the nose and pharynx are, as a rule, aggravated by acute exacerbations, a residence in the Western States, and especially in the southwestern parts (California, Arizona, New Mexico, Southern Utah), is less likely to intensify or maintain nasal disturbances than living in the Middle or Eastern States. Moreover, as irritative symptoms (sneezing, asthma, etc.) are usually promptly relieved by the western climate, especially at moderate altitudes, excepting in dusty regions, patients often experience much benefit from a trip to these parts of the country. Regarding its influence upon inflamed nasal passages, Colorado is not praised by its own physicians, but, in the author's experience, his patients have usually been benefited by its dryness and sunshine. Regarding the Southern States east of the Rocky Mountains his own. impressions have been much less favorable. There are, however, many chronic conditions, such as deepseated suppurative foci and hypertrophic lesions, that will not disappear under climatic influences alone, although the subjective annoyance produced by them is reduced by favorable climatic environment. 15. Factors in the Etiology of Diseases of the Upper Respiratory Organs.-Of great etiologic importance in the pathology of the upper air-passages are the anatomic configuration and the changes resulting from previous disease. It can be readily observed clinically that both suppurative and hypertrophic processes occur predominantly in narrow nasal passages, narrow either from pronounced relative narrowness of the skull or encroachment of the external nasal wall upon the caliber. Wide passages, on the other hand, appear in the minority in nasal affections, except in ozena, to which they predispose. Even more important are circumscribed encroachments upon the caliber of the passages, such as deflections of the septum, crests upon the septum, hypertrophies of mucous membrane, and enlargement of the pharyngeal lymphatic tissue. Hypertrophic processes accompanied by inflammation thus tend to perpetuation, by reason of the vicious circle to which they give rise. In one-sided nasal stenosis it is especially noticeable that any acute and ordinarily transient inflammation is likely to become persistent on the narrower side of the nose, or to extend to the ear of that side. Striking, too, is the diminished liability to acute "colds" after a properly indicated removal of a pharyngeal tonsil, a successful septum operation, or cauterization of redundant tissue. There are, moreover, some inflammatory processes, which, even though they seem to have healed entirely, as judged by clinical evidence, create a disposition to their own recurrence, such as acute inflammation of the frontal sinus, and especially tonsillitis. Hence the surgical treatment of existing chronic lesions, even when they cause but little discomfort, plays an important rôle in the prophylaxis of nasopharyngeal affections. The liability to structural changes depends often on hereditary peculiarities. Enlargement of the pharyngeal tonsils is strikingly frequent in some families; in others, it is totally absent. 16. Although most of the diseases of the nose and pharynx are strictly localized processes, their occurrence and persistence are in some instances more or less dependent upon morbid conditions elsewhere in the body. A specialist can never afford to lose his interest in general pathology. The liability to "colds" is increased by anemia and other conditions of malnutrition, and diminishes again with returning systemic vigor. Of acute infections of the accessory sinuses, the majority are incident in the course of infectious diseases, as shown by autopsies. While most of the sinus involvements under these circumstances present but few clinical symptoms, yet a small number turn into chronic and persistent forms. In affections of the maxillary sinus the origin must be sought in carious teeth in a moderate proportion of cases. Inflammatory processes in nose and throat are also largely influenced by disturbances of the digestive system. The various forms of dyspepsia, and especially constipation, are often a serious obstacle in the treatment of diseased air-passages, and proper attention to diet and the function of the bowels is not rarely the first step in the road to success. In chronic constipation which does not yield to fruit and exercise, enemata of hot water prove more serviceable in the end than the habitual use of laxatives. The discomfort due to a given degree of nasal disease is to some extent an index of the condition of the nervous system. Thus, for instance, chronic suppuration of the accessory cavities need not give rise to much actual suffering in subjects with vigorous nervous system, whereas in neurasthenic conditions such processes may cause considerable pain in the form of headache and neuralgia. The tone of the nervous system is also indicated strikingly by the vascular irritability in the nose and the so-called reflex disturbances thereby engendered in those cases in which there is enlargement of the cavernous plexus in the nasal lining. Thus it is not uncommon to see these disturbances intensified during pregnancy. In such instances more can often be accomplished therapeutically by advice from the standpoint of the neurologist than by treatment limited to the nose, although, of course, both lines of therapeutics should be considered. 17. From an etiologic point of view the habits of the individual must not be ignored. It can be readily observed that smoking tobacco irritates and increases the secretion in affections of the posterior parts of the nose and of the throat. The difference is promptly noticeable if the patient reduces his allowance of tobacco, especially if this is used in the form of cigarettes. If he can restrict himself within the limits of two or three cigars daily, or their equivalent in the pipe, it is generally unnecessary to insist on total abstinence. There is, however, one form of pharyngeal disease in the etiology of which smoking plays a greater rôle than in any other affection. It is the diffuse chronic pharyngitis, usually dependent, in the first place, upon nasal stenosis or nasal suppuration, and characterized by thickening and uniform injection of the pharyngeal wall, and especially its adenoid elements, the tonsils and strands of lymphatic tissue behind the posterior pillars. In this form the throat is very sensitive to mechanical contact. According to personal experience, this form of pharyngitis occurs mainly-though not quite exclusively-in smokers, and necessitates total abstinence for relief. Alcoholic excesses, too, may have some share in the etiology of this pharyngitis. The morning vomiting of hard drinkers is often dependent on this diffuse pharyngitis; sometimes, however, it is due to chronic inflammation of the lingual tonsil. Attention has also been called to the injurious influence that the drinking of very hot fluids may exert upon the pharynx. Inflammatory disease of the upper air-passages is also engendered and maintained by exposure to irritating dust and acrid gases. Workmen employed in lime, cement, arsenic, and especially chrome works frequently suffer from ulceration of the nasal septum. 18. Age is an important factor in the predisposition to different ailments of the upper respiratory passages. Although all ages are equally liable to acute coryza as well as chronic purulent rhinitis, suppuration of the sinuses is rarely seen clinically in young children, and, indeed, not often under the age of puberty, although anatomically it has been demonstrated frequently in connection with infectious diseases of the upper air-passages. The accessory cavities are but poorly developed until after the seventh year. Septum deformities, too, are uncommon. in childhood, especially crests and spurs, while deflections may occur before the second dentition, although they are infrequent. Hypertrophies of the nasal mucous membrane, in particular polypi, are rare lesions in childhood. This is one of the reasons why children are almost exempt from postnasal catarrh. Atrophic rhinitis. (ozena), on the contrary, usually begins early in life. The lymphatic structures in the pharynx do not grow morbidly after the first three or four years of life, unless hypertrophy had begun previous to that time. After puberty the morbidly enlarged tonsils, especially the pharyngeal tonsil, may recede moderately. When enlarged, they give rise to more annoyance during childhood than in later life, partly because pharyngeal and tonsillar inflammations are more especially an ailment of childhood and adolescence, and, in part, because the lymphatic structures become more fibrous and less vascular in the course of years. Infectious diseases localized in or involving the upper air-passages, such as diphtheria and the eruptive fevers, become less and less common as early childhood is passed. |