The douche should be continued until the water comes out clear. In a few hours the crusts form again. But on irrigating twice a day properly, the secretion soon diminishes, becomes clearer and less tenacious, and crusts can be prevented. An important addition, and to some extent a substitute for the douche, is the tampon introduced by Gottstein. A pledget of cotton of the size of a little finger is pushed up into the nose and replaced in the course of hours as soon as it feels wet. It may be wound on a probe with a screw-thread, which is then withdrawn by rotation, or it may be rolled permanently on a wooden tooth-pick. Its application must be learned by the patient. As long as the surgeon applies the tampon himself, packing with gauze is, if anything, more agreeable to the patient than cotton. If possible without interference with nasal breathing, the tampon may be worn on both sides continuously, otherwise alternately. Its use during the night depends on the patient's tolerThe tampon starts a more abundant but thinner flow of mucus, which diminishes in the course of some days. The tenacious pus is thus removed more completely by absorption by the cotton plug, while desiccation becomes impossible. If properly applied after a thorough cleansing, the tampon removes all odor within a few days. On stopping the treatment, the odor returns after a time, varying in duration according to the previous improvement. By the use of the douche and the tampon, every case of ozena can be made comfortable and improved up to a variable limit. A small number, perhaps 10 per cent., are completely cured in the course of many weeks. The possibility of cure depends less on the degree of atrophy than the absence of suppuration of accessory cavities. ance. Grünwald has shown that ozena rebellious to all other treatment can be cured by opening up all foci of suppuration in the different sinuses which may be involved. Quite often the sinuitis is multiple, and may hence require multiple operations. The difficulties of recog nizing and curing affections of the accessory cavities (compare Chapters VI. to VIII.) are at present so great that but few reports have appeared confirming or limiting Grünwald's claims. The writer's personal observations are favorable to them, but he can neither share his radical views concerning the all-importance of sinuitis, nor his sanguine statements regarding their speedy surgical cure. Many other methods of treatment have been recommended, but none have obtained general indorsement. Medicinal applications of methyl-blue, ichthyol, oil sprays, mild caustics, and a host of other measures have found but little favor on tests made by others than their first originators. Electrolysis carried out by means of a copper probe used as negative electrode with a current of from 15 to 25 milliampères for a few minutes has also been found uncertain, although at first highly praised. Massage by means of vibratory movements with a cotton-wound probe, or with an electromagnetic vibrator, seems to have given satisfaction, but definite reports regarding permanent cures are still to appear. Injection of diphtheria antitoxin, a procedure without any theoretic foundation, has been reported curative, but the unfounded and arbitrary reason for this procedure has not attracted much confirmation. CHAPTER X. ANTERIOR DRY RHINITIS. PERFORATING ULCER OF THE SEPTUM.-HEMATOMA AND ABSCESS THERITIC RHINITIS. AND DIPH ANTERIOR DRY RHINITIS (RHINITIS ANTERIOR SICCA).— PERFORATING ULCER OF THE SEPTUM. 75. Anterior dry rhinitis is the term applied recently by Siebenman to a frequent nasal affection which had previously been ignored, perhaps by reason of its seeming innocuousness. It is an inflammation of the lower part of the cartilaginous septum, with formation of adherent crusts and tendency to ulceration. On the surface of the cartilaginous septum, barely behind the vestibule and just above the floor of the nose, adherent thin scabs are found on one side, as a rule. They are not purulent, and look like dry scales of varnish. When detached (with difficulty), the surface underneath is found excoriated and liable to bleed. Later on deeper ulceration may be seen. The disease remains limited to a small area. It has little tendency to heal spontaneously, and may last long periods of time, leading in many instances finally to a perforating ulcer of the septum. As the disease advances the mucous membrane is destroyed, and the cartilage is seen exposed. The ulceration extends through the center of this denuded area, and then spreads centrifugally until a perforation approximately circular and rarely over 2 cm. in diameter results. The disease never extends beyond this stage, but the edge of the perforation may remain excoriated for a long time. Finally this heals too, and nothing but a hole with smooth undeformed edge remains. During its entire course the disease causes very little disturbance. The patient complains of slight annoyance from the crusts and is apt to pick at them. Occasionally persistent and repeated bleeding occurs, especially after enfeebling diseases, like typhoid fever. There is no liability to acute inflammation or other complications, but the disease may sometimes be associated with a purulent rhinitis. 76. The cause of dry rhinitis is not known. The disease is not ordinarily seen in children. Fragments of excised mucous membrane show round-cell infiltration, especially along the course of the blood-vessels, some hyaline degeneration of the mucous membrane, and the presence of plasma-cells. Hemorrhages occur into the tissue, and leave evidence of their presence in the form of yellowish pigment granules, which give the surface a yellowish appearance. Such discolored areas have been described by Zuckerkandl under the name xanthosis. The cylindric epithelium changes into flat cells with keratous degeneration. Later on the epithelium. is, of course, lost. The progressiveness is apparently due to changes in the blood-vessels. When it comes to actual ulceration, the diseased area is found infiltrated with cocci, to the presence of which the destruction must be ascribed. The adherent scabs consist of dry mucoserous secretion with very few round cells. Similar adherent and persisting crusts are sometimes seen after surgical wounds in the cartilaginous part of the septum, but in these instances no tendency to progressive ulceration is observed. 77. The disease is but imperfectly controlled by treatment, perhaps for the reason that patients lack the necessary endurance, in view of the slight annoyance which it causes them. Nitrate of silver applications, 5 to 20 per cent. in strength, exert a distinct, but not always permanent, influence. The crust-formation is controlled by cotton tampons as long as the patient is willing to wear them. Treatment is likewise inefficient after 1 Workmen handling chrome or arsenical salts or those manufacturing cements frequently suffer from ulceration of the septum. the ulcer has perforated. Here, too, nitrate of silver applied to the edges is of some benefit. Stronger caustics or the galvanocaustic burner give no satisfactory results. But while we may not be able to check the ulceration, we can be certain of its benign and ultimately limited course. It 78. It is very important to distinguish between this benign perforation of the septum and syphilitic ulceration. The former produces little disturbance, never extends beyond an area of about a five-cent piece in size, is approximately round, and its edges are not thickened or deformed and are covered only with thin crusts. never extends beyond the cartilaginous septum, and when the edges heal, the crust-formation ceases. Syphilitic ulcers, on the other hand, the result of either a circumscribed gumma or diffuse gummatous involvement of the blood-vessels, cause decided disturbance, at first in the form of pain, and later on by reason of the copious secretion and the thick purulent crusts. The edges of syphilitic ulcers are always thickened, infiltrated, and more or less deformed, and the ulceration, if not checked, extends beyond the cartilage into the bony septum. If not controlled, it may cause extensive loss of substance down to the floor of the nose and high up in the bony septum. Such extensive ulcers cause later on sinking-in of the bridge of the nose, which never follows nonsyphilitic ulceration. On the other hand, syphilitic ulceration is rapidly controlled by thorough specific and proper local treatment. (Compare Figs. 1 and 2, Plate I.) HEMATOMA AND ABSCESS OF THE SEPTUM. 79. A very rare occurrence, almost invariably of traumatic origin,-hematoma,-is an effusion of blood under the perichondrium of the cartilaginous septum. It occludes the nose and appears as a soft swelling on the septum. It rarely undergoes absorption. As a rule, it lasts a number of days and then changes into an abscess which may bulge on either side or on both sides of the sep |