neuralgia, and general constitutional disturbance with febrile symptoms. The nose and neighbouring part of the cheek may be acutely red, swollen,

and tender. Reflex symptoms and ear and eye troubles may also follow, as in other acute diseases of the nose.

Diagnosis. The diagnosis can usually be readily made from the

presence of the above symptoms, but should be confirmed by inspection, by examination with the probe, or, when the foreign body is of metallic origin, by means of the X-rays. The latter are especially useful in cases, such as that of the style above mentioned, in which the foreign body lies in a position where it cannot be seen by rhinoscopy or reached with the probe.

In children, instead of making an attempt to clean away the discharge. so as to see into the nose, or to use the probe, it is better to introduce a strabismus hook, or a probe with its point bent to a right angle, through the middle meatus above and beyond the supposed foreign body and then by drawing it forward to make the diagnosis and to remove the foreign body at the same time. It is a great advantage to make the diagnosis by this method as a child easily becomes frightened by the use of a probe. He often resists vigorously, and the foreign body is apt to be pushed further in. The affection which gives rise to the most difficulty in diagnosis in children is the unilateral form of fibrinous rhinitis. By using the hook as above described a piece of membrane, or a foreign body, as the case may be, will be removed. In adults the affection has to be distinguished from the various forms of ulceration, especially from tertiary syphilis, from necrosis and sequestra, from sinus suppuration and from rhinitis caseosa. If cocaine be applied and the nose cleaned, the diagnosis by inspection, aided by the probe usually presents no difficulties.

Treatment. The best method is to extract the foreign body with a hook in the majority of cases an ordinary strabismus hook or a tonsil probe (Fig 58) answers the purpose admirably. Sometimes, however, when a smooth, rounded, foreign body is present, the hook tends to slip off, and for these bodies a hook with a looped end should be used (Fig. 58) As a rule, if the child is not very nervous and has not been previously frightened, no anaesthetic need be given.

Under good illumination the hook is passed with the greatest gentleness, and without touching the mucous membrane, through the anterior nares, up into and through the middle meatus of the nose, until it is well behind the foreign body, which is almost invariably situated in the anterior third of the inferior meatus. The hook is now lowered into the inferior meatus and drawn gently forward. When it comes in contact with the foreign body it may give rise to pain, and the child's head will be rapidly drawn back. This, however, only hastens the extraction. When the child is very nervous or frightened, when previous attempts at extraction have failed, or when the foreign body is tightly wedged in, a general anaesthetic should be given and extraction carried out in the same way.

To grasp a

The use of the forceps is not nearly so convenient. foreign body accurately a view of it must be obtained, and even then, if smooth or rounded, it is extremely apt to slip from the grasp of the forceps, or to be pushed further in by attempts to grasp it. In difficult

cases it is often recommended to push the foreign body through into the throat. There is, however, no necessity for this, as extraction can always be accomplished with the hook.

The very rare cases in which a large foreign body has been forcibly thrust into the nose and is perhaps partially embedded in its walls come under another category. Different methods of treatment altogether are required, and some preliminary operation such as Rouge's may be necessary. In a case of a style occurring in my own practice, I opened the nasal fossa through the canine fossa and antrum as in the radical operation upon that cavity.

Other methods may be briefly mentioned. It has been recommended to apply a solution of cocaine and suprarenal extract to the nose until

VAYER & MELTZER

FIG. 58.-HOOK WITH SIMPLE PROBE END AND WITH LOOPED END, FOR REMOVING
FOREIGN BODIES FROM THE NOSE.

the nasal mucous membrane is completely anaesthetic and collapsed, and then the patient may be able to expel the foreign body by forcibly blowing the nose. If much inflammation be present, however, cocaine will not act well, and this method is therefore generally ineffective.

Again, Politzer's method of inflation has been recommended. The nozzle of a Politzer's bag is introduced into the healthy nostril, and the soft palate being raised by directing the patient either to blow out the cheeks or to swallow, air is forcibly driven in, and the foreign body driven out from behind forwards. On a similar principle it has been recommended to inject fluids down the healthy nostril whilst the patient's mouth is wide open and thus to wash out the foreign body. Both these methods are dangerous, as they are extremely likely to force purulent material or fluid into the Eustachian tubes and middle ear, and thus to set up acute otitis. Moreover, they will not dislodge a foreign body which is at all large or fixed.

(For a full discussion of the whole subject see Proc. Laryngol. Society of London, 1896, iii. pp. 58-60 and 73-80, reported in Journ. of Laryngol., 1896, x. p. 310, and in current literature.)

RHINOLITHS.

Rhinoliths, or stony concretions, consist of inorganic material deposited from the nasal secretions. There is usually a nucleus consisting of a small foreign body or of a particle of dried blood or mucus. Any of the foreign bodies above enumerated may form the centre of a rhinolith.

A

nucleus is probably always present: the cases in which a thorough histological examination has been made without finding one are extremely rare,1 When no history of a foreign body is obtainable, it may be found that the nucleus is a particle of food which has entered the nose during vomiting (Hopmann)2 or that it is a piece of necrosed bone. Chemically, rhinoliths have been found to consist chiefly of calcium phosphate (50 to 60 per cent.), calcium carbonate (10 to 20 per cent.), phosphate and carbonate of magnesia in smaller and variable proportions, 15 to 20 per cent. of organic constituents, and 4 to 10 per cent. of water. A specimen of Cheatle's analysed by Jackson yielded equal parts of calcium phosphate and calcium carbonate.3 Histologically they may be found to contain large masses of bacteria and leptothrix; an active rôle has been ascribed to these (Gerber), but they probably play only a passive part.4

Rhinoliths may be met with at all ages and in all situations. They generally occupy the inferior meatus, but occasionally are found in the middle. If large, they may occupy both meatus, may even perforate the septum and lie in both nostrils, or extend from the anterior to the posterior nares. The presence of two rhinoliths is very rare. They usually form roundish or oval masses, with irregular outlines and sharp angles, and vary in colour from a greyish brown to a dark green. The colour is probably due to blood pigment. Most of them are of earthy consistence, but occasionally they are very hard.

Symptoms. The symptoms of a rhinolith are exactly similar to those of a foreign body in the nose, and need not be again repeated. They are, however, characterised by even greater variations. Thus a rhinolith may remain twenty, or even forty, years in the nose without giving rise to any marked symptom. On the other hand it may set up the most acute inflammation, not only of the nose, but of the neighbouring parts, such as the palate, pharynx, etc. On examination the body may be seen free in the nose, without any secretion or surrounding inflammation, or it may be entirely hidden by purulent bloody discharge, or imbedded in exuberant granulations. In rare cases, when long retained, a rhinolith may attain. huge dimensions; it may fill or even distend the whole nasal fossa, cause atrophy of the turbinates, and perforation of the septum. It may be visible by both anterior and posterior rhinoscopy.

Treatment. The treatment is exactly similar to that of a foreign body in the nose, but it may be necessary before attempting removal to reduce the size of the rhinolith, either by cutting it with a pair of strong forceps or scissors, or by crushing it. This is in most cases easily accomplished,

1See, however, Halász, Archiv für Laryngol., 1904, xvi. p. 539.
Journ. of Laryngol., 1900, xv. p. 208.

Cheatle, Journ. of Laryngol., 1902, xvii. p. 358.

See Lantin, Archiv für Laryngol., 1896, iv. p. 137.

and the extraction then gives rise to no difficulty. liths Rouge's operation has been recommended.

For very large rhino

It can very rarely be

necessary: but I have once advised it in the case of a densely hard incrustated sequestrum.

Bibliography.

SEIFERT. Heymann's Handbuch der Laryngol. u. Rhinol., Wien, 1899, Bd.

iii. p. 550.