nostrils seems to increase the intense irritation and makes the sneezing worse. The discharge from both eyes and nose gradually grows thicker and may become semipurulent. There is often a certain amount of chemosis, and sometimes photophobia, besides the usual pricking and stinging of the conjunctival surfaces. There are frequent transient paroxysms of lacrimation, and there is often much swelling of the eyelids as well as of the conjunctivæ. The face becomes puffy and edematous, and the senses of taste and smell become impaired. The pharynx, mouth, and tonsils share in the engorgement and become red, and simultaneously the inflammation of the eyes, nose, and throat becomes intense and painful. Swallowing may become so difficult that there is little rest night or day. Insomnia is common and is often attended by nervousness and a sense of suffocation out of all proportion to the gravity of the condition. Cough is not a constant feature, but in a considerable proportion of cases it comes on in the second week, and lasts through the attack. Generally it is spasmodic and so incessant at night that sleep is impossible, and there are soreness and pain resulting from the straining

of the diaphragm and intercostal muscles. Bronchitis does not usually result, and expectoration is absent or scanty until late. Cough may continue after all other symptoms have ceased. The pulse and temperature are not generally altered, but later in the attack the temperature may be raised two or three degrees, doubtless from disturbed rest. A "sufferer" records that, in some, the genito-urinary and rectal passages give the first warning by intense itching and burning. In one instance, a more than generally severe paroxysm induced rupture of the capillaries in the lacrimal caruncle of the right eye, causing engorgement of the organ and displacement of the visual axis, with consequent double vision for some days. The direct and reflex changes in the vocal apparatus vary from loss of timber and harshness to complete inability to utter nasal vowels and consonants.

The disorder varies much in intensity even in the same person within short intervals of time, so as to almost give an intermittent character to the complaint.

COMPLICATIONS AND SEQUELAE.

The attack finally ceases almost as suddenly as it came on, leaving no trace of local lesion or systemic disturbance. It is accompanied in some patients with nettle-rash. Asthma is a late symptom, coming on after the acute symptoms have abated, and cough has existed for some time. It may appear at the height of the attack. It is more common in autumnal catarrh than in the early forms. Its period, as a rule, begins at the fourth week, and it does not vary from ordinary asthma. It is sometimes periodic, occurring at the same hour night after night. Paroxysms appear associated with antecedent bronchial rather than nasal symptoms. Nasal reflex phenomena, without cough, may occasion paroxysms. Persistent cough more usually exists in the intervals between paroxysms. Beard says that four-fifths of the sufferers have cough or asthma. The symptoms are not usually of equal severity each year. Asthma generally comes on in the daytime, a little ropy mucus being expectorated, and later, an abundant frothy secre

COMPLICATIONS AND SEQUELA.

85

tion. There may be only a slight remission, the dyspnea continuing so long as exposure continues. The attacks rarely produce emphysema of the lung, and sooner or later recovery ensues. Bosworth estimates that the asthmatic attacks come on earlier each year in those who have suffered from hay-fever in connection with asthma, and he believes that an attack of hay-fever is especially liable to develop an attack of bronchial asthma as a natural consequence of the disturbance in the nasal chambers. He also observed a number of cases in which hay-fever symptoms gradually abated while the asthma became a prominent factor, and, again, that victims of hayasthma finally acquired the perennial form of the disease, the attacks occurring at all seasons without reference to the presence of pollen in the air.

As already evidenced in Sajous' case, in a number of cases the attacks are preceded by cutaneous eruptions. Laflaive cites cases with urticaria and eczema preceding the onset of hayfever. Facial pruritus and herpetiform eruptions are occasionally seen. J. N. Mackenzie speaks of an inflammation of the external auditory

meatus in all respects analogous to that of the nose in hay-fever, occurring repeatedly in a lady during the summer months.

Besides asthma, already mentioned, there is little tendency to permanent ill-effects except thickening of the nasal mucous membrane from the prolonged irritation. Taste and smell may be impaired during and for a long time after the attack. General irritability and nervousness may be more or less persistent. Elderly sufferers for a long time may have weakened hearts which intermit during attacks, which may recover with returning health or result in cardiac dilatation. Wyman mentions pneumonia in three cases during attacks. In one case the catarrh ceased for two weeks to return after the pneumonia disappeared, when asthma also came on for the first time.