SOME REMARKS ON THE PATHOL OGY OF INTRA-NASAL HYPERTROPHIES.

Read before the Pathological Society of Philadelphia, at their Conversational Meeting, held November 10, 1881,

BY CARL SEILER, M.D.,

Lecturer on Laryngology at the University of Pennsylvania, Pathologist to the Presbyterian Hospital, Curator of the Pathological Society, etc.

IN

N spite of the common occurrence of nasal diseases, very little is known about the pathological conditions giving rise to them. The cause of this want of know!edge must be sought in the fact that all portions of the nasal cavities cannot be explored in the living subject, and that, nasal diseases being but rarely fatal, this portion of the body is not, as a rule, included in post-mortem examinations made with a view to determine the cause of death in other diseases; and even in those cases in which it would have been practicable to disfigure the face of the subject by an exploration of the nose, very few investigators have taken the trouble and time to do so. It is true that since the introduction and perfection of the rhinoscope, as well as of the improved methods of inspecting the nasal cavities from in front, much has been discovered which goes to explain the symptoms we notice in nasal diseases; yet there is still a large field left unexplored; and to take a step or two upon the broad expanse of this terra incognita is the object of these remarks.

Before, however, entering upon the consideration of the pathological conditions, allow me to say a few words about the anatomy of the nasal cavities and the histology of their lining mucous membrane.

the lower turbinated bone is called the inferior meatus, the one between the lower and middle turbinated bones is the middle meatus, and the one between the middle and superior turbinated bones is the superior meatus.

The nasal cavities are separated from each other by a septum or division-wall, composed of the perpendicular plate of the ethmoid bone and the vomer posteriorly and the cartilaginous septum anteriorly, thus presenting a smooth surface as the inner wall of each cavity.

Di

The floor is formed by the palatine process of the superior maxillary bone and by the palate bone, and runs in a slanting downward direction from before backward. The roof is formed by the nasal bones and nasal spine of the frontal in front, in the middle by the cribriform plate of the ethmoid, and posteriorly by the under surface of the body of the sphenoid bone. rectly communicating with the nasal cavi ties by narrow channels are other cavities, situated in the bones of the skull, the lining mucous membrane of which no doubt is largely affected by the pathological processes in nasal diseases: these are the antra of Highmore,-large triangular cavities situated in the body of the superior maxillary bone and communicating with the nasal cavities by an irregularly-shaped opening in the middle meatus; then the frontal sinuses, two irregular cavities situated between the two tables of the frontal bone. The communication between them and the nasal cavities is established by the infundibulum,-a round opening in the middle meatus,-and finally the sphenoidal cells or sinuses found in the body of the sphenoid bone, communicating with the nasal cavities by small openings in the superior meatus.

That portion of the nasal cavities which projects beyond the end of the nasal bone is surrounded by cartilages forming the alæ of the nose.

Malformations in the bony walls of the nasal cavities are by no means rare, and the most common of them is deviation of the septum. This is so frequent that Semeleder found the septum straight in only ten out of forty-nine skulls examined, and Allen* found the nasal chambers normal in eighteen out of fifty-eight adult skulls examined. This deviation of the septum

American Journal of the Medical Sciences, January,

must in a great measure be attributed to the fact that at birth both the vertical plate of the ethmoid bone and the cribriform plate are not as yet ossified, and do not become rigid until a much later period of life, and may therefore be easily distorted by external violence applied to the nose by blows or falls. The act of blowing and wiping the nose with the handkerchief must also be considered as a factor in the production of deviation of the septum.

In the cartilaginous septum of the lower animals we find a small cavity lined with mucous membrane, called, after its discoverer, Jacobson's organ, the minute anatomy of which has lately been described by Kline.* This organ in man is, however, only rudimentary.

The nasal cavities are lined with mucous membrane, which varies greatly in thickness in different localities, and which ma- | terially decreases the size of the cavities in the living subject from that seen in the denuded skull. This mucous membrane is covered by ciliated epithelium in man, with the exception of that portion which lines the vestibule,-i.e., that portion of the cavities of the nose surrounded by cartilage only, which is covered by pavement epithelium. In the lower animals we find that in the olfactory region the ciliated epithelium is either absent or that ciliated and non-ciliated epithelium alternate in patches. I have not been able to find a statement in the literature on the subject as to the kind of epithelium found in the accessory cavities in man; but it is very probable that the mucous membrane of the frontal sinuses and the antra of Highmore is covered with ciliated epithelium: otherwise it would be difficult, if not impossible, for the secretions of that mucous membrane to pass through the narrow channels into the nasal cavities. The color of the normal nasal mucous membrane is of a light pink shade in what is termed the respiratory portion, while it is of a yellowish hue in the olfactory region, that portion of the mucous membrane which covers the roof and outer wall of the nasal cavities down to the upper margin of the middle turbinated bone and the septum down to about the same level. It is in this region that the nerve-ends of the olfactory nerve are distributed. Immediately beneath the mu

Quarterly Journal of Microscopical Science, January, 1881 † Henle, Anatomie des Menschen, vol. ii.

cous membrane and between it and the periosteum of the bony walls and the perichondrium of the cartilaginous portion of the septum we find a tissue which bears a striking resemblance to the erectile tissue of the genital organs. It is composed of a net-work of fibrous tissue, the trabecula of which contain a few organic muscular fibres. Its meshes, of various sizes and shapes, are occupied by venous sinuses lined with endothelium. These are supplied with blood by small arterioles and capillaries, which are quite numerous in the fibrous tissue and can readily be demonstrated under the microscope. In this arrangement of elements of the nasal mucous membrane we find a ready explanation of the fact that liquids of greater or less density than the serum of the blood, when introduced into the nasal cavities, produce pain;§ for we have here the most favorable conditions for osmosis, which will cause either a contraction or a distention of the sinuses. In the larger masses of fibrous tissue between the sinuses or caverns we find embedded the glands, with their ducts opening out between the epithelial cells of the mucous membrane. There are two kinds of glands in this region, which have been described by Kline,||-viz., serous and mucous glands.

This cavernous erectile tissue is most abundant at the lower portion of the septum and the lower turbinated bone; and, although it has been recognized and described as true erectile tissue by Henle, Virchow, and others, yet to Prof. Bigelow, of Boston, belongs the honor of having first called attention to the part which this tissue plays in nasal diseases. He gave to it the name "turbinated corpora cavernosa."¶

This short sketch of the anatomy of the nasal cavities will, I trust, be sufficient to enable me to make myself clearly understood when describing the morbid processes and pathological conditions underlying the formation of intra-nasal hypertrophies.

If we closely observe the course of a case of simple acute coryza, we will find that the first symptom is a feeling of fulness, accompanied by sneezing, and that this usually occurs in one nostril at first, the

Henle, loc. cit.

Seiler, Hand-Book of Diseases of the Throat and Nasal Cavities, p. 97 Loc. cit. Boston Medical and Surgical Journal, April 29, 1875.

other one being affected later in the same manner. An inspection of the mucous membrane shows it to be in a state of congestion, and so much swollen in certain portions, especially on the inferior turbinated bone, as to touch that of the septum. This produces partial stenosis of the nasal cavity, and is felt as fulness. The congestion having continued for some time, a watery discharge makes its appearance, which is produced by a hyper-stimulation of the serous glands. According to Cornil and Ranvier, lymph-corpuscles are found in this watery discharge of the early stage of acute coryza. Later the discharge becomes thicker by the admixture of the secretion of the mucous glands and of epithelial cells which have undergone fatty degeneration and are thrown off by the rapid formation of new cells under the stimulus of the increased blood-supply. The mucous membrane, as well as the submucous and cavernous connective tissue, becomes infiltrated with numerous leucocytes, and the venous sinuses become distended.

As the acute inflammation subsides, these conditions gradually disappear, leaving, however, the stretched mucous membrane thrown into folds as it contracts, which are especially noticeable at the posterior extremity of the inferior turbinated bone. While spreading, the inflammation involves the glandular tissue situated in the vault of the pharynx, the so-called adenoid tissue or pharyngeal tonsil,* and excites it to hypersecretion of the thick yellowish mucus which is expectorated towards the end of the attack. The mucous membrane lining the accessory cavities also participates in the general inflammation, and the accumulation of secretion within them, produced by the obstruction of the narrow outlets by tumefaction of the cavernous tissue, causes the dull pain in the head which accompanies an attack of this kind. Frequent repetitions of acute coryza at short intervals must of necessity produce a permanency of the inflammatory infiltration in the mucous membrane and submucous tissue, which infiltration finally becomes organized so as to form connective tissue; at the same time the venous

sinuses remain more or less distended, and the epithelium of the gland-ducts begins to proliferate. In this way permanent

* Luschka, Der Schlundkopf des Menschen.

Sketch of rhinoscopic view, showing posterior hypertrophies in both posterior nares, and projecting into the vault of the pharynx.

tilaginous septum-are usually sessile and of a bright-red color, while the posterior ones-occurring on the posterior extremity of the turbinated bones-usually have a short pedicle-like attachment and project into the vault of the pharynx. Their color is either a dark-brownish purple or a

light-yellowish pink; and I find that those of a dark color are much softer than the

† W. C. Jarvis, The Pathology and Surgical Treatment of Nasal Catarrh: Archives of Laryngology, vol. ii. No. 2.

light ones. Under the microscope a condition of the tissues in these swellings is noticed which I have already outlined.

Thus we see in a thin section of one of these hypertrophies that the epithelium is intact, although many of the cells, especially in the neighborhood of the openings of the glandular ducts, have undergone fatty degeneration. The basement membrane upon which the cells are mounted appears thickened, and immediately beneath it we find the mucosa densely infiltrated with a small-celled infiltration, so as almost entirely to obscure the mucous tissue. The gland-ducts are seen to be filled with proliferated epithelium, as are also the glands themselves. The bands of fibrous tissue forming the caverns in the erectile tissue are much thicker than in the normal structure, and the venous sinuses are large and irregular in outline. Here and there we find the endothelial lining of these caverns proliferating. Scattered through the connective tissue are seen

FIG. 3.

when the swelling springs from the cartilaginous portion of the septum.

Thierfelder describes and figures the microscopic appearance of a nasal hypertrophy found by accident in a subject dead from mitral insufficiency, and to the heartlesion he ascribes the formation of the swelling in the nose.. There is, however, no doubt that these swellings are of inflammatory origin, and that in Thierfelder's case it coexisted with, but was not directly caused by, the heart-trouble, as he supposes. The erectile character of the tissue composing the hypertrophies causes them to increase in bulk under certain circumstances. Thus, I have noticed that they are larger in women during the menstrual periods, and probably during the first months of pregnancy. Alcoholic stimulants cause them to swell up, as does mental and sexual excitement,-in fact, anything which tends to increase the bloodpressure in the head. In some cases they are larger in damp weather, while the

numerous lymph-corpuscles. In some sections made from hypertrophies I have noticed myxomatous change taking place in the fibrous tissue. There is but a slight difference in structure between the anterior and posterior hypertrophies, viz., that the venous sinuses in the anterior hypertrophies are not as numerous nor as large as in the posterior variety, and that usually the inflammatory infiltration, as well as the new-formed connective tissue, is much more extended: so that we notice the venous sinuses only near the periosteum when situated on the turbinated bones, and close to the perichondrium

moisture in the atmosphere does not affect them in others. It is probable that in the first instance they have undergone myxomatous degeneration, giving them hygroscopic properties.

The glandular tissue situated in the vault of the pharynx, and known as the adenoid tissue or pharyngeal tonsil, also becomes involved in the general chronic inflammation, and is likely to become permanently hypertrophied. When thus enlarged, this tissue presents a rugged appearance in the rhinoscopic mirror, with rounded eminences projecting into the pharyngeal cavity. The

secretion of this gland, when thus hypertrophied, is a thick, glairy mucus, which tightly adheres to the wall of the pharynx. Detached pieces of the tissue, when examined under the microscope, show the glandular elements greatly increased in number, the epithelium in the glands and ducts proliferating, and the scant connective tissue infiltrated with small-celled infiltration. This condition, however, but rarely interferes with the functions of the nasal cavities, except that it imparts to the voice a nasal sound by decreasing the size of the post-nasal cavity,

and thus interferes with the normal nasal resonance, as I have pointed out in a paper read before the American Laryngological Association at its annual meeting in 1881. On the lower portion of the cartilaginous septum we frequently notice protuberances which to the eye closely resemble the sessile hypertrophies of the mucous membrane, but which, when touched with a probe, have a hard, elastic feel, the same as is conveyed to the hand when touching the cartilaginous septum in other apparently normal portions. These are not localized deviations of the septum,- for we do not find a corresponding depression on the other side,-but they are true hypertrophies of the cartilage, as I had occasion to prove by removing a very large one and submitting it to microscopical examination. Gottstein claims that they are the result of a localized chronic perichondritis,* secondary to the chronic inflammation of the nasal mucous membrane; and this seems very plausible to me, for these cartilaginous hypertrophies are met with only in cases of long-standing catarrh.

On the floor of the nose we frequently see bony excrescences springing from the superior maxillary bone, which were described by Dr. Allen. These are usually congenital, and, unless they give rise to pain and inconvenience by pressure through their size, are harmless.

According to Virchow's definition, these hypertrophies should be considered as tumors (which would be a strong point in favor of my friend Dr. Formad's inflammatory theory of tumors); but, inasmuch as they are not true neoplasms, but only localized increase of size of the normal tissues, and as they are not permanent,often atrophying without having previously undergone destructive changes,-they cannot be considered as such; and the term hypertrophy, which has been used to designate them, is, in my opinion, a proper There is, however, a class of tumors, so called, found in the nasal cavities, which, springing from the mucous membrane or periosteum of the turbinated bones, or more rarely from the septum, differ in their histological elements, as well as in shape and size, from the hypertrophies, viz., nasal polyps.

one.

Two varieties of nasal polyps are usually

Ueber die verschiedenen Formen der Rhinitis und deren Behandlung vermittelst der Tamponade: Berlin. Klin. Wochenschrift, No. 4, 1881. † Loc. cit.

*

recognized,-the mucous and the fibrous variety, to which I would add a third,— the cystoid.

Like the hypertrophies of the mucous membrane and of the cartilaginous septum, these polyps are due to inflammation; and Galen recognized this fact, for Virchow quotes him as saying "that the nasal polyps are due either to inflammation or develop from a node or from germinal matter." And Virchow himself§ says that on mucous surfaces tumors for the most part occur in places where there previously was a simple inflammatory disturbance,-where the simple inflammatory hyperplasia of chronic catarrh precedes the growth of polyps.

It is therefore evident that they may occur on any portion of the nasal mucous membrane, and that they will be found more usually in those portions of the nasal cavities which are most exposed to the irritating influences of the air and dust,viz., in the respiratory portion. They are, however, also found in the antra of High