RESULTS 
OF THE 
Examination of the ghroat and Hose of 
guro thousand Children to geter* 
mine tire frequent® of Certain 
Abnormal Conditions. 
BY 
WALTER F. CHAPPELL, M.D., M.R.C.S. Eng., 
Attending Physician to the Chest and Throat Department, Presbyterian Hospital, 
Assistant Surgeon Manhattan Eye and Ear Hospital (Throat Dept.) 
Nezu York. 
Reprinted from The American Journal oe the Medical Sciences, February, 1889. 
[second edition.] 
NEW YORK: 
Printed at the New York Institution for the Deaf and Dumb 
1892. RESULTS 
OF THE 
Examination at the $Braat and gLose at 
^ura S^°^sand Children to geter* 
mine the frequency of Certain 
Abnormal Conditions. 
BY 
WALTER F. CHAPPELL, xM.D., M.R.C.S. Eng., 
Attending Physician to the Chest and throat Department, Presbyterian Hospital, 
Assistant Surgeon Manhattan Eye and Ear Hospital (Throat Dept.) 
Nero York. 
Reprinted from Ths AmsRican Journal of thk Mkdical Scibncbs, February, 1889. 
[second edition.] 
NEW YORK 
Printed at the T^e\V York Institution for the Deaf and Dumb, 
1892. EXAMINATION OF THE THROAT AND NOSE OF 
TWO THOUSAND CHILDREN TO DETER- 
MINE THE FREQUENCY OF CERTAIN 
ABNORMAL CONDITIONS. 
By Walter F. Chappell, M.D., M.R.C.S. Eng., 
ATTENDING PHYSICIAN TO THE CHEST AND THROAT DEPARTMENT, PRESBYTERIAN 
HOSPITAL, NEW YORK. 
{E r traded from the American Journal of the Medical Sciences for February, i88g.) 
In February, 1888, Dr. Franklin Hooper, of Boston, read a 
paper before the Laryngological Section of the New York 
Academy of Medicine on adenoid growths in the vault of the 
pharynx. In the discussion which followed a great diversity 
of opinion prevailed as to the frequency of this disease in 
the children of this city and vicinity ; some thinking that as 
many as two or three per cent, were sufferers ; while others, 
that, according to their experience, it was less than one per 
cent. One speaker believed it to be a rare disease. 
To settle this point, which is certainly one of importance, 
I undertook, associated with Dr. Andrew H. Smith, the ex- 
amination of these children, hoping that some definite opinion 
might be arrived at. While making the examination, we took 
the opportunity of studying the condition of the other parts 
of interest in this region. Of the 2000 children, 955 were 
taken from the New York Juvenile Asylum, 176th Street and 
Tenth Avenge, by the kind permission of Mr. A. G. Agnew 
and Mr. E. M. Carpenter, and Dr. Baruch, the attending 
physician ; 645 from Grammar School No. 49, by permission 
of Mr. A. G. Agnew, and Mr. Pettigrew, the principal ; 500 4 
CHAPPELL, DISEASES OF THROAT AND NOSE. 
from the Half Orphan Asylum in East 10th Street, and the 
remaining number from various sources. 
In the entire number the following abnormal conditions 
were found : 
Adenoid growths, 60 
Enlarged tonsils, 270 
Deviated septa 330 
Spurs on septa, .... .... 150 
Hypertrophy of inferior turbinated bodies, . . 260 
Hypertrophy of middle turbinated bodies, . . .161 
This shows that 1231 were sulf ering from some anatomical 
abnormality, and usually with its accompanying smmptoms of 
respiratory obstruction and catarrah. I will only give a short 
sketch of the observations made in each condition. 
Adenoid Growths, or Post-Nasal Disease. 
It has been shown that 60 suffered from this disease ; of 
the entire number, 1292 were boys ; 49 of whom had adenoid 
growths ; 708 were girls, 11 having the disease, scarcely more 
than half in proportion to the number occurring in the boys. 
The ages varied from four to sixteen ; few cases occurring un- 
der six years or over fourteen ; the largest number being in 
children between eight and ten years, the frequency increas- 
ing toward puberty and decreasing after it. Condition of life 
and surroundings seem to have no effect on the occurrence of 
this disease. The children from Grammar School No. 49 and 
others, taken from the better classes, suffered equally with 
those in the asylums. Two classes of cases were observed 
sufficiently different in appearance and symptoms to allow of 
separate description. 
In the first class the growths were irregular red masses, vary- 
ing in size from that of a pea to that of a small cherry, and 
having a tense, glistening appearance. They occupied chiefly CHAPPELL, DISEASES OF THROAT AND NOSE. 
5 
the vault of the pharynx, and resembled the glandular tissue 
of this region much hypertrophied. Thirty-five cases of this 
kind were observed. The growths were numerous, and hung 
down from the vault so as to fill the post-nasal space. They 
secreted a copious, thick yellow mucus, whi<;h hung from and 
around the growths, and in some cases large desiccated scabs 
covered the masses. The vocal sounds were thick and dead in 
character, and the nasal respiration much impaired at times, 
while at other times it seemed comparatively free. None had 
the high palatine arch and pigeon breast deseribed by some 
observers. There was no case of decided deafness, although 
10 had slight impairment of hearing. All these children would 
be classed as of the scrofulous type, and, I think, this disease 
is largely due to diphtheria, scarlet fever, and measles, occurring 
in such children, whose mucous membrane and glands, if once 
inflamed, show very little recuperative power. Throat com- 
plications are more severe in this class when suffering from 
diphtheria and scarlet fever ; in place of returning to its natural 
condition, the mucous membrane remains swollen and inflam- 
ed, and after a short time that which was only the result of 
acute inflammation becomes organized tissue. This form, 
though differing anatomically from the other class of post- 
nasal growths, requires the same treatment. 
Second Class.-The growths were small, pale pink or gray 
in color, and, in some cases, presented a fringed appearance ; 
while in others they were flat and round, and occurred singly 
or in clusters. 25 of this class were observed : 19 of which 
had only a moderate amount of growth, confined chiefly to the 
vault and around the Eustachian Tube. The remaining 6 
were marked cases of the worst type of this disease. The 
growths were numerous, sessile, and long, and completely 6 
CHAPPEEL, DISEASES OF THROAT AND NOSE. 
packed the post-nasal space, and extended in a chain-like for- 
mation down the pharynx ; and seemed continuous with the 
tonsils. The tonsils were hypertrophied in all the six cases. 
In 1 case not quite so severe as the others, the growths occu- 
pied the posterior margin of the septum and the margins of 
the posterior nares. All of these children had complete nasal 
obstruction, the " dead " voice, high palatine arch, small 
nostrils, and pigeon breast, and also the restless, irritable con- 
dition pescribed by all writers on this subject. The 16 who 
were affected only in a moderate degree presented only moder- 
ate symptoms, and only 2 had impairment of hearing. All of the 
6 severe cases had impaired hearing. One child could hear 
only the loudest sounds. The mucus secreted in these cases 
was white and frothy in character, and very copious. In this 
case the disease, I think, is often hereditary, and occurs in 
several members of the same family. 
The examination of the post-nasal space was made chiefly 
with the mirror, and in the public institutions afforded a re- 
markable proof of the effect of fear and discipline on the re- 
flexes. The children felt that they were carrying out a com- 
mand, and although afraid, their discipline was so good that 
they made no objection or efforts of resistance. The condi- 
tion seemed to paralyze their faucial muscles, and allow the 
soft palate to hang away from the posterior pharyngeal space. 
This is in marked contrast to the condition in which the phy- 
sician finds the child who comes to him in private practice, 
who, if adverse to being examined, has little difficulty in show- 
ing that it is master of the situation. 
In some cases the formation was such as to leave but little 
space between the soft palate and the posterior wall of the 
pharynx. In these cases, by causing the patient to say " ah," CHAPPELL, DISEASES OF THROAT AND NOSE. 
7 
the soft palate was drawn upward and backward, and if the 
mirror was in readiness, when the palate relaxed and fell for- 
ward, a little anterior to its normal position, it allowed of a 
good momentary view. By repeating this once or twice a 
very satisfactory examination can be made. In twenty of the 
children the .finger had to be used for diagnosis. 
A good light is of the greatest importance, and I obtained 
the best views with a magnesium lamp, loaned me by Messrs. 
White & Son, of this city. But this could not be used for any 
length of time, as the light was so bright, that after examin- 
ing eight or ten cases, I would be unable to see any thing dis- 
tinctly for at least an hour. For short examinations, however, 
where a bright light is of importance, nothing equals it. 
Hypertrophy of the Anterior Part of the Inferior 
Turbinated Bodies. 
This was confined chiefly to the mucous membrane. Only 
the most marked cases were noted; of these there were 260. 
In 102 the hypertrophy was bilateral and pressed the septum 
on all sides ; in 140 it was unilateral, occurring chiefly on the 
left side, very large, often occluding the nostril and and press- 
ing the septum to the opposite side ; in 18 cases the hyper- 
trophy of the inferior and middle turbinated bones was so 
great as to occlude completely the nares, and on anterior rhino- 
scopic examination gave the appearance of two red masses 
filling the nasal cavities. If a diagnosis should be made rely- 
ing only on the symptoms, without a rhinoscopic examination, 
they would be all pronounced cases of adenoid disease of the 
worst type. This shows how necessary it is to make a thor- 
ough examination in every case before introducing the post- 
nasal forceps. There are some surgeons who think mouth- 8 
CHAPPELL, DISEASES OF THROAT AND NOSE. 
breathing and dead voice sufficient to warrant them in operat- 
ing without any further examination. As a result of this, I 
have several times seen the post-nasal space clear of all its 
glandular tissue and not a little of the mucous membrane with- 
out any relief to the patient. 
This condition of hypertrophy of the inferior turbinated 
bodies occurs with equal frequency in males and females, but 
is rare in very young children. Colored children and Italians 
are remarkably free from it. 
Hypertrophy of Middle Turbinated Bodies. 
161 had this condition ; in 51 it was bilateral, and 110 uni- 
lateral. In 2 cases the mucous membrane and bone were so 
much enlarged that the tumor touched the floor of the naris. 
The bilateral cases presented chiefly an hypertrophy of the 
mucous membrane, but in the unilateral there was mostly a 
bony hypertrophy, and in 75 of these cases the cartilaginous 
septum was deviated to the opposite side ; its concavity corre- 
sponding to the hypertrophied middle turbinated body. No 
child presented any evidence of reflex symptoms, and those 
cases of hay fever, reflex headache, and cough, which are re- 
lieved and sometimes cured by cauterization, or by removing 
part of the middle turbinated body,must be due to some con- 
dition of later development, as certainly, if hypertrophy or 
pressure alone could cause these reflex diseases, we ought to 
have had them with great frequency in these cases. 
Deviated Septum. 
330 examples occurred ; 270 presenting deviations of the 
cartilaginous, 50 of the bony septum, and 10 of both bone and 
cartilage. Of the cartilaginous deviations, 148 were to the 
right, and 122 to the left. Of the bony, 35 to the right and 15 CHAPPELL, DISEASES OF THROAT AND NOSE. 
9 
to the left. The bone and cartilage deviations were S-shaped. 
The cases of deviations were 50 per cent, more numerous in 
boys than girls ; 25 per cent, gave a history of injury, and the 
same number were due to hypertrophy of the middle turbinat- 
ed bone. Only ten deviations of the cartilage were observed 
in children under the age of seven, and they gave history of 
injury. In deviation of the bone, the children were all over 
eight. In 30 per cent, the obstruction was sufficient to impede 
respiration ; and in all cases it increased the nasal discharge. 
From these observations it would seem that deviation of the 
cartilage is rare under seven, and that when occurring, it is 
due to traumatic causes. It is well established that deviations 
of the septum occur in about 75 per cent, of adults examined, 
and this, of course, must be due to some cause which does not 
affect the very young. I think a large percentage is due to 
one of four causes : 
First. Traumatism. 
Second. Hypertrophy of middle turbinated body, or some 
other source of unilateral pressure. 
Third. Hyperplasia from long-continued irritation. 
Fourth. Difference in period of development of the bones 
of the face and septum. 
Spur on Septum. 
Only the part of the septum visible through the anterior 
nares is considered under this heading. 150 were observed ; 
100 on the right side, and 50 on the left. The largest number 
were situated at the anterior inferior angle of the cartilage, 
close to the floor of the naris, and varied from one quarter of 
an inch to an inch in length ; were shelf-like in appearance, and 
concave on the under surface. 25 of the other children had a 
long ridge starting from the anterior inferior angle of the 10 
CHAPPELL, DISEASES OF THROAT AND NOSE. 
septum and running upward and backward from one to one and 
one-half inches. They were very large, often occluded the 
nasal passage of that side, and caused frequent attacks of epi- 
staxis. I think spurs on the septum are often caused by slight 
injury to the nose, and, although small at first, grow rapidly. 
Enlarged Tonsils. 
Only those presenting very considerable enlargement were 
noted. Of these, there were 270; 183 being of both tonsils, 
and 87 of one only. 160 cases were in males, and 110 in 
females. 7 cases were of extreme enlargement, preventing a 
view of the posterior wall of the pharynx and causing dif- 
ficulty in introducing the finger into the post-nasal space. 6 
cases had great impairment of hearing, and all breathed with 
the mouth open, to a greater or less extent, and had other 
symptoms of obstruction. 
Resume. 
I think we may fairly infer from these examinations that en- 
larged tonsils and adenoid growths are the only anatomical ab- 
normalities that could be classed as belonging to very early 
life. The other abnormal conditions are acquired, usually 
after the age of six years, increasing rapidly with each suc- 
ceeding year until puberty. All social classes are liable to 
them at about equal proportions, and at the same age. Males 
suffer more frequently than females, probably owing to great- 
er exposure to the causes which produce catarrhal congestion 
and inflammation. In glandular organs it is but a step from 
congestion to hyperplasia, and an increased afflux of blood be- 
ing once established, a slight irritation will serve to keep it up, 
and hypertrophy is the necessary result. 
The increased number after six years seems to be due to 
several causes : CHAPPELL, DISEASES OF THKOAT AND NOSE. 
11 
hirst. More children suffer after that age from scarlet fever, 
measles, diphtheria, whooping-cough, and a few other diseases 
of childhood which are specially liable to produce inflammatory 
conditions of the throat and nose. 
Second. After this age children are more exposed to falls, 
blows, and accidents of various kinds. They are given more 
liberty to run about and take care of themselves, and mingle 
with other children. It is well known that the nose is a favor- 
ite place for the receipt of blows, great and small, which are inci- 
dent to the pains and pleasures of every-day life of most children. 
Third. Climate certainly has an important influence on the 
mucous membranes. Persons coming from abroad to New 
York and other parts of America, goon compjain of catarrhal 
symptoms of the throat and nose, which had been unknown to 
them before. On examination, the mucous membrane of the 
nares and throat is found congested and hypertrophied to a 
far greater extent than is observed in adults and children in 
England and on the continent. 
Fourth. Hypertrophied tonsils and all forms of nasal ob- 
struction produce catarrh by their interference with the re- 
spiration and circulation. It is also probable that they are the 
cause of the hypertrophied condition of mucous membrane in 
in many cases of the children examined. 
It would seem that persons having the oversight of children 
should have them examined between the age of six and four- 
teen years, to ascertain the condition of the throat and nose. 
It is not the throat and nose alone which suffer from these 
abnormal conditions, but many other ailments, especially of 
the pulmonary, digestive, and nervous systems, can be traced 
to prolonged nasal obstruction and irritation.