polypi may be expected sooner or later if the primary suppuration is not removed. Yet there are instances in which polypi are not accompanied by any form of intranasal or adjoining suppuration. Another condition which is often found clinically as a predisposition to polypus formation is the narrowing of one nasal passage from septum thickening or from deviation. In such cases, however, polypi are usually found on both sides of the nose. Polypi cannot be considered analogous to other hypertrophies of the mucous membrane; for the overgrowth constituting the polypus is not diffuse, but is strictly localized in a small area which continues to grow after it has separated itself from its source by a pedicle. The constriction of the pedicle implies that the growing process takes place only in the body of the polypus. There must hence be some strictly localized stimulus causing this growth. All research for bacteria has hitherto been negative.

102. A polypus incompletely removed undergoes rapid regeneration, but complete abscission at the base of the pedicle eradicates it. The removal of a polypus often permits small ones hitherto concealed by it to grow at a more rapid rate, but when the polypi have been completely taken away, their reappearance need not be expected unless some suppurative process persists.

103. The removal of a polypus is easily accomplished by placing the snare loop around its pedicle at its base and cutting through. Under the proper use of cocain this is painless and generally not very bloody. If the loop cannot be pushed up to the very base of the pedicle, it is better to tear off the polypus after tightening the wire, rather than to cut it off incompletely. As a rule, some of the mucous membrane from which it springs is thus torn away with it, and the removal is complete. The method of the older surgeons to seize polypi with forceps, especially without the use of the mirror, can only be condemned as inefficient and barbarous. When the polypus is not accessible to the wire loop, its

In the case of

base may be cut away with a sharp curet. The hot snare has no advantage over the cold wire. The use of the galvanocaustic burner involves the risk of obliterating the orifices of accessory cavities. narrow nasal passages various accessory operations may be necessary for the complete eradication of polypi. When they are multiple on or underneath the middle turbinal, it is often best to amputate the front end of

FIG. 57.-Papilloma on the inferior turbinal (Zuckerkandl).

that process. When a thickening of the septum interferes with the accessibility of the growth, some form of operation on the septum may be necessary before the nose can be entirely cleared. After the removal of polypi all hidden foci of suppuration must be sought and cured in order to prevent subsequent growth.

104. Papillomatous tumors are localized overgrowths found, as a rule, mainly on the inferior turbinal. In their clinical significance they are analogous to polypi,

differing from them only by reason of the different area of mucous membrane from which they spring. They are much less common than polypi. Their structure is that of the mucous membrane covering the inferior turbinal with inflammatory round-cell infiltration. These growths occur either as hard or as soft papillomata, the difference being due to the preponderance of fibrillary connective tissue in the former, while in the latter the abundant presence of round cells gives them almost the structure. of granulation tissue. The name of papilloma is given to these growths on account of their minutely lobulated surface, which thus resembles the papillary structure of the skin. In appearance they may be aptly compared to a raspberry, which they also resemble in color. They occur most frequently in connection with chronic purulent rhinitis, and their presence helps to perpetuate the suppuration. They can be easily and permanently removed by snaring (Fig. 57).

13

CHAPTER XV.

NASAL STENOSIS.-COLLAPSE OF THE SIDES OF THE NOSE.-SYNECHIÆ. OCCLUSION OF THE POSTERIOR CHOANÆ.

NASAL STENOSIS.

105. While the width of the nasal passages varies in different subjects with the width of the skull, the normal nose offers no appreciable resistance to the current of air during quiet or even during forcible respiration. Any narrowing or encroachment upon the caliber of sufficient extent to impede the respiratory current is termed stenosis. In default of more accurate physical methods of measurement we can gauge the normal or diminished permeability of the nasal passage by auscultation. When the caliber is sufficient, the ingoing or outgoing air produces no sound, even while breathing forcibly. Any interference, however, with the respiratory capacity of the nose causes a sound varying from a gentle rustling noise to a sharp hiss. The more forcible the breathing, the more distinct is the sound. Either side must be tested while the other is closed by the thumb. In a nose otherwise not diseased stenosis or even occlusion of one side causes no annoyance ordinarily as long as it is compensated by full width of the other. For the animal system has in most of its functions an excess of capacity, and hence some physiologic latitude. But when the breathing is deepened in consequence of severe exertion, the nasal passages of less than average capacity become insufficient, and the individual is "short-winded." If, however, both nostrils are narrowed,—a condition which occurs only in consequence of disease and not merely as a structural anomaly, -the subject feels the difficulty of breathing, and upon the least exertion is forced to breathe

through the mouth. Especially is this the case in the recumbent position (during sleep), when the increased venous blood pressure in the low-lying head causes additional nasal obstruction by turgescence. As the path of the air through the mouth is cut off whenever the tongue arches upward so as to touch the soft palate, which movement often takes place while the mouth is open, the sleep is apt to be interrupted or troubled by momentary dyspnea.

Mouth-breathing, furthermore, subjects the throat and lower air-passages to abnormal and irritating conditions. The inspired air is both warmed and nearly saturated with moisture in passing over the convoluted surface of the normal nasal passage, while the dust it contains is almost wholly deposited there. None of these conditions. are fulfilled during mouth-breathing. The cool, relatively dry, and possibly dusty air reaching the pharynx and lower air-passages acts as an irritant. While this irritation by itself is not sufficient to cause local disease, it aids other pathogenic influences, such as infection, in overcoming the resistance of the tissues.

106. Nasal stenosis is an important determining condition in the persistence and chronicity of all forms of nasal inflammation. It favors the prolongation of a coryza in the form of a chronic purulent or simple rhinitis. It predisposes in the latter case to the occurrence of hypertrophies, even of polypi. It hinders the free drainage in acute suppuration of the accessory cavities, and thus aids. in changing these into chronic affections. Last, but not least, all forms of stenosis exert the most pernicious influence by favoring the extension of inflammatory disease through the Eustachian tubes into the ear. Of all nasal diseases, ozena is the only one the predisposition to which is not augmented by stenosis.

When a one-sided nasal stenosis has become complicated by actual nasal disease, stenotic annoyance is felt by the patient on both sides on account of the variable turgescence of the cavernous tissue, which causes tran