General Etiology And Pathology Of Diseases Of The Upper Respiratory Tract

General Etiology And Pathology Of Diseases Of The Upper Respiratory Tract
By J. H. BRYAN, M. D.,
OF WASHINGTON, D. C.

DISEASES of the upper respiratory tract that term for the purpose of this article being confined to the naso pharyngo laryngeal region may be either local conditions or local manifestations of some general disease, and they are as varied as are the tissues which go to make up these complex organs. Thus we may have any known pathological condition of the mucous membrane, cartilages, bones, blood vessels, or glandular tissue.

In an article devoted to the consideration of the general etiology, pathology, and symptomatology of diseases of the upper respiratory tract, it will be possible to give only a general idea of some of the more common conditions met with in this region.

Of all the tissues composing this tract, the mucous membrane is the one most frequently affected, and it is subject to three forms of inflammation, viz., the catarrhal, the croupous, and the diphtheritic.

Catarrhal inflammations affect adults as well as children, and they are the most common affections we have to deal with. They have been recognized from the earliest times; early writings showing the familiarity of the ancients with these affections and their influence on the general health. These inflammations have become more frequent and have increased in severity during the present century, owing to the complex conditions of modern civilization, which has no doubt developed Dew influences which operate to produce these severe conditions.

They have a widespread distribution over the earth's surface, and are more frequently met with in cold than in warm climates and in high than in low latitudes. In the temperate zone, according to Seitz,' they are most frequently observed between the isotherms of 18' and 4'; although there is no region absolutely exempt. In a study of the etiology of these affections it is desirable to know the superficial contour as well as the geological character of the region before the full influence of the humidity and the temperature and barometric changes can be estimated. Changeable temperature has a great influence in the production of these affections; therefore they are more prevalent in the spring, when the temperature and winds are more variable, than in the fall.

The causes of catarrhal inflammations are both exciting and predisposing. Among the exciting causes may be mentioned a sudden exposure to cold when the body is scantily clad, thus giving rise to the phenomenon of “catching cold." There are several theories as to the process of catching cold. The theory of Rosenthal is that the cold acting upon the surface of the body excites the arterioles to contraction, by which the blood is driven from the surface to the internal organs including the mucous membranes, and there acts as an irritant, exciting an inflammation. This theory is based upon the faulty assumption that a part is inflamed because it receives more blood, whereas it really receives more blood because it is inflamed.

The theory of Seitz is that inflammations resulting front catching cold are the result of' removing heat to an undue extent from the external surface of the body, this sudden removal causing some functional disturbance of the body by which a morbid process is set up. Neither of these theories explains satisfactorily the phenomena that take place. Bosworth' is more nearly correct when he states that the action of cold upon the body is probably upon those nutritive changes which are constantly going on within the body, and by which animal heat is produced. Any interference with this heat production results in a morbid process which, in a mucous membrane, shows itself in the form of an inflammation.

A much more potent factor in the production of catarrhal inflammations than simple exposure to a low temperature is the degree of the relative humidity of the atmosphere. Probably the most frequent cause of this form of inflammation to day is the influenza, an infectious disease which appears in epidemic form, rapidly spreading from place to place. It is of microbic origin, and bacteriologists have succeeded in isolating the specific germ which causes it. The local conditions of this affection differ in Do wise from a simple catarrhal inflammation, except in the degree of the inflammatory process.

Aside from the effects of the changes of temperature, the inhalation of irritating vapors and finely divided mechanical irritants is an important factor in the production of these conditions. Stich irritants are particularly noticeable in our large manufacturing cities, where the atmosphere is heavily laden with smoke and gases produced by the large factories, as well as with particles of dust which come from the pulverizing of asphalt in our modern pavements. These substances being constantly inhaled produce more or less irritation, which eventually results in a low form of inflammation. A more limited number of cases arise from some systemic or organic influence or front 'some functional disturbance; and a few cases may depend upon some structural defects in the parts themselves. Prominent among the predisposing causes from within the organism are gastrointestinal disturbances arising from errors in diet or over indulgence of the appetite. It is a matter of common occurrence that a defective digestive process and imperfect assimilation exert their harmful effects in the production of reflected irritation in the upper air passages. This frequency is noticed in children tinder the third and fourth year, in whom attacks of indigestion so readily occur, and who show a great degree of reflex sensitiveness. Aside from the so called reflex disturbances, the gastro intestinal disorders are frequently the direct source of inflammation of the tipper respiratory tract. Chronic pharyngitis, one of the most universally distributed diseases of this region, has probably for its most common origin disturbances of the stomach. Dr. T. R. French 2 who has recently made a very interesting contribution to the study of this subject, states that in all cases of chronic pharyngitis there is some disorder of the stomach. In conjunction with Dr. C. S. Fisher be examined the throats of 23 patients whose stomach contents bad been examined after a test meal, and in all of these patients there was found some form of stomach disorder associated with a pharyngeal catarrh. It is not only the pharynx and nasopharynx, but also the nose and larynx that may be affected by such conditions. Ariza, cited by Moreau Brown,' mentions three forms of laryngeal disturbances that result from gastric affections:

(1) Laryngeal hyperesthesia, where the patients complain of a burning sensation and pain in the larynx, but where the fauces and larynx are perfectly normal.

(2) A condition in which the vocal cords and surrounding parts are both hyperemic and painful, varying in intensity according to the severity of the gastric disorder.

(3) A reflex paralysis dependent upon gastro intestinal disturbance.

Then there are apt to be acute attacks frequently occurring in the neurasthenic, and accompanied by more than ordinarily profuse serous discharge.

Aside from the dyscrasia, such as syphilitic and tubercular diatheses, which render the mucous membrane peculiarly liable to take on inflammatory action, there are other constitutional affections which play a very important role in the production of diseases of the upper respiratory tract, such as gout and rheumatism. There are certain conditions of the throat in which the pain is out of all proportion to the amount of local disturbance observed; and it is in such cases that gout or rheumatism will in the majority of instances be found to be the exciting cause. While my own experience leads me to believe that the association of certain forms of tonsillitis and rheumatism is something more than accidental, I consider the question to be still unsettled. If the researches of Henry L. Wagner and others who claim to have found the same microbe in tonsillitis and in the blood in rheumatism are confirmed, it will go a long way in clearing up this much mooted relationship of tonsillitis to rheumatism. There are certain forms of rhinitis, especially the hyper esthetic variety, either associated with asthma or not, which are frequently observed in overfed and plethoric subjects, and which have for their causation a surcharging of the system with uric acid.

Prominent among the causes of catarrhal inflammations of the pharynx, larynx, and trachea may be mentioned the pernicious habit of mouth breathing resulting from some morbid condition within the nose', or to hypertrophy of the lymphoid tissue in the vault of the naso pharynx. The cold, unfiltered, and unmoistened air passing over the pharynx into the larynx and trachea affords a great disposition to catarrhal inflammations of these organs.

The strong influence of many modes and habits of life in the production of these affections is obvious, among which may be mentioned a sedentary life in a close vitiated atmosphere, and the custom of overheating the houses so frequently observed in this country, thereby rendering the subject sensitive to the changes in the weather.

Numerous micro organisms find an excellent culture soil in the oropharyngeal tract, some of which are harmless, while others are pathogenic in character and are the source of the infectious and contagious affections, such as diphtheria, scarlet fever, whooping cough, and phlegmonous inflammations that are met with in this region. Lennox Browne further subdivides these micro organisms into a third group, which are innocuous so long as the subject enjoys perfect health, but so soon as this is depressed or there is any abrasion of the mucous membrane systemic infection takes place, with sometimes serious results. In this later group may be classed the leptothrix buccalis, the pneumococcus, and the diplococcus, all of which are frequently found in the healthy mouth and throat. To these may be added the staphylococcus albus and aureus and the streptococcus pyogenes.

The nose, on the other hand, does not offer such a fertile soil for the growth of these micro organisms as does the oro pharynx, for according to the researches of St. Clair Thomson' and Hewlett, who have recently investigated this subject, it may be stated that the occurrence of micro organisius on the Schneiderian membrane is so infrequent that their presence must be regarded as quite exceptional. This is borne out by our clinical experience, for infectious diseases of the nose are much less frequent than in any other part of the upper respiratory tract. Paget' has confirmed the above results, and finds the nasal cavities in the normal state free from microbes except at the anterior part and vestibule. He concludes that the asepsis of the nasal cavities is due to the structure of the canal, to the ciliated epithelium, and to the germicidal quality of the mucus, which he finds is absolute for the anthrax bacillus, very marked for the Klebs Loffler bacillus, and less so for the staphylococcus and streptococcus organisms. This explains why operations in this region show a certain degree of immunity front infection.

Pathology. While the pathology of ordinary catarrhal inflammations is comparatively simple; there are certain conditions which are much more difficult to understand. Among them may be mentioned by hypertrophy of the

Lymphoid tissue in the vault of the pharynx, hypertrophy of the turbinal bodies, and deformities of the septum, resulting either front ecehoindroses, exegeses, or deflections. In order to, comprehend fully the pathology of inflammations of the tipper respiratory tract, it is necessary to understand the pathology of inflammations in general. They may be said to result either from the action of microorganisms, or from an irritant of which cold is the most common example. The impression produced by cold upon the vaso con strictor nerves stimulates them to contract the capillaries of the skin, the result Of which is a diminution of the blood supply to the periphery and a reflex to the internal organs including the mucous membranes. If these organs are in a state of health no harm will result. In those cases, however, where there is a deviation from the normal and the internal resistance is not sufficient to maintain the equilibrium, the capillaries dilate at the weakest point from overpressure. This is the condition of hyperemia or the first stage of inflammation. If now the cause is removed and the paralyzing effect on the vessels overcome, the hyperemia may subside and recovery occur If, however, the cause should continue to operate, or the paralyzing effect on the blood vessels cannot be overcome, the case passes on to the second and third stages of inflammation. The increased rapidity of the circulation, which is the first effect of the dilatation, is soon followed by a slowing of the blood current; the, leucocytes begin to seek the periphery of the stream, which adds to its stagnation; while the pressure from behind continuing, a transudation of the fluid constituents of the blood through the walls of the vessels takes place, and is thrown out on the surface of the membrane. This exudate varies in quality, according to the intensity of the inflammation, from a thin serous to a thick mucous discharge this constituting the second stage of inflammation. If the inflammatory action increases and the leucocytes form a part of the exudate, we have the third, or suppurative, stage.

In acute inflammations the quantity of mucus is largely increased over that of the normal flow; but in the chronic processes the apparent increase may be, as Bosworth 3 suggests, a diminution, owing to the fact that the normal secretion of serum which serves to dilute the mucus in health, and which disappears by evaporation without being noticed by the patient, is diminished when the membrane is inflamed, leaving behind a thick mucous discharge which soon makes itself evident.

Croupous and Diphtheritic Inflammation. The other forms of inflammation met with in mucous membranes are the diphtheritic and croupous. In both of these affections, the exudate, instead of being fluid as in the catarrhal variety, is characterized by a membranous deposit. Occasionally we meet with conditions characterized by pseudo membranous deposits causes by irritants, non microbic in character, such as steam, ammonia, and chlorine.

Until within recent years the two diseases known as croup and diphtheria have been considered as separate and distinct affections; but since the advances made in bacteriological research there is a tendency to consider them as one and the same affection. Clinically, they are similar only in the sense that both are characterized by the formation of a membranous deposit. True croup lacks many of the constitutional symptoms of diphtheria, such as the high temperature, septic infection, and the frequent serious sequele of the latter affection. The confusion of these two affections has been caused by finding the Klebs Loffler bacillus, the cause of diphtheria, in the croupous deposit. When we consider that this bacillus is frequently found in the throats of patients who are not suffering from diphtheria, we are forced to the conclusion that their presence in the croupous deposit is either accidental, or, as. Moritz Schmidt' suggests, these two affections may bear the same relation to each other as do tuberculosis and lupus of the skin.

Nasal Obstruction. Thus far we have considered the pathology of simple inflammations of the mucous lining of the upper respiratory tract. There are other conditions, however, whose pathology is not so readily explained. In order to understand the so called obstructive affections of this region, it will be necessary to make some reference to the physics of the nose and its relation to the rest of the respiratory tract. Without encroaching too much upon the domain of physiology, it will only be necessary to refer to the nose as a respiratory organ, the significance of which has only within recent years been fully appreciated ; one of its principal and most important functions being to heat and moisten the external air on its way to the lungs. When from any cause this function is interfered with, mouth breathing results with all its accompanying evils. The disturbances which mouth breathing produce are the more serious the younger the subject and the longer the existence of the interference with the free passage of air through the nose. The conditions which give rise to interference with free nasal respiration are obstructive in character, and they may result from congenital or acquired closure of the nostrils; from paralysis of the aloe nasi ; from hypertrophy of the inferior turbinal bodies, or of the lymphoid tissue in the vault of the pharynx ; from ecehondrosis, exostosis, or deflections of the septum; from polypi and granulation tissue, resulting from suppurative inflammations of the accessory sinuses ; or from foreign bodies. The effect of these nasal obstructions on the rest of the respiratory tract is to render the subject prone to attacks of pharyngitis, laryngitis, and tracheitis, which when once established are liable to become chronic.

In obstructions resulting from hypertrophy of the inferior turbinal, bodies there is generally an antecedent chronic rhinitis, producing congestion and swelling of the erectile tissue sufficient to produce a temporary stenosis of the nasal chamber. Among other causes for nasal stenosis maybe mentioned the constant inhaling of irritating vapors, which causes a chronic congestion and swelling of the parts. Bosworth,' on the other hand, believes that these cases in the majority of instances are dependent upon septal deformity, either as a deflection or projecting spurs, tracing the origin of these etiological factors back to infancy, when the child received a blow on the nose sufficient to produce the deformity. There is no doubt that septal deformities, either in the shape of deflections or projecting spurs, are in a large number of cases associated with hypertrophy of the inferior turbinals, although they are not always present. Wherever these stenoses are situated, the atmospheric pressure behind the obstruction has become diminished, and in consequence a chronic congestion is produced.' This, of course, means an increased nutrition of the body with a resulting hypertrophy, in which there is an increase of all the tissue; which go to make up these bodies, viz., the epithelial and fibro elastic layer, and the submucous tissue containing the racemose glands and venous sinuses. The degree of by ertrophy varies, in I P

some cases being very slight, not causing sufficient obstruction to the respiration to attract the attention of the patient; while in other instances the increase in size is sufficient to block up the nasal chambers and occasionally to project backward, presenting tumefied masses in the naso pharyngeal space.

Septal deformities may be either deflections or in the form of ecchondroses or exostoses. They may originate either as a result of traumatism or from an inflammation of the mucous membrane. Traumatism in early youth or infancy plays no doubt a most important part in the production of these deformities, but I believe it is by no means the frequent cause that is so generally assumed. It may happen that these injuries in infancy are readily overlooked or forgotten; but when they do not occur until later in life, an injury sufficient to produce a marked bending of the septum is not apt to pass entirely out of the memory. These conditions have their beginning in the infancy or early life of the subject. When such a person is exposed to cold a catarrhal inflammation of the lining membrane of the nose sets in, with a resulting nasal stenosis. This, of course, acts in the same manner as in hypertrophic rhinitis by producing a rarefaction of the air posterior to the stenosis, with a resulting hyperemia which eventually becomes chronic. The consequence is an increased nutrition of the parts with, in the case of the cartilaginous portion of the septum, a production of cartilage cells beneath the mucous membrane. This production of cells continues as long as the irritation lasts, and there is a distinct projection from the septum into the nasal chamber known as an ecchondrosis. The same process holds true for the vomer, when the projecting process or tumor is composed of bone, and is known as an exostosis. They may exist either alone or the one may be continuous with the other, and they generally have their starting at the sutural junction between the triangular cartilage and the vomer. Occasionally we find them without any deflection of the septum, but in the majority of cases there is some decided bending to the side corresponding to the ecchondrosis or the exostosis. Syphilis is also, in my experience, a common cause in the production of these conditions.

The deformities resulting from deflection of the septum are not so readily explained. It is occasionally congenital, and in many cases it results from traumatism, but this is not so common an etiological factor as to explain this very frequently occurring deformity. Inflammations explain the process of bending in a few cases by the weakening of the septum, the atmospheric pressure being greater on one side than on the other at some period of the process causes it to bend in the direction of the least resistance. In most instances it is the result of a physiological process the septum being fixed between two unyielding planes, bends to one side or the other in order to make room for its increased growth.

Adenoid Hypertrophy. Situated in the naso pharynx, pharynx wall, and at the base of the tongue there is a certain ring of tissue, similar in structure but differing from the neighboring tissues of the upper respiratory tract, which plays a very important part in the pathology of the diseases of this region. While all the lymphoid tissue forming this ring has a striking similarity in structure, there is a decided difference as regards its life history when diseased, in that the tissue in the naso pharynx shows a tendency to atrophy at puberty, while that in the fauces and lingual region may continue into adult life; indeed, the lymphoid tissue at the base of the tongue is rarely diseased until after puberty. This brings us to the consideration of the next and probably the most important form of obstructive disturbance met with in the upper respiratory tract, and that is hypertrophy of the lymphoid tissue in the vault of the pharynx. This affection has been variously described as enlargement of the third tonsil and adenoid vegetations. It has been recognized for many years, but it was left to the late Prof. Wilhelm Meyer' to point out the frequency of its, occurrence and its clinical importance. It is essentially a disease of childhood, occurring occasionally at the earliest periods of life. While it shows a tendency to disappear at puberty, it is frequently observed in adults. Although this affection cannot properly be said to be due to heredity, it is nevertheless observed as occurring very frequently in families with the so called lymphatic temperament. Several members of the same family may be afflicted in the same manner, all showing a tendency to hypertrophy also of the faucial and the lingual tonsils.

Climate has a very decided influence in the production of this condition, it being much more frequently observed in cold, damp countries than in those where the atmosphere is warm and dry.

Probably the most frequent cause of the hypertrophy of this tissue is frequent and neglected attacks of catarrhal inflammations of the nose and naso pharynx the lymphoid tissue becoming once inflamed, shows a tendency to continue and become chronic through the same agencies that produce hypertrophy of the inferior turbinal bodies, with which it is very frequently associated. Among the other exciting causes may be mentioned diphtheria and the exanthemata.

The stenosis resulting from an acute catarrhal rhinitis, or from that due to one of the previously mentioned obstructive nasal disorders, may be sufficient to excite a hyperemia and swelling of the post nasal lymphoid tissue by rarefying the air in the naso pharyngeal space. This congestion resulting from lessening of the atmospheric pressure in this region causes an increased nutrition of the tissue with a consequent hypertrophy of its constituent elements.

In the faucial lymphoid tissue there are several distinct pathological conditions recognized, viz., the acute inflammations, which may involve only the mucous covering of the gland or extend into the follicles, giving rise to the croupous or follicular variety; or the whole gland may be involved, and, going on to the suppurative stage, result in abscess of the tonsil or peritonsillar tissue. In the chronic form we recognize the hypertrophic variety, and, according to the classification of Bosworth, the hyperplastic, which is in reality an advanced stage of the hypertrophic form.

The croupous variety is a simple inflammation of the follicles that go to make tip the gland, infectious in character, and manifested by a thick deposit making its appearance at the mouths of the crypts, and occasionally spreading out as a membrane on the surface of the gland. This exudate is soft and easily wiped away from the tonsil, when it can be seen exuding from the mouths of the follicles. In the hypertrophic variety of tonsillitis there is an increase in all the tissues that constitute this gland. The follicles occasionally become over distended with secretion, giving rise to a constant fetid discharge from the gland. In the hyperplastic variety there is an increase in the connective tissue elements, with a gradual destruction of the lymphoid tissue proper. in these cases the gland becomes hard and fibrous in character.

The lingual tonsil situated at the base of the tongue is liable to be affected by any of the pathological conditions mentioned as affecting the other lymphoid glands; but it is much more rarely affected. It is essentially a disease of adult life, and may have for its origin any of the infectious diseases; but it is more frequently associated with some form of gastric disturbance.

SYMPTOMATOLOGY.

Many of the diseases affecting the naso pharyngo laryngeal tract have symptoms which are common to one or more of them, and in a general way they may be either subjective or objective the former relating to the disturbance of functions of the organs affected, while the latter are such as can be seen by the observer only.

Obstruction to nasal respiration, resulting in mouth breathing, is one of the most prominent symptoms among nasal disturbances, as previousIv set forth.

Occasionally the patient will be found to insist that he has perfect nasal respiration, especially when the intranasal obstruction is not sufficient to make a very decided impression on him, but careful questioning will generally elicit the further information that lie awakens in the morning with the mouth open and dry, and that there is snoring during sleep. This symptom is probably more frequently noticed in children who are also very restless during sleep, frequently awakening and calling for water to moisten their parched throats. When the mouth breathing has existed for some time most decided changes are noticed, not only in the soft parts, but also in tile bony frame work of the mouth and chest, which are more severe the younger the individual. The features are relaxed and assume a well recognized indolent and stupid expression.

Disturbances of speech, such as stuttering and imperfect articulation, are also frequently observed.

Headache is a common symptom noticed in many forms of intranasal disturbances, especially when resulting from the pressure on the soft parts of bony or cartilaginous projections from the septum, from pressure due to swelling of the middle turbinals, and in inflammatory conditions of the accessory sinuses.

Loss of memory and lack of mental application to the extent of being unable to concentrate the attention upon any one subject are symptoms frequently observed in these nasal and post nasal disturbances. it is especially noticeable in children suffering from hypertrophy of the post nasal lymphoid tissue. These little subjects frequently get the reputation unjustly of being stupid, when their mental inactivity is entirely due to some form of nasal obstruction. This is the condition described by Guye of Amsterdam as aprosexia.

Nocturnal enuresis is a symptom so frequently associated with nasal obstruction in children, especially that resulting from lymphoid hypertrophy, that its concurrence can scarcely be called accidental. Groubech, cited by Schech, out of 192 cases of hypertrophy of the post nasal lymphoid tissue, found enuresis 24 times. Twelve of these cases were cured after operation.

The Palate and Teething brief reference in this place may be made in connection with mouth breathing to the changes in the arch of the hard palate, which in the very young becomes altered, assuming an acute bow or V shape. This deformity results from a combined pressure of the buccal muscles exerted on both sides and a column of air constantly striking the hard palate. Korner distinguishes between the alterations of the upper jaw of children who have suffered from nasal stenosis before the shedding of the deciduous teeth, and those which result from nasal stenosis during the change of teeth. In the first instance there occurs generally the cupola shaped elevation of the palate; the alveolar border which naturally forms a semicircle assumes the form of an ellipse; but there is no change in the position of the teeth. If the nasal stenosis exists at the time of the change of the teeth, then the lateral alveolar borders are approximated while the anterior border is pushed forward, and the high arch of the palate increases until it encroaches upon the cavities above. The teeth in these cases assume a very irregular shape.

Diseases of the ear frequently accompany nasal and post nasal disorders, and vary from a simple occlusion of the Eustachian tube, resulting from an acute rhinitis, to a severe suppuration of the middle ear, with all its dangerous sequele. Children suffering from hypertrophy of the post nasal lymphoid tissue frequently exhibit various degrees of deafness, varying according to the size of the growth from a slight diminution of the hearing to almost complete deafness.

Loss of smell, varying from a slight impairment to a complete loss of the function, known as anosmia, may accompany almost any form of intranasal disturbance involving the upper part of the nose ; but it is most frequently associated with development of polypi and other inflammatory conditions of the ethmoid bone. In many cases where there is a loss of smell there will also be observed some disturbance in the function of taste. While the taste may not be absolutely lost, it will often be found very much diminished for the perception of flavors.

Voice. The influence of nasal diseases is frequently observed on the voice, the obstructive affections of the nose and naso pharynx modifying its tone and rendering articulate speech thick or muffled and difficult to understand. These defects are occasionally observed in paretic conditions of the soft palate which so often accompany disorders of the nose and naso pharynx, giving the voice a nasal character, so that it is difficult at times to distinguish it from that due to nasal stenosis. The pronunciation of certain consonants under these conditions is considerably modified; for example, d sounds like n, and 6 is similar to m, while the sound of g is very difficult to make. It frequently becomes a nice point to decide whether the cause of these speech defects lies within the nose, naso pharynx, or is of central origin.

In laryngeal affections the voice may be natural in speaking and altered only in singing, breaking in the passage from the lower to the higher registers. It may be hoarse or uncertain, being natural at times and husky at others, or it may be entirely absent as in aphonia. The respiration may be seriously embarrassed both in nasal and laryngeal affections. In the former it may be obstructed by either acute swelling or hypertrophy of the turbinal bodies, hypertrophy of the post nasal lymphoid tissue, deformities of the septum, or by new formations within the nasal cavities, such as polypi.

Respiration. In laryngeal affections the respiration may be more or less embarrassed, hurried, or retarded, according to the nature of the affection. It is often accompanied by a loud noise which may be either stridulling inspira ous or stertorous in character the former generally accompanying tion, when it indicates some laryngeal obstruction resulting from new formations or foreign bodies, spasm of the laryngeal muscles, false membranous deposits, or paralysis of the abductor muscles of the vocal cords; while stertorous breathing more frequently accompanies expiration and is associated with general paralytic conditions.

Cough is a common symptom of diseases of the larynx, varying in character according to the location and intensity of the inflammation from a simple backing cough or clearing of the throat to one that is hoarse, barking, or metallic in sound. It may occur in paroxysms and is frequently suffocative. Cough is also a not infrequent symptom of diseases of the nose and naso pharynx, when it is said to be reflex in character, and due to some pressure on the sensitive nerve filaments in these regions or to an undue irritability of certain sensitive areas, as in the auditory canal, which when irritated give rise to an annoying form of paroxysmal cough.

Deglutition in diseases of the upper respiratory tract may be either difficult, a condition known as dysphagia; painful, odonphagia; or at times impossible, aphagia.

While dyspliagia is not a symptom very common to nasal affections, it nevertheless occurs occasionally in those cases where there is a decided enfeeblement of the soft palate resulting from nasal and post nasal inflammations. It is much more frequently observed in those cases in which the pharynx and larynx are involved, especially where there is obstruction in the fauces, pharynx, or esophagus, or where there is any ulceration or destruction of the velum, either with or without an enfeeblement of the nervo muscular control of the constrictor muscles of the pharynx. It frequently happens in such cases that the food passes into the nares. Occasionally also, when the epiglottis is either ulcerated or destroyed through the action of syphilis or tuberculosis, the food has a tendency to pass into the larynx until the parts so adapt themselves as to enable it to follow the natural channel into the esophagus.

Odonphagia is associated with nearly all the acute inflammatory affections of the pharynx, particularly tonsillar inflammations, and also with many of the chronic conditions of the larynx, such as tubercular laryngitis, especially when the epiglottis is involved; or when this organ is the seat of malignant disease.

Aphagia is generally present when the larynx or the pharyngo laryngeal tract are the seat of malignant disease, and results either from the act of swallowing being so painful that the patient refuses to swallow, or the obstruction is so marked that it cannot be overcome.

Under the beading of objective symptoms or those revealed to the physician by the various methods of examination, may be mentioned a change in the color, form, position, and secretion of the parts studied.

The color may be increased or diminished according to the nature of the disease, being increased in all affections of an inflammatory nature, the intensity varying in degree according to whether the parts are the seat of an acute, subacute, or chronic inflammation It is frequently diminished in those cases where there is general anemia or a marked depression of the heart's action.

It may be altered when the patient is suffering from such general conditions as jaundice, when the membrane assumes a decidedly yellow hue, or from tuberculosis in its early stages, when the membrane frequently presents a grayish appearance.

The form may be changed by an increase of tissue, as in the hypertrophic form of inflammation so often noticed in the nasal and naso pharyngeal cavities, or by a decrease of tissue, such as is observed in atrophic rhinitis. In the larynx the lining membrane may be the seat of a serous, purulent, tubercular, syphilitic, or malignant infiltration, sufficient at times to encroach upon and diminish the caliber of the glottis to a marked degree. The size and shape of the glottis may be changed by the several positions assumed by the vocal cords in the various paralyses of the intrinsic muscles of the larynx. The position of the nose may be altered by any morbid growth springing from within the nasal cavity, but otherwise it is rarely changed. The larynx, however, is very frequently displaced from its normal position by such extra laryngeal affections as bronchocele, cancer, or enlarged glands of the Deck; while contraction of the cicatricial tissue resulting from syphilitic ulceration in many instances disturbs the normal relation of the parts within the cavity.

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