had necrosed. Fistulous openings were found at the inferior edge of the orbit. The implicated side of the nose was occluded by an accumulation of cheesy material. In the third case, the fistulæ had formed at the root of the nose and communicated with the enlarged upper nasal meatus, which was filled with cheesy material.

The nature of the material removed from the first two cases differed somewhat from that in the third case. In the first and second case there was an amorphous material, the second case having in addition a large number of bacteria, among them almost a pure culture of the bacillus coli communis. In the third case, the mass removed from the nose contained connective-tissue cells, many of them broken down and in parts making the impression as though acini of glands had been cut across. Between the cells quantities of calcium salts had been deposited.

In the first of these cases, the history of a sudden onset, with chills and fever, inflammatory swelling, the formation of an abscess, and the desquamation of spiculæ of bone after incision of the abscess, would indicate that the root of the nose was the seat of an osteo-myelitis, although this would not account for the large encapsulated mass of detritus in the nasal fossæ. This seemed rather to come from one of the accessory cavities of the nose, most likely either the ethmoidal cells or from the pneumatic cells of the superior turbinated bone. It had encroached upon the bony wall separating the nose from the orbit and formed an orbital abscess. It had also brought about a distension of the nasal fosse with considerable stretching of the nasal mucous membrane. The stretched mucous membrane encased the cheesy mass and accounted for the extension of the tumor into the naso-pharynx. The retained mass had probably undergone degeneration, as a result of secondary infection from the mouth and naso-pharynx, and had been transformed into a thick cheesy material. The distension of the ethmoidal cells with pus depends largely upon the resistance of the periosteum. It is distended by pressure, causes absorption of the bony septa between the cells, forming one large sac as it were.

This case could have been mistaken for abscess of the lachrymal sac. However, the lachrymal apparatus was in good condition, and there was no history to indicate an obstructed tear duct. Dermoid, cholesteatoma, and syphilitic affections could also simulate our case, but there were no other features present to indicate any of these conditions.

In the second case, the necrotic process had been so extensive that it would be impossible to form any conclusion as to its primary seat or exact nature. As in the first case, there were swelling, abscess formation, rupture, and the formation of fistulæ. There was also nasal obstruction. In this case, the fistula near the inner canthus also led through the necrosed external wall of the nose into a large cavity filled with a mass resembling a cholesteatoma. The antrum of Highmore, whose median wall was necrosed, contained only granulation tissue. The masses in the nasopharynx and at the base of the skull were most likely adenoid vegetations. The presence of the bacillus coli communis, almost in pure culture, in the necrotic mass was an interesting feature of this case and would indicate infection from the buccal cavity.

Our third case was of especial interest, because the mass found in the abscess cavity contained broken-down tissue cells, some of which were arranged in lamella and in other parts so as to resemble gland ducts. Developing so soon after an attack of scarlet fever, supports the view that the masses were the result of secondary infection. In position, the formation in this case corresponded to the location of the ethmoidal cells, and it is not improbable that the cells, infected from the naso-pharynx, became the seat of the abscess formation.

It is reasonable to believe that the process in the ethmoidal cells was similar to the breaking down of the cell walls and the coalescence of numerous small cells in the formation of one large cavity as we see it in the mastoid bone. The broken-down soft tissue found in our case evidently had its origin in the mucous membrane lining the cells.

The diagnosis of cases like those reported is based upon

the discharge of putrid pus from the nose and the formation of fistulæ externally, especially near the inner canthus. In some of the cases the cheesy masses in the nasal fossæ can be recognized by rhinoscopic examination.

The first object of their treatment should be to incise them from within, through the nose. If this is not possible, external operation will have to be resorted to. With the fistula as a guide, the necrosed bone should be removed and the cavity cleansed and well drained.

It might be of interest to cite from literature several of the most typical cases similar to the three reported.

Avellis observed three cases of empyema of the antrum of Highmore in which a fetid cheesy material had formed in the nose. They were all cured by irrigation through the alveolus with a boric-acid solution.

Escat published one case very similar to these, in which a cure was effected by treatment through the nose.

A case seen by Bride' developed with symptoms similar to those in one of our cases. The left side of the face and nose swelled, pus discharged from the nose, and the patient suffered with pain in the head. Examination revealed reddish masses in the left nasal fossæ, and their removal exposed a grayish-yellow putrid cheesy mass. This was made up microscopically of broken-down tissue cells, pus corpuscles, and numerous bacteria of different species.

Three cases were recorded by Killian.' In one of these, the antrum of Highmore was filled with a granular white material devoid of all odor. It was made up largely of fatty crystals arranged in bundles. In the other two cases, the material was cheesy and rather tenacious. They were all cured by simple irrigation.

A very interesting case was reported by Bournonville' which began with severe pains in the entire right side of the face, accompanied by lachrymation and obstruction of the right nasal passage. Abscesses developed, which after

1 Avellis, Arch. f. Laryngologie u. Rhinologie, Bd. x., Heft 2. Arch, méd. de Toulon, No. 4, Feb., 1896.

3 Intern. Centralblatt f. Laryngologie, xi., p. 880.

Heymann's Handbuch der Laryng. u. Rhinolog., iii., p. 1013. 5 Centralblatt f. Chirurgie, 1885, p. 262.

incision left fistulæ close to the right inner canthus and at the upper and inner border of the left orbit. During the examination of the right side of the nose with a finger inserted in the nostril, the patient, during efforts at retching, discharged through the mouth several masses of a foul grayish material resembling putty. The largest piece was the size of a walnut. The inferior turbinate was almost totally destroyed, and the meatus communicated with the antrum by an opening large enough to admit a finger. The antrum contained similar material to that discharged. After this was all removed by irrigation the right fistula closed spontaneously. The left one, which led to the frontal sinus, did not heal until the fistula was enlarged and the sinus curetted and irrigated.

This case, as well as our cases, gives evidence of the destructive nature of the caseous formation in the sinuses. They also show that the process can be cured by thorough cleansing and drainage.

TWO CASES OF ANEURISM OF THE ARTERIA

A

CAROTIS CEREBRI.

BY DR. A. V. ZUR-MÜHLEN of Riga.

Translated by Dr. MILTON J. BALLIN, New York.

NEURISM of the large cerebral vessels does not seem to be as rare a disease as one would perhaps be inclined to suppose judging from the publications on this subject, the number of which have, however, been increasing during the last few years. They are in fact, according to E. von Hofmann,' a rather common occurrence in those individuals who have died suddenly and where an official autopsy was performed. The reason why they are relatively seldom diagnosed is undoubtedly due to the fact that a number of intracranial aneurisms do not give rise to any, or only slight, disturbances during the life of the individual, while in other cases the combination of symptoms is so complex and ambiguous that the thought of an aneurism is not awakened in the mind of the attending physician. Inasmuch as cerebral aneurisms can bring about a change in the organ of hearing to a varying degree, and indeed as these disturbances are sometimes the only symptoms of the disease, it may perhaps not be such a rare occurrence for the otologist to have occasion to treat, amongst his patients, a case of this nature. The two following cases may therefore be of interest.

Mrs. A. H., fifty-seven years of age, came to my office on October 9, 1902, complaining of tinnitus in the right ear, which had existed since the summer. It manifested itself suddenly one

'Ueber Aneurysmen der Basilararterien und deren Ruptur als Ursache des plötzlichen Todes. Wiener klin. Wochenschr., 1894, No. 44.