welfare of the individual. It guards against the inhalation of noxious gases and prevents the ingestion of unwholesome food. Besides this it adds much to the pleasures of life and increases the appetite for, and the enjoyment of, food.

Anosmia may be divided into three etiological groups. (1) Obstructive anosmia due to any form of nasal obstruction which prevents the olfactory particles in the air reaching the olfactory mucous membrane. (2) Essential anosmia due to some affection of the olfactory mucous membrane or of the peripheral nerve endings. (3) Central anosmia due to disease or injury to the brain or olfactory nerve.

Obstructive Anosmia. Among the causes of obstructive anosmia may be mentioned all forms of nasal obstruction such as alar collapse, deflections and thickenings of the nasal septum, inflammatory swelling of the mucous membrane-especially of the middle turbinate, tumours of the nose and especially polypi, foreign bodies, rhinoliths, adhesions, etc. It is also possible that when the nasal passages are extremely wide as in ozaena the stream of air may pass along the inferior meatus and not reach the olfactory region.

Treatment. The treatment of this form of anosmia consists in the removal of the cause. If this can be effected recovery may take place although the sense of smell has been completely lost for years. Morell Mackenzie makes the statement that if the sense of smell has been in abeyance for two years the prognosis is extremely unfavourable. I have, however, had several cases of nasal polypi under my care in which anosmia has been present 6, 8 and even 10 years and yet the power of smell has returned almost completely after the eradication of the polypi. A few similar examples of recovery after long absence of smell are recorded by others.

Essential Anosmia, or affections of the olfactory region itself. Amongst the causes of essential anosmia are various toxic poisons. Thus, the application of cocaine solution to the olfactory region will quickly cause temporary loss of smell; solutions of morphine and atropine are said to act in a similar way. It is stated that excessive use of tobacco may produce anosmia, but this is not proved (Onodi). The anosmia which occurs in ozaena is probably due to atrophy of the olfactory mucous membrane; it is usually incurable, persisting after all discharge has ceased. Extensive ethmoidal disease in nasal polypus may also lead to permanent anosmia. Loss of smell has also been ascribed to the use of carbolic acid in nasal douches.1 Personally I have not found this.

Influenza is another frequent cause. During the acute attack the anosmia may be due to mechanical interference with the air stream as the result of swelling of the nasal mucous membrane. But it frequently lasts weeks or even months after all indications of nasal trouble have subsided. In these cases it is probably due to some alteration in the 1 McBride, Journ. of Laryngol., 1903, xviii. p. 326.

olfactory nerve endings; the exact lesion is unknown.

This form of

anosmia may be partial or intermittent; the patient may be able to perceive some odours better than others, or the sense of smell for certain odours alone may be lost. Again the patient may be able to smell fairly well during some part of the day, but the olfactory power is easily tired.

Anosmia is also met with during many fevers and in poisoning by morphia, lead, mercury, etc. Syphilis also has been considered as an exciting cause. The most probable lesion if really due to the syphilis would be gumma of the nerve or of the olfactory bulb.

Treatment. When due to influenza the most hopeful treatment is the internal administration of strychnine and quinine. Arsenic has also been strongly recommended. If the anosmia is intermittent or partial, complete recovery will ensue probably after a few weeks or months. In complete anosmia the prognosis is very doubtful, but even in such cases recovery is not uncommon. When syphilis is suspected appropriate remedies must be adopted. If a toxic poison or if excessive use of tobacco be probable, the cause must be removed and strychnine may be prescribed.

Central Anosmia. The olfactory nerve may be affected by injuries to the head such as fractures of the base of the skull, by tumours including gummata, and by certain central nervous diseases such as tabes, syringomyelia, etc. In a few cases anosmia has been ascribed to hysteria, or to neurasthenia. Loss of smell on the same side as the paralysis is said to be common in hemiplegia.

Treatment. The treatment consists in the removal of the cause as far as possible. If this can be done the prognosis is good. Neurasthenic and hysterical cases must be treated by appropriate general measures.

HYPEROSMIA.

Hyperosmia is a very rare affection. It is met with in hysteria and in a few other nervous conditions. It may be produced by strychnine poison, and often occurs intermittently in the early stages of pregnancy. It must be remembered that some people are much more sensitive to smells than others and are especially susceptible to certain odours. Thus various smells may turn some people quite faint, or make them sick, etc. The prognosis and treatment is dependent upon the cause, and needs no discussion.

PAROSMIA.

Parosmia may be defined as the condition in which some or every odour excites an abnormal sensation in the patient, generally of an unpleasant character: this perverted sensation often long survives the cause which excited it. Parosmia must be distinguished from the hallucinations of smell which occur in the insane, when odour may be complained of without any definite objective cause. Perversions of smell

differ from perversions of other senses in that they are almost always of an unpleasant, even of a most vile character. The patient complains that everything smells of burnt substances, of decaying things, etc. The chief causes are hysteria, neurasthenia, influenza, the psychoses of pregnancy, and some central nervous affections such as tabes, epilepsy, etc. Before a diagnosis of parosmia is made the greatest care must be exercised to exclude any local hidden cause for the smell either in the nose, mouth, accessory sinuses, throat, stomach, lungs, etc. Patients with antral suppuration may seek relief entirely for the evil smell in the nose, and be quite unconscious of or deny the presence of any unusual nasal discharge or of any other symptom whatever. The same applies to affections of the other sinuses. Again syphilitic ulceration or necrosis in the posterior part of the nose may give rise to parosmia, and may be easily overlooked. In doubtful cases the mouth should be examined for carious teeth, the throat for decomposing particles in the follicles of the tonsils, etc. Disorders of the stomach and diseases of the lungs should be looked for. In one case under my care the most intense parosmia was due to bronchiectasis, although the patient never complained of chest trouble. The greatest care must be taken to exclude all these causes before a diagnosis of true parosmia is made.

The treatment is similar to that of true or essential anosmia; the prognosis is as a rule good.

References.

ONODI. Journ. of Laryngol., 1900, xv. p. 579.

ONODI. Archiv für Laryngol., 1903, xv. p. 125.

REUTER. Archiv für Laryngol., 1899, ix. p. 147 and p. 343.

ZWAARDEMAKER. Archiv für Laryngol., 1896, iv. p. 55.

CHAPTER VI.

FOREIGN BODIES. RHINOLITHS.

FOREIGN bodies in the nose are most frequent in children, and are introduced by them in play or because of some local irritation. They are rarely met with in adults, except in lunatics or as the result of accident. Children will put all sorts of things into their own or each other's noses: the most common are beads, boot buttons, bits of paper, string, indiarubber, pencils, small stones; vegetable substances, such as peas and beans: almost anything of a convenient size may be met with. In adults the most common foreign body is a pledget of cotton wool, which has been introduced by a surgeon and forgotten.

It must also be remembered that foreign bodies may enter the nose through the post-nasal space during swallowing, when there is either deficient action or paralysis of the palatal muscles, or when some deformity, such as perforation of the palate exists. I have one patient who repeatedly suffers from a foreign body in the nose without any apparent cause a piece of food enters during swallowing, and is often retained until severe symptoms, such as suppuration, result. In the act of vomiting it is by no means uncommon for some of the stomach contents to enter the nose, more especially during intoxication. Again, medical literature teems with records of foreign bodies, such as bullets, fragments of knife blades, and pieces of stick, etc., which have been forcibly thrust into the nose through external wounds and have been broken off. Amongst rarer instances it may be mentioned that styles inserted in the lachrymal duct occasionally find their way into the nose. The style usually passes backwards, and lies in the inferior meatus high up in the concavity of the inferior turbinate, its head remaining in the lower end of the duct. this position the foreign body cannot be seen by rhinoscopy, and in the majority of cases cannot even be touched with a probe. Its presence may be demonstrated by the Röntgen rays (see Fig. 57).

Aberrant teeth may be found in the nose-a very rare Occurrence. Seifert has collected a series of cases and others have been recorded by

1 Rev. de Laryngol., 1895, xv. p. 1021.

G

2

Daal,1 Jurasz, and Hecht.3 Their occurrence may be accidental or due to faulty development. Sometimes they are displaced normal teeth, usually the canine, or they may be supernumerary. They are found on the floor of the nasal fossa just behind the vestibule and are usually attached to the mucous membrane only. They are easily recognisable by their colour and consistence and may also be demonstrated by the X-rays.

Foreign bodies belonging to the animal kingdom are rarely seen in this country. Bond has recorded the case of a woman from whose nose two larvae were removed. They were identified as the larvae of Piophila Casei. Such cases are apparently much more common in America and elsewhere. Thus Miller 5 removed 76 bluebottle larvae, and Folkes 6 removed 131 worms each half an inch long from the nostril of a negro.

Foreign bodies in the post-nasal space are very rare. I have removed a curtain ring which was partially lying in this space and giving rise to symptoms of adenoids. Other cases are recorded by Parker and Patterson. Foreign bodies may also gain entrance to the accessory sinuses, either by being forcibly thrust in through the walls, for example, bullets, pieces of knives, etc., or a piece of straw or other light substance may be inhaled into the nose and enter the cavity through its ostium. A tube inserted by a surgeon may also slip up and lodge in the antrum.

Symptoms. The symptoms vary greatly, depending upon whether the foreign body is round and smooth, or rough and angular, or consists of vegetable or other absorbent material. The most common and characteristic symptom is a unilateral purulent, foetid, blood-stained nasal discharge, which produces excoriation of the upper lip. The presence of this symptom in children should always excite suspicion of a foreign body in the nose. When the foreign body is round, smooth and non-absorbent, all symptoms may be absent, unless it be large enough to cause nasal obstruction. A rough and angular body always sets up more or less acute rhinitis, but the most severe symptoms are those resulting from the presence of an absorbent substance, which readily becomes soaked in decomposing discharges, or of a vegetable body, such as a bean or pea, which may swell up and actually sprout in the nose. In the latter cases besides profuse discharge there may be severe pains in the nose, headache, facial

1Archiv für Laryngol., 1895, ii. p. 301.

2 Archiv für Laryngol., 1904, xvi. p. 325.

3 Archiv für Laryngol., 1905, xvii. p. 167.

* Proc. Laryng. Soc. of London, 1895-96, iii. p. 66, and Journ. of Laryng., 1896, x.

p. 236.

"Medical Fortnightly, 1897, x. p. 282.

6 Medical Record, 1897, li. p. 677.

Proc. Laryng. Society of London, 1899, vi. p. 61, and Journal of Laryngology, 1899, xiv. p. 252.