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Report of the Medical Officer (Education).
95
uncommon is persistent conjunctival troubles and blepharitis, which if a cure is to be hoped for
requires treatment at a throat rather than an eye hospital. The associated conditions of throat and
nose are a common cause of recurrent headaches in young children.
For some reason apart from the organs of the special senses the existence of hypertrophied
lymphatic structures in the naso-pharyngeal region, adenoids especially, is associated with a peculiar
mental condition which has been termed aprosexia. Such children are often submitted for examination
as suitable for special schools, and the condition has been classed as spurious mental defect.
Apperception is greatly lowered and the attention cannot be maintained. The nutrition of the frontal
areas of the brain seems affected, whether by accumulation of fatigue products from interference with
lymphatic drainage, or in other ways, cannot be settled. The condition is remarkable for variability.
Quite sharp and intelligent at times, they are as often dreamy, absent-minded and wool-gathering.
The variations depend on the condition of the nose and throat, and are more obvious when the structures
there are swollen from catarrh, or from humidity of the weather. These children are always
mouth breathers, and often have other sequelae of the adenoids from which they suffer, not the least
of which is said to be a character in later life timid, fearful and doubting. The most important
immediate change is, however, a thickening of the tissues starting in the structures about the Eustachian
tubes, leading to the middle ears, often causing secondary aural changes and leading to very intractable
deafness in later life. In slighter cases recovery appears to take place, and they may leave school
apparently well, whilst the slow changes are leading to ultimate inefficiency from hardness of hearing.
Dr. Fairfield has drawn attention to the considerable number, over 5 per cent., of the mothers attending
medical inspection who present hardness of hearing due to aural suppuration or old adenoids.
Sometimes during childhood the grosser form of suppuration of the ears takes place and this is more likely
to happen in those scarlatinal or measles cases who suffer from adenoids than in others. In 1,000
East-End children Miss Ivens found aural suppuration existing in 15 per cent, of the mouth-breathers,
but only in 2.8 per cent, of the others. Mouth-breathers are more disposed to all the dangers of
suppuration of the ears, meningitis, or blood poisoning than other children, and many lives are cut short
from neglect of this condition. Even in the inspection of children sitting in their places the majority
of mouth-breathers are at once apparent, and it is also noticeable how educationally they gravitate to
the lower classes. It is difficult to be sure whether by mere mechanical obstruction a vicious circle is
set up, but every surgeon with experience knows how the child with open mouth, frequently nasal
discharge, and generally unintelligent appearance is often wonderfully altered by operative treatment.
The breathing drills of the infant school should require the child to breathe both in and out
with the mouth shut, and would have good effect in calling the teacher's attention to the condition
when existing. Any teacher who notices the conditions should warn the parents. If in addition the child
habitually snores regularly at night, it may be confidently asserted that such child requires operation
to clear the naso-pharynx from obstructions. Up to 10 per cent, of children at admission will be
found to be mouth-breathers, and during school ages the proportions remain comparatively steady.
In the Islington schools about one-third of the children were noted by Mr. Cecil Rowntree as
having enlarged tonsils or adenoids, and in one-third of these (10 per cent, of all) to a pathological
extent, whilst about one-third of this last number (about 3 per cent, of all) urgently required surgical
treatment. The proportions, however, vary at different seasons and in different districts. Miss Ivens,
found in the East-End among the aliens that 34 per cent, of those who heard well had open mouths,
whilst of those who presented discharging ears 78 per cent, were mouth-breathers. In a careful
examination of 1,500 children in Chelsea schools Mr. Macleod Yearsley gave 44 per cent, as having
enlarged tonsils or adenoids and 7 per cent, as requiring surgical treatment. It has hitherto been
taken that other conditions, such as dental caries would be materially caused by or contribute to this
lymphatic hypertrophy, but enquiries carried out by Dr. Norman show that, at different ages in both
boys and girls, dental caries is about equal in amount in both mouth and nasal breathers.
In many cases, even after operation, mouth breathing persists unless the child is taught correct
breathing, and in the mentally defective about 50 per cent, are mouth-breathers, the habit having
been set up by some infantile catarrh and allowed to persist. Some medical authorities have suggested
that mere breathing exercises alone will act as a remedial means for the relief of the symptoms of nasal
obstruction arising in connection with adenoids, and by this means one large hospital is reputed to keep
its operative list of child out-patients down. It would only be in the slightest cases of mouth-breathing
that it would ever be practicable to get material benefit by means only of breathing exercises. Dr.
A. C. Williams selected boys whose throats were not normal, but in whom the symptoms scarcely
required surgical treatment. They included cases without other symptoms but with enlarged tonsils;
or which showed a tendency to mouth-breathing; cases which might mean slight adenoid growth
where there was a history of snoring, some nasal discharge, or granules noticeable in the pharynx.
Several of these had previously had operations for adenoids. Some of these cases were treated by
the ordinary school breathing exercises. Some others were always put in the front row and the
teachers kept them under special observation. The mothers were also asked to see that the children
went through ten minutes' breathing exercise night or morning. Watched through six to twelve
months or more, improvement was not always easy to determine, but as the conditions were carefully
noted before the procedure was determined the estimate as to improvement is quite unbiassed. In
a few cases "not improved" the conditions were distinctly worse.