exist both in adults and in children without any indrawing of the drums.1 This latter indeed depends entirely on Eustachian obstruction and has no

FIG. 40.-TYPICAL DEFORMITY OF THE UPPER JAW PRODUCED BY PROLONGED NASAL OBSTRUCTION. Note the rotation of the central incisors, the backward displacement of the lateral incisors, the projection forward of the canines and the approximation of the second bicuspids and first molars. The axes of the teeth slope inwards. (From a cast kindly lent by J. G. Turner.)

direct connection with nasal obstruction. It is most commonly seen in adenoids where the obstruction to nasal breathing, and consequently

FIG. 41.-TYPICAL DEFORMITY OF LOWER JAW PRODUCED BY PROLONGED NASAL
OBSTRUCTION. The deformity is exactly similar to, but less marked than, that
occurring in the upper jaw. Čompare Fig. 40. (From a cast kindly lent by J. G.
Turner.)

the most marked negative pressure, is located behind the orifice of the tubes.

1 British Medical Journal, 1902, ii. p. 605 (Brit. Med. Assoc. Meeting at Manchester).

(3) Symptoms resulting from the Constantly open Mouth. Facial Aspect. The gaping mouth with projecting incisor teeth but half

FIG. 42.-DIAGRAM ILLUSTRATING CHANGES IN SHAPE OF PALATE PRODUCED BY NASAL OBSTRUCTION. The dotted lines show the normal palatal arch, the black lines a high saddle shaped arch. (1) Normal position of the second bicuspid which is displaced to (2).

concealed by the shortened upper lip, the hanging lower jaw and the consequent obliteration of the folds of expression round the mouth give

FIG. 43.-DIAGRAM SHOWING CHANGES IN SHAPE OF ALVEOLAR ARCH PRODUCED BY NASAL OBSTRUCTION. The deformed V-shaped alveolus is super-imposed on the normal horse-shoe shaped alveolus.

the patient the well-known stupid look (Fig. 52). The appearance is not unlike that of certain idiots (compare Fig. 30), a resemblance

intensified by the deafness, listlessness, and mental obtuseness so common in nasal obstruction.

The shape of the nose is altered. The alae nasi are collapsed, reducing the anterior nares to mere slits; there is a deep crease between the alae nasi and the nasal bones; the bridge appears widened as a result of the narrowing of the anterior part of the nose, or may actually be widened by swelling and congestion of the soft parts overlying the nasal bones. There is often an enlarged vein, or veins, running transversely across the root of the nose, and the soft parts in this region may appear bluish, congested, or swollen. Dark circles round or under the eyes are common, especially in the morning as a result of disturbed rest. In addition there is often

FIG. 44.-DEFORMITY OF UPPER JAW DUE TO NASAL OBSTRUCTION IN A CHILD AGED 6. Showing commencing superior protrusion and open bite. The temporary teeth which at this age should be widely spaced are tightly crowded together. (From a photograph.)

some deformity of the nasal septum and occasionally lateral deflection of the nose itself (Fig. 47).

The Maxillary Bones and the Teeth. When chronic nasal obstruction exists in early life its effects upon the soft and actively developing bones. of the face may assume proportions of the greatest importance. Although these results are most common in, and indeed are often looked upon as symptomatic of, adenoids, they may occur in nasal obstruction due to any other cause. The exact factors in their causation and even their relationship to nasal obstruction have given rise to a large amount of discussion. In the investigation of this subject I have been greatly aided by Mr. J. G. Turner.

The following changes are met with in the upper jaw: (1) The whole bone is ill-developed. (2) The arch of the hard palate is high and narrow. (3) The alveolar arch is V-shaped. (4) The teeth are crowded and irregular.

(1) The deficient development of the upper jaw is often marked and may be recognised even in early life. Normally, between the ages of 4 and 6 years small spaces appear between the temporary teeth. At six years old all the temporary teeth are spaced, that is, the jaw has outgrown them and is ready to receive the larger permanent teeth as they erupt. When nasal obstruction is present this spacing of the temporary teeth does not occur; they remain closely packed together, there is no room

FIG. 45.-DEFORMITY OF UPPER JAW AND CROWDING OF TEETH DUE TO NASAL
OBSTRUCTION IN A GIRL AGED 17.

Showing the projection forwards of the canines,

and the sloping axes of the central incisors. (From a photograph.)

for the permanent set to erupt naturally, and in consequence they become crowded and irregular, as will shortly be described.

(2) The arch of the hard palate is high and narrow; sometimes it is saddle-shaped, at others steep and almost pointed. It has indeed been stated that the arch of the palate is not actually raised, but that the increased height is only apparent as a result of the lateral approximation of the alveolar processes. It is impossible to decide this point without making very accurate measurements of a large series of cases But the frequency with which deflection of the septum is associated with this deformity indicates that there often is actual elevation of the palate. For if the palate be actually raised, the floor of the nose must also be raised; this would diminish the vertical diameter of the nasal fossa, and cause crumpling of the nasal septum. The appearance of a high arched palate could also be produced in another way: not by actual elevation of the centre of the palate, but by a downward and inward displacement of

the lateral parts of the arch, that is, of the alveolar processes (see Fig. 48). This would bring the molar and the bicuspid teeth on a lower level than normal, and would produce an "open-bite," for the molar teeth of the upper jaw being on a lower plane than the incisors, would come into contact with those of the lower jaw before the front teeth met. Now an open bite is also frequently seen in prolonged nasal obstruction, and if this be the true explanation, the centre of the palate will not be raised, the nasal fossa will attain its full vertical development, and there will be no deflection of the septum. Although at present I have made too few

FIG. 46.-DEFORMITY OF UPPER JAW AND CROWDING OF TEETH PRODUCED BY NASAL OBSTRUCTION IN A GIRL AGED 18. Showing backward displacement of lateral incisors and rotation of central incisors and canines. (From a photograph.)

observations to be sure that this relationship is constant, I have frequently observed it. I am therefore inclined to believe that in some cases the centre of the palate is actually raised, when the nasal septum is deflected; and that in others the lateral parts of the arch are drawn downwards and inwards, when there is an open-bite, but no deflection of the septum. The open-bite may sometimes be due simply to deficient development of the anterior part of the upper jaw.

(3) The alveolar arch becomes V-shaped. The normal alveolus is shaped like a horse-shoe, the first molar being at the widest part of the arch. In nasal obstruction the front of the arch usually becomes pointed, and the sides run almost straight back from the incisor teeth to the first molar. The second and third molars, which develop later, when the mouth