Diseases of the nose, throat and ear, medical and surgical

Front matter

DISEASES

OF THE

NOSE, THROAT AND EAR

Preface To Second Edition

The exhaustion of the first edition within a year has given the author an unexpected opportunity. He has sedulously endeavored to remove the imperfections unavoidable in an issue from the original manuscript, and to make such improvements as are naturally suggested by having the whole book before the eye in printed form. Each line has been scrutinized to insure clearness, every page carefully corrected and many rewritten, and in several chapters new material has been added — the whole book, in short, being brought abreast of its subjects to date of issue. Among other changes may be mentioned the redescription of the operation for submucous resection, with several new engravings. The chapter on the surgery of the nasal accessory sinuses has been greatly enlarged, several new operations being described and fully illustrated. The same is true of the chapter on the surgery of the tonsils. The functional tests of the labyrinth and their clinical application, as elaborated by Barany, Neumann, and others, are fully described and illustrated. This addition places the section on the Ear on a new and higher plane. The otologist of today cannot render full service to his patients without the application of these tests and their clinical deductions, hence the author has endeavored to make them plain both by carefully describing them and illustrating the technique. Several pages would be required to enumerate the changes and improvements in this edition, and those above mentioned must stand as examples.

The general purpose of the work is unchanged. It was designed as a text-book for students, as a guide for the general practitioner, and as a reference for specialists. Its contents are very comprehensive, as they include the medical and surgical treatment of the diseases in the entire region of the nose, throat, and ear, specialties naturally belongingtogether. A feature that has been favorably received is the elaborate illustration throughout the work. Thus the successive steps of nearly every accepted operation are shown, so that the reader can master them at leisure. The engravings are mostly from original drawings. In this revision there are one hundred and twenty-five new figures, showing the latest surgical procedures and diagnostic measures. Many iv PREFACE

of the pen drawings in the first edition have been replaced with more effective brush work. It may not be amiss to characterize the volume as a combined text-book and atlas covering its three subjects.

The author desires to thank Dr. J. R. Fletcher for his valuable aid in preparing the section on the Functional Tests of the Labyrinth and their Clinical Applications, and Dr. W. Golden Mortimer for assistance in the proofreading and in the preparation of the Index.

As the publishers gave the author absolute liberty to make such changes in the text and illustrations as he might deem for the advantage of the work, the type has been wholly reset.

W. L. B.

Chicago, 1909.

THE NOSE AND ACCESSORY SINUSES,

Chapter I. The Clinical Anatomy And Physiology Of The Nose And Accessory Sinuses

THE NOSE.

The Nasal Chambers. — The nose is divided, by the nasal septum, into two chambers, the right and the left. The nasal chambers are for respiratory, olfactory, phonatory, and gustatory purposes. The inspiratory current passes upward from the vestibules to the middle and superior meatuses, and is thence deflected downward and backward by the middle turbinals and the roof of the nose to the choanal, into the epipharynx. The expiratory current is deflected from the vault of the epipharynx into the choanal, and thence forward through the middle and inferior meatuses to the vestibules of the nose (Fig. 2).

The practical clinical application of the foregoing facts lies in the different effects of stenosis in the inferior and in the superior portions of the nasal chambers. An obstructive deformity of the lower portion of the septum may interfere somewhat with the expiratory current, as it blocks the inferior meatus while the middle and superior meatuses are free, and the expiratory current, therefore, passes through the nasal chamber upon the obstructed side with but little or no impediment. The obstruction in the lower portion of the nasal chamber does not materially interfere with the inspiratory current, as its course is normally higher in the nasal passage. There are exceptions, however, to this rule. If, for example, the deformity of the septum extends well forward into the vestibule of the nose it will materially interfere with the inspiratory current, as it blocks the entrance to the nose. (See Chapter IV.)

The Septum. — This subject is fully discussed in connection with the deformities and malformations of the septum. (See Chapter IV.)

The Turbinated Bodies. — The turbinated bodies, three in number, are located upon the outer wall of the nasal chambers, and are known as the inferior, middle, and superior turbinated bodies (Fig. 2), of which 2 only the inferior and middle are of clinical importance. These are characterized by the presence of venous plexuses in the submucous tissue of the membrane, known as " swell bodies/' or the erectile tissue of the nose. The erectile tissue is chiefly distributed along the inferior border of the inferior turbinal, and on the posterior ends of the inferior and middle turbinals. Its function is supposed to be that of warming the inspired air and of regulating the amount of serous secretion. Either process is of vital importance to the lower respiratory tract. The lower respiratory tract does not secrete enough moisture for physiological purposes (protective), nor is it capable of warming the inspired air sufficiently to bring it to the body temperature without injury to its mucous membrane. It is important that the heating and humidifying apparatus of the nose should be in good physiological condition. When, therefore, the vasomotor nerves which regulate the erectile tissue are disturbed in their function, the preparation of the inspired air for the lower air tract is imperfectly performed. The lower air tract is exposed to the irritating influence of the inspired air, and irritation of the lining mucosa and of the endothelial cells which line the air vessels of the lungs may result in bronchitis, while the transfusion of the gases, oxygen and carbon dioxide, may be disturbed in the air vesicles. The processes of tissue metabolism or the chemistry of nutrition are perverted.

In addition to the foregoing conditions resulting from the disturbed functions of the "swell bodies," the patient may experience either a sense of "stuffiness" of the nose or of a foreign body, or the reverse, an unduly open nose. If, for example, there is an anterior or vestibular obstruction from any cause, the negative pressure thus brought about causes an engorgement of the "swell bodies," with the resultant disagreeable symptoms already described. This condition is known as rhinitis with turgescence. If, on the contrary, the patient is anemic, the swell bodies may become collapsed and the nasal chambers unduly patulous. This condition is known as rhinitis with collapse of the erectile tissue. The turbinated bodies are of clinical interest, for the further reason that they divide the nasal chambers into three partial chambers or meatuses. The inferior meatus is the space between the floor of the nose and the inferior turbinal. The middle meatus is the space between the inferior and middle turbinals. The superior meatus is the space above the middle turbinal. The meatuses are of great clinical interest on account of the accessory nasal sinuses opening into them.

The Meatuses. — The inferior meatus is of clinical importance, as the nasal orifice of the tear duct opens in its anterior portion (Fig. 167), and because it is a part of the expiratory air tract.

The Middle Meatus. — The middle meatus is of great clinical importance because the frontal, anterior ethmoidal, and the maxillary sinuses open into it. The frontal and the anterior ethmoidal cells drain into the infundibulum in 50 per cent, of the cases. The bulla ethmoidalis and the cells in the middle turbinal (Fig. 142) do not drain into the infundibulum, but open directly into the middle meatus. The bulla is often quite large and bulges so much toward the septum that it encroaches

THE NOSE 19

upon the infundibulum and entirely obstructs it. It thereby interferes with the drainage of the frontal, maxillary, and the anterior ethmoidal cells. The cells opening into the middle meatus are referred to for convenience as Series I.

When pus is present in the middle meatus it is significant of empyema of one or more of the cells comprising Series I, namely, the frontal sinus, the anterior ethmoidal, and the maxillary sinuses (antrum of Highmore).

The Superior Meatus. — The superior meatus is of clinical interest because the posterior ethmoidal and the sphenoidal cells (Series II) open into it. This meatus cannot be directly inspected on account of its hidden position above the middle turbinal. It may, however, be examined with a probe. When pus flows into it from the posterior ethmoidal and sphenoidal sinuses, and the olfactory fissure is not completely closed, it may be seen lying between the septum and the middle turbinal (the olfactory fissure).

The superior meatus is of still further clinical interest because the terminal filaments of the olfactory nerve are distributed there. (See Olfactory Nerves.)

The Sinuses Residual Organs. — The nasal accessory sinuses in man are the remains of the olfactory organ, hence they have a low recuperative power after operations. I have repeatedly observed the slow and sometimes incomplete repair after operations, even after the most thorough exenteration, especially of the ethmoidal cells. I attribute this to the fact that the structures in man have ceased to perform the function they were originally designed to do. Through long ages of retrogression the tissues have lost some of their vitality and do not regenerate with the same degree of vigor as those structures which still perform their functions.

The Nerve Supply of the Nose. — The Sensory Nerves.— The sensory nerves of the nasal septum, the X. ethmoidalis anterioris and the N. nasopalatine, send their filaments to the anterior and posterior portions of the septum respectively. The N. ethmoidalis anterioris passes through the anterior portion of the cribriform plate (Fig. 1), thence forward and downward to the vestibule. The X. nasopalatine extends forward and downward on the septum to the canalis incisivus, anastomoses with that of the other side, and ends in the mucous membrane, of the hard palate.

The sensory nerve supply of the outer walls of the nose is derived from the X T . ethmoidalis anterioris and from branches of the ganglion sphenopalatinum. The X T . ethmoidalis anterioris supplies the anterior portion of the lateral walls in front of the turbinated bodies, and the turbinated bodies are supplied by branches of the sphenopalatine ganglion (Fig. 2). The hard and soft palates are also supplied from this ganglion. These anatomical facts may be utilized in injecting cocaine for anesthetic purposes (Killian) and in injecting alcohol in the treatment of hyperesthetic rhinitis (O. J. Stein).

Vasomotor branches are also supplied to the vessels of the mucous membrane and erectile tissue of the turbinated bodies from the ganglion sphenopalatinum, and are under the control of the vasomotor centers of the medulla; there is probably a connection with the nuclei of the vagus through association fibers (Watson Williams).

Fig. 1

Nerve supply of the septum nasi, a, N. ethmoidalis anterioris; b, N. olfactorii; c, N. nasopalatinus; d, canalis incisivus. (After Spalteholz.)

Fig. 2

Nerves of the lateral wall of the nose, a, ganglion sphenopalatinum; b, rami nasales posteriores superiores laterales; c, rami nasales posteriores inferiores laterales; d, Nn. palatini; e, Nn. olfactorii; f, rami nasales interni, N. ethmoidalis anteriores. (After Spalteholz.)

The distribution of the accessory nerves over the septum and the outer walls of the nose, and especially the branches from the sphenopalatine ganglion over the turbinate, at once suggests the reason for the sensitiveness of these areas when the mucous membrane is inflamed, or is so

THE NOSE 21

swollen that it impinges against the septum. It also suggests the reflexphenomena, as asthma, often observed when there is inflammation or other disease of these regions. The association fibers, referred to above, connecting the sphenopalatine ganglion with the vagus establish a physiological relationship between the upper and the lower respiratory tracts, hence the asthma of nasal origin. I have repeatedly seen cases in which the asthma promptly disappeared after the removal of nasal polypi, or after an exenteration of the ethmoidal labyrinth for sinuitis. The irritation of the terminal filaments of the turbinal branches from the sphenopalatine ganglion was thus removed, and the reflex stimulus through the ganglion to the vagus and thence to the bronchial muscles ceased to be given off; hence, the bronchial spasm (asthma) was cured.

The vascular engorgement present in chronic rhinitis with turgescence is due to a paresis of the vasomotor constrictor muscles supplied by the branches of the sphenopalatine ganglion.

The Olfactory Nerve. — The olfactory nerve descends through the lamina cribrosa (cribriform plate) from the under surface of the olfactory bulb and is distributed in the mucous membrane covering the upper portion of the superior turbinal and a corresponding portion of the septum (Figs. 1, 2, and 5). Formerly it was thought that the distribution of the olfactory nerve in man covered a much more extensive area, the upper and median surfaces of the middle turbinal and a corresponding area of the septum being included in the alleged area of distribution. In many of the lower animals the nerve has a wider distribution; the sinuses communicate more freely with the nasal chambers and arc utilized for the spread of the terminal olfactory nerve filaments. In man they are the remains of the organ of smell, and only communicate with the nasal cavities through small ostei or cell openings, as they are no longer needed for olfaction.

To return to the olfactory nerve. It is obvious that if the middle turbinal and the septum are in apposition, the inspired air does not reach the olfactory region, and anosmia or loss of smell results. It follows that if the obstruction to the olfactory fissure is overcome, either by the removal of the middle turbinal or by the correction of the deviation of the septum, air is admitted to the olfactory region and the sense of smell is restored, provided the nerve has not undergone degeneration.

Inasmuch as the distribution of the olfactory nerve is limited to the superior turbinal and the corresponding portion of the septum, the middle turbinal and the ethmoidal cells may be removed in their entirety without interfering with its distribution. In such operations the superior turbinal should be left intact in so far as it is compatible with a complete exenteration of the ethmoidal cells.

The Blood Supply of the Nose.— The middle meningeal artery gives off the sphenopalatine branch, which, when it reaches the posterior portion of the lateral wall of the nose, subdivides into the lateral posterior nasal arteries. These are distributed over the middle and inferior turbinals and the middle and inferior meatuses. The superior turbinal and the anterior portion of the outer wall of the nasal chamber are supplied by the posterior ethmoidal and the anterior ethmoidal arteries respectively (Fig. 3).

Fig. 3

The arterial supply of the lateral wall of the nose, a, A. meningea anterior; 6, A. ethmoidalis anterior; c, A. ethmoidalis posterior; d, Aa. nasales posteriores laterales; e, A. sphenopalatina; /, Aa. palatinae major et minores.

Fig. 4

The arterial supply of the septum nasi, a, A. ethmoidalis anterior; b, A. ethmoidalis posterior; c, A. nasales posteriores septi; d, anastomosis with the A. palatina major. (After Spalteholz.)

As the posterior lateral nasal arteries are of considerable size, it is to be expected that the removal of either the middle or inferior turbinated

THE PHYSIOLOGY OF THE NOSE bodies may be attended by considerable hemorrhage. As a matter of fact, the removal of the middle turbinal is usually followed by more or less bleeding for twenty-four hours. There is a free anastomosis between the lateral nasal arteries and the anterior ethmoidal artery; hence, after the removal of the turbinated body bleeding may come from both sources though but one artery is injured.

The septum is supplied by the A. nasales posteriores septi, a branch of the A. sphenopalatina, through the foramen sphenopalatinum. It has three main branches : one supplies the posterior, another the inferior, and the other the middle and posterior portions of the septum.

The A. ethmoidalis anterior and the A. ethmoidalis posterior are distributed to the anterior and the superior portions of the septum (Fig. 4). Severe hemorrhage occasionally attends or follows an operation upon the septum, especially when the operative field includes the middle branch of the A. nasales posteriores septi.

Fig. 5

THE PHYSIOLOGY OF THE NOSE.

The functions of the nose are olfactory, phonatory, respiratory, gustatory, and the ventilation of the nasal accessory sinuses. The gustatory function in man is probably of least importance, the olfactory of secondary importance, the phonatory of tertiary importance, while the respiratory and ventilating functions are of the greatest importance.

The Sense of Smell.— The olfactory nerve, or organ of smell, is located in the upper portion of the nasal chambers, The olfactory nerve (Fig. 5) is distributed over the attic of the nose as far downward as the upper margin of the middle turbinated body and on the septum over a corresponding area. A knowledge of the area of distribution of this nerve is of practical importance in the diagnosis, prognosis, and treatment of certain diseases of the nose. If there is anosmia, or loss of the sense of smell, the question arises as to whether the impairment is due to a degenerative change in the nerve itself, or to an obstruction to the entrance of the odoriferous particles or emanations to the terminal cells of the olfactory nerve.

Showing the area of distribution of the olfactory terminal nerve cells in the human nose. The triangular flap is the septum turned upward; the area of distribution is limited to the region of the superior turbinal, and a corresponding area of the septum, the middle turbinal receiving few or no olfactory cells.

The lesions may, however, be intracranial, in which case there may be no evidence of either an obstructive lesion or of degenerative changes in the attic of the nose.

The loss of the sense of smell, while not comparable to the loss of the nasal respiratory function, is, nevertheless, attended by considerable inconvenience. The pleasure experienced by the recognition of certain odors is longed for by those affected by anosmia. More than this, they have lost one of the senses whereby they are protected from harm by certain substances, as ammonia, etc. By its aid we are warned of the near approach to decaying matter, or other foul-smelling and unsanitary substances. In the lower animals the sense of smell is of much greater utility in seeking food and in detecting the approach of hunters and animals intent upon their destruction.

Phonation. — The function of the nose in speaking and singing is so important that Jeane de Reske has said that the more he studies the voice the more he is convinced that it is a question of the nose. I have often noted that popular public speakers had well-developed nasal resonance, while speakers lacking resonance had difficulty in holding the attention of their audiences. While the initial tone is produced by the vibrations of the vocal cords, the voice is decidedly unpleasant and unmusical if it is not rich in overtones from the resonance chambers of the nose, throat, and chest. (See The Singing Voice.) The nasal chambers and accessory cavities are of prime importance in voice production, and any obstruction from swelling of the mucous membrane, deflection, or other lesion of the septum so materially alters the quality of the voice as to make it disagreeable and inartistic.

Nasal Respiration. — As before stated, the respiratory function of the nose is the most important. The nasal chambers are more than mere tubes through which air is drawn into the lungs; they produce certain changes in the air which prepare it so that the normal transfusion of oxygen and carbon dioxide may take place through the walls of the air vesicles. The respiratory functions of the nose are threefold, namely: (a) to temper, (6) humidify, and (c) filter the inspired air.

Experiments have demonstrated that no matter what the temperature of the air may be before it is inhaled, it is raised or lowered, as the case may be, to near the body temperature. The delicate structures of the deeper respiratory tract are thereby protected against the great variations and extremes of temperature.

It has also been shown that the air in passing through the nasal chambers receives moisture from the nasal mucous membrane. The mucosa of the lower respiratory tract and the epithelial walls of the air vesicles of the lungs are thus protected from the varying humidity of the atmosphere. In passing through the nose the air is raised (usually) in temperature, thus expanding it and increasing its capacity to absorb moisture. The " swell bodies," or erectile tissue of the nose, and the serum-secreting glands of the nasal mucosa give off moisture, which is rapidly taken up by the expanded air and carried to the lower respiratory tract, where

THE PHYSIOLOGY OF THE NOSE 25

the serum-secreting organs are much less developed. It has been estimated that approximately one pint of serum is thus transferred from the nasal cavities to the lower respiratory tract in twenty-four hours.

The part of the nasal structures which secrete most of the serum is generally supposed to be the ''swell bodies" or erectile tissue, located chiefly along the free border of the inferior turbinated bodies, and on the posterior ends of the middle and inferior turbinated bodies. The latter portions sometimes become enlarged and form the so-called mulberry hypertrophies. It is probable that the mucous glands also secrete some of the serum. The "swell bodies" are under the control of the vasomotor nervous system, which, under normal conditions, regulates the supply of moisture to meet the demands. If the air is dry the swell bodies enlarge and become just active enough to fully saturate the expanded air in the nose; whereas if the atmosphere is humid they are less active. When an obstructive lesion, or catarrhal inflammation, is present, the "swell bodies" and glands do not respond normally to the atmospheric conditions, hence the air is not properly humidified in its passage through the nose. The treatment of these conditions should be, therefore, so directed as to restore the "swell bodies" and glands to their normal activity. In order to do this, it may be necessary to give stability to the vasomotor nervous system by judicious bathing, outdoor exercise, etc. In addition, local massage of the mucous mem brane and other treatment may be necessary. Surgical interference should always be accomplished with respect to the location of the "swell bodies," care being exercised to avoid their destruction, except in those cases in which they have undergone considerable hypertrophy. The surgery of the middle turbinated body may be practised with much greater freedom, because it does not have so much to do with the respiratory functions of the nose. The inferior turbinated body, however, should be treated surgically only when its secretory function is largely destroyed, or when it is so enlarged by hypertrophic or hyperplastic changes that it obstructs nasal respiration.

That the nose is a filter is evident upon inspection of the secretions and the vibrissas of the vestibule, as they are loaded with dirt. The vibrissa? guarding the atrium of the nostrils act as a coarse filter, the larger particles lodging on them, the smaller ones entering the nasal cavities, where they are caught upon the irregular surface of the moist mucous membrane. The lower air tract is thus protected from the irritation which would otherwise result. F. C. Cobb, under the direction of Frederick Coolidge, of Harvard University, has shown by a long series of experiments that the secretions posterior to the vestibules of the nose are sterile, thus demonstrating the great physiological importance of the vibrissa* and the sterilizing quality' of the nasal secretions.

The Gustatory Function of the Nose. — The real gustatory or taste sense (sweet, sour, acid, bitter, and salt) is supplied by the distribution of the glossopharyngeal and the fifth nerves to the fauces and the base of the tongue, whereas the delicate flavors which give so much pleasure to the consumption of foods and drinks are appreciated through the olfactory nerve. If the nostrils are closed and the eyes covered it is almost impossible to distinguish between coffee and water of the same temperature, as the aromatic flavor cannot be appreciated by the nose when closed.

Ventilation of the Sinuses. — I have assumed a fifth function of the nose — the ventilation of the accessory sinuses — which has not heretofore been described under the physiology of the nose. It is obvious to anyone who has had an abundant opportunity of observing inflammation of the sinuses, that ventilation is a prime requisite for the maintenance of the mucous membrane of these cavities in a healthy condition. Any interference with the ventilation of these cavities lowers the resistance of the mucous membrane and the diminished amount of oxygen allows the secretion to undergo rapid decomposition.

Summary: The functions of the nose are fivefold, namely:

1. Olfactory, located in the attic of the nose.

2. Phonatory, enriching the voice by overtones.

3. Respiratory.

(a) The air is warmed or tempered to or nearly to the body temperature in passing through the nose, thereby preventing shock and irritation to the mucosa and air vesicles of the lower respiratory tract.

(b) The air is expanded by the warmth of the nasal chambers, and its capacity to absorb the moisture thrown off by the "swell bodies" and mucous glands is increased. The mucosa and air vesicles are thus moistened, or, at least, their moisture is not absorbed (the air being already saturated in its passage through the nose), and irritation is prevented. The nose keeps the inspired air in a state of saturation.

(c) The air is filtered in its passage through the nose by the vibrissa? and the moist mucous membrane. The irritation to the mucosa and air vesicles which would otherwise occur is thus prevented.

4. The gustatory (olfactory) sense complements the sense of taste.

5. The ventilation of the accessory sinuses maintains the normal resistance of the mucous membrane and prevents the rapid decomposition of the secretions.

Chapter II. The Nose, Throat, And Ear In Relation To General

MEDICINE.

The writings of William Meyer, of Copenhagen, William Daly, of Pittsburg, and E. P. Friedreich, of Leipsic, have given a breadth to rhinology, laryngology, and otology which they did not have in the days when practice along these lines was regarded as a "specialty." With this broader view they are now regarded as the pursuit of the practice of general medicine and surgery, with special reference to the diagnosis and treatment of diseases in general, and those of the nose, throat, and ear in particular.

A proper comprehension of the relation of the nose, throat, and ear to general medicine and surgery will be facilitated by a brief analysis of the interdependence and coordination of the various organs and parts of the body.

ELEMENTARY FACTS.

(a) The Breathway. — The upper respiratory tract is the channel in which the air is prepared for the interchange of gases which takes place in the air vesicles of the lungs. The nose is especially concerned in the process of humidifying, warming, and filtering the inspired air, and it is obvious that any disease or obstruction that interferes with these physiological processes will affect the transfusion of gases through the capillaries of the walls of the air vesicles. The absorption of oxygen by, and the elimination of carbon dioxide from, the blood will not occur in normal ratio. The blood will be deficient in oxygen and surcharged with carbon dioxide. As oxygen is essential to the processes of assimilation and nutrition, its lessened quantity in the blood gives rise to certain disturbed conditions of the digestive, the assimilative, and the nutritive functions. The presence of an excess of carbon dioxide also adds to these disturbances. It is well known that the excessive accumulation of carbon dioxide in the blood acts as a poison to the leukocytes, thus interfering with their functional activity. A normal amount of carbon dioxide in the blood favors the assimilative, nutritive, and leukocytic processes, and it is only after a greatly increased amount of it is present that there are marked disturbances. It not only interferes with the activity of the leukocytes, but also with other cellular structures of the body as well. The combined effect, therefore, of an increased amount of carbon dioxide and a diminished quantity of oxygen in the blood is to produce general anemia, indigestion, malassimilation and nutrition, and infectious processes.

The xanthin group of toxins, including indican, are thrown into the circulation and give rise to certain nervous phenomena, as restlessness, peevishness, headache, mental depression, aprosexia, and a general feeling of malaise.

The digestive disturbances are still further increased by the ingestion of the infected secretions from the epipharynx and the tonsils. Putrefactive as well as pathogenic bacteria are swallowed with the secretions from the nose and throat, and give rise to what is commonly known as chronic dyspepsia or indigestion. It is probable that the putrefactive germs are more potent in this connection than the streptococci and the staphylococci. The conditions of the nose and throat which most commonly give rise to this kind of discharge are nasal stenosis, atrophic rhinitis, chronic rhinitis, sinuitis, epipharyngeal catarrh, and chronic follicular tonsillitis.

There are certain conditions of the stomach and of the intestinal tract which affect the mucous membrane of the upper respiratory tract. If, for example, there is chronic indigestion, there is also malassimilation and faulty metabolism. The imperfect products of indigestion are incompletely oxidized and are thrown into the circulation, where they irritate the mucous membrane of the nose, as well as the vasomotor nerves, thus causing local congestion and overnutrition. The secretions of the glands of the mucous membrane of the upper respiratory tract are also thereby modified, thus predisposing to, or at least intensifying, the catarrhal disease present. In the same way hyperacidity and subacidity of the stomach may indirectly irritate the mucosa of the nose and throat. One of the most potent influences exerted by the products of indigestion is through the reflex nervous system, pharyngitis, hypersensitiveness, sneezing, etc., being the direct expression of this condition.