Papillary (Edematous Nasal 
Polypi and their Relation 
to Adenomata. 
BY 
JONATHAN WEIGHT, M.D., 
BROOKLYN. 
REPRINTED FROM THE 
Kcto Nortt iHeMcal Soutnal 
for November 13, 1897. Reprinted from the New York Medical Journal 
for November 13, 1897. 
PAPILLARY (EDEMATOUS NASAL POLYPI 
AND THEIR RELATION TO ADENOMATA.* 
By JONATHAN WRIGHT, M. D., 
BROOKLYN. 
Billroth, in Ms classical work, Ueber den Ban der 
Schleimpolypen, in 1855, reported two cases of nasal 
tumor to wMch he gave the name of Zotterikrebs. One 
sprang from the middle turbinated bone among a mass 
of oedematous polypi. It was removed and recurred, and 
finally resulted fatally. In the other case the growth 
sprang from the inferior turbinated body. It passed 
from his observation, hut he regarded it as belonging to 
the same category as that of the first case. In the light 
of our present knowledge of such cases as the latter we 
may he allowed to conjecture that it was a papillary 
hypertrophy of the inferior turbinated body. The rea- 
sons for this surmise will appear later in the course of 
this article. Hopmann (1), in his welLknown paper on 
Papilloma of the Nose, gave a careful description of a 
papillary growth of the middle turbinated bone and re- 
* Read before the American Laryngological Association at its nine- 
teenth annual congress. 
Copyright, 1897, by D. Appleton and Company. 2 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
ferred to a similar one by Michel, which they both called 
an epithelioma papillare, but Hopmann hastens to say 
that he regarded his own growth as of a benign charac- 
ter. In another paper (2) I have had occasion to remark 
upon the confusing nomenclature introduced into rhino- 
logical literature by Hopmann in describing nasal 
growths, and I may add that in this instance it certainly 
seems unwise to give the name of epithelioma to a be- 
nign growth. Hopmann’s case was also associated with 
oedematous growths. Zarniko (3) reported a similar case 
in a man of fifty years under the name fibroma of the 
nasopharynx, of a peculiar shape and structure; but it 
evidently had its origin in the region of the middle tur- 
binated bone among oedematous growths. Again, a 
year later, Kiesselbach (4) reported a case, and adopted 
Hopmann’s classification of a benign epithelioma papil- 
lare. 
Several years ago I examined microscopically a 
growth removed by Dr. Charles H. Knight, of New 
York, from the middle turbinated bone of a man of fifty 
years. Figs. 2 and 3 represent drawings of the micro- 
scopic appearances of this growth. 
About a year ago Dr. F. W. Hinkel, of Buffalo, sent 
me a slide containing sections of a growth, from which 
I have had a drawing made representing the structure 
(Fig. 4). Later, he very kindly furnished me with the 
following history of the case: 
No history of the case can be obtained at this time. 
Mrs. J. G-. C., aged thirty-five years, in the winter 
of 1891 had an attack of la grippe. After this she be- 
gan to notice the gradual increasing obstruction of the 
right nostril and a feeling of pressure in the right ear. 
During the summer she had blown a few fleshlike pieces PAPILLARY (EDEMATOUS NASAL POLYPI. 
3 
from that nostril and there had been a slightly purulent 
discharge. Her general health was fairly good, although 
she was never very strong. On November 22, 1892, 
examination showed a red papillary mass filling the right 
nasal chamber, bathed in pus, but not extending beyond 
the vestibule. A posterior rhinoscopic view could not 
be obtained. The tumor was movable and attached to 
the upper and back part of the nasal cavity. The infe- 
rior turbinated body was slightly atrophied or com- 
pressed. The growth was quickly removed by the snare, 
and its dimensions were found to be about 2.5 X 1.5 X 1 
ctm. It was a soft, friable, feathery, papillary mass. The 
haemorrhage was moderate but persistent. Upon Febru- 
ary 17, 1893, the patient returned, when the pedicle was 
seen to project from above the middle turbinated bone. 
This was removed by the snare. She was seen four days 
later, and again after an interval of seventeen days. She 
was feeling quite weak, and there was a pultaceous dis- 
charge over the vault of the pharynx. Some adhesion 
of the right middle turbinated bone to the sseptum had 
occurred. For three years and a half there was no recur- 
rence of the symptoms, but three months later, symptoms 
having again appeared, the patient was examined, and it 
was found that the growth had recurred. 
Dr. E. T. Dickerman (5), of Chicago, has lately pub- 
lished the report of a case which he called a nasal papil- 
loma. The photograph of a microscopic section of 
the growth which accompanied the report led me 
to think that it probably belonged to the class re- 
ferred to in this paper, and at my request he very gener- 
ously placed the remaining part of the tumor at my dis- 
posal. Fig. 5 represents a drawing made from a section 
of one part of it, and Fig. 6 that of a section made from 
another part of the same growth. From Dr. Dicker- 
man’s published report of the case I copy the clinical his- 
tory of it: 4 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
“May 2, 1896.—John O’Connor, aged sixty-two 
years, presented himself at my clinic complaining that 
his right nostril had been occluded for some time. 
The man was in perfect health, and his previous and 
family history good. He stated that nine years ago his 
nose had first become occluded, and that he consulted a 
local surgeon, who had gone blindly into the nose with 
forceps and curette, and had removed a large amount of 
* flesh.’ For about a year he was well, but for the last 
five years his nose had been closed. On examination I 
found nothing of importance externally. On looking 
into the right nostril I found the nose filled to the vesti- 
bule with a pinkish-gray cauliflower mass. It was not 
ulcerated and was movable, apparently having a small 
pedicle. With a probe I was able to locate its attach- 
ment to the upper and anterior part of the quadrangular 
cartilage to what seemed to be a small ecchondrosis. 
Posteriorly the choana was filled with the same growth, 
with the one exception that here one or two of the 
branches appeared oedematous and protruded through 
the middle meatus. The absence of ulceration, infiltra- 
tion at the point of insertion, and enlargement of glands 
and the duration of the disease, compelled the diagnosis 
of sseptal papillary fibroma. With a strong pair of scis- 
sors I was able to remove a large portion of the growth 
with the thickened portion of the sasptum attached. 
The remainder was removed with the cold snare and the 
base cauterized. The haemorrhage was at no time pro- 
fuse, and at the present time there is no recurrence of 
growth.” 
By the drawing of Dr. Hinkel’s case (Fig. 4) you 
will see at a glance the nature of the external configura- 
tion of the growth and of its structure—numerous finger- 
like processes springing from a common base. Many of 
them have rounded or club-shaped extremities. Exam- 
ined microscopically, it is seen that these processes are 
made up of loose oedematous fibrous tissue covered by PAPILLARY (EDEMATOUS NASAL POLYPI. 
5 
one or two layers of columnar ciliated epithelium; but it 
is apparent that the epithelial development is a complex 
one. In no place is there any marked thickening of the 
layers, hut the surface epithelium is seen to communicate 
and to he continuous with deep indentations and rami- 
Fig. I.—Schematic drawings from Amann. 
In order to make this matter more clear I reproduce here some of the sche- 
matic drawings from Amann’s book. 
A cross-section of the duct a. at the line indicated, would give us the appear- 
ance b. There may be a solution in the continuity of the epithelium as in c; 
then in cross-section we have the appearance d. The cells of the acini may pro- 
liferate also as in eor in/, and a cross-section would give the appearance gor a 
still more complicated figure in the cross-section of f. 
After careful study I am unable to distinguish the actual segmentation of the 
cells in their long axes, and I am inclined to think that some of the cells at 
least are formed from the underlying connective tissue, or hy some other form 
of proliferation than segmentation through their long axes ; but the compara- 
tively slight increase in the number of layers and the convolutions of the rows 
of epithelium would bear out Amann’s description. 
fications of it into the underlying stroma. Separate rings 
of epithelium, ovoid, circular, or ramified in shape, and 
varied in extent, are seen to occupy and make up a large 
part of the hulk of the growth. The structure in Dr. 
Dickerman’s case and its external configuration is almost 
identical with the above. 
Examined with the high power one is immediately 6 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
struck with the amount of mitotic granules in the epi- 
thelial cells (Fig. 7). Evidently proliferation is rapid- 
Fig. S.—Ur. Knight’s case. 
ly going on, hut not in such a way as to increase marked- 
ly the number of layers. By the study of these growths 
Fig. 3.—Dr. Knight’s case. 
alone it is impossible to arrive at an understanding of the 
method of their pathogenesis. To do that, we must not PAPILLARY (EDEMATOUS NASAL POLYPI. 
7 
only study like processes in other parts of the body, 
where their more frequent occurrence furnishes a more 
ample opportunity, hut we must study analogous nasal 
processes and this same epithelial proliferation at an 
earlier stage if possible. 
I quote from Cornil and Eanvier (6) the following: 
“ Among the polypi of the nasal fossae are some which 
so resemble the cystic adenomata of the uterus that it 
is impossible to distinguish them by comparative examina- 
tion with the naked eye or with the microscope.” * 
Fig. 4.—Dr. P. W. Hinkel’s case. 
Birch-Hirschfeld (7) and Weichselhaum (8), in their 
works on pathological anatomy, both describe and give 
drawings of papillary cystomata of the ovaries and of 
processes of chronic inflammation of the uterine mucosa 
which closely resemble the nasal growths under con- 
* I have in my possession a good example of the same process in a 
glandular polypus of the rectum. 8 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
sideration, and Amann (9) has lately given an admirable 
description and explanation of their complicated struc- 
ture. He shows that in glandular hypertrophy the cells 
of the ducts and of the acini of the glands proliferate by 
segmentation parallel to their long axes. This causes 
an elongation of the rows of epithelium and not an in- 
Fig. s.—Dr. Dickerman’s case, showing adenomatous tissue. 
crease in the number of the layers. This necessarily 
leads to a convolution of the ducts or to an invagina- 
tion of their walls. The walls of the acini are also dou- 
bled and folded on themselves in such a way as to in- 
crease the labyrinthian maze of epithelial rows. On 
cross section, therefore, we have very much the same 
appearance as would he presented by section through a 
bunch of angleworms. 
Now to return to our nasal growths. On a study of 
the mitotic changes in the columnar cells of the surface, 
it may be seen that this proliferation goes on there as 
well as in the glands, so that the surface is raised into 
papillae by the extension of the rows of epithelial cells. PAPILLARY (EDEMATOUS NASAL POLYPI. 
This overgrowth of epithelium within the substance of 
the tissue of a polyp would crowd out much of the 
oedema and compress the stroma fibres. This is the con- 
Fig. 6.—Dr. Dickerman’s case, showing oedematous structure. 
dition we have both in Dr. Hinkel’s (Fig. 4) and in 
Dr. Dickerman’s specimen, in that part from which Fig. 
sis taken. You will observe, however, that in the other 
Fig. 7.—Dr. Hinkel’s case, showing mitosis in the cells. 
section from Dr. Dickerman’s case (Fig. 6) the structure 
is that of an ordinary mucous polypus. The stroma 
in Dr. Hinkel’s case is also oedematous in places, and 10 
papillary (edematous nasal polypi. 
this must be borne in mind with the clinical fact appar- 
ent in most of the histories, that these growths have 
usually been found combined with polypi of the middle 
turbinated bone. It becomes necessary for us, therefore, 
to see if any pathogenic connection exists between these 
growths. 
You may remember that several years ago I read 
a paper (10) before this association to show that nasal 
polypi are not usually myxomatous. In the light of 
much subsequent experience in the histological examina- 
tion of morbid nasal conditions I am ready to state my 
Fig. B.—Papillary oedematous polyp. 
belief that true myxoma, as it is understood by histolo- 
gists, never occurs in the nose. In arriving at this con- 
clusion I have examined, in the aggregate, nearly a hun- 
dred mucous polypi from the nose. I believe that they 
are the result of chronic inflammation. 
It so happens that I have preserved one or more PAPILLARY (EDEMATOUS NASAL POLYPI. 
slides of nearly all my pathological material, and in look- 
ing over those of oedematons polypi I am able to select a 
series of slides which show fairly well an apparent transi- 
tion from the ordinary smooth form of the latter to the 
papillary state (Figs. 8, 9, and 10). 
It is evident that other influences are at work be- 
sides epithelial proliferation to produce this papillary 
surface in mucous polypi. Zuckerkandl (11) says that 
he has observed a dilatation of the mouths of the glands 
produce a curvature of the surface epithelium: “The 
Fig. 9.—Papillary oedematous polyp. 
chief ducts of the glands become dilated; the same oc- 
curs in their communicating acini, which thus among 
themselves and with the ducts unite to form indenta- 
tions ” (Buchten). On a reference to the drawings from 
my specimens, as in Fig. 10, at x you will note the phe- 
nomenon referred to by Zuckerkandl. This will doubtless 12 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
explain some of the puzzling curvatures of the epithelium 
within the growth (Fig. 3) and yet communicating free- 
ly with the surface, hut will not suffice by itself as an 
explanation for the enormous development shown in 
the specimens of Dr. Hinkel and Dr. Dickerman. The 
segmentation of the glandular and surface epithelium, as 
Fig. 10.—Papillary cedematous polyp. X, dilatation of gland ducts. 
noted above, will supply this deficiency, hut we still have 
another influence at work to lengthen out the papillae 
of the surface, and that is the proliferation of the fibrous 
tissue. Abundant mitotic figures may also be seen in 
some of the cells of the connective tissue. This brings 
us to the realization of the fact that we have instances 
of these processes going on in other growths of the nose 
than mucous polypi, and in other situations than upon 
the middle turbinated bone. I have suggested that the 
dilatation and collapse of the erectile tissue determines, 
to some extent, the configuration of the surface in the PAPILLARY (EDEMATOUS NASAL POLYPI. 
13 
“ mulberry hypertrophies ” of the inferior turbinated 
bodies, but the increase in the fibrous tissue, and the 
dilatation of gland ducts, here, as in the oedematous 
growths of the middle turbinated bone, are the chief ad- 
juvants to the epithelial proliferation in the production 
of a papillary surface. I have slides from growths of 
the inferior turbinated bodies to show as an illustration 
of this also. One of them (Fig. 11) shows that the 
Pig. 11.—Papillary hypertrophy of the posterior end of the inferior turbinated 
body. 
growth of the fibrous tissue is the chief element in the 
digitations, while the other (Fig. 12) shows also con- 
siderable epithelial hyperplasia. 
Since the completion of the observations which form 
the subject of this paper I have received from Dr. F. E. 
Hopkins, of Springfield, a specimen which proves to be 
an adeno-carcinoma of the nose. In many places it is 
impossible to distinguish the structure from that found 
in Dr, Hinkel’s and in Dr. Dickerman’s cases, and it is 14 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
therefore impossible to say with certainty that there 
are not, in unexamined parts of their growths, car- 
cinomatous elements which are not to he found in the 
parts submitted to me for examination. Dr. Hopkins, 
I believe, is to report his case at this meeting, and you 
will see from the drawing of the microscopic appearances 
the resemblance of the structure to that of those growths 
of which I have been speaking. 
Fig. 12.—Papillary hypertrophy of the inferior turbinated body approaching an 
adenomatous condition. 
Thus you will see the gradations in development from 
the ordinary mucous polypus through a benign ade- 
nomatous growth to a malignant one. In the mucous 
polyp and in the adenoma we have the results, I believe, 
of an inflammatory process. At first we have the effusion 
of serum into the tissues from the blood-vessels. After- 
ward, or pari passu with it, we have the proliferation of 
the fibrous tissue. This makes an oedematous mucous 
polyp. Then, in these rare adenomatous and papillary 
growths we have the proliferation of the glandular and 
surface epithelium. PAPILLARY (EDEMATOUS NASAL POLYPI. 
The tendency of adenomatous growths to become sar- 
comatous or carcinomatous is well known, and has been 
long recognized. This brings us to the astiology of car- 
cinoma and sarcoma, and into that I am not capable of 
entering. 
We know that epithelial proliferation of another 
type produces the fibroma papillare or true papilloma of 
Virchow, and that this also has some affinities with 
chronic inflammation, as exemplified in the pachydermia 
verrucosa of the larynx. The tendency to papillary 
formations is seen not only in the epithelium covering 
fibrous tissue, but, as I have lately had occasion to observe, 
lymphoid tissue of the faucial tonsil is occasionally 
thrown into the digitations covered by proliferated 
squamous epithelium, which give to the surface a papil- 
lary vegetating appearance. 
In fact, so close a relation exists between the prod- 
ucts of inflammation and many of the various forms of 
benign tumors that I must acknowledge my inability to 
draw any practical line between them. So far as my 
observation goes in reading works on pathology, this can 
only be done to the satisfaction of those who know noth- 
ing of the subject, but it is a great convenience to the 
teachers of students. 
In presenting this paper I desire to express my sense 
of great obligation to the gentlemen who have so gener- 
ously placed their pathological material at my disposal 
for study. 
1. Hopmann. Virchow’s Archiv,Uo. 93, pp. 234-336. 
2. Wright. N. Y. Medical Journal, December 26, 
1891; Trans. Am. Lar. Assoc., 1891. 
3. Zarniko. Virchow’s Archiv, No. 128, p. 132. 
4. Kiesselbach. Virchow’s Archiv, No. 132, p. 371. 16 
PAPILLARY (EDEMATOUS NASAL POLYPI. 
5. Dickerman. Annals of Ophth. and Otol., October 
1896, p. 1125. 
6. Cornil and Eanvier. Manuel dhistologie patholo- 
gique. 
7. Birch-Hirschfeld. Lehrhuch der path. Anatomie, 
Bd. ii, p. 746, 1887. 
8. Weichselbaum. Grundriss der path. Histologie, 
1892. 
9. Amann. Lehrhuch der mihr. gyndkologischen 
Diagnostik, 1897. 
10. Wright. N. Y. Medical Journal, November 4, 
1893; Irans. Am. Lar. Assoc., 1893. 
11. Znckerkandl. Norm, und path. Anat. der Na- 
senhohle, ii, 1892, p. 109. The New York Medical Journal. 
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