Hofmeier: "Ueber die entgültige Heilung des Carcinoma Cervicis Uteri durch die Operation," Zeitschr. f. Geburtshülfe und Gynäkologie, 1886, vol. xiii, p. 360.

Wallace: Brit. Med. Jour., 1883, vol. ii, p. 519.

Gusserow: "Die Neubildungen des Uterus," Deutsche Chirurgie, by Billroth and Luecke, Leipzig, vol. lvii, p. 233.

Schatz: "Klinische Beiträge zur Extirpation des ganzen Uterus durch die Vagina,” Arch. f. Gynäkologie, 1887, vol. xxxi, p. 409.

Binswanger: Centralbl. f. Gynäkologie, 1887, vol. xi, p. 1.

Ruge und Weit: Zeitschr. f. Geburtshülfe und Gynäkologie, vol. ii, p. 415.

Sänger: Arch. f. Gynäkologie, 1883, vol. xxi, p. 29.

Frank: “Ueber extraperitoneale Uterusextirpation," Arch. f. Gynäkologie, 1887, vol. xxx, p. 1.

Hagar und Kaltenbach: Die operative Gynäkologie, Stuttgart, 1886.

Tauffer: "Zur Frage der Totalextirpation des carcinomatösen Uterus,” Arch. f. Gynäkologie, 1884, vol. xxiii, p. 367.

Brennecke: "Ueber die vaginale Totalextirpation des Uterus," Zeitschr. f. Geburtshülfe und Gynäkologie, vol. xii, p. 56.

Storck: Berlin. klin. Wochenschr., 1882, vol. xix, p. 12.
Boeckel: Virchow's Jahresb. f. 1884, vol. ii, p. 626.

LIVING AND DEAD OSTEOMATA OF THE NASAL

AND ITS ACCESSORY CAVITIES, ILLUS-
TRATED BY A CASE OF ENCYSTED ORBITAL
OSTEOMA ORIGINATING IN THE ETHMOID
BONE*

SPENCER Watson called attention, in 1868,† to the fact that a peculiar form of exostosis not infrequently developed from the walls of the ethmoid cells and the sinuses of the frontal and ethmoid bones. Frequently these osseous tumors developed into the orbit and encroached upon the eye, displacing and finally destroying it by pressure. It was the practical importance of the latter fact that directed especial attention to the so-called orbital osteomata. Cruveilhier had before this shown that osseous tumors were often encysted or surrounded by a peripheral layer of bone. Virchow pointed out that orbital osteomata often developed in the diploë of the surrounding bones, expanding their cortical substance so as to be "encysted" by a layer of the latter, but at the same time he made the distinction between these enostoses and true exostoses originating in the periosteum of the walls of the orbit.

Arnold first called attention to the fact that orbital osteomata often had their primary seat in the surrounding sinuses, and from here later in their growth entered the orbit. The true relation of the encysted osteomata of the orbit, of Cruveilhier, to the nose and accessory cavities, was not thoroughly revealed until 1881, when Bornhaupt, in an excellent article describing an orbital osteoma originated in the frontal sinus and operated upon by Volkmann in Halle, gathered from the literature not less than 50 cases of these tumors. From Bornhaupt's exhaustive investigations on this subject, the most important points regarding the development, as well as the diagnosis, prognosis, and treatment, hitherto unknown, have been brought forth; and we owe to him our present somewhat thorough knowledge of the subject, together with most valuable practical suggestions as to the rational method of operating for their removal.

Tillmanns has lately called attention to the fact that similar osteomata develop also from the walls of the nasal cavity, and that the dead osteomata described by Dolbeau, lying loose in the frontal sinus, belong to the same class of osseous tumors.

* Jour. Amer. Med. Assoc., 1888, vol. xi, p. 185.

† Transactions of the London Pathologic Society, 1868, vol. xix, p. 314. Langenbeck: "Ein Fall von linksseitigem Stirnhöhlen-Osteom, nebst Bemerkun gen über die in den Nebenhöhlen der Nasen, sich entwickelnden Osteome," Arch. f. klin. Chir., 1881, vol. xxvi, p. 589.

§ "Leber todte Osteome der Nasen und Stirnhöhlen," ibid., 1885, vol. xxxii, p. 677.

My attention has been especially directed to this subject by the following case:

Morits Mayer, twenty-four years of age, tailor, was admitted to Cook County Hospital April 27, 1887. He gives the following history: Parents lived to old age, and there is no history of tumors or deformities in any of his ancestors or relatives. Patient had measles when a child, but otherwise has always been strong and healthy. He dates his present illness from 1878, when he was struck by a club at the inner canthus of the right eye, causing fracture of the bones of the nose. In the course of a year a swelling appeared and increased slowly and without pain in the above-named region, causing the right eye to be pushed outward. He thinks the swelling has remained stationary for the last eight years. Five years ago a discharge of pus from the right nostril commenced, and has continued ever since. Four months ago an abscess formed in the inner canthus. It was opened and left two fistulous openings which discharge a moderate amount of pus.

Present Condition. The patient is well nourished, somewhat pale, but otherwise looks healthy..

On the right side of the root of the nose is a flat prominence which fills up its inner third from the superciliary arch down to the infra-orbital ridge, and extends a little in front of the bridge of the nose. The superciliary region of the frontal bone, that is, the anterior wall of the frontal sinus, is not enlarged or pushed forward. The skin covering the tumor is normal, with the exception of a red, inflamed area around the two fistulous openings. The probe introduced through these finds roughened bone near the surface, and the entire tumor feels hard, as if consisting of bone covered only by skin. The infra-orbital margin can be traced to within a line or two inside the infra-orbital foramen, where it gives place to the hard tumor arising from below.

The eye is pushed downward and somewhat outward, and on examination by Dr. E. M. Smith, oculist to the Cook County Hospital, presents the following condition: Right eye deviated outward and downward; distance from nasal crest to pupil on left side, 30 mm.; on right side, 50 mm.; consequently the outward deviation is 20 mm.; deviation downward, 10 mm.: exophthalmos, 7 mm. There is slight hypermetropia; the pupil is active; the tension of the eyeball, normal. Ophthalmoscopic examination shows the fundus normal, the optic papilla not swollen, but the veins are somewhat engorged and tortuous. Acuteness of vision good.

Inspection of nose shows, 11⁄2 inches inside the nostril, instead of the inferior and superior meatus and the concha, an irregular mass covered with bluish-red mucous membrane, to which several small polypi the size of a pea are attached.

The infra-orbital region is somewhat prominent in its nasal half, but no distinct tumor can be felt behind the upper lip above the alveolar process of the upper maxilla.

Inspection of the mouth and palate shows no difference between the two sides, and the soft palate and pharynx are normal. Rhinoscopic examination is impossible on account of the thickness and size of the soft palate, the movements of which the patient cannot control. Palpation of the nasopharyngeal cavity with the finger reveals a hard,

irregular, rough, bony mass filling up the right posterior choana. A small exploratory incision, dilating the fistulous opening of the tumor, in the inner canthus showed the roughened bony surface of a large osseous tumor which was hard and immovable.

Diagnosis. Orbital osteoma originating in and being part of a large ethmoid osteoma, the place of origin either in the lower medial point of the frontal sinus or in one of the ethmoid cells.

Operation. On May 3, 1887, the patient was anesthetized and an attempt made to introduce a Bellocq's tube, with a view to tamponing the right cavity of the nose posteriorly and anteriorly, so as to avoid hemorrhage down into the pharynx. This was frustrated by the tumor in the nose, which made the introduction of the tube impossible. The patient was then placed on his back, with his head hanging downward, to be operated upon in Rose's position. A longitudinal incision was made midway between the eye and the root of the nose, commencing on the frontal bone 1 inch above the orbit, and extending downward 3 inches to the ala of the nose. The incision having been carried down to the tumor, the soft parts were detached by a gouge from the anterior and orbital surface of the latter. The tumor was found to extend far back in the orbit, from 1 inch to 11⁄2 inches. The surface of the tumor is very hard, and the tumor itself is immovable. With a view of getting at the base of the tumor, if it existed, or, rather, of uncovering the mass of the tumor, I removed with the chisel the nasal and frontal portions of the superior maxilla and the right nasal bone, together with the nasal process of the frontal bone. Having thus opened the frontal sinus, I was so fortunate as to find the end of the tumor reaching up, with only a small corner which was not attached to the walls of the frontal sinus at all. Through the large lateral opening into the nasal cavity the tumor was found filling it up, and by grasping with a firm bone forceps it was easily made movable and brought out through the opening. The bony tumor which was formerly felt in the posterior nares was still there, but it was loose and was removed through the same opening as the other tumor. There was now left a large cavity opening into the frontal sinus and posterior nares, and the nasal and submaxillary cavities below. In the orbit the periosteal covering of its inner wall was intact, covering the eye and its accessory organs. The remainder of the cavity was covered with its mucous membrane, on which several small polypi were found and removed.

There was no considerable hemorrhage, and the wound was united and the cavity washed and packed with iodoform gauze. With the exception of a slight rise in temperature on the second day, the course of the after-treatment was aseptic. The iodoform gauze dressing remained until the close of the second week, at which time the wound had united.

Description of Tumor. The living osteoma weighs 2 ounces, measures 21⁄2 inches in length and 11⁄2 inches in diameter, and is irregular in shape, since it consists of several portions, corresponding to the different cavities which it occupied. These portions, separated by distinct depressions from the central body of the mass, are: (1) The orbital portion, which forms a rather square mass of bone, measures 11⁄2 inches from above downward, 11⁄2 inches in anteroposterior, and 3/4 inch in transverse, diameter. Its anterior ridge is denuded and roughened, while the rest of the tumor is covered with periosteum and a thick layer of mucous membrane. The orbital portion reaches from the internal anterior border of the orbit back to the orbital foramen. From the upper inner corner of the orbital portion a small round projection the size of a pea extends up into the frontal sinus. (2) The portion occupying the antrum of Highmore is a rounded pyramid, 1⁄2 inch broad, 1/4 inch high, and occupies the cavity mentioned, the nasal wall of which has disappeared.

(3) The nasal portion, which forms the bulk of the osteoma, is an irregular square of the above-mentioned diameter in all directions; its inner surface is covered with a thick layer of mucous membrane, from which three mucous polypi the size of a pea have grown out. At the anterior upper corner of this nasal portion is a large polypous growth, 2 inch long, 1/4 inch broad, and pedunculated. It contains a small bony nucleus the size of a pea; in other words, forms a small osteoma, by means of a pedicle movable against the large tumor, in which there is a small depression into which it partially fits. The posterior inferior surface of the nasal portion is concave, 1 inch in diameter, and covered with a thick layer of smooth connective tissue. The concave surface forms a cup into which the upper rounded surface of the dead osteoma, so to speak, articulates. On the middle of the inner surface of the nasal portion is found a square plate of the ethmoid bone 1/2 inch in diameter, which I consider the point of origin of the osteoma.

The cut surface of this large osteoma shows a peripheral layer, 1⁄4 inch in thickness, of extremely hard, compact osseous substance—so hard that a sharp chisel or knife will only with difficulty cut into it, and a smaller central area of cancellous substance, which is so friable as to be penetrated with considerable ease with sharp instruments.

Microscopic examination of the layer of soft tissue covering the tumor shows the following: A layer of cylindric epithelium, under which is a heavy layer of mucous membrane proper containing numerous tubular mucous glands. Finally, nearest to the bone, a layer of fibrous tissue constituting the periosteum.

The dead osteoma is about 11⁄2 inches long, and 3/4 to 1 inch in diameter. Its upper surface, which has articulated in the above-described cavity in the large tumor, is rounded, slightly nodular, smooth and hard, like ivory. The rest of the surface is uneven and roughened. Parts of the tumor had been broken off, so that when the whole tumor was put together, it would form a large mass the size of a walnut. The broken surface shows this to consist of a very thin outer shell of very hard, compact bone substance, and within a mass of fine spongy substance, resembling pumice-stone.

On the dead osteoma there is nowhere a trace of any membrane covering it, and it emits a penetrating fetid odor. No odor at all emanates from the living osteoma.

Etiology and Mode of Origin.-Bornhaupt has found in the literature 23 cases of osteomata in the frontal sinuses, 12 cases of osteomata in the ethmoid cells, 10 cases of osteomata in the antrum of Highmore, and 5 cases of osteomata in the sphenoid cavity or sinus-in all, 59 cases of encapsulated orbital osteomata. These seem to be more common than the orbital exostoses, of which the literature furnished him only 7 cases. This class of tumor is more prevalent in youth, 54 per cent. occurring before the age of puberty, 87 per cent. before the thirtieth year-that is, before the final or finished development of the accessory cavities of the nose. It is thus likely that they owe their origin to some disturbance in the development of these cavities.