) mucous membranes.
So the many similarities between the two diseases were well known. Other similarities are:

  1. Sudden onset
  2. Sudden end
  3. Violent paroxysms
  4. Inflammation (hyperaemia)
Asthma differs from hay fever in that hay fever causes violent sneezing and discharge of the nasal passages, while hay fever presents with inflammation and redness of the upper respiratory tract and eyes, while asthma presents with inflammation of the air passages.  

Hay fevermay also be mistaken for other diseases, as Holopeter notes:
The first attacks are likely to be mistaken for ordinary coryza, but here the abrupt onset, the characteristic edematous puffiness of the eyelids, the absence of constitutional symptoms will indicate the difference. In children, moreover, attacks of hay-fever are most liable to be mistaken for acute colds or rhinitis,—but here, again, the above points may serve to distinguish, together with the sequence of the symptoms, the time of year, and the physical signs of an acute bronchitis, if it extends so far. The approach of cold weather and the coincident departure of the symptoms will make clear a diagnosis, while the history of previous attacks at the season of the year most favorable tohay-fever, the presence of certain irritants, and the general condition of the bodily symptoms may be of aid in distinguishing the affection."
The best way to differentiate between simple coryza, catahrr, asthma, colds, and other ailments is the timing of the disease; that it occurs at the same time every year, or when exposed to the same exciting cause.

Note:  For a differential diagnosis between hay fever and colds and other similar ailments, click here and then scroll down one or two pages (Morill Wyman, 1876, "Autumnal Catarrh," page 153-154).
References:
  1. Hollopeter, William Clarence, "Hay-fever and its successful treatment," 1898, Philadelphia, P. Blakiston's Son and Co., page 94-97

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