has not found described in literature, has been observed a few times as a sequel to an acute inflammatory attack -usually an attack of influenza in patients previously subject to hypertrophic rhinitis. Both sides of the nose were occluded for weeks by edematous infiltration of the entire mucous membrane. The lining appeared grayish pale and distinctly soggy. There was slight turgescence of the cavernous tissue. The reduction of the turgescence by cocain restored transiently very imperfect nasal permeability. There was no secretion and no lesions were found, except those of hypertrophic rhinitis. The edema was removed, and nasal permeability gradually restored by the use of dilating tampons moistened with cocain solution. As soon as the nasal caliber had been partially reestablished, the existing hypertrophies were removed and the cure thus completed.

CHAPTER XIV.

NASAL POLYPI. PAPILLOMATOUS TUMORS.

POLYPI OF THE NASAL PASSAGES.

99. Although but a form of circumscribed hypertrophy of the mucous membrane, nasal polypi present peculiarities which require a separate description. The term polypus is applied to any tumor springing from a free surface by a constricted pedicle. Nasal polypi appear as elongated tumors, usually pendant and freely movable. They are either of a "fleshy" appearance, slightly more reddish than the normal mucous membrane, and of solid consistency, or more generally they are soft and grayish translucent by reason of edema. They vary in size from that of a small pea to the largest masses which can be accommodated by a nasal passage. They are more often multiple than single, more often bilateral than one-sided. Their most frequent points of origin are the free border and external surface of the middle turbinal and the region of the hiatus semilunaris. Smaller ones are often hidden underneath the middle turbinal, springing from the smaller ledges of the ethmoid or from the vicinity of the infundibulum. In rare instances a polypus from the upper part of the maxillary sinus protrudes through the hiatus into the nose. Much less common is their origin from the upper ethmoid structures. Very rarely a polypus is attached to the upper part of the septum. Different, however, from the ordinary polypus is a polypoid bleeding tumor occasionally seen on the septum-the bleeding polypus of the septum (¶ 237). Characteristic polypi do not grow from the inferior turbinal, although sometimes a cavernous hypertrophy may assume a polypoid shape (Figs. 54 and 55).

Polypi are rare in childhood, very common only after adolescence. Zuckerkandl found polypi in over 10 per cent. of unselected subjects in the dead-room.

100. The symptoms of polypi are nasal obstruction, more or less proportionate to their size. Patients often feel the moving of the pendulous masses during forcible breathing. When small tumors do not occlude the pas

FIG. 54.-External wall of the right nasal passage, with polypi in the middle and the superior meatus and on the inferior ethmoturbinal: b, Polypus originating from the middle turbinal; c, polypus in the inferior ethmoidal fissure; /, dilated infundibulum harboring a polypus (Zuckerkandl).

sage mechanically, they are apt to cause transient obstruction by turgescence. In such cases there is usually much nasal irritability, and sneezing fits, transient watery discharge, and distant nervous symptoms are quite comThe most frequent distant disturbance caused by polypi is asthma. In most instances polypi are associated with purulent rhinitis or suppuration of accessory cavi

mon.

ties, especially the anterior ethmoid cells. There are, however, cases in which there is no discharge. Bleeding is not caused by typical polypi. Occasionally polypi are partly angiomatous in structure, in which case free hemorrhages may occur.

IOI. Histologically, polypi present the structure of mucous membrane with inflammatory round-cell infiltration (Fig. 56). The term myxomatous tumor, formerly

FIG. 55.-Lateral wall of the right nasal chamber, with two large polypi: b, Infundibulum; c, cyst of the mucous membrane; a, accessory maxillary orifice (Zuckerkandl).

applied to them, is hence quite incorrect, as they are neither tumors in a pathologic sense nor do they consist of the embryonal connective tissue which makes up a myxoma. The gelatinous appearance of many polypi is due to edema. This edema is shown by the enormous shrinkage which such polypi undergo upon drying. Under the microscope it reveals itself by infiltration of the tissue with serum, which coagulates when placed in

alcohol. The serous infiltration may distend the meshes of the connective tissue to such an extent as to give some polypi a cystic appearance. True cysts, however, lined by epithelium occur only to a small extent in polypi. The growths are covered by the normal nasal epithelium. Polypi are generally not very vascular, and possess but few nerves.

The number of glands found in

FIG. 56.-Histologic structure of a nasal polypus. The normal stratified cylindric epithelium changes toward the right side to a less regular stratified series of flattened pavement cells. In the areolar tissue are meshes of variable size, filled with serum. There is not much more than the normal amount of cellular (leukocytic) infiltration except around the blood-vessels.

them varies with the area of mucous membrane from which they spring.

The inflammatory origin of these growths is shown by clinical observation. They occur mainly in connection with suppurative disease of the nasal passages or of the accessory cavities. Well-ascertained histories often teach that polypi are started by prior suppurative disease, which their presence then serves to perpetuate. The finding of the polypus should always direct a search for suppuration of accessory cavities, especially the ethmoid cells. and the maxillary sinus, for the recurrence of extirpated