DEPARTMENT OF PEDIATRY.

CONDUCTED BY ROBERT W. HASTINGS, A.M., M.D.

ORIGINAL COMMUNICATIONS.

MOUTH BREATHING IN CHILDREN PARTICULARLY AS A RESULT OF ADENOIDS.*

ARTHUR G. HOBBS, M.D.

THAT the nose was intended by nature only as an olfactory organ is the accepted belief of the laity. But that so many of the profession should yet entertain the same idea is more to be wondered at. It would seem that many doctors have never taken the time to allow it to occur to them that olfaction is only a secondary function of the nose and that the space allotted to this least important of the senses is confined to a very small part of this most prominent feature.

The nose is intended for breathing through, and because of this very important function and on account of its possible closure from accident, or otherwise, the mouth may be brought into service as an auxiliary in time of need, but only temporarily-indeed only as an auxiliary to respiration. As an automatic organ, there are but few in the body to compare with the work performed by the lining membrane of a healthy and natural nasal mucous membrane. It supplies the proper moisture to adapt the air to the lungs by secreting an immense amount of fluid for dry air to pass over, or a much less amount when the air is moist, thus automatically adapting itself to the humidity of the inspired air. As in the gills of a fish, nature has supplied a large superficial area of mucous membrane surface to this upper part of the respiratory tract—about 36 square inches as computed

* Read before the American Laryngological, Rhinological and Otological Society, May 12, 1898, at Pittsburg, Pa.

by Dr. Onodi. And Binz, Onodi and others have estimated that as much as two pints of fluid are secreted daily by this large surface when the air is devoid of humidity in order to supply it with sufficient moisture to make it suitable to the parts below where the mucous membrane is less active in its secretory function and hence less automatic in its response to the necessities of a uniform degree of humidity of the inspired air. The ciliated epithelium of the mucous surface of the lower air passages performs another function than that of active secretion, which is generally the office of a membrane with a squamous epithelium, such as we the nasal and pharyngeal mucous membrane supplied with.

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In mouth breathing the inhaled air cannot pass over more than one-half of the moist surface that it does when inhaled through the nose, and this small surface is insufficient to impart the necessary moisture. Hence and how natural-the parched mouth and dry throat of one who has breathed, during sleep, through nature's auxiliary, the mouth, only. It would not be a stretch of the imagination should we reason by inference alone, without pausing to consider the many well known and easily demonstrable results, how disastrous to the lower air passages a constant and continuous mouth breathing would necessarily be to a growing Ichild. But this is not all. The other one of the principal functions of the nasal membrane seems even more wonderful in its automatic action. It warms the inspired air when it is too cold for the lower air passages. The arterial circulation of the membrane becomes greatly accelerated by the inhalation of cold air, without reference to its secretory function, and automatically regulates its surface heat according to the temperature of the inspired air. When the air is dry and warm its secretion alone is accelerated, and when it is cold and not devoid of humidity the increased activity of the arterial circulation supplies more heat

than fluid.

It would then be unnatural to expect an organ so delicately

poised not to easily become unbalanced when it is so

constantly

and directly subjected to the many sudden changes of temperature and humidity. And how much more. So when we remember that it has to bear the brunt, indirectly, of so many of nature's traversed laws through other, and even the more distant. parts of the body. Particularly should we be impressed

the fact when we remember that this organ is called upon

with

to per

form these automatic functions even in our climate with its almost daily changes of humidity and- its great ranges of temperature.

It is not necessary to follow up the pathological results of this constant battle that never ceases, where in so many cases it finally fails to preserve its physiological condition. Each recurrent attack adds to the effect produced before, ere nature has had the time, or the opportunity, to bring about the proper resolution. Hence, the result is nasal stenosis from an hyperplasia, or an hypertrophy of the turbinal membrane. Mouth breathing naturally results, and it is fortunate that nature has provided this auxiliary in such cases of need. Yet this substitute may, on the other hand, be considered a misfortune to the growing child when we think of the many results of a chronic stenosis: The circulation of the blood is interfered with, and hence the development of the child is perverted and retarded, the facial expression becomes unnatural, the palate becomes more arched, and the nose more flattened, together with many more results so well known to all who see these cases daily.

After childhood and especially when adult life is reached, the space between the opposing mucous surfaces are so much greater that a stenosis from turbinal thickening alone rarely results in mouth breathing during the waking hours, although the voice tone may be so much muffled as to suggest an adenoid or a polypus.

In children, the nasal stenosis which results from turbinal thickening has the additional factor of the undislodged secretions which can result only in mouth breathing. But when due to this cause alone the history usually shows a short duration, since nature's efforts, assisted or not, are as a rule equal to the emergency of bringing about the proper restoration unless the recurrent attacks become too frequent.

But how different is the picture when adenoid growths fill this cavity and necessitate breathing through the mouth. The history of the case does not then tell of an acute, or a transitory condition. The child's pinched face, open mouth, voice tone, and general appearance of malnutrition would belie such a statement.

There are many cases that present themselves to us for relief and too often with the vain hope of obtaining it. We occasionally have cases that we may selfishly wish had gone to some one else,

knowing full well that neither could accomplish the end desired. A few of us have learned that we can assist nature to cure some of the cases sometimes; many of us think we can do so in some of the cases all of the time; but the majority of us have learned enough to know that we cannot cure all the cases all the time. But fortunately, when mouth breathing in a child is caused by an adenoid stenosis or a polypus we know as confidently what the result of proper treatment will be in all such cases as we could know anything in surgery positively.

Over

The

I will quote some lines from my paper describing a new instrument for the excision of adenoids: "A post-pharyngeal adenoid is as truly an overgrowth of Luscka's tonsil as is a wart an growth of a papilla of the epidermis. The two differ in all respects only as the corium of the skin differs from the lymphoid cushion in the pharynx when each has its respective origin. resemblance between them may be seen in the different degrees of consistency that each presents, due in both cases to the ra pidity of growth, the age, and the peculiar condition of irritation to which either may have been subjected. While it is so-called hypertrophy it is but little like the hypertrophies that we counter elsewhere, particularly in children."

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Nothing is definitely known as to the cause of adenoid growths, unless an hereditary tendency, as a predisposing cause, together with often-recurring colds as the excitant, can be regarded as a satisfactory etiology. They occur most frequently in children, and may disappear spontaneously when the subject has nearly or quite reached maturity; still it is not a rare occurrence to find them in young adults or even in those who have reached middle

age.

The diagnosis is not difficult; indeed, by exclusion, the nature and character of the growth can be determined by digital examination as the surest means in children. The finger finds a mass in the superior pharynx that is yielding and gelatinous, with a furrowed surface that imparts a wormy feeling.

A glance at the child or even to have heard his muffled tone is often all that is necessary to form a diagnosis. But the age should be considered and also the extent and character of the deafness if any, the open mouth with the vacant expression;

the

imperfect chest development; the ill-shaped nose with its small alæ; the inability to blow the nose, together with the history of

snoring, or difficult sleep breathing. On the other hand it does not always follow that the child has adenoids because he snores and keeps his mouth open and is constantly enjoined by the mother and nurse to blow his nose, since a catarrhal tumefaction of the turbinals, enlarged tonsils or foreign bodies such as buttons, beans, etc., deliberately thrust into the nose by the child may have been the cause. In children it is not so necessary to exclude polypi or post-nasal abscesses, or bony growths, as these are rarely found at this time of life.

It would not be apropos in this paper to discuss the sequelæ of nasal stenosis in children farther than to mention the not unfrequent middle ear inflammation with its natural results of a rupture of the drum membrane, which in scorbutic children usually ends in chronic suppuration. In any case the treatment that succeeds in restoring an opening to nature's normal breathing space which will enable the nose to perform its double function of supplying moisture and warmth to the inspired air, accomplishes many good results that are oftentimes unexpected. The use of the finger-nail or the gouge-shaped thimble is advocated by some, but should be resorted to only in urgent cases. Meyer, who has the honor of first having described adenoid vegetations, still resorts to the post-nasal curette in children. Voltolini seems to prefer the wire loop inserted beneath the palate, a very questionable proceedure in children. The bullet forceps of Loenburg and Michael may be resorted to and safely used, in many cases. Gleitzman and Elsburg's forceps are much more frequently used in England and on the continent than in this country. In most cases requiring an operation in little fellows who have to be held, as well as in many of those who are reasonable enough to accept the inevitable, I use my own forceps which have large fenestræ and small shanks. These large openings in the blades allow the soft mass to pass through, which enables the operator to very rapidly make a number of grasps on the mass without having to withdraw the instrument. These forceps are equally as adaptable to operating when anæsthesia is considered necessary.

I will not mention the many other instruments that have been, and are now being used for the excision of adenoids. Notwithstanding their large number and variety no one instrument, or no one means of operating, has seemed to have gained any decided preponderance of favor. The very nature of these cases,