probably because the original injury causes a fracture of the cartilage of the septum. Gumma most usually occurs in adults, attacks the bony septum and rapidly ulcerates; it is often unilateral, and the evidences of acute inflammation are less marked.

Treatment. This consists in immediate evacuation of the pus by free incision on both sides of the septum. This is usually successful, but the patient should be seen every second or third day at least, and the incisions kept open by gently inserting a probe. Should the pus reaccumulate, it is

better to snip out a small piece of the abscess wall on one or both sides. This is easy, effectual, and does no harm. On the other hand, it is difficult to secure drainage by packing the cavity or by fixing in a drainage tube, except by passing the latter quite through the septum. This latter method is almost certain to produce a permanent perforation, and should therefore be avoided.

As a general rule complete healing takes place in from 10-14 days without any deformity. Sometimes, however, when there has been severe trauma, when evacuation of the pus has been too long delayed, or when a virulent infection is present, necrosis of cartilage may occur, may lead to prolonged suppuration, and result in permanent perforation, or, more

rarely, in slowly progressive falling in of the tip or bridge of the nose. This deformity, when the patient is first seen, may be concealed by the swelling due to the abscess. I know of no method to prevent this.

Reference.

GOUGUENHEIM, Archiv für Laryngol., 1896, v. p. 69.

PERFORATIONS OF THE SEPTUM.

Perforations of the septum may be due to congenital defects; to syphilis ; to tubercle or lupus; to trauma or surgical operations; to traumatic rhinitis; to gangrene; to abscess of the septum; to diphtheria, typhoid fever or other specific infection; and finally to the atrophic or perforating ulcer of the septum. They will again be mentioned in the descriptions. of the various affections from which they may arise. It is convenient, however, to discuss the subject as a whole here, with special reference to aetiology and diagnosis.

Whilst it cannot be denied that a congenital perforation may occur, it must be extremely rare. The only examples known to me are those recorded by Zuckerkandl.

Perforations due to tertiary syphilis, congenital or acquired, are common, probably amounting to 50 or 60 per cent. of all cases. When their edges have healed, they may exactly resemble perforations due to the atrophic. ulcer. Generally, however, they are larger and extend to the osseous septum. All perforations through the bony septum, in the absence of a definite trauma such as a surgical operation upon the septum, and in the absence of signs of other causal affections, may be confidently ascribed to syphilis.

Perforations due to tubercle and lupus are usually situated in the cartilaginous septum. The diagnosis depends upon the presence of active tubercular disease or of destruction and scarring as the result of it on the skin, or on the external or internal parts of the nose (see Chap. XII.).

Perforations resulting from the acute infections, such as diphtheria, abscess of the septum, typhoid fever, traumatic rhinitis, etc., cannot always be distinguished from those due to the atrophic ulcer. Sometimes a reliable history may be obtained, or the perforation may occur in early life, before the age at which the atrophic ulcer is met with. Perforations from any of these causes are rare.

Excluding the above, there remains a considerable number of perforations of the septum-some 40 to 50 per cent.-due to a peculiar form of ulcer with definite characteristics, the so-called atrophic or perforating ulcer of the septum. The ulcer is always situated on the lower part of the triangular cartilage, and never extends to the osseous septum, it is round

or oval, with thin, slightly raised edges, and runs a chronic, almost imperceptible course, ending in a small perforation which slowly extends

in size.

THE ATROPHIC OR PERFORATING ULCER OF THE SEPTUM.

Aetiology. In inspiration the column of air entering the nose impinges first upon the moist mucous membrane on the anterior part of the septum, from which it takes up moisture and on which it deposits any dust that it contains. Should the patient be anaemic or alcoholic, or should the nasal secretion be deficient from any other reason the result is a deposit of dry mucus or dust on a small circular area of the cartilaginous septum. When the inspired air is exceptionally dry and full of dust, as may occur amongst the workers in certain industries, no predisposing cause is necessary.` In a considerable number of patients no general or local predisposing cause can be found. That dust in the air especially tends to collect in this area may be seen from the effects produced on workers in factories where strong irritants such as bichromate of potash, arsenic, or corrosive sublimate, are used: for, as the result of the inhalation of the chemically irritating particles, acute ulceration and sloughing of this part of the septum may occur (Chap. VIII.). It may also be demonstrated experimentally by the lycopodium test (see page 29).

One other predisposing cause may be pointed out. If one nostril remain patent when there is deflection of the septum or other cause of unilateral nasal obstruction, it will have double work to do, and consequently a double strain will be imposed upon that area of its mucous membrane with which the air first comes in contact.

The effect of this collection of dry dust and mucus upon the mucous membrane is to produce changes in the superficial epithelium, as was first pointed out by Suchannek. The highly specialised, ciliated, columnar cells lose their cilia, become cubical, and are finally changed into squamous epithelium. This allows the crusts and dust to adhere more firmly than ever. The irritation of the crusts induces efforts to clear the nose, either by constant picking with the finger, or by violent blowing. The superficial epithelium is removed with the crusts, and excoriation. of the mucous membrane results: this is shown by frequent slight attacks of epistaxis. The extravasated blood-clot and serous exudation have a still greater tendency to collect dust and to form adherent crusts. The continuance of this process leads to superficial ulceration which slowly becomes deeper and deeper until the cartilage becomes exposed and necroses. The mucous membrane on the opposite side of the septum becomes thin and undermined, if it is not already taking part in a similar process, and finally a perforation results. In the early stages the atrophy and degeneration of the septum are possibly aided by haemorrhages into the mucous membrane, followed by obliteration of some of the capillaries.

Zuckerkand stated that the ulceration of the septum was predisposed to by the abnormal richness of the part in blood vessels, and that as the result of slight trauma, such as picking or forcibly blowing the nose, haemorrhages took place under the mucous membrane and lessened its vitality. This effusion of blood gives rise to an alteration in colour, a condition termed by Zuckerkandl xanthosis, which he said always preceded ulceration. This explanation appears to me insufficient alone, but it may be a factor in the process above stated.

Others have asserted that a small effusion of blood forms as the result of trauma, and that ulceration follows when this is infected by the staphylococcus or streptococcus pyogenes. That organisms would be found. in these cases is of course to be expected, but the ulceration, as seen clinically, makes slow, almost imperceptible progress, and is not an acute affection, such as would result from infection with the pyogenic organisms.

When a perforation has formed, the ulceration may cease, and the surface epithelium on the two sides of the septum may spread over its edges. There is always, however, a tendency for crusts to adhere to the edges of the perforation and to produce its slow extension. The final perforation may vary in diameter from the size of a crow quill to that of a shilling or more, but the bony septum is never affected.

Symptoms. The patient may complain of slight symptoms, such as nasal obstruction, the sensation of a foreign body in the nose, and, whilst the ulcer is forming, of more or less nasal discharge and repeated slight epistaxis. The perforation itself gives rise to no symptoms, and will probably not be discovered by the patient. If the ulcer is seen before perforation takes place, it may be recognised by its thin, shallow, ill-defined edges, by its dry crusty surface, with minute haemorrhages and blood crusts, and by its tendency to bleed on the slightest touch. When a perforation has occurred and its edges have healed it is often impossible to determine its cause. A prolonged history without any acute symptoms, other signs of dry rhinitis, the age of the patient, a history of repeated epistaxis, the limitation of the disease to the cartilaginous septum, are all in favour of an atrophic ulcer.

Treatment. This is essentially that of the causal disease (see especially Rhinitis Sicca, Chap. IX.). For the perforation itself nothing can be done.

CHAPTER VIII.

ACUTE RHINITIS.

MANY varieties of acute inflammation of the nasal fossae are met with, and although it frequently happens in practice that one form cannot be sharply distinguished from another, for convenience of description they may be classified into :

1. Simple Acute Rhinitis, the common "cold in the head."

2. "Drug" Rhinitis, a form of coryza due to the internal administration of certain medicines, such as Potassium Iodide.

3. Traumatic Rhinitis, or "Trade" Rhinitis, an acute inflammation arising from the local action of irritants inhaled into the nose.

4. Acute Purulent Rhinitis, a severe infection due to pyogenic organisms, to the gonococcus, etc.

5. Symptomatic Rhinitis, a local manifestation of a specific affection,

such as measles.

6. Fibrinous, Croupous, or Membranous Rhinitis.

7. Acute Specific Inflammations of the Nose, such as erysipelas or diphtheria.

To these is sometimes added

8. Vasomotor Rhinitis, which includes those forms of rhinorrhoea, paroxysmal sneezing, etc., commonly known as "hay fever."

SIMPLE ACUTE RHINITIS.

Simple acute rhinitis is too well known to require much description. The affection is most common in children and in the aged less common in adults, who are probably more resistant to this as to other infections. Morell Mackenzie, however, considered colds were comparatively rare in the aged.

Predisposing Causes. The most important predisposing causes are chronic nasal diseases, such as chronic rhinitis, hypertrophy of the turbinates, septal deflections, polypi, sinus suppurations, and more than all -the presence of adenoids in children. Persons with narrow nasal fossae seem to take colds more readily and to suffer more severely than those