The allergic rhinitis which is closest to hay fever, without being hay fever in the strict sense of the word, is that due to mold spores. These are the molds which have so often unhappily surprised you growing on bread or fruit, in the cellar, or on the shower curtain. They grow best on decaying vegetable or animal matter in damp warm places and propagate by shedding billions of tiny spores which are carried about like pollen in the air currents. They are very common, especially during warm weather, and may be the only cause of a case of severe hay fever, though more often they are contributing causes, the individual being sensitive also to one or more pollens. Usually the patient has his symptoms only through the warm months, when the whole outside world supports mold life and the air is full of spores. But an occasional unfortunate will suffer all year long because the mold spores to which he is sensitive are in his houseperhaps growing in his damp cellar and being circulated throughout the building by an antiquated hot air furnace. Of all the offenders in this group, and there are many of them, a little fellow who grows in grayish colonies with white whiskers, called Alternaria, is by far the commonest.
Of very minor importance from the standpoint of the number of patients affected, but of interest as an example of a very odd and seemingly impossible allergen, is the lowly caddis or sand fly. This insect abounds in the region of the Great Lakes of the United States, hordes of them swarm each spring over the city and countryside in a restricted area around Buffalo, N. Y. They die rapidly, dry out in the sun, and form a powder to which people may become sensitive another pollenless cause of hay fever. The mold spores, the caddis fly, and in the West, grain smuts and rusts are the chief inhalant causes of seasonal vasomotor rhinitis other than pollen.
Many other inhalants cause vasomotor rhinitis, but usually they will not have a seasonal character unless there is some special circumstance in the patient’s environment that is responsible for his having a greater exposure at some particular time. Thus, the house dust victim tends to have more trouble during the winter when his house is shut up tight and the dust is carefully kept inside for him to inhale. But this may be reversed if he lives in a house during the winter that has an air-filtered heating system. When he takes up his summer residence in an ordinary house, dust exposure may be sufficient to give him symptoms, and likely as not he will blame them on some pollen to which he is completely insensitive.
A very amusing and rather unusual case of a similar nature was referred to us recently for diagnosis. This man complained of hay fever starting in the middle of May and ending with frost. Symptoms were always worse at night and were so severe that they materially interfered with his sleep; by the time summer was over, he was so worn out as to be scarcely able to carry on his work. Skin tests were done. No pollens reacted. The molds were negative. Finally one of the test sites began to show a typical wheal reaction surrounded by its aura of red. Silk. The man was sensitive to silk. But why the seasonal hay fever? “Well, you see, doctor, when it comes along spring, my wife changes from woolies to silk night gowns. Come the fall, with a little nip in the air, and back she goes to the woolies.” The cure was obvious. Wifie was put into cottons and hubby has had no more “hay fever.”
And so it is with many other inhalants. A person who is sensitive to the fine flakes of skin, called dander, that all animals normally shed, may get vasomotor rhinitis or “hay fever” when he goes to the farm for his vacation. An ardent suitor may sneeze when he is with his girl because of the orris root in her cosmetics or the flaxseed or karaya gum in her wave set. Fly spray, used for the most part only in the summer, will give it to some people. ‘While these common causes of trouble are well known and easily detected, it must be remembered that nearly anything of the vegetable or animal kingdoms, which does or has lived, has the potentiality of being an allergen and causing some individual untold misery until it is ferreted out and brought to light.
Less common as a cause of seasonal vasomotor rhinitis, but not therefore to be overlooked as possibilities, are the foods. In general in these days we eat practically the same foods during winter and summer and vasomotor rhinitis from food is usually not seasonal. A school teacher complained of frequent sneezing and running nose all year long. She was particularly miserable in winter because she would pick up one severe cold after another. She was al-most incapacitated, but had been struggling along in this way for several years. Skin tests failed to show a cause among the inhalants. Tests for foods showed sensitivity to beef. Elimination of the beef from her diet resulted in the cessation of her symptoms almost over night and she has gone on several years with only infrequent respiratory infections and almost completely unhampered in her work. Whenever she becomes adventurous and tries beef, the old symptoms are back again in a few hours. This is a nice straightforward case; most of them are not so easy to diagnose.
A man who was a cook in a large cafeteria complained of frequent colds in the winter time, but his chief complaint was severe hay fever starting in the middle of August and lasting until frost a typical ragweed history.
Skin tests failed to show a pollen sensitivity. Tests for other inhalants were positive only to house dust. Food tests gave a strong positive reaction to tomatoes. Then the story came out. Our friend was a tomato fancier. Each year he planted many more tomatoes than he and his family could eat, but when they ripened in August, they all pitched in and ate as many as possible to keep them from rotting on the vines. The relatively few tomatoes which he ate during winter were not enough to give him acute symptoms; it was only when he ate large amounts that he came down with “hay fever.” Elimination of the offending food cleared up his trouble. Then, just to be sure, one Christmas time we had him eat a large number of tomatoes. He had a typical severe attack.
Other foods which commonly cause seasonal vasomotor rhinitis are asparagus, strawberry, peach, and corn. Such cases are not common compared with the number of cases of true hay fever, but every allergist sees them in his practice. Perennial vasomotor rhinitis from foods is more common than the seasonal.
Knowledge of the role of bacteria in causing vasomotor rhinitis is very incomplete and very controversial. That bacteria can and do cause it, is undoubtedly true. The best theory is that people actually become sensitive to pockets of bacteria (called focal infections) in the same manner that they do to other allergens. But skin tests to demonstrate this sensitivity do not work and treatment with bacterial extracts or vaccines is usually disappointing if used alone without taking other measures to clear up the focus. The sites where these focal infections most commonly develop are the teeth, tonsils, and nasal sinuses, though other places in the body can probably harbor organisms to which a person may become sensitive. The different kinds of bacteria found in these foci is legion, but those usually associated with the common cold, such as staphylococci, streptococci, and pneumococci, are the most frequent offenders.