MOUTH-BREATHING—ITS CAUSES, EFFECTS AND 
TREATMENT.* 
By.Thomas R. French, M. D. 
Lecturer on Laryngoscopy and Diseases of the Throat, Long Island College Hospital, 
Brooklyn, N. Y. 
AS you are all aware, the subject assigned to me for presentation 
at this meeting is “ Mouth-Breathing.” A subject about 
which so little has been written, that it is fair to assume that the 
pernicious effects of the habit are but little appreciated by tbe 
medical profession, and, naturally, those conditions of which 
medical men take little or no notice, as detrimental to health, will 
scarcely be thought injurious by the laity ; and so it is that at the 
present day this baneful habit is allowed, with scarcely a warning 
voice from our guardians of health, as to the nature and extent 
of the evils resulting from its practice. 
Mr. George Gatlin was the first, I believe, to call attention to 
this subject. This he did in a very forcible manner, in a mono- 
graph entitled, “The Breath of Life,” which was published in 
1872. While his work can scarcely be called scientific, his 
denunciation of the habit of breathing through the mouth as a 
cause of loss of strength and many of the ills of mankind, espe- 
cially in the growing age, has served largely in drawing the attention 
of medical scientists to the subject. 
Dr. Clinton Wagner published last year a monograph entitled, 
“Habitual Mouth-Breathing,” in which the subject is carefully 
considered. 
In the January number of the American Journal of Obstetrics 
*Reacl before the Circle of Willis, February 2, 1882. of this year, Dr. R. C. Brandeis has an article on “ Nasal Catarrh 
in the New Born: Its influence on Respiration and Nutrition.” In 
this paper the author clearly sets forth the effects of mouth- 
breathing upon very young children. 
With the exception of the little that has been written on a 
branch of the subject, viz., the effect of mouth breathig upon 
hearing, the above is all the literature of the subject of which I 
am aware. 
In order to understand the abnormal, we must first know what 
the normal condition of a part should be; therefore, before 
entering upon a consideration of the conditions which give rise 
to mouth-breathing, let me remind you of the office of the nasal 
passages. 
Besides being the seat of the sense of smell, these passages, in 
their normal condition, serve to warm, cleanse, and moisten the 
air inhaled into the lungs. The mucous -membrane lining the 
nares presents a very extensive surface, and in a comparatively 
small space. It is richly supplied with blood, and on this account 
the nasal cavities are warmer by a degree or two than the cavity 
of the mouth. Air passing through the nose is therefore warmed 
before it reaches the throat. On the other hand, air passing 
through the mouth is not sufficiently warmed to be non-irritating 
till it reaches the trachea, perhaps even the bronchi. 
Just within the nostrils are a number of hairs which, together 
with the cilia of the epithelium covering the mucous membrane 
of the nasal passages, serve to arrest and entangle particles of 
dust; thus the nose acts as an air-filterer. When respiration is 
carried on through the mouth, foreign particles are carried into 
the air-passages, and lodging on the mucous membrane covering 
the pharynx, larynx, trachea and bronchi, act as irritants. 
The mucous membrane of the nasal cavities is supplied with a 
lajge number of follicular glands, the secretion from which serves 
to moisten the air passing through them, thus removing that 
quality of the air which, when breathed through the mouth for a 
length of time, causes irritation. 
Air inspired through the nose passes through a refining process 
which prepares it for the lungs very much as mastication prepares 
food for the stomach. If food is improperly masticated, the 
stomach suffers. If air is improperly refined, the air-passages suffer. The nose and not the mouth, was designed as the gateway 
to the lungs. 
The conditions causing mouth-breathing are found in two 
situations—the nose and pharynx. We will consider them sep- 
arately. 
Nasal causes.—A deflected nasal septum though usually caus- 
ing obstruction to but one passage, may be so curled upon itself as 
to impede respiration through both passages. The cartilaginous 
and bony portions of the septum are sometimes the seat of 
interstitial enlargement or outgrowth, which encroaching upon 
the calabre of the nares, causes partial or complete stenosis. 
Exostoses may spring from any portion of the bony framework of 
the nasal passages. They may attain great size, and of course 
impede nasal respiration. A variety of tumors are developed in 
the nasal cavities ; of these, the gelatinous polypus is met with 
most frequently, and obstructs nasal respiration in proportion to 
the size and number of growths present. Foreign bodies may be 
lodged in the nasal passages, causing obstruction, and give rise to 
symptoms of nasal catarrh. 
Hypertrophic nasal catarrh, is perhaps the most common cause 
of mouth-breathing. Hypertrophy of the mucous membrane 
lining the nasal passages, but more especially that enveloping the 
turbinated bones, has been found in the majority of cases of nasal 
catarrh which have come under my observation. The hypertrophy 
consists of an increase of all the normal elements of the mucous 
membrane ; thus constituting a true hypertrophy. While the 
hypertrophy sometimes involves the membrane lining the nasal 
passages throughout, it is usually most marked on the convexity 
of the turbinated bones, 
Frequently the hypertrophy is limited to certain localities. 
These points are the anterior and posterior ends of the inferior 
turbinated bones ; and, of these, posterior hypertrophy is most 
frequently met with. 
Anterior hypertrophy when examined with the aid of the 
speculum, presents the appearance of a smooth, or slightly mam- 
millated growth, of a bright or ]3ale-red color, attached by a broad 
base to the end of the inferior turbinated bone. 
Posterior hypetrophy can of course be seen only by the aid of 
the rhinoscopic mirror. When of large size, it may fill up the 
posterior opening of the nasal passage of one side, and even reach 4 
across the septum and cover part of the opening of the opposite 
passage. As the tissue of these growths has a hygroscopic char- 
acter, their size will depend somewhat upon the condition of the 
atmosphere ; being larger in damp than in dry weather. 
I have here a sketch (Figure 1) taken from my case book, which 
shows hypertrophy of the tissues covering the posterior ends of the 
inferior turbinated bones. The larger growth was removed by 
Jarvis’s operation, which will be described further on. 
The most prominent symptoms of hypertrophic nasal catarrh 
are a more or less copious discharge of muco-pus flowing from the 
anterior nares, or down the throat from the posterior nares, or 
from both, according to the situation of the most active part of 
the disease ; and, partial or complete obstruction to nasal res- 
Fig. i. 
Pharyngeal causes.—One of the most prominent of these is 
retro-nasal adenoma. This consists of hypertrophy of the col- 
lection of adenoid tissue at the vault of the pharynx, sometimes 
spoken of as the pharyngeal tonsil, and the glandular tissue in its 
neighborhood. The mass may be simply an appreciable enlarge- 
ment of the tonsil, or maybe so large as to veil the posterior nares 
and pharyngeal mouths of the Eustachian tubes, causing nasal 
obstruction and deafness. 
The condition of that part of the posterior pharyngeal wall 
which can be seen by direct iilumination through the mouth, is 
never a reliable indication of the condition which may exist in the 5 
upper pharyngeal space. The use of the rhinoscopic mirror, or the 
finger passed behind the velum to determine by the sense of touch, 
are the only reliable methods of examination. 
It would scarcely be necessary for me to more than mention 
hypertrophy of the tonsils as a cause of mouth-breathing, were it 
not for the fact that they again are often the cause of nasal steno- 
sis, and that therefore their removal is not always followed by a 
re-establishment of nasal respiration. If the tonsils are enlarged 
in childhood and continue a number of years, the nasal passages 
not being called upon to perform their natural function, either do 
not develop properly, or there is established a nasal catarrh with 
resulting thickening of the lining membrane. Therefore it is, 
that after removal of the tonsils, we occasionally find that the 
nasal canals are inadequate to pass to the lungs the requisite 
quantity of air. 
Effects of Mouth-hreathing.—Unless the nasal or pharyngeal 
obstruction is sufficiently great to necessitate the keeping of the 
mouth open at all times, this cause of disease will often be over- 
looked. The mouth may be closed on going to sleep, opened 
while sleeping, and when consciousness arrives, is closed again, 
and so many are ignorant of the fact that they ever breathe 
through the mouth. If these people are questioned closely, the 
fact will be elicited that the mouth and throat are always dry in 
the mornings, and that it may be several hours before this condi- 
tion wears away. 
In infants, when nasal respiration is impeded, the act of 
sucking is difficult, and, in some instances, impossible 
In young children nasal obstruction gives rise to impairment 
of health in proportion to the amount of stenosis present. In the 
normal condition of respiration, when the air passes through the 
nose, sufficient time is usually taken to properly masticate food, 
but when the nasal passages are blocked and respiration must be 
carried on through the mouth, during the process of mastication 
breathing is suspended. Under these circumstances, food is not 
properly subdivided, and in this condition is hurried on to the 
stomach. This necessitates extra labor on the part of that organ, 
which, together with the secretion from a nasal or pharyngeal 
catarrh, usually present in these cases, soon gives rise to gastric 
and intestinal disturbances. 6 
When chronic enlargement of the tonsils is the cause of month- 
breathing in children, it is well known to us all that the chest is 
not developed as rapidly as the rest of the body. Pigeon-breast or 
sunken sternum are often the result. The air supply to the lungs 
is not sufficient to resist the external atmospheric pressure, and, as 
a natural consequence, the chest sinks in. 
Effects upon Hearing.—Diseases of the ear may be caused in 
several ways. First—by direct pressure of the hypertroyhied 
mass in the upper pharynx upon the mouths of the Eustachian 
tubes. Second—by extension of the catarrhal inflammation to the 
Eustachian tubes or cavities of the tympanum. Third—by ob- 
structed nasal respiration. If the nasal passages are occluded the 
tympanic cavities are not properly ventilated. Under these circum- 
stances the air in these cavities is rarified at each act of degluti- 
tion, and as a consequence the drumheads sink in and lose their 
elasticity. Again, in the acts of coughing, sneezing or blowing 
the nose, the air not finding sufficient exit through the nose is 
forced into the tympanic cavities, and being condensed there, gives 
rise to a condition directly opposite to that just described:—bulging 
outwards of the drumheads, and consequent loss of elasticity. 
That enlarged tonsils are occasionally the cause of deafness, is 
shown by the fact that their removal will sometimes be followed 
by improvement or re-establishment of the hearing power. 
Effects on the Voice.—The nasal cavities play a very important 
part as resonators in vocalization ; when they are obstructed, this 
function is, of course, impaired in proportion to the degree of 
stenosis present. The loss of resonance together with the im- 
possibility of pronouncing the nasal sounds m, n and ng, give rise 
to what Meyer calls the “ dead” pronunciation or “dead” speech. 
Nasal catarrh is present in the majority of cases of nasal stenosis; 
the acrid discharge flowing from the posterior nares into the 
pharynx, and from thence into the larynx, excites a catarrhal con- 
dition of the membranes of those parts ; in other words, a pha- 
ryngitis and laryngitis. The fact that secretion from the nares 
does get into the larygeal cavity, I have been able to demonstrate, 
and in the following manner : If a colored fluid is placed on the 
posterior wall of the pharynx in sufficient quantity to trickle down 
the membrane to the oesophagael opening, a laryngosopic examina- 
tion made a few minutes after the application, will show that some of the fluid has passed over the arytenoid cartilages into the 
larynx. 
Besides the conditions which I have spoken of as resulting 
from this baneful habit, the expression of the face is changed, in 
some instances simulating the idiot ; and as the character of man 
is often Judged by the expression of his face, it is important that 
the condition which cauees it should if possible be removed, and, 
as I shall now proceed to show, this can often be accomplished. 
Treatment.—Successful treatment of the conditions causing 
o 
mouth-breathing in children is usually difficult and often impos- 
sible. When the obstruction is due to adenoid hypertrophy at the 
vault of the pharynx, it should be scooped out with the currette. 
If the condition is not great, scratching the surface with the nail 
of the index finger is often sufficient to destroy it. Brandeis re- 
ports most satisfactory results in several cases of hypertrophic 
nasal catarrh in infants, from cleansing the nasal cavities with 
solutions of sodium-bicarbonate or baracic acid, and afterwards 
applying a twenty-five per cent, solution of the pernitrate of iron, 
by means of a cotton carrier. 
Rectification of a deflected nasal septum can be accomplished 
in many A hole can be punched through the septum at the 
most prominent portion of the bend, and a piece taken out. The 
protruding portion may be ground off with the dental engine, as 
proposed by Dr. Goodwillie. The mucous membrane may be dis- 
sected off, a portion of the cartilage chiseled out, the flap replaced 
and held in position by plugs of cotton. The cartilage may be 
divided by a stellated puncture, and then forcibly bent straight 
and kept so by the use of plugs, as recently suggested by Dr. Steele 
of St. Louis, or, the cartilage may be forcibly broken, bent straight 
and held in position by large plugs, as suggested by Mr. Adams. 
My only experience has been with Mr. Adams’ operation. It is 
performed as follows: Whilst the patient is under an antesthetic, a 
pair of strong forceps with straight parallel blades are introduced 
into the nose, one blade into each nostril, when the septum is 
grasped and forcibly broken. A retention apparatus, consisting 
of a steel screw compressor with two blades, is then introduced 
and the septum held in position for two or three days. Ivory or 
ebony plugs are then inserted and worn for two or three days 
longer. The plugs recently introduced by Dr. Steele are a great 
improvement upon those of Mr. Adams. 8 
The advantages of this operation are, that the cartilage is not 
exposed to the air, and the support of the septum is not weakened. 
I must confess that my results with this operation have not 
been entirely satisfactory, and though I have had no experience 
with Dr. Steele’s operation, I am inclined to believe that it offers 
better prospects of success. 
Nasal tumors can be removed with the wire snare, but better 
still with the polypus forceps. In cases where the nasal passages 
are very narrow, the blades of the ordinary polypus forceps will be 
found too thick to allow of free movement after they have been 
introduced into the nasal cavity. To obviate this difficulty I have 
had the blades of a pair of Duplay’s jmlypus forceps ground down 
to half their original thickness. These have proven sufficiently 
strong and very serviceable. 
In hypertrophic nasal catarrh when of long standing, and the 
thickening of the membrane is general and considerable, washes 
and sprays are of little use except to keep the parts clean. The 
tissue must be destroyed in order that free nasal respiration shall 
be established. This can best be done with caustics, or the gal van o- 
cautery. Of the caustics, I prefer chromic and glacial acetic 
acids. Galvano-cautery if carefully applied, causes but little pain, 
though there is more or less inflammation and swelling for a few 
days following the application. 
Hypertrophy of the tissues of the posterior end of the inferior 
turbinated bone, can best be removed with an exceedingly ingen- 
ious wire snare ecraseur, devised by Dr. W. C. Jarvis, of New 
York. 
The instrument is described by Dr. Jarvis, as follows : 
“The ecraseur (fig. 2) consists of two metal canulae ; the large 
one is six inches in length and flexible ; the smaller, about four 
inches long, slides freely upon that part of the main one nearest 
the operator. The surface of the main canula occupied by the 
secondary one is threaded for the movement on its surface of a 
milled nut. Wire is passed through the main canula and attached 
to two retention pins fixed to the proximal end of the small one. 
A slight indentation upon the small canula, fits a corresponding 
surface on the larger one. This arrangement prevents rotation of 
the secondary canula, and so overcomes the tendency of the wire 
to twist and become loosened from its attachment to the growth. 
The nut when turned pushes the outer canula before it, its speed 9 
varying from an imperceptible advance, to a rapid motion along 
the thread.” 
In performing the operation the use of the rhinoscope is 
essential in order that the movements of the loop in the posterior 
nares may be watched. 
The operation is performed as follows : The wire loop is bent 
slightly towards the side to which the hypertrophied mass is 
attached, and then the instrument is passed into the nasal passage. 
With the aid of the mirror in the fauces the loop is carefully 
guided until it is seen to encircle the growth, when it is drawn 
Fig. 3. 
home. In order to avoid haemorrhage it is necessary to make 
traction very slowly ; two hours or more should be consumed in 
the operation. With this instrument I have removed large masses 
of hypertrophied tissue, not only from the posterior nares but the 
anterior nares as well ; and obtained eminently satisfactory results. 
Retro-nasal adenoma can be scooped out with the currette as 
before suggested, or it can be destroyed with caustics or the 
galvano-cautery, but as their application requires some special 
skill I will not detain you with a description of the methods 
employed. 
The question of haemorrhage after excission of the tonsils has 
been much discussed of late. At the International Laryngological 
Congress held at Milan in 1881, several fatal cases from haemorr- 
hage after removal of the tonsils with the guillotine were reported, 
and several throat specialists of large experience frankly avowed 10 
their unwillingness to remove these glands with cutting instru- 
ments. On the other hand, one surgeon in New York reports 
having removed several thousand tonsils with the bistoury and 
guillotine, without a fatal haemorrhage, and hut two cases that 
required vigorous treatment to check the bleeding. 
I have used cutting instruments in performing this operation 
in a very large number of cases, and have never had to use more 
active measures than sipping ice-water. Judging, however, from 
the experience of others, this operation, while not often serious, is 
not always as simple as many writers on this subject would have us 
believe. Several cases of alarming haemorrhage following removal 
of the tonsils with the bistoury have been reported by Dr. Lefferts, 
in which, after removing the clots, the source was found to be a 
large artery cut across, the bleeding from which resisted astringents 
and pressure, but was immediately checked when the artery was 
caught in forceps and twisted. In performing this operation I 
use a dulled guillotine, as with it the tissues are less cleanly 
divided than with a sharp instrument. 
As injury to the palato-glossal fold is one of the chief causes 
of haemorrhage in this operation, and as it is often found firmly 
attached to the tonsil, a bent probe should always be introduced 
between it and the tonsil, and the adhesions broken up before the 
tonsil is removed. Sore throat following tonsillotomy is usually 
due to injury of this fold. 
As enlarged tonsils are likely to atrophy at puberty, when they 
are present in children and give little or no inconvenience, I 
believe it good practice to leave them with this hope. 
When dryness of the throat is caused by sleeping with the 
mouth open, if the nasal passages are found to be sufficiently large 
to supply the lungs with air, the mouth should be kept closed by 
wearing a skull-cap with strings or straps fastened to its sides, 
which being tied or buckled under the chin, hold the jaws 
together.