not only in syphilitic subjects, but in scrofulous individuals as well, such little ulcers sometimes have a tendency to penetrate deeply, and finally even to attack and destroy the bony walls so that they may result in extensive losses of substances in the gums, the septum and the turbinated bones. Although such extreme forms are not frequent, yet they do certainly occur, as Semeleder (Rhinoscopic, page 55; Boebachting, 21) has proven, and one is therefore not justified in pronouncing in favor of constitutional syphilis exclusively on the ground of such ulcerations and defects. This conclusion is still less justifiable in the case of children, because even primary diseases of the bones and their adnexa may lead to the same results.

Ashurst, in his encyclopædia of surgery, looks upon syphilis as the cause of deformities of the nasal cavity.

Carl Stoerk, in his book-Klinik der Krankheiten des Kehlkopfs, der Nase und des Rachens-denies that ozæna scrofulosa produces perforation of the cartilaginous septum. He admits its possibility in chronic rhinitis, and of course in syphilis.

The title of this paper has been suggested by my own observations in six cases, where perforation alone of the cartilaginous septum existed. The bony walls were intact. But when they are involvedwhere we obtain caries of the vomer, ethmoid, sphenoid or turbinated bones-I have never thus far failed to find well marked indications of lues elsewhere. I would lay especial stress therefore upon its being perforation of the cartilaginous septum, which may exist independent of syphilis, and having for its cause diphtheria, measles, a purulent rhinitis, etc., etc. Three of these cases has been seen by specialists, and a syphilitic taint insisted upon, though no other constitutional remnant could be found anywhere of whatsoever kind or nature. These cases were being submitted to an antisyphlitic course, which was immediately stopped when they came to me.

There

I will cite to you in a few words the history of these cases. are others that I have notes of, but as I have not had them under observation sufficiently long I will pass them over.

Case I. Miss F- ætas 20, a strong, healthy, ruddy complexioned blonde, never had any illness that she knows of save measles and scarlatina, both severely, consulted me in 1883, about a severe coryza (influenza), involving the pharynx, and eustachian tube simultaneously. In examining her rhinoscpoically found a peforation about as large as a 5 cent silver piece. Borders well cicatrized and rounded off. She knew nothing of her deformity. The nose was not sunken in. A thorough physical examination-found no evidence of a primary

lesion--nothing to indicate that this was luetic. Patient had been seen by a specialist who evidently suspected syphilis, as his treatmeut would indicate.

Case II. Mr. W- -, manufacturer, also seen by a specialist, who tried to persuade him that he must have had a chancre sometime or other. He was ignorant of any such thing. He has several strong, healthy children, and though I have attended them for years, I have never seen any indication of a luetic nature. Mr. W. has been under my care from time to time for over nine years. Nose not deformed.

Case III. Mr. J. S., boss carpenter, perforated cartilage, sunken tip, no other signs of lues in nine years-atrophic catarrh— otitis media chronica. Healthy children, wife well and no miscarriages. No history of lues at any time. Patient has been under my care for nine years. No antisyphilitic treatment from me or any one else. Edges well cicatrized. Diphtheria of nose and throat in child. hood.

Case IV. Mr. H. S.-.

Perforation of cartilaginous septum. Nose retains its normal form, hole about the size of a ten cent silver piece, surfaces well smoothed off. Patient under observation 14 years. Never any evidence of syphilis elsewhere. Six healthy children and one miscarriage from a fatty placenta, as shown by mircroscope. This person examined by specialist-syphilitic.

Case V. Mrs. P., ætas 30-a woman in perfect health. Consulted me about a dry, tickling cough, due to an elongated uvula. In examining nose and throat found a perforated septum, opening small and of old standing. A careful physical examination detected nothing of a syphilitic nature. Two years under observation. Was ignorant of perforation.

This lady without exception was as healthy a person physically as I have ever seen. She had the habit as a child to pick at her nose constantly, producing profuse hæmorrhage at times. The nose deviated to the left and cartilage projected.

Case VI. Rev. J. C consulted me for a tracheo-bronchitis. During my examination I noted on the left side of the cartilaginous septum a firm scale. In detaching it quite a smart hæmorrhage followed, and beneath a depression with eroded surfaces was found. On throwing the light from the other side just the merest tissue paper thickness of the membrane kept the nose still divided into two fossæ. At the point of erosion the membrane was most decidedly thinner than anywhere else and only needed an extra application of the longer

finger nail to go through. It is to be presumed from his high position in the clerical world that his word may be trusted. He has had this crusty formation from time to time for the past eight or nine years. No evidence of syphilis anywhere. A little white carbolized vaseline. applied on a camel's hair brush has relieved him completely. This case of all was the most interesting to me. Had it been luetic, we all know full well that without antisyphilitic treatment this small erosion would gradually have eaten away at its leisure until arrested by local and constitutional treatment.

Some of these cases have so impressed me with the possibility of a destruction of the cartilage-in part anyhow-without the proof of lues elsewhere, that I have ventured to lay them before you. In the hands of specialists they would be diagnosed as syphilitic and injury arise to the patient and no honor accrue to the misled medical man.

REFERENCES.

Watson, in his work upon diseases of the nose, claims besides other things that rodent ulcers, scorbutic ulcers, abscesses following exanthemata and erysipelas, and in idiopathic ozana necrosis of cartilage of septum may occur, independent of syphilis.

Fleming, in the Medical Journal of Medical Sciences, Dublin, cites cases of perforation following bloody tumors and abscess.

Kitchen, in his small monograph, speaks of ulceration in chronic rhinitis, but of no destruction.

Eichorst, in his Lehrbuch der Physikalischen Untersuchungs methoden innerer Krankheiten, has little to say on the condition of the mucous membrane of the nasal fossa.

Dr. Knight, of Boston, in the Archives of Laryngology, cites two cases of lupus of nose with destruction of cartilaginous septum.

Again, Dr. Shurley, of Detroit, cites a similar case to those of Dr. Knight.

Dr. E. Y. Moure (Bordeaux) cites in his work besides syphilis--the inhalations of minerals--as Mercury, etc. He does not allude to other

causes.

One of the most interesting of observations is that of Fraenkel. Besides his own he speaks of four examinations, critical and microscopical, on ozæna. These are to be found: E. Fraenkel (Virchow's archiv., Bd. 75). Gottstein (Breslauer ârztl. Zeitschrift, 17-18, 1879). Hartmann (Deutsche Med. Wochenschrift, 13, 1878). Herrman Krause (Bd. 85, Virchow archiv.) These cases, examined with the utmost thoroughness and precision, are worthy of our utmost attention. They

all claim that where ulceration, or destruction of the cartilage or bone exists syphilis, phthisis or scrofula is the cause. Ozana they consider a disease of the mucous membrane.

Again we note cases of primary lupus of the mucous membrane of septum with destruction of cartilag. septum. V. Cozzolino Archiv. italin. di laryng., '86.

Simple ulcer perforating septum of nose. Wachselbaum, '82. Allgem. Wiener Med. Zeitung. Necrosis of ethmoid, its remote influence upon the development of polypi narium. In some 80 observations of Dr. Ed. Woakes, of the London Hospital Throat Department, he has found such a condition, and patients have attributed it to an eruptive fever, repeated and tenacious nasal catarrh. Traumatism played no part. Both sides were equally involved.

Dr. V. Cozzolino, in a work dealing principally with the pathological view of ozana, admits destruction of the nose in the simple and scrofulous form. Ozeno o rinite ulcerosa fetida a pseudo-ozeniStudi patologici clinici e terapeutici.

Abscés aigu de la cloison des fosses nasales. E. J. Moure, Bordeaux. An acute idiopathic abscess in a strong, healthy girl of 23 of eight days' standing brought to him. Exposure to cold in February was the only cause found. Destruction of cartilage with depression followed. 'SS. Simple ulcer perforating cartilage of septum. Jessop, Leeds and Westriding medico-chirurg. soc. Lancet, '88. Quelques

cas assez rares de perforation de la cloison nasale. Schmiegelow Monograph. Further references on this point may be found in Cornil's, Diday's, Fournier's, Lee's, Bumstead & Taylor's, Dowse's, Mauriac & Wagner's, Bassereau's, Profeta's Fürth's, Buzzard's, Turenne's, etc., Hill's, Kerr's, Lane's, Otis', Kaposi's, Whistler's, Chauvet's, Reumont's and still further, Watson's, Cohen's, Robinson's Seiler's, Woakes', Bosworth's, Kitchen's, Eichhorst's, Tobold's, L. Browne's, Fauvel's works.

Some of these argue from experience, some lean upon the "on dit " of the past, some maintain their points from reasonable deductions and observations of cases.

I am of the opinion and would like to impress it upon my hearers, that we obtain a perforated cartil. septum, due neither to traumatism nor syphilis. It is important to recognize and accept this FACT.

INDIVIDUAL PROPHYLAXIS OF DIPHTHERIA.

BY A. WORRALL PALMER, M. D.,

NEW YORK CITY.

The general subject of prophylaxis of diphtheria has been considered and reconsidered time and time again, until we are almost fatigued with the idea. Yet diphtheria is of such frequent occurrence and causes such a high rate of mortality, that it is a subject concerning the treatment and prevention of which we have plenty of room to improve. So we ask your attention to the consideration of one of its branches or divisions, which, as far as I have been able to ascertain, has been very little thought of, far less than its merits seem to me to warrant, viz: Individual Prophylaxis. By this is meant the employment of preventive measures or administration of drugs directly to the body of the individual to preclude his succumbing to the contagion of the disease to which he has been or is unavoidably exposed.

Although all consideration of quarantine, disinfectants and hygiene are entirely excluded, do not infer that the writer discards them. Far from it; it is our duty as true followers of Esculapius to do everything in our power, whatever be the source from which the means do come, to both cure disease and prevent its onset. Thus this is not advocated as a substitute, but as a supplement to the other measures used heretofore.

Although in this paper only writers of reputation are quoted, yet from the change in our conception of the disease, diphtheria, we now may take exception to the correctness of the diagnosis in some of the The author will not vouch for some of the reported cases that were cured in a remarkably short time; nor for the regularly recurring case of another gentleman.

cases.

Not only for the benefit of those of our own persuasion who still lean toward the scientific school and those few who may yet believe diphtheria to be a local dyscrasia, but because we can obtain information from any thoughtfully written article: first we will mention a few means employed by our brethren of the opposite school: