•.;?CTro{ SoS"- ' '^ *rsS§* r*fv**vwi RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINI avaan tvnouvn 3NOia3w do AHvgan tvnouvn snqiqsw do Aavaan tvnouvi VRY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN Q- VaaiT TVNOUVN 3NOI03W JO A8va8IT TVNOUVN 3NIDIQ3W dO AaVHSIT TVNOI1V ARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICIN Aavaan tvnouvn 3nidio3w jo Aavaan tvnouvn snoichw jo Aavaan ivnoiiv -o s 2 ✓,\Cl?W-v o stems' X 5 E TEihTTSD WIN dOS90t79€9 088X q9S8H gg/K NLM051647262 n tvnouvn 3NIDI03W JO AHVdaiT IVN THE BREATH, AND THE DISEASES WHICH GIVE IT A FETID ODOR. WITH DIRECTIONS FOR TREATMENT. BY JOSEPH W. HOWE, M. D., AUTHOR OP "EMERGENCIES;" PROFESSOR OP CLINICAL SURGERY IN BELLE- VUE HOSPITAL, MEDICAL COLLEGB J CLINICAL PROFESSOR OF SURGERY IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF NEW YORK; VISITING SURGEON TO CHARITY HOSPITAL; FEL- LOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC. THIRD EDITION', REVISED AND CORRECTED. NEW YORK: D. APPLETON & COMPANY. 1880. I ^"V/>->-, 7fd$ 2-h... /r Entered, according to Act of Congress, in the year 1874, By D. APPLETON & CO., In the Office of the Librarian of Congress, at Washington. % AS THE CONDITION OF THIS VOLUME WOULD NOT PERMIT SEWING, IT WAS TREATED WITH A STRONG, DURABLE ADHESIVE ESPECIALLY APPLIED TO ASSURE HARD WEAR AND USE. PREFACE. Marked changes in the breath have here- tofore received little consideration from the profession. Our medical text-books contain scarcely an allusion to their existence. I have endeavored, in the following pages, to give a succinct account of the diseased condi- tions in which a fetid breath is the most im- portant feature. The principal facts detailed concerning the production of the offensive odors are the results obtained from personal investigations, conducted both in private practice and in our city hospitals. J. W. H. 88 West Twenty-fourth St., ) September 1874. \ CONTENTS. CHAPTER I. PHYSIOLOGY. OF EEPAIE, DECAY, AND INSPIRATION. General Considerations.—Sympathetic Connections.—Changes in the Food during the Process of Digestion.—Destruction and Repair of Tissue.—Compounds resulting from Physiological Decay and Putrefaction.—Composition of Air inhaled and exhaled.—Effects of Medicinal Substances on the Breath.—Causes of Fetid Breath......... page 7 CHAPTER II. FETID ODORS FROM EMOTION, ETC. General Effects of Excessive Emotion.—Cases in which it destroyed Life, and produced Serious Disorders.—Emotion as a Cause of Bad Breath.—Class of Persons most subject to its Influence.— Prevention.—Constipation, its Effects on the Respired Air and Secretions.—Special Deodorizers.....21 CHAPTER III. FETID ODORS FROM DYSPEPSIA. Causes of Indigestion.—Symptoms.—How Indigestion affects the Air passing from the Lungs.—Relation to Constipation.—Examples. —Various Methods of Treatment.—Bad Breath from Congenital Deficiency of the Eliminating Apparatus of the Intestines 38 6 CONTENTS. CHAPTER IV. FETID ODORS FROM BAD TEETH AND ULCERS OF THE MOUTH. Decayed Teeth as a Cause of Bad Breath.—Effects of Decomposing Food in the Cavities of the Teeth.—Causes of Decay.—Develop- ment of a Vegetable Parasite in the Mouth from Uncleanli- ness.—Accumulation of Tartar and its Chemical Composi- tion.—Bad Breath from Inflammations and Ulcerations of the Mouth ... . . . . . . . page 50 CHAPTER V. FETID ODORS FROM CATARRHAL DISORDERS. Clergyman's Sore-Throat (Follicular Pharyngitis).—Peculiarities of the Inflammation.—Effects of Decomposing Mucus on the Breath.—Complications.—Treatment.—Cancerous Diseases of the Tongue and Pharynx.—Fetid Odors following Diphtheritic Diseases of the Throat, etc.......67 CHAPTER VI. CATARRHAL ODORS (CONTINUED). Ozaena depending upon Syphilis, Scrofula, Necrosis, and Caries of the Nasal Bones, and Herpes.—Character of Fetid Odors.— Bad Breath from Ulceration of the Larynx and Trachea.—Putrid Bronchitis.—Bronchiectasis, etc.—Treatment... 78 CHAPTER VII. FETID ODORS FROM MINERAL POISONS. Use and Abuse of Mercury.—Organs which eliminate the Drug.__ Effects on the Salivary Glands.—Quantity of Drug necessary to produce Salivation. — Mercurial Fetor. — Remedies.—Bad Breath from Arsenic, Lead, Antimony, Phosphorus, etc.— Treatment.........98 THE BREATH. CHAPTER I. REPAIR AND DECAY--RESPIRATION. General Considerations.—Sympathetic Connections.—Changes in the Food during the Process of Digestion.—Destruction and Repair of Tissue.—Compounds resulting from Physiological Decay and Putrefaction.—Composition of Air inhaled and exhaled.—Effects of Medicinal Substances on the.Breath.—Causes of Fetid Breath. An offensive breath is a functional disor der liable to occur at all periods of life. Men are more subject to it than women. It is a prominent symptom of many morbid condi- tions. The affection derives its importance from the fact that it is a constant source of misery to all who, by force of circumstanQes, are compelled to associate with the unfortu- nate patient. In its worst forms it effectu- ally destroys the communion of friends, and 8 THE BREATH. the pleasures of social intercourse. Even the harmony of the home-circle is invaded by a feeling of repugnance, which the best of us can scarcely control. Yet how few of the afflicted persons detect the cause of their iso- lation, or recognize the barrier which effect- ually prevents the approach of those near and dear to them ! With the best intentions in the world, we rarely whisper a word of their disorder or suggest a source of relief. This false kindness—this demoralizing weak- ness—is universal. In order to become acquainted with the sources of the fetor, to be enabled to prevent as well as to remove it, we must investigate some of the physiological processes mani- fested in the continual working of the animal organism. In a work like this such investi- gation must necessarily be limited. Enough can be learned, however, to give a proper understanding of the disorder in its various phases. Each organ has characteristics peculiar to itself, and, though each process is distinct, SYMPATHETIC CONNECTIONS. 9 there is no real isolation, for a multitude of nervous and vascular links bring all parts of the mechanism in close relationship. From the aggregation results one harmonious whole — a microcosm complete, and filled with exceeding beauty. . The nerves constitute a telegraphic sys- tem, through which the most delicate impres- sion is transmitted from one part to another, with almost immeasurable rapidity, until it is registered in the great central office of the brain. The net-work of blood-vessels per- meating the tissues throughout carries a con- stant stream of nutritive material to every part, neglecting none, and delivering its ele- ments, according to the special needs of the organ it traverses. Thus the brain abstracts from the blood the peculiar food which sus- tains the nervous ganglia in their varied func- tions. The lungs remove from it carbonic acid, which has arisen from the molecular decay of tissue, and give to it a fresh supply of oxygen for sustaining the vital forces. The kidneys take away the excrementitious 10 THE BREATH. materials which constitute the urine. The liver receives from it the ingredients of the bile, as .well as the nitrogenized substances, for its own sustenance. And so it travels, giving up one element here and another there, meeting constantly the diversified de- mands upon it, and creating a unity of ac- tion which makes up the life of the individ- ual. When morbid changes arise in the struct- ure or in the functions of an organ, the whole body gives evidence of the pernicious effects. If the blood which circulates through the encephalic mass is deficient in nutritious elements, or'poisoned by adventitious sub- stances, the outflow or generation of thought is retarded, and the mental processes gener- ally weakened. We wander from the subject —we forget. Our ideas are incoherent and pointless. There is a general feeling of de- pression, weariness, and anxiety. On the other hand, over-excitation of the brain over- drawing the reservoirs of nerve-force, weak- ens the power of digestion and impairs the EFFECTS OF MORBID CHANGES. 11 quality of the nutritious elements taken into the system. Consequently the blood becomes impoverished, and in its turn increases and keeps up the disorder for an indefinite period. Again, when the heart is filled with the de- praved blood, or when its nervous force is not sufficient to sustain its vitality, it be- comes irregular in its action and beats with diminished force. The distant organs which depend upon it for a proper amount of vital fluid to keep them in working order are en- feebled, and fail to furnish healthy secretion. In this manner the morbid action is commu- nicated to the whole human mechanism, until every fibre feels the change. It is mainly, however, to a disarrangement of the functions of digestion and assimilation that we must look for the origin of "bad breath." The starches, sugars, fats, inorganic salts, and nitrogenized bodies, constitute the different elements necessary for alimentation, or for the support of life. The most impor- tant of these are the albuminoid bodies which are obtained from meat, bread, cheese, etc. 12 THE BREATH. The albuminoid substances contain nitrogen, and hence are known as nitrogenized bodies. The great mass of muscular, osseous, nervous, and vascular tissues, in the body, is made of these substances in varied proportions. In the stomach, the fibrine and albumen of the meat, the gluten of the bread, the casein of the cheese, are mixed with the gastric juice and changed into a substance called albumen- ose. In this state they are absorbed by the blood-vessels, and carried by the blood, to- gether with other portions of digested food, to the different tissues which they nourish and keep alive. With the process of supply there is also one of waste. Death of tissue is pro- ceeding with a rapidity equal to the amount of repair. Life and death go hand-in-hand. Absolute death is essential to a renewal of life. The products of decay or " destructive assimilation" are carried off by the kid- neys in the shape of urea, creatine, creati- nine ; by the lungs in the form of carbonic acid and water; by the bowels in the forms of excretine, and various gases, such as sul- PRODUCTS OF DECAY. 13 phuretted, carburetted, and phosphuretted hydrogen. Some of the gases are manufact- ured in the intestinal canal by the decom- position of undigested food. Sulphuretted hydrogen, which has an odor resembling rot- ten eggs, is found in greater abundance than the other compounds of hydrogen. These gases are secreted by the mucous membrane of the intestines; sometimes they are thrown off by the glandular apparatus in the skin. This is often noticed when large doses of sul- phur have been taken internally. In some persons the quantity of sulphuretted hydro- gen passing off by the skin is sufficient to stain metallic articles carried in the pockets. Outside of the body nitrogenized substances undergo decay as they do inside. But in the latter case the changes are so gradual, that we usually fail to notice their extreme offen- siveness. They pass through similar changes whether decomposing in the intestinal canal —the follicles of the mucous membrane—or in cavities of the teeth. Coincident with the process of putrefaction, fetid gases may be 14 THE BREATH. secreted by the secreting apparatus of the intestines. The air we take into the lungs with each inspiration is composed of seventy-nine parts of nitrogen, twenty-one of oxygen,- a trace of carbonic acid and of ammonia. In certain localities adventitious gases are added, which render it exceedingly unhealthy. This is es- pecially true of parts of New York, where street-cleaning has become one of the "lost arts," and, as a legitimate consequence, sewer and garbage effluvia are constant elements in the respired air. The large amount of nitrogen in the air dilutes the oxygen, so as to divest it of all irritating qualities and make it re- spirable. With each inspiration we take in only twenty cubic inches of air. This passes with each act as far as the first bifurca- tion of the bronchial tubes. As the capaci- ty of the lungs is about two hundred and fifty cubic inches, it is therefore seen that but a small portion of the contents of the lungs PHYSIOLOGY OF RESPIRATION. 15 is changed by each respiratory movement. There is, however, a constant interchange or diffusion of gases, by which the heavier oxy- genated air is carried down to the air-cells, and the heated carbonic acid carried up. The movement is assisted by the ciliated epithe- lium lining the walls. These cells "play" from below upward, thus creating a current at the sides, which assists the passage of the expired air through the bronchial tubes. The oxygen passes through the walls of the air- cells into, the capillary ramifications of the pulmonary veins, and is carried off into the general circulation to the tissues in every part of the organism. The products of decay or retrograde meta- morphosis eliminated by the lungs, as before stated, are carbonic acid (composed of one atom of carbon and two of oxygen), water (formed of one equivalent of hydrogen and oxygen each, and a trace of animal matter). In a healthy state, when every organ is work- ing naturally, there is no unpleasant odor from the expired air; but, as soon as the 16 THE BREATH. machinery gets out of order—as soon as ex- traneous materials are added—the breath is tainted. We may illustrate by taking the well-known effects of various volatile sub- stances intruded into the system. Balsam- copaiba, in small doses, passes off by the kidneys; in large doses the lungs assist in its elimination, and its presence is then readi- ly detected in the breath. Sandal-wood oil will affect the breath in thirty minutes from the time it is swallowed. Turpentine may be noticed in from thirty minutes to an hour. Sulphur will produce a very marked odor in the perspiration and expired air in two hours. The characteristic and more familiar odor of alcohol is easily recognized in the breath of an imbiber in ten minutes. These drugs pass off through the lungs when or- dinary emunctories are overworked. Prof. A. L. Loomis, of this city, has at the present time under observation an in- teresting case of diabetes mellitus. The pa- tient has all the well-known symptoms of this disease, and, in addition, a breath which EXCRETION THROUGH THE LUNGS. V\ gives off a well-marked odor of sugar. In diabetes, there is a greater quantity of sugar manufactured than is required for the wants of the system. The surplus is thrown off, generally, by the kidneys. It is an exceed- ingly rare occurrence for the lungs to take part in getting rid of the sugar. In this case, however, there was probably an un- usual amount made, or less of it assimilated, than usual; therefore, every organ capable of excretion was compelled to assist in throw- ing it off. In Bright's disease of the kid- neys, urea is retained in the blood. This substance combines with the water in the circulating fluid to form carbonate of am- monia. In a short time the skin and the lungs endeavor to get rid of the poison, and then we can discern, in the perspira- tion and in the expired air, the character- istic odor of ammonia. In the same manner, gaseous results of decaying nitrogenized tissue may be carried off when the other gate-ways are closed. A little sulphur in excess, combined with the 18 THE BREATH. hydrogen of the watery vapor going off dur- ing expiration, forms sulphuretted hydrogen, and causes at once an offensive breath. A simple rearrangement of the atoms of car- bon and hydrogen will give carburetted hydrogen (CH2), which also communicates to the breath a peculiar and disagreeable odor. These facts being understood, it may be stated, as a general proposition, that any morbid condition of the system which pre- vents the elimination of metamorphosed ni- trogenized tissues through the mucous mem- brane of the intestines, or retards the pas- sage of the decomposing detritus through the bowels, will produce a fetid breath. The same result probably follows structural changes in the kidneys. Nature, to get rid of the poisonous accumulations, to maintain an equilibrium, must throw them off else- where, either in their offensive form or in modified, non-offensive combinations. Or, where the waste of tissue exceeds the re- pair, as in chronic, debilitating diseases and CAUSES OF BAD BREATH. 19 low fevers, the eliminating glands are unable to do the work imposed upon them, and vica- rious elimination necessarily follows. Thus the gaseous products of the stomach, the ex- halations from the skin, become more or less poisoned and fetid from admixture with foul- smelling gases. The bad odor in the respired air is more noticeable than from any othei part, but a close examination of the patient will show that the skin likewise gives off a very disagreeable fetor. The various diseased conditions which prevent the intestinal glands from eliminat ing the products of destructive metamorpho- ses are mental emotions, constipation, indiges- tion, congenital deficiency in the eliminating glandular system, general debility, and low forms of fevers. The local causes are decayed teeth, caries of the nasal or maxillary bones, ulceration of the lining membrane of the nose, mouth, pharynx, layrnx, trachea, or bron- chial tubes, or " putrid bronchitis." Chronic poisoning from lead, arsenic, or mercury, may also be enumerated as a common cause of 20 THE BREATH. halitosis.1 In the subsequent chapters these various diseased conditions will be consid- ered, together with the appropriate treat- ment necessary for each. 1 The term " halitosis " signifies diseased breath. It is de- rived from the Latin halitus (breath), and the Greek nosoa (disease).—Harvard. CHAPTER II. FETID BREATH FROM EMOTION, ETC. General Effects of Excessive Emotion.—Cases in which it destroyed Life, and produced Serious Disorders.—Emotion as a Cause of Bad Breath.—Class of Persons most subject to its Influence.— Prevention.—Constipation, its Effects on the Respired Air and Secretions.—Special Deodorizers The influence of mental emotion on the animal economy has never received the con- sideration which its importance demands. Accustomed to regard the mind as some- thing apart from the rest of the human mechanism, we are apt to overlook it when investigating questions of animal pathology; and we constantly underrate its power over the processes of growth and decay going on within us. It is the tendency of the times to accept only what we can see, feel, and weigh, and gauge by our own narrow, in- finitesimal conceptions the expansion of the 22 THE BREATH. .infinite. We separate too widely mind from matter, and consequently come short of a cor- rect appreciation of morbid physical changes. This is not the place, however, for the illus- tration of this subject; nevertheless, it will be necessary for illustration to give a few instances of the effects of mental emotions in totally changing healthy conditions, and replacing them by serious and even fatal disorders. A criminal, who had been condemned to death for murder, was given into the hands • of a celebrated French surgeon. He was told that his judges had decided that he should be bled to death on a certain hour the following day. When the appointed time arrived he was blindfolded and placed in a> bed. The surgeon then made a small incision through the skin, which did not involve any of the blood-vessels. One of the persons interested in the experiment placed his fingers on the pulse, another held a vessel of lukewarm water above the wound- ed arm and allowed the liquid to trickle over FEAR AS A CAUSE OF DEATH. 23 its surface and drop on the floor. Meanwhile the surgeon, in his conversation with the as- sistants, alluded to the gradual weakening .of. the pulse, the fluttering of the heart, and the paleness of the countenance, until the criminal, fully convinced that his end was near, fainted and died, without having lost a single drop of vital fluid. A similar incident occurred in Moscow a few years ago. A criminal, who had been condemned to suffer the death-penalty, was told that he was to sleep in a bed from which the dead body of a cholera patient had just been removed. He was then con- ducted to a well-ventilated room and placed in a bed perfectly clean, which had never been used. Toward morning he was taken with all the symptoms of cholera, and died in a few hours. Instances of less violent results from men- tal emotion are not uncommon. Terror has changed the color of the hair from black to' w'hite. Fear may excite the sweat-glands to such an extent as to bathe the skin in a pro- 24 THE BREATH. fuse perspiration. The same emotion may so excite the action of the heart as to make its impulse perceptible through the clothing. A single thought will often take away the appetite, or the remembrance of .some favor- ite article of diet will create one, and also increase the .secretion of saliva and buccal mucus. Excitement has been known to cause convulsions, dizziness, intense pain in the head, and dimness of vision, which dis- appeared on the return of calmer feelings. Mental excitement may also alter the se- cretions of the alimentary canal and affect the functions of the glandular system, so as to prevent the proper elimination of the disorganized, useless, nitrogenized materials through the ordinary channels; and then, as a natural consequence of the change, we must expect an alteration in the composition of the air passing off from the lungs, and a contamination by gases, which give it a fetid character. In such cases, the effect is brought about simultaneously with the excitement; in others, again, it develops subsequently. FETID BREATH FROM EMOTION. 25 At one moment the breath will be sweet, at the next fetid and unbearable. The odor is not so penetrating or disagreeable as that arising from decomposing food in the cavi- ties of decayed teeth or from dead teeth. The patients are usually conscious of its ex- istence, which is not the case in many other varieties of the affection. They are subject to violent fits of temper, easily excited, and as easily depressed. The appetite is varia- ble. Sleeplessness is a common accompani- ment. The following cases from my note- book afford good examples of the class under consideration: Case I.—Mrs. Gr., aged forty; occupation, singer. She is slight, but firmly built, and has an extremely sensitive nervous organiza- tion ; is able to endure fatigue without dis- comfort ; never had any hysterical mani- festations, although extremely liable to lose control of herself under provocation. She has been subject at intervals to a bad breath, and is always conscious of its presence. It comes on suddenly, and is accompanied by a 2 26 THE BREATH. peculiar taste in the mouth. It follows or accompanies fits of depression or anger, but never occurs from pleasurable excitement. Preceding the menstrual epoch it is aggra- vated ; it disappears with the flow. Once in two or three months an intense headache comes on, with vomiting of bilious matter. This sometimes occurs without affecting the breath. She calls it a " feverish breath." Her appetite is good, and she is able to digest her food, except when suffering from depression. Constipation is also present at such times, but it follows and does not pre- cede the bad breath, showing that the tor- pidity of the bowels is likewise an effect of the mental condition, and not a cause. She thinks the affection has lasted about five years. Case II.—Mrs. R., aged thirty-two. Is a lady above the medium height; inclining to embonpomt. She enjoys excellent health, has a good appetite, and digests her food readily. She is not subject to any special manifestations of excitement; fits of depres- FETID BREATH FROM EMOTION. 27 sion, however, are not uncommon at the men- strual epoch. The peculiarity in her case consists in this, that, whenever she is pre- paring to receive company, her breath be- comes perceptibly " feverish." The odor con- tinues until the excitement consequent upon the entertainment has subsided. Under simi- lar circumstances the same thing has occurred for four years. During the free interval her breath is pure and sweet. An examination of the mouth and throat showed (as in the previous case) that there was no local cause for the affection. Case III. occurred on the 23d of May last. On the morning of that day Mrs. R., a lady of forty-five, was bitten by a pet dog in the arm. She was very much alarmed at the occurrence, and fainted. I saw her an hour afterward, and, while examining the wound, discovered that her breath was very fetid. Having seen her frequently before without noticing any thing abnormal in the breath, I questioned her concerning it. She stated that she had been in perfect health up to 28 THE BREATH. the time of the accident, and that her breath had not been affected before it. The suddenness with which the offensive breath develops in these cases may be ex- plained by the theory spoken of above, or it may be that unusual nervous excitement induces a greater destruction of tissue than normally obtains, and, before the intestinal glands can accommodate themselves to the in- creased labor, other organs must assist in get- ting rid of the overplus of noxious material. Bad.breath, arising from mental emotion, is less amenable to treatment than any other variety, because it often depends on the will of the patient whether the cause shall be re- moved or not. There is no local fault which can be grasped and removed. The treatment, consequently, must be directed to the gener- al system. All sources of mental irritation should be removed. Cold sponge-baths daily are of great service in giving tone to the nervous system. In certain cases shower- baths are good, but delicate persons are over-stimulated by them. Plenty of exer- CONSTITUTIONAL TREATMENT. 29 cise in the open air is also a requisite. As much vegetable food as is consistent with a Jbealthy state should be eaten at each meal, and the animal food diminished. When mental excitement is known to occur at cer- tain stated intervals, the following prepara- tion will be found of great service. It acts as a stimulant to the nerves, and enables the patient to pass the difficult date with ease: IJ. Tinct. lavand. comp., f § ij. Tinct. valerian., £ % ss. Mist, camph., f 3 iij. Aquae carui, f § j. Dose, fifteen drops on sugar every hour until the depression is relieved. In some cases five or ten grains of musk, repeated once or twice during twenty-foui hours, will be found efficacious. Or either of the following may be em- ployed : ^. Tinct. Valerianae amnion,, f 3 ss. Tinct^castorri comp., f 3 j. ^Etheris, gt. xv. Aquae anethi., f 1 iss. Half of this preparation may be taken two or three times each day. 30 THE BREATH. IJ. Tinct. assafcetidae, f f j. * Tinct. hyoscyami, f 3 ij. Tinct. cinnam., f § iss. Aquae menth. pip., f 3 ij. M. Dose, one teaspoonful in water every three hours. Should the breath be affected in spite of the preventive remedies, a wafer or pill, com- posed of the following ingredients, may be allowed to dissolve in the mouth. It effect- ually destroys the bad odor. Before using it, the teeth should be thoroughly cleansed and the gums sponged with a solution of" myrrh and water: IjL Pulv. cinnam., Pulv. pimentae, Pulv. cardam., aa 3 ss. Sacchari alb., 3 j. Mucil. gum. acacia?, q. s. Make fifty pills. Fifteen drops of oil of nutmeg, mixed with one teaspoonful of olive-oil, is a good deodorizer. It should be rubbed on the gums and cheeks with the finger. Sometimes it is necessary to act on the CAUSES OF CONSTIPATION. 31 bowels with a mild cathartic before the odor can be removed. When the secretions of the intestinal canal are increased, the other medi- cines are more certain in their curative ac- tion. In such cases, a combination of rhu- barb, myrrh, aloes, and oil of peppermint, acts beneficially. This compound passes un- der the name of "compound rhubarb-pill." Two or three may be taken at bedtime. COXSTIPATION Is more frequently a cause of bad breath than the preceding. A diminished secretion of mucus from the lining membrane of the in- testinal canal, or deficient peristaltic action of the muscular coat, are its most common causes. Persons of indolent habits, who are accustomed to lounge in-doors, and rarely ex- ercise in the open air, are very subject to it. A watery condition of the blood (anmmia) may produce constipation by lessening the normal amount of the secretion, or deterio- rating the elements which enter into their composition. Nearly all forms of indiges- 32 THE BREATH. tion have constipation as one of the promi- nent accompaniments. When constipation exists, the disentegrat- ed materials, which are thrown off through the mucous membrane, and the remains of undigested food, accumulate in the canal. The mass is passing rapidly through all the various stages of decomposition, and, by its pressure and irritation of the glands, it di- minishes the normal excretory function, and Nature, to maintain an equilibrium, throws its surplus of excretory materials on the glands of other mucous membranes. Then, again, the gases, in solution, arising from the decomposing accumulation, may be taken up by the blood-vessels, and thus increase the effluvia. It will be noticed, in most of these cases, that the skin is darker than is natural, or has a yellowish, semi-jaundiced hue, and that the odor of its secretion is percepti- bly changed. The tongue is coated. The mucous membrane of the lips may be dry and parched, and, in certain places, its epithe- FETOR FROM CONSTIPATION. 33 Hal covering peels off, leaving the membrane denuded. The breath is fetid, but the pa- tient is generally unaware of it. When no- ticed by the patient, he usually expresses the fact by saying that the breath is ufeverish." Other signs of general disturbance of the func- tions of the body may after a time appear; but their consideration belongs to other de- partments, and will not be touched upon here. The treatment of this class of cases, when properly carried out, is eminently successful. The fetor can always be removed. In the first-place, however, the patient must be made to understand that medication alone will not produce any permanent improve- ment. An entire change of habit is required. Vigorous exercise out-of-doors should be con- stantly enjoined. Where this is not practica- ble, sparring, dumb-bell, or club exercise, will be of great benefit. Fruit, such as oranges, peaches, pears, etc., should be eaten in the morning, before or during breakfast. Fruit eaten in this way is a valuable adjuvant In keeping up proper action of the bowels. 34 THE BREATH. Friction of the abdomen with a rough towel after a bath, or at other times, will be found useful in promoting the same object. The patient should select for himself the most nu- tritious and digestible articles of diet best suited to his individual palate. What will answer for one will often interfere with the digestion of another; therefore no special diet can be laid down. In the majority of cases it will be found necessary to act on the bowels with gentle cathartics. They should be repeated every second day until the mu- cous membrane is restored to its normal con- dition. Active purgatives are rarely' needed. The following tonic and laxative prepara- tions are exceedingly useful: IJ. Pulv. aloes socot., grs. xij. Ext. nucis vomicae, grs. ij. Pulv. ferri sulph., 3j. Make twenty pills. One pill to be taken two or three times each day before meals, until the evacua- tions are regular and natural in appearance. If there be pain and flatulence in connec- tion with the constipation, it will be neces- TREATMENT. 35 sary to combine carminatives with the cathar- tic medicine: IJ. Pulv. aloes socot., grs. xij. Pulv. rhei., * 3ij. Ext. nucis vomicae, grs. iv. Pulv. zingiberis, 3 j. Make thirty pills. One pill before or after each meal. Or the following may be tried : IJ. Magnes. carb., 3j. Sp. lavand. comp., f § ss. Olei anisi, 3j. Aquae menthae pip., f § vj. One tablespoonful four or five times each day be- fore eating. The officinal mixture of rhubarb, soda, and peppermint, given in teaspoonful doses five times in twenty-four hours, is also good in flatulence. A piece of rhubarb chewed, and the juice swallowed, will often answer the same purpose. As in the previous cases, the mouth and teeth should be cleansed thoroughly with the solution of myrrh and water (one tea- spoonful of the tincture of myrrh to a wine- glass of water), or the carbolic-acid solution 36 THE BREATH. (four grains to two ounces of water). The tincture of cinnamon, slightly diluted with water, can be applied to the interior of the mouth and gums with a brush. It will com- municate its flavor to the breath for a con- siderable length of time. Pieces of charcoal- cake as large as a hazel-nut may be eaten half a dozen times during the day with ben- efit. These things, however, only diminish, but do not entirely dispel the offensive odor. As a permanent deodorizer, the wafer men- tioned in a previous page may be employed in conjunction with the following: IJ. Pulv. carui sem., Pulv. coriandri sem., Pulv. cinnam., aa 3 ss. Sacch. alb., 3 j. Mucil. gum. acaciae, q. s. Make fifty pills. Dissolve one in the mouth when necessary. The root of Acorus Calamus, or sweet-flag, when chewed, impregnates the breath strong- ly with its peculiar aromatic principle. A piece the size of a pea will answer. The odor obtained by masticating the leaves of DEODORIZERS. 37 the common partridge-berry {Gaultheriapro- cumbens) is exceedingly agreeable, and makes an excellent deodorizer; or, one teaspoonful of tincture of gaultheria and one of tincture of myrrh, added to an ounce of water, will be found equally efficacious. Cigarettes, in which are mixed small pieces of cascarilla or cinnamon bark, may be smoked by persons who are in the habit of using to- bacco. Where the constipation and bad odor are kept up by a general lax condition of the system, a course of tonic medicines alone will often suffice to bring about a cure. Vegeta- ble tonics, as a rule, agree better with the stomach than mineral ones do. A mixture, composed of equal parts of tincture of wild- cherry and cinchona barks, is good. If iron is indicated, the following may be given : IJ. Ferri pyrophosph., 3 ij. Quinae sulph., 3 ss. Acidi sulph. dil., q. s. Glycerinas, 1 iv. One teaspoonful in a wineglass of water four times each day. CHAPTER III. FOUL BREATH FROM INDIGESTION, ETC. Causes of Indigestion.—Symptoms.—How Indigestion affects the Air passing from the Lungs.—Relation to Constipation.—Examples. —Various Methods of Treatment.—Bad Breath from Congenital Deficiency of the Eliminating Apparatus of the Intestines. The false mode of life characteristic of the nineteenth century, the hurry, excite- ment, and worry, are generators of innumer- able ills. Their most common sequences are disorders of the digestive functions. Seden- tary habits, overwork, and the disgusting practice of " bolting" food, assist them in sapping the vitality until Nature gives way under the strain. Men eat as if they wished to get the food into the stomach in its most indigestible form. Their object is to save time — to save time, perhaps, for the cigar or bar-room. This is a great mistake. No reasonable excuse can be made for such a INDIGESTION. 39 vicious practice, for all who indulge in it know, to their cost, the penalty, which, in the shape of dyspepsia and its kindred evils, constantly threatens them. The symptoms which characterize indiges- tion are, in some respects, similar to those con- nected with chronic constipation. In many instances, torpidity of the bowels is but a result of a poor indigestion; yet, as indiges- tion frequently occurs independently of con- stipation, and, as habitual constipation is of- ten associated with excellent digestive pow- ers, it is but fair to make a distinction between them. There are, however, in addi- tion to the symptoms before enumerated, pain and weight in the stomach after eat- ing, and eructations of gas and acid liquids into the mouth. The gas may disturb the stomach and intestines so as to cause con- siderable pain. It rarely has a bad odor. Diarrhoea may be present, though the bow- els are usually constipated. There are often great nervousness and depression of spirits, amounting, in some cases, to melancholia. 40 THE BREATH. The breath becomes fetid very soon after the commencement of the disorder. The of- fensive odor is worse in the morning and evening. Fatigue and nervous excitement invariably increase it. Immediately after eat- ing, it is scarcely noticeable. The odor may be due to the decomposi- tion of undigested food in the bowels, or from failure of the excretory glands to throw off the products of disintegration, or it may arise because decay of tissue is increased by the lack of support, resulting from the dimin- ished quantity of nutritious elements taken into the system. This deficiency of nutri- ment is a constant and necessary effect of indigestion; and, with the excess of disinte- gration and the general torpor in the glands of the intestines, there is a demand for in- creased work in other parts to assist in throwing off the detritus. The following cases show the course of the affection in its various phases: Case I.—Mary M. Gr., aged thirty-one; oc- cupation, nurse. Was first taken sick May, INDIGESTION. 41 1870. At that time she began to lose her appetite and feel uncomfortable after eating. A heavy meal was always followed by a pain in the epigastrium and side. Solid food af- fected her more than any other kind. With the pain a burning sensation (heart-burn) was sometimes felt in the chest. Pressure over the stomach excited nausea and vomit- ing. Cold water taken at night caused a painful feeling of distention over the abdo- men, and a profuse flow of saliva into the mouth. On rising suddenly from the reclin- ing posture, her head would become dizzy and her sight dim. She attributed this to her weakness. In the morning her tongue was coated with a yellowish-white fur, and her breath was exceedingly offensive. She was not aware of this latter symptom until informed of it by a friend, but since then the odor has been very perceptible to her own olfactories. On examination of this patient I found her face sallow and care-worn, and her breath very fetid. Her eyes were heavy, and the 42 THE BREATH. edges of the lids red. The skin was dry and rough, like that of one convalescing from a fever, and the odor arising from it was un- pleasant. While under observation, she ab- stained from all solid food, and confined her- self almost exclusively to a milk-diet. This resulted in complete relief from her unpleas- ant sensations. Afterward she went to the country, lived out-of-doors, and finally re- covered, without the aid of any kind of med- ication. Case II.—J. C, aged twenty-seven; occu- pation, book-keeper. Has been employed in a hardware establishment. For two years past he has been in the habit of working from eight in the morning until ten or eleven at night. The only exercise he took was walking to the store in the morning. About two years ago he began to be troubled with flatulence. Every thing he ate seemed to turn sour on his stomach, and he was con- stantly belching up large quantities of gas, which had an unpleasant odor. The bowels were alternately constipated and loose. In EXAMPLES OF INDIGESTION. 43 about three months from the beginning of the complaint severe pain after eating was added to his other symptoms. The pain was burning in character, and almost unbearable until relieved by getting rid of the gas. He was in the habit of taking brandy after each meal, because it seemed to assist in di- gesting the food. His breath, he said, was feverish from the beginning; he noticed it was much worse in the evening than in the morning. There was a bad taste in the mouth continually. He thought the fetor was caused by the yellowish matter which accumulated on the tongue and gums be- tween meals. This coating was made up principally of epithelial cells and fine gran- ules. It gave off a slight fetid odor; but its removal made little or no change in the char- acter of the breath. These cases are typical, and they consti- tute at least one-third of the practice of many of our medical men. The same general hygienic measures rec- ommended for the cure of constipation, and ----------------------*--------------- 44 THE BREATH. the bad breath accompanying it, are neces- sary in every form of indigestion. Fresh air, nourishing food, change of habitation, rest from work and worry, do more toward pro- moting a cure than the most scientific medi- cation. Unfortunately, many of our patients, from necessity as well as inclination, remain under bad sanitary influences. When there are acid eructations, showing excessive acidity of the stomach, alkalies may be administered. Carbonates of soda or pot- ash, given in five or ten grain doses, and re- peated at short intervals, will give temporary relief. Lime-water is also good in certain cases, especially when there is nausea. To empty the bowels, and at the same time stimulate the secretions, the following powders may be given : IJ. Hydrarg. chlor. mitis, grs. viij. Pulv. rhei., x. Olei anisi, gt. v. Make two powders; one to be taken at night, and the other in the morning. If the patient is robust and full-blooded, both powders may be administered to- gether. In the majority of cases it is best to com- TREATMENT OF INDIGESTION. 45 mence with a cathartic before resorting to tonics or deodorizers. A pure milk-diet, continued for several weeks, will often remove the indigestion, and with it the offensive breath. Pieces of crack- er may be soaked in the milk, or an egg may be beaten up with it once or twice each day. While pursuing this course, all varieties of solid food, except bread and light crackers, should be avoided. The quantity of milk taken must depend on the inclinations of the patient. In most cases, it may be increased until four or five quarts are consumed daily. When the milk disagrees with the patient, a trial must be made of other digestible articles of diet until something is found to suit the delicate stomach. The bowels may be regu- lated by the pills of iron, nux-vomica, and aloes, or by Kissingen-water, taken in the morning before breakfast. For the relief of the distressing sensation of weight and fullness in the stomach after eating, caused by flatulence, the following is always useful: 46 THE BREATH. IJ. Bismuth, subnitrat., 3 ij. Pulv. zingiberis., 3 iij. Spts. lavand. comp., f § jss. Aquae, f § ij. M. One teaspoonful four or five times each day, or as often as the distressing symptoms prevail. The medi- cine must be taken in water. Should the liquid prepa- ration not agree with the stomach, the bismuth and ginger may be tried in the form of powder. Strong peppermint-tea, made by adding half an ounce of the leaves to half a pint of water, is also serviceable. If this plan of treatment is followed out faithfully for a few weeks, the offensive breath, with the other disagreeable symp- toms, will be entirely removed. When the patient recovers, the physician should insist on a strict observance of all ordinary hygienic laws in order to prevent a recurrence of the disorder. For the immediate relief of the fetid breath, any of the previously - mentioned medicaments (page 36) may be employed. The charcoal-cake alone, when eaten four or five times during the day, will often suffice to remove the odor. When the tongue is CONGENITAL BAD BREATH. 47 much coated, it must be scraped clean, and the whole mouth washed with a solution of myrrh-and-lavender (one teaspoonful of tinct- ture of myrrh to a wineglass of lavender- water), or with the carbolic - acid solution. Unless this is done, the coating will become decomposed and add to the general offensive- ness of the breath. CONGENITAL BAD BREATH. There are a few unfortunate persons who are afflicted with a bad breath from their childhood. At first, the affection is attrib- ' uted to indigestion. As the child grows, however, he exhibits the ordinary amount of flesh, strength, and capacity for digest- ing food that other children do; he sleeps well, and has a good appetite, and, in all other respects, appears to be in perfect health. There is not one appreciable cause of bad breath to be discovered in the work- ing of any organ. A close examination of the patient will show that the skin gives off a fetor similar to that coming from the lungs, 48 THE BREATH. but much less intense. In warm weather, or when under the influence of alcoholic stimu- lants, the breath of the patient is almost un- bearable. Like some other forms, it is some- times worse at night than in the morning. It is probable that, in these cases, there is some defect in the eliminating apparatus of the intestines, or a peculiar tendency to the formation of one class of metamorphosed decaying substances instead of another. If this view is correct, we may have a portion of the carbonic acid and vapor of water, car- * ried off from the lungs, replaced by some of the fetid gases mentioned in the first chap- ter. Similar changes may also occur in the secretions of the skin and other organs. The treatment of congenital bad breath is more palliative than curative. We cannot remove the fetid odor completely; we can, however, hide or modify it. The patient should take a tepid bath daily, and after- ward sponge the surface of the body with - cold water. -When the skin has been rubbed dry, a dilute solution of Florida-water should TREATMENT. 49 be applied with a wet towel. An infusion of partridge-berry leaves, or cologne-water, may be employed in the same manner. A few drops of spirits of camphor act as a per- fect deodorizer in some cases. Every local cause which might add to the fetor must be removed. The mouth and teeth ought to be kept scrupulously clean. Charcoal, again, comes in here as a useful disinfectant. Sweet - flag, partridge - berry leaves, cinnamon - bark, etc., may be used constantly. A small portion kept in the mouth will hide the offensiveness of the breath. If necessary, all the deodorizers be- fore recommended may be tried in turn, and the most suitable for the case selected foi permanent use. 3 CHAPTER IV. FOUL BREATH FROM DECAYED TEETH, ETC. Decayed Teeth as a Cause of Bad Breath.—Effects of Decomposing Food in the Cavities of the Teeth.—Causes of Decay.—Develop ment of a Vegetable Parasite in the Mouth from Uncleanliness. —Accumulation of Tartar and its Chemical Composition.—Bad Breath from Inflammations and Ulcerations of the Mouth. Premature decay of the teeth is often witnessed in persons suffering from scrofula. The teeth of such persons become discolored at an early age, and crumble with very little pressure. It is symptomatic of the general lack of vitality, which exists in scrofula. Teeth decay, likewise, from uncleanliness. Small particles of food accumulate in the cavities between the teeth, and in a short time decompose. The decomposed material, as it becomes packed and denser, presses on the enamel, destroys it, and then has free ac- cess to the soft bone beneath. In connection PARASITIC FORMATIONS.—TARTAR. 51 with this deposit, a minute vegetable para- site is developed in the mouth, called the Septothrio bucollis. When examined under the microscope, it presents the appearance of a granular mass covered with filaments. On the addition of iodine, a violet-color is produced. In nearly every case of decayed teeth, these parasites may be found. When lodged between the teeth, they sprout with the same rapidity that other fungous growths do. It forms masses, which become harder and denser as the development proceeds, un- til it absorbs the enamel in its neighborhood. If a portion of teeth under it be examined, its surface will present a roughened appear- ance, and, in the course of time, a large cav- ity is formed, opening into the interior of the tooth. Another result of uncleanliness is a deposit of tartar on the inner surface of the teeth, near their insertion in the gums. It adheres to the enamel like mortar, and, if allowed to remain, causes destruction of that part of the tooth upon which it presses. Tar- tar, which may be recognized by its hardness 52 THE BREATH. and yellowr-gray color, consists of phosphate of lime, mucus, salivary matter, and a pecul- iar animal substance, soluble in chlorhydrie acid. The density and compactness of tartar are due to the phosphate of lime, the mate- rial which gives to bone its hardness. When, in the deposit, the animal matter is in excess, small parasites will often be found. The use of acids for a length of time, either in the form of medicines or of unripe fruit, is another common source of decay which is often overlooked. Decaying bone in all parts of the body, when exposed to the air, exhales a fetor. The same destructive process in the teeth occa^ sions less odor than decay in other bony tissues. When a fetid breath is associated with rotten teeth, it is usual to assume that they alone are responsible; this, however, is not the case. The decaying structures of the teeth are but accessories in producing the fe- tor. During the process of mastication, many particles of food become lodged in the mi- FOUL BREATH FROM CARIOUS TEETH. 53 » nute Cavities of the teeth. The heat and moisture of the mouth excite decomposition in the mass. The animal matters it contains, as well as the alkaline salts, assist in continu- ing the destructive process. In a day or two it is thoroughly rotten, and emits the foul- ness characteristic of putridity under other Circumstances. Thus each decaying tooth be- comes the receptacle and storehouse for de- caying animal matter in its most disgusting forms. The portions of decaying material near the carious cavity become condensed and fastened into the crevices of the tooth. Daily the rotten mass receives fresh layers, which form on the top, until it is very diffi- cult to distinguish the animal matter from the bone. As a necessary consequence of this putrefactive change, the breath becomes impregnated with foulness, so that it is al- most impossible to remain in close proximity to the patient. The odor is worse than most other varieties, but it is soon relieved by ap- propriate treatment. The proper person to consult in these 54 THE BREATH. cases is the dentist. He should carefully cleanse the teeth from all incrustations of tartar, and remove the decaying substances from their cavities. These cavities may then be filled with what is known as "soft-filling" or with gold. Amalgam fillings are not con- ducive to health. They do not make the breath any sweeter, nor do they preserve the teeth from decay. The particles of food should be extracted from between the teeth after every meal by means of a toothpick. The teeth may then be washed with a solution of soap-and^water, applied with a soft brush. Hard brushes in- jure the enamel. The soap-solution destroys the parasitic accumulations of the mouth, be- sides acting to a certain extent as a disinfec- tant and deodorizer. When from any cause recourse to a dentist is impracticable, animal charcoal can be pressed into the cavities, al- lowed to remain for half an hour, and then be removed by washing. A solution of car- bolic acid (two grains to the ounce of water) is an excellent deodorizer. It can be applied DEODORIZERS. 55 thoroughly when the charcoal is removed, and repeated if necessary. As the odor of carbolic acid is not always agreeable, its ap- plication may be followed by the myrrh-and- cinnamon solution: IJ. Tinct. myrrhse, Tinct. cinnam., Aquae mentbse viridis, M. This mixture may be applied with a tooth- brush. The tincture of myrrh may be used alone, diluted with sufficient water to pre- vent it from irritating the mucous membrane. Either of the following may be tried : IJ. Tinct. calami, Tinct. gaultheriag, aa 3 j. Spiritus myristicae, § j. Aquae, § ij. M. IJ. Spiritus lavandulae comp., § ss. Aquae menthae piperitae, § ij. M. These preparations may be used in a more diluted state if the patient is young. In aa, f 3 ij- 56 THE BREATH. some cases a diluted solution of nitric acid (ten drops to two ounces of water), used in- side the putrid cavities, will destroy the ani- mal deposit. Hydrochloric acid (fifteen drops of the diluted preparation to half an ounce of water) may be applied to the incrusta- tions of tartar. This is done by dipping a piece of match or splinter of wood, prepared for the purpose, in the solution, and then rub- bing it over the tartar until it is dissolved. It is better, however, to let the dentist attend to this also. When the teeth and mucous membrane of the mouth are kept clean by these means, the offensive odor of the breath will disap- pear. In all cases it is well to examine carefully the condition of the patient's health. When there is loss of appetite or general debility, fresh air and nourishing diet must be pre- scribed. A course of tonic medicines may also be found necessary. Necrosis of the Jaw comes more within the province of the surgeon. The fetid odor NECROSIS OF THE JAW. 57 connected with it is of small consequence in comparison with the pain and constitutional disturbance attendant upon it. It may re- sult from decayed teeth, syphilis, or mineral poisons. When it is caused by dead teeth, usually but a small portion of the bone is involved in the morbid process. If it follow the introduction of mineral poisons into the circulation, the disease is far more extensive, and may destroy the whole of the bone. The necrosis produced by phosphorus is located generally in the lower jaw. The treatment consists in removing the dead bone. When that is accomplished, the fetor will disappear. Should circumstances delay the operation, the bad odor can be di- minished^ temporarily by applying pure nitric or hydrochloric acid to the surface of dead bone. This cannot be accomplished, how- ever, unless the bone is denuded of its soft tissue, and then other deodorizers, such as car- bolic acid, creasote, etc., must be resorted to. Bad breath arising* frorn putrid inflamma- tion of the mouth (stomacace) is a peculiar 58 THE BREATH. and comparatively rare affection. It usually commences with congestion of the mucous membrane of the buccal cavity, followed by increased secretion. In a short time the gums begin to swell, and bleed from very slight pressure. Around the margins of the ulcers there is a yellowish exudation, which is thick and viscid, and not easily removed. The odor from the commencement to the termination of the disease is extremely offen- sive. It can be recognized at some distance from the patient. If the affection is not con- trolled by proper remedies, the cheeks be- come involved in the ulceration. Mastica- tion and deglutition become very difficult, and the life of the patient may even be en- dangered. The disease is said by some to be contagious. It is often met with in chil- dren. The treatment is simple and usually successful. A solution of chlorate of potash, used repeatedly, in the course of a day or two stops the ulceration and removes the fetor. For adults, the following solution is the best: SCORBUTIC FETOR 59 IJ. Potassas chloratis. 3 j. Syrup, zingiberis, § ss. Aquae, § iij. One teaspoonful in water every three hours. The mouth may be washed with the same preparation. Half the quantity of the adult dose may be given to children. Scorbutic Ulceration of the Mouth is pre- ceded by loss of flesh and strength. When the disease is fully developed, the gums be- come bluish-red, swollen, and painful. The tongue is coated with a yellowish exudation, and there is some increase in the quantity of saliva. Small extravasations of blood appear under the mucous membrane, and ulcers make their appearance, which bleed on slight press- ure. In all these cases the breath is fetid, but the fetor is not so penetrating as that arising from stomacace. The disease requires local and constitu- tional treatment. The local treatment con- sists in the application of astringent washes to the mouth, such as solutions of alum, tan- nic or gallic acid, uva ursi, and hydrastics. 60 THE BREATH One teaspoonful of powdered alum may be added to four ounces of water, and the mouth washed five or six times each day. The car- bolic-acid solution also is good—it corrects the fetor. The constitutional treatment con- sists in the administration of lime-juice, lemon- juice, and vegetable acids. The diet should be made up mainly of fresh vegetables, such as cabbage, potatoes, carrots, beets, etc., and a moderate amount of fresh meat. Syphilitic inflammation and ulceration of the mouth and fauces are always accompanied by a bad breath. The ulcers rarely occur without signs of secondary or tertiary syph- ilis being present. There may be eruptions on the skin or periosteal inflammations at the same time. The ulcers are usually cir- cular and superficial. They are covered by a thin whitish or semi-transparent coating, and do not bleed easily. In their vicinity small, hard nodules or raised patches of mucous condylomata may sometimes be seen, or their margins may be indurated. The odor is not alone due to the secretion from the sur- SYPHILITIC FETOR. 61 face of the ulcer, but also to some change in the secretion of the salivary glands. Per- haps the change is effected by the matter from the ulcer acting upon the salivary in- gredients. The first thing to be done in these cases is to cauterize the sores thoroughly with ni- trate of silver. A strong solution of car- bolic acid and glycerine, in the following proportions, may then be applied over the ulcer and the whole mucous surface with a camel's-hair brush. IJ. Acidi carbolici., Glycerinae, Aquae, M. Twice each day will be sufficient to make the application. The black and yellow wash (page 88) is often employed. Iodoform is an excellent remedy. The ulcers may be dusted with the powder two or three times each day. It is generally combined with gly- cerine (one drachm of iodoform to half an 3 ss. 1 ij- 62 THE BREATH. ounce of the solvent), and applied with a brush. Equal parts of myrrh and cinnamon (one teaspoonful each), added to a wineglass of water, can be used to rinse the mouth when the odor is bad. The constitutional treatment for syphilis must be commenced at the same time (see page 90), and continued until the ulcers are healed. " Spontaneous Stomatitis " is said to occur suddenly, without any appreciable cause. It is ushered in with soreness in the tongue, gums, and teeth, and an increase in the flow of saliva. Two or three days afterward there is considerable swelling of the mucous mem- brane. The whole interior of the mouth is of a deep-red color, and very tender on press- ure. The flow of saliva becomes very great. It runs from the mouth incessantly. It is fetid, and communicates its fetor to the breath. In some cases ulceration of the mar- gins of the gums takes place, but this is rare. This disease resembles in many respects FETID STOMATITIS. 63 the stomatitis excited by mercury. The diag- nosis is made by inquiring into the habits of the patient, and ascertaining whether mer cury has been used or not. Treatment.—The mouth should be washed with warm water containing a few drops of laudanum to allay the soreness. A solution of chlorate of potash (ten grains to the ounce) may be subsequently used on the inflamed surface, and repeated every three or four hours; or the potash may be combined with glycerine and belladonna (see page 72). Chlorate of potash is also useful as an in- ternal remedy. Ten grains three times each day will be sufficient. Follicula/r Stomatitis occurs at all ages. The inflammation commences in the follicles of the mucous membrane on the inside of the lips, near their lower portion, and the sides of the tongue. Small red spots, which are firm to the touch and painful, first ap- pear. Softening of the membrane, in the centre of the hard mass, then takes place, and a small excavated ulcer results. In some 64 THE BREATH. cases the disease commences by a vesicular eruption (herpes). The vesicles heal, and leave small superficial ulcers. Hot liquids and solid food taken into the mouth cause much pain. The salivary secretion is in- creased, and the breath has an exceedingly disagreeable odor. This odor is present from the commencement until the termination of the disease. As follicular stomatitis often depends on general debility, tonics are always indicated in the treatment. Combinations of wild- cherry, cinnamon, and cascarilla barks, are very beneficial. They may be given in the form of an infusion, half a pint of each mixed. A wineglassful, taken before each meal, will be sufficient. Tincture of gentian and calum- bo (equal parts), given in teaspoonful doses three or four times each day, may also be tried. If the bowels are constipated, mild cathartics can be used. Soothing demulcent applications are required at the commence- ment of the inflammation. Mucilage, or sweet-oil, containing a little laudanum, is FETID GUMS. 65 useful. Glycerine, with borax, is a common remedy, which brings good results. When ulcers form, they may be touched with ni- trate of silver; or sulphate of copper, or oxide of zinc, may be sprinkled over them. The preparation of iodoform and glycerine is sometimes needed. Gingivitis is an inflammation confined to the gums. It is more common in children than adults. The gums swell, become pain- ful, and finally ulcerate. The ulcerative process is confined to the junction of the gums with the teeth. The breath is intense- ly fetid from the commencement of the ul- ceration. If the disease is not stopped by appropriate treatment, the teeth may loosen and drop out. A strong solution of nitric or hydrochlo- ric acid (twenty drops to half an ounce of water) may be applied to the ulcers and their inflamed margins two or three times in twenty-four hours; or the ulcerated sur- face may be cauterized with the acid nitrate of mercury or silver. Alum, in solution or 66 THE BREATH. powder, is also used. Chlorate of potash, employed as a wash, and taken internally, is one of the best remedies. Tonics should be given in all cases. CHAPTER V. CATARRHAL ODORS. Clergyman's Sore-Throat (Follicular Pharyngitis).—Peculiarities of the Inflammation.—Effects of Decomposing Mucus on the Breath.—Complications.—Treatment.—Cancerous Diseases of the Tongue and Pharynx.—Fetid Odors following Diphtheritic Diseases of the Throat, etc. Clergyman's sore-throat is a chronic in- flammatory affection of the mucous mem- brane lining the pharynx. The disease is lo- cated principally in the follicular pouches of the membrane. It occurs in persons who are broken down from overwork and sedentary habits, or who have been compelled to do a great deal of public speaking. In its ad- vanced stages the disease is always accom- panied by an offensive breath. It may arise from repeated colds, or it may extend from an inflammation of the lining of the nose or mouth. Sometimes the injudicious applica- 68 THE BREATH. tion of caustics to the membrane keeps up and increases the disorder. At first there is more or less soreness in swallowing. The voice becomes husky when singing or talk- ing, and accordingly the act of speaking is painful. In the morning the patient feels as if a foreign body were sticking in his throat, and he endeavors to remove it by " hawking " or coughing. This sensation is caused by the thickened mucus which collects in the follicles, and on the surface of the mem- brane. After a time these follicles remain filled with the inspissated secretion. It be- comes cheesy in consistency, decomposes, and gives off a very penetrating fetid odor that is communicated to the breath, and which remains as long as the disease exists. It takes from six months to a year for the disease to make a marked change in the sweetness of the breath; occasionally the breath is bad from the beginning. On examination of the membrane, it will be found thickened, congested, and dark red in appearance. The blood-vessels in its sub- CATARRHAL ODORS. 69 stance are dilated and varicose. The follicles are choked up with a whitish material which can be picked out or scraped from the sur- face. It is from this substance that the odor comes. In some parts the epithelial cover- ing which gives the membrane its smooth appearance is destroyed, and a rough, granu- lar surface is seen, resembling the conjuncti- va in " granular conjunctivitis." In the ma- jority of cases the mucous lining of the pos- terior nares will be found involved in the morbid action. The cases recorded below are full of in- terest as examples of the usual course of this disease: Case I.—Martin C, aged thirty; married. Patient has been employed in a large rail- way-station, in this city, for some years. His work consists in calling the stopping-places before the departure of each train. He has been in the habit of using tobacco to excess for some years. Two years ago he noticed that his voice was becoming weaker, and that, when leaving work in the evening, he 70 THE BREATH. was extremely hoarse. A soreness followed the hoarseness, which has continued with but little intermission ever since. At times there is a sensation in the throat as if a pin or piece of bone were sticking there. In the morning it takes several minutes' hawking and coughing before he can clear his throat. Sometimes it is hard to swallow. He takes cold very easily, and every fresh attack is accompanied by a profuse expectoration. There is also a free discharge from the nasal passages. His breath has been affected for over a year. He did not know it until he observed that persons turned their heads away from him while in conversation. Upon throwing a powerful light into the pharynx, I found that the whole mucous lining was studded over with grayish-white points, and between them the membrane was of a dark-red color. In some places the epi- thelium had been entirely destroyed. The tonsils showed similar changes. The offen- siveness of the patient's breath was percep- tible at the distance of a yard. CATARRHAL ODORS. 71 Case II.—Mary A., aged twenty-two; is occupied as a school-teacher eight hours dur- ing the day. The room in which she teaches is very close and warm. Mne months ago she noticed a tickling sensation in the throat, which was soon followed by a hacking cough. The cough became worse toward the close of school-hours. The voice was clear in the morning, but at night it grew very hoarse. A short time before presenting herself for treatment, she expectorated large quantities of yellowish mucus, which con- tained small, firm masses of cheesy matter, that had a bad odor. On examination, I found the pharyngeal mucous membrane of a deep-red color in some places, and covered with whitish patches in others. Her breath was ex tremely fetid, yet she was not aware of it. The mucus scraped from the surface of the membrane emitted a pungent fetor. The lungs were normal. This variety of sore-throat is difficult to cure, because it is generally neglected until 72 THE BREATH. the mucous membrane has become infiltrated with the products of inflammation. But re- lief can always be afforded, and the offensive- ness of the breath completely destroyed. As the fetor depends, in a great measure, on the decomposition of the contents of the fol- licles, these must be emptied and kept com- pletely free from the abnormal exudation. This may be accomplished by means of gar- gles or by spraying the throat with various solutions. The instrument for vaporizing the liquids is easily obtained at any drug-store. One of the best solutions for either gar- gle or spray is the following: IJ. Potassae chloratis, 3 ss. Ext. bellad., f 3 j. Glycerinae, § j. Aquae, § iij. M. To be applied four or five times each day. The nose may be washed at the same time by means of a syringe or with the spray-producer. Another excellent solution, where the se- cretion from the throat is very profuse, is made by adding one teaspoonful of the tinct- CATARRHAL ODORS. 73 ure of the chloride of iron and one of gly- cerine to barely a pint of water. The appli- cation should be made as often as desired; or the following may be employed: 3. Tinct. myrrhae, f^ss. Tinct. hydrastis, f 1 j. Aquae, 1 iv. M. The mixture to be well shaken, and applied as before. When the fetor is considerable, the throat may be cleaned first with a strong solution of carbolic acid (ten grains to an ounce of water). A weaker solution may afterward be employed exclusively, with decided bene- fit. The deodorizers previously mentioned are also useful. When the secretion is puru- lent, a solution of permanganate of potash, thirty grains to five ounces of water, will be found of great value. It is to be used in the same manner as the other preparations. If the mucous membrane be much thick- ened, and the epithelium destroyed, a strong solution of nitrate of silver (four grains to the ounce) should be applied to the surface 4 74 THE BREATH. daily for a couple of weeks, and then be followed by the preparation of chlorate of potash and belladonna previously mentioned. These local applications must be per- sisted in for a long time, in conjunction with a course of tonic treatment. Tonics, fresh air, and exercise, are absolutely necessary to give strength to the system. So long as there is debility attendant upon the catarrh, local remedies have little effect. The use of tobacco should be stopped, as well as all other habits injurious to the health. If the disease has lasted so long as to prevent a cure, the constant use of deodor- izers will be necessary to keep the breath in a good condition. Syphilitic ulceration of the pharynx must be treated in the same manner as syphilitic ulcers in the mouth (see page 61). Clironic enlargement of the tonsils ia another source of offensive breath. The dis- ease is apt to occur in young persons with the scrofulous diathesis. It often arises inde- CATARRHAL ODORS. 75 pendently of neighboring inflammation. The offensive odor arises from accumulations of inspissated mucus in the follicles - of the gland, and its subsequent decomposition. The odor is not as offensive as that produced by follicular pharyngitis. The treatment consists in keeping the tonsils perfectly clean with the gargles pre- viously mentioned. If the tonsils are en- larged, they may be painted with tincture of iodine, or with a dry solution of nitrate of silver. DIPHTHERITIC ODORS. Diphtheria and diphtheritic sore-throat have an offensive breath as one of their most prominent symptoms. Especially is this true of epidemic diphtheria. But it is the seque- lae of these diseases, rather than the diseases themselves, that are under present considera- tion. When true diphtheria disappears, we find that the patient has a strong predisposi- tion to catch cold and develop a sore-throat. Slight exposure suffices to inflame the mu- 76 THE BREATH. cous lining of the fauces and pharynx, and produce an offensive breath. As soon as the secretion of mucus increases, as a result of the morbid action, there is present a well- marked fetor, not so pungent, however, as that occurring in the original disease. In the simple forms of diphtheritic sore-throat there is also a fetid breath. It is, however, more easily remedied than the odor of true s diphtheria. The thickened mucous secretion found in these cases is very thick and viscid, and it adheres tenaciously to the membrane. In some parts it is collected in lumps, which stick like glue to the tissues beneath. It is this peculiar secretion which occasions the fetor. As general debility is a common sequence of diphtheritic disease, our efforts should be directed to building up the system by means of tonics, nourishing diet, etc. In addition, astringent washes should be applied daily such as— IJ. Aluminis, 3 j. Aquae, % ii*. M. J Gargle the throat three times each day. DIPHTHERITIC FETOR. 77 The muriated tincture of iron with gly- cerine, in the proportion of one drachm of iron to an ounce of glycerine, may be ap- plied to the inflamed membrane, with a cam- el's-hair brush, three times in twenty-four hours. A nitric or muriatic acid solution (ten drops to an ounce of water) applied with a spray-producer, or used as a gargle, will often act beneficially in restoring the normal secretions and diminishing the bad odor. A combination of carbolic acid and tincture of iodine, in the following propor- tions, is recommended by Dr. Beverly Robin- son: IJ. Acidi carbolici, grs. x. Tinct. iodinii, f 3 ij. Glycerinae, § j. These preparations may be applied with a brush or in the form of spray. CHAPTER VI. CATARRHAL ODORS (CONTINUED). Ozaena depending upon Syphilis, Scrofula, Necrosis, and Caries of the Nasal Bones, and Herpes.—Character of Fetid Odors.— Bad Breath from Ulceration of the Larynx and Trachea.—Putrid Bronchitis.—Bronchectasis, etc.—Treatment. The nasal mucous membrane is subject to a variety of catarrhal affections. Some are simple in their nature, and give but little inconvenience. Others are characterized by a profuse muco-purulent discharge, and a dis- gusting odor. The term ozwna is applied to the latter class of cases. The fetor arising from this disease is more offensive than any other. According to French authorities, the odor in it is similar to that arising from a crushed bug. On this account they designate the patient by the term punais. Ozcena depends on a variety of causes, such as syphilis, scrofula, herpes, foreign CATARRHAL ODORS. 79 bodies in the nasal passages, and death of the nasal bones. The worst form of the disease, however, has no assignable cause. In syphilitic ozaena both nostrils are gen- erally inflamed. In scrofulous affections, only one nostril is involved. The discharge at first is thin, irritating, and not very profuse. If allowed to remain on the edges of the nose and lips, it causes excoriation. After a time the discharge is mixedVith blood and pus. The odor of the breath is extremely offen- sive to the patient, as well as his friends. It sometimes fills the apartment in which he rests. If the interior of the nose be examined with a speculum, some portions of the mu- cous lining will be found ulcerated, and the bottom of the ulcers covered with a grayish- white exudation. 'The remainder of the membrane is generally much tumefied, exco- riated, and of a dark-red color. In the course of a few months the bones become involved, and the nose is consequently depressed, pro- ducing a peculiar deformity, which is pathog- 80 THE BREATH. nomonic of the disease. Other signs of sec- ondary or tertiary syphilis are usually found in different parts of the body, which, with the history of the patient, lead to a correct diag- nosis. The following case affords a good illus- tration of syphilitic ozaena: Jane O, aged thirty-six; occupation, seam- stress. Contracted syphilis from her husband in the summer of 1868. She passed through the secondary form without much trouble. Six months afterward she noticed that her nose was sore, and that small scales formed on the inner surface. There was also a dis- charge which was extremely offensive, and which affected her breath seriously. She went to one of the city dispensaries and had it washed daily, and also took some tonic medicine. The treatment relieved her temporarily. During the winter of 1872 the nose again commenced to smell and be pain- ful. The discharge was more profuse, and the breath more offensive, than at any previ- ous time. Small pieces of bone came away SYPHILITIC FETOR. 81 in the discharges. When I first saw her, the discharge was of a dark color, and the odor of her breath was absolutely unbearable. The poor creature was herself conscious of its painful character. Her nose was flattened near the upper portion. In passing my probe into the nostril, I found that the nasal bones, or what was left of them, were mov- able and dead. The mucous lining was de- stroyed in several places. Her general health was also very much affected by the disgusting odor, the discharge, and by the consciousness that she was an object of disgust to her best friends. As she had no means, and could not be cared for at her own home, I sent her to the hospital, where she remained four months, and was finally discharged cured. SCROFULOUS OZAENA Usually affects but one nostril. It is apt to attack young females who are broken down in health. It is preceded by all the symptoms of a common cold, such as sneezing, coughing, and increased secretion from the eyes and 82 THE BREATH. . nose. In a short time the discharge becomes offensive, and affects the breath. It is sanious and watery, and excoriates the integument. It will often cease for several days, and then return with increased fetor. The fetor is not as offensive as in the syphilitic form of ozae- na. An examination of the mucous mem- brane shows that it is swollen and corru- gated. In some places there are fissures and ulcers from which a sanious fluid exudes. Occasionally the disease is situated so far up the nostril that its effects on the membrane cannot be seen. We then judge of the con- dition by the character of the discharge and the amount of fetor. The glands of the neck are sometimes enlarged, and there may be a deposit of tubercles in the lungs. IDIOPATHIC OZJENA. The worst form of ozaena is one which commences without any assignable cause. It usually attacks robust individuals who are accustomed to the use and abuse of alco- holic stimulants. Young children are also li- FETOR FROM OZMNA. 83 able to it. When once fully developed, it may last for years, resisting all attempts at cure. The patient at the beginning of the dis- ease is conscious of a "stuffed" feeling in the nose, like that resulting from an ordina- ry cold. A slight soreness accompanies the fullness. In a few days, the secretion from the mucous surface is increased. It is at first clear and ropy, but afterward becomes opaque and purulent. During the night the discharge may pass backward into the phar- ynx and down into the stomach. This pro- duces nausea and vomiting. The breath is affected from the inception of the disease to its termination. The odor is sometimes so offensive that the patient is made sick by it. His wretched condition, only too apparent to his senses, causes great mental depression, and, unless relief is applied by medical treat- ment, he may become completely prostrated in mind and body. The affection may last several months be- fore ulceration of the mucous lining takes place. Some portions of the membrane may 84 THE BREATH. be thickened and others atrophied. The lat- ter condition is most commonly noticed in the later stages. The ulcers which form are superficial, and rarely eat deeply into the substance of the membrane. HERPETIC OZAENA Is a rare form of the disease. It may co- exist with an eruption of herpes upon the cutaneous surface. The affection is char- acterized in its early stages by a watery discharge from the nostrils, which is some- times tinged with blood. There is con- siderable itching at the end of the nose. After a time, small haemorrhagic crusts ap- pear in the discharge, and the breath be- comes affected. The odor is not so disgust- ing as that occurring in syphilis or scrofula. Still it is the most troublesome feature of the disease. OZM8A FROM POLYPI AND FOREIGN BODIES. Polypi situated in the upper part of the nasal cavities may excite inflammation of the FETOR FROM FOREIGN BODIES. 85 mucous lining, and a purulent fetid dis- charge. The growth of the polypus is ac- companied by a sensation of fullness in the nose, and difficulty in breathing with the mouth closed. An examination of the nostrils will determine the location of the tumor. A cure usually follows its re- moval. Children of tender years frequently insert peas, beans, and foreign substances into the nasal cavities, which enlarge by the absorp- tion of moisture, and, by an increase of press- ure, cause great irritation. Peas and beans have been known to sprout in the nasal cavi- ties after having remained there several days, giving rise to serious inflammation of the mucous membrane and spongy bones. The discharge takes place generally from the nostril in which the foreign body is located. With the commencement of the inflammatory process the breath becomes more or less fetid, and continues so until the foreign body is removed. 86 THE BREATH. OZAENA ARISING FROM DEAD BONE Is sometimes the result of injuries which destroy the vitality of the bone. The necro- sis may also be due to scrofula or syphilis. A diagnosis is easily made if small pieces of bone drop out of the nostrils, or by pass- ing a probe up to the dead structure. If the bone is dead, a rough, grating sensation will be communicated to the fingers. Cases, however, occur in which the soft parts covering the bone remain intact for a long time after necrosis has occurred. This prevents it from coming away, or from being made perceptible with a probe. In such pa- tients the nose, or the region occupied by the nasal bone, will often be swollen and pain- full on pressure. The pain, too, is generally worse during the night. As the worst feature of all varieties of ozaena is the horrible odor of the breath, our first object should be to remove it and dimin- ish the unhealthy character of the secretions. Remedies for this purpose are applied indis- FETOR OF OZAENA. 87 criminately, without reference to the causes of the disease. The constitutional treatment, however, is directed to a removal of the cause, and consequently must vary in each case. Whether a complete cure is possible or not, the alteratives and disinfectants rarely fail to remove the disgusting features of the disease. An ordinary glass or rubber syringe, a nasal douche, or " spray-producer," may be employed in cleaning the nose, or applying medicinal agents. The nasal cavities should, therefore, first undergo a thorough cleansing with warm water, in order that the disinfectant may be applied directly to the diseased surface. If scabs, inspissated mucus, or pus, be allowed to remain in any part, the medicine will fail to affect the membrane underneath. When the cleansing process is completed, the nasal douche may be filled with a strong solution of carbolic acid (eight grains to the ounce of water), and a steady stream of it al- lowed to pass through the nose for fifteen or twenty minutes. If the disease is situated 88 THE BREATH. at the upper portion of the Schneiderian membrane, the liquid can be forced up by compressing for a moment the nostril oppo- site to the one in which the nozzle of the na- sal douche is placed. This process should be repeated at least four times the first day, so as to clean away every particle of bad-smelling material, and make a positive change in the secretions of the mucous membrane. Af- ter the second day, the operation may be repeated twice in twenty-four hours. If there is ulceration of the membrane, nitrate of silver may be used to cauterize the parts before any disinfectant is employed. A solu- tion of chlorinated soda is a very good sub- stitute for the carbolic acid. It may be used in the proportion of one tablespoonful of the solution to half a pint of water. Either the black or yellow wash may answer in some cases, but their disinfecting power is infe- rior to either of those mentioned. The black- wash is made by adding one drachm of calo- mel to a pint of lime-water; the yellow-wash by adding half a drachm of corrosive sub- TREATMENT OF FETOR. 89 limate to one pint of water. These mercuri- al washes are specially applicable to patients suffering from syphilitic ozaena. Creasote- ointment, or creasote in solution, is also ad- vised. Powders consisting of borax and su- gar, or of chlorate of potassa, may be blown up the nostril. Warm water, obtained from the White Sulphur Springs, is recommended by some physicians as an alterative and seda- tive to the ulcerated mucous membrane. As sulphur-water is not as irritating as some of the other medicaments are, it may be applied to the nostrils five or six times each day. The odor of sulphur, however, is not a good substitute for the fetor of ozaena; it will be well, therefore, to follow the wash by one of the deodorizers mentioned at page 55. The combination of carbolic acid and iodine will sometimes destroy the fetor when the carbolic acid alone fails. The strength of the solution may be increased in proportion to the intensity of the odor. Coffee has lately been introduced to the notice of the profession as a disinfectant. If the beans be 90 THE BREATH. chewed, the breath becomes strongly impreg- nated with their characteristic odor. In ozae- na, a cold infusion of coffee may be injected into the nasal cavities. It will be necessary, before using it, to strain carefully, in order to remove the small particles of coffee exist- ing in the liquid. Carbolate of zinc is highly spoken of. It is employed in solution (five grains to an ounce of water). Where there is much excoriation of the integument at the borders of the nostrils, cold cream, " glycer- ine-cream," or sweet-oil, may be applied con- stantly. When ozaena arises from syphilis, mer- cury and iodide of potassium must be em- ployed, in conjunction with the local treat- ment. If it accompany secondary syphilis, one grain of the protoiodide of mercury may be administered three times each day until the gums begin to feel sore. In the tertiary form iodide of potassium, in from, five to ten grain doses, may be given four times each day. Tonics are also necessary. When scrofula causes the ozaena, the pa- TREATMENT OF FETOR. 91 tient must have plenty of exercise in the open air, nourishing diet, and tonics. Cod- liver oil alone, or combined with prepara- tions of iodine or bromine, will be found of special benefit. If the stomach will not tol- erate the oil, fresh cream may be substituted. Among the best tonics used in scrofulous and other kinds of ozaena, are the following: FJ. Tinct. ferri mur., f§ss. Quinae sulphatis, f 3 ss. Glycerinae, f 1 *v- Dose, one teaspoonful in a wineglass of water, four times each day, before meals. IJ. Tinct. sarsae, 3 iij. Tinct. guaiaci, 3 ss. Tinct. cinch, comp., 1 iv. Dose, one teaspoonful five times each day before meals. Infusion of wild-cherry bark, and infusion of catechu, in tablespoonful-doses, are also of benefit. The idiopathic form of ozaena requires, in many cases, the same tonic treatment and lo- cal applications. Herpetic ozaena is treated at first by strong alkaline solutions, such as— 92 THE BREATH. IJ. Liq. potassae, f 3 ij. Aquae, § ij. or— IJ. Liquor, sodse chlorinatae, f 3 ij. Aquae, § ij. These preparations should be applied to the membrane in the manner previously de- scribed. When the nose is clear, and the scabs cease to be formed, deodorizers may be applied. Ozaena from foreign bodies cannot be cured until every irritating particle is re- moved. If the patient is seen at the begin- ning of the inflammation, snuff, or other sternutatory, may be introduced into the nostril opposite to the one in which the ob- struction is lodged, in order to induce sneez- ing. This method will often dislodge the foreign body, and force it out of the nostril; or a stream of water may be thrown into the nostril with the nasal douche, in order to wash it out. When these simple measures fail, a long curved polypus forceps may be passed up carefully to the foreign body TREATMENT OF FETOR. 93 closed upon it, and drawn down. Subse- quently the inflamed membrane may be treated as in the previous cases. Ozaena from dead bone can only be cured by removing the irritating material. It may be reached with a forceps through the nostril, or an incision may be made un- der the upper lip, behind the root of the nose, and carried upward until the dead bone is reached. The originator of this method is Dr. Ronge, of Lausanne, Switzer- land. BALITOSIS FROM ULCERATION OF LARYNX, TRA- CHEA, BRONCHIAL TUBES.—BRONCHIECTASIS. There are two varieties of laryngeal ul- ceration liable to affect the breath; these are the tubercular and syphilitic. The latter is more frequently accompanied by fetor than the former. Syphilitic ulceration of the larynx is an accompaniment of either secondary or ter- tiary syphilis. It is usually found in connec- 94 THE BREATH. tion with inflammation of the periosteal cov- ering of bones, nocturnal rheumatism, gum- my tumors in various parts, and other signs of tertiary syphilis. The breath becomes offensive when the ulcers are fully formed, rarely before. The fetor is worst in the morning. In the tubercular form of the disease, there will be a history of long - continued cough, expectoration of blood, emaciation; and there will be signs of tubercular deposit at the apices of the lungs. The breath is more offensive in the evening if hectic fever is present. It is not so unbearable as that arising from syphilis. The offensive breath from syphilitic ul- ceration may be controlled, during the heal- ing of the ulcers, by the inhalation of vari- ous disinfectants. The following solution may be placed in a large-mouthed bottle, and the vapor inhaled for two or three min- utes at a time. If sufficient vapor does not arise from the heat of the hands, the bottle FETOR OF SYPHILIS. 95 may be held over a spirit-lamp while the in* halation is taking place: IJ. Tinct. iodinii comp., Aquae ammoniae, Spts. vini rectif., M. Shake well before using. Another method of inhalation success- fully employed is to cover the patient's head with a cloth, place the dish with the solution under it, close to the mouth, and then insert into the liquid a hot piece of iron wire to vaporize it. Dr. John H. Ripley uses a pa- per funnel for the same purpose. The small end is placed in the patient's mouth, and the broad end held over a hot shovel, upon which have been placed sub. sulphur and mercury. The steam-atomizer is often of great service in these cases. A solution of carbolic acid, or of any other disinfectant, is placed in the chamber. The lighted lamp at the bottom in a few minutes generates steam, and an extremely fine vapor is thrown from ff ss. f3ij. ffj- 96 THE BREATH. the mouth-piece. The inhalations may be repeated five or six times each day, unless they produce too much irritation. For the relief of the offensive breath in tubercular ulceration, any of the deodorizers advised in the second chapter will be found efficacious. Putrid Bronchitis is a rare affection. We know very little concerning its origin. In connection with all the ordinary signs of bronchitis, the breath is exceedingly offen- sive, and the matter coughed up from the bronchial tubes has also a fetid odor. This disease bears some' relationship to idiopathic ozaena; the fetid secretion prob- ably originates in a similar way in both diseases. The remedies for the odor are the same as those recommended in syphilitic ul- ceration of the larynx. Bronchiectasis, or dilatation of the bron- chial tubes, is sometimes a cause of fetid breath. The mucus accumulates in the cav- ity of the bronchus until it decomposes. When the cavity is full, the foul matter is FETOR OF BRONCHITIS. ' 97 expectorated in large quantities. Perhaps once in twenty-four hours the tubes are evacuated in this way. To remove the fetor, use any of the dis- infectants. 5 CHAPTER VII. FETID ODORS FROM MINERAL POISONS. Dse and Abuse of Mercury.—Organs which eliminate the Drug.— Effects on the Salivary Glands.—Quantity of Drug necessary to produce Salivation.—Mercurial Fetor.—Remedies.—Bad Breath from Arsenic, Lead, Antimony, Phosphorus, etc.—Treatment. Many years ago mercury was considered a panacea for every ill. It was administered in all forms of disease. Whether the patient had fever, a chill, pain or numbness, wakeful- ness or drowsiness, or whether he was full- blooded or thin-blooded, short, tall, stout, or emaciated, a plebeian or aristocrat, the mer- cury was given; and it was not considered to have fully accomplished its work until the " gums were touched." In those days, mercu- rial fetor and salivation were an ordinary oc- currence. Even at the present time, cases of poisoning by this drug are not rare. MERCURIAL FETOR. 99 Mercury is prescribed for all forms of syphilitic disease; for sluggishness of the liver, and constipation. It is generally car- ried out of the system through the kidneys. When the blood is overloaded with the poi- son, these organs fail to eliminate a sufficient quantity. The liver, salivary glands, the mu- cous membrane of the alimentary canal, and perhaps the lungs, then assist in its removal. The salivary glands throw off the largest amount, A large quantity of liquid is se- creted by them in order to retain the mer- cury in a solution, and we have, as a result, the characteristic salivation. Mercurial fetor may be produced by tak- ing one grain of calomel three times each day for four or five days. It can be noticed when the soreness of the gums is scarcely appreciable. Blue mass, given in two-grain doses, with the same intervals, will affect the breath in seven days. If the kidneys are diseased, a much less time is .necessary to produce fetor and salivation. In such cases > • 100 THE BREATH. I have seen a cathartic dose of calomel cause salivation in twelve hours. Mercurial stomatitis is apt to occur among persons who work in quicksilver-mines or looking-glass manufactories. At the beginning of the disease there is noticed a disagreeble metallic taste in the mouth, which the patient likens to the taste of copper. There is a peculiar feeling of soreness experienced at the roots of the teeth when the jaws are closed. The gums are sore to the touch. A disagreeable fetor is communicated to the breath, both from the mucous membrane and the saliva. It is the most disagreeable feature of the disease. Shortly after, the saliva flows profusely. A grayish white line appears around the edge of the gums. The gums swell and may ul- cerate. The teeth often become loose. If the disease is not removed by proper remedies, the tongue and cheeks become involved, and swell up so that eating is almost impossible. This condition adds an element of danger to the case. TREATMENT OF FETOR. 101 Treatment.—If the patient is taking mer- cury as a medicine, it should be stopped. Or if he has developed the disease working in quicksilver, another employment must be chosen. The mouth should be washed thor- oughly four or five times each day with a strong solution of chlorate or permanganate of potash—the chlorate ife the most suitable. Glycerine and borax may also be used. A teaspoonful of powdered alum in a wineglass of water is a good application when the flow of saliva is very great. Half a teaspoonful of tincture of opium in an ounce of mucilage is an excellent anodyne if the soreness is great. Belladonna may be substituted for the opium if desired. Twenty grains of tan- nic or gallic acid, dissolved in an ounce of water, may also be used to diminish the se- cretions. If these various washes do not destroy the disagreeable odor of the breath, any of the deodorizing liquids or pills, previ- ously mentioned, may be used. The internal remedies^for chronic mercu- rial poisoning are iodide.of potassium and 102 THE BREATH. chlorate of potash. The former is more fre- quently used. Either the iodide or chlorate may be given in five or ten grain doses, four times each day. The iodide of potassium is supposed to join with the mercury in the blood and tissues to form the soluble iodide of mercury which is eliminated through the salivary glands and other organs. ARSENICAL SALIVATION May result from a long, constant use of Fowler's solution, or arsenious acid, or from inhalations of microscopical particles of ar- senic which arise from the green surface of room-paper and artificial flowers. The sys- tem becomes saturated with the drug, and Nature calls upon the salivary glands, the skin, and other organs, to carry it off. The fetor and salivation may be preceded by a disordered condition of the alimentary canal, such as nausea after eating, pain in the epigastrium, and diarrhoea. The skin presents the waxy pallor of Bright's disease. ARSENICAL FETOR. 103 Eruptions, such as eczema, also occur, and are probably due to the attempt of Nature to eliminate the poison through the skin. Early in the disease the breath has a disa- greeable odor% It is said by some to resem- ble the garlicky odor obtained by burning arsenic. The fetor is increased by the indi- gestion, which is always an accompaniment. The salivation is not so profuse as in mercu- rial poisoning. Small ulcers may form at the edges of the gums, and on the mucous linino* of the cheeks and throat. Where these make their appearance, the fetid odor is increased. The administration of preparations of iron is advisable in all cases. As a direct antidote, a teaspoonful of the hydrated ses- quioxide of iron may be given every three or four hours. Muriated tinct .ire of iron is an excellent remedy in twenty-drop doses, large- ly diluted, every four hours; or the prepara- tion may be given in combination with qui- nine and glycerine (see page 91). When mixed with glycerine, the iron is also useful 104 THE BREATH. as a local application to the inflamed mucous membrane. It diminishes, to a great extent, the fetid odor. Fresh air and nourishing diet are necessary auxiliaries in the treat- ment. Half a teaspoonful of cajeput-oil added to half an ounce of sweet-oil is a good de- odorizer to use in arsenical salivation. A. small quantity may be rubbed over the gums and inside of the cheeks with the fin- ger. The application may be made every two or three hours. LEAD. A fetid breath from lead-poisoning is a comparatively common occurrence. It mani- fests itself generally with the constipation which is one of the first effects of the poison on the system. Chronic poisoning may be caused by using hair-dyes, drinking beer or water which flows through lead pipes, constant handling of the tin-foil covering chewing - tobacco, manufac- turing or mixing white-lead. It is some- LEAD FETOR. 105 times produced by wearing Brussels lace, the material of which owes its white color to carbonate of lead. The symptoms which fol- low the fetor, and constipation, are intense colicky pains in the abdomen; retraction of the abdomen, due to paralysis of the recti muscles; soreness of the gums, with a blue line around their edge ; increase in the" flow of saliva, and " thumb drop " and " wrist drop " from paralysis of the extensor muscles. These symptoms vary in intensity with the amount of the poison taken into the system. Some- times the only symptoms manifested are the disagreeable odor to the breath, blue line around the gums, and constipation. The existence of constipation adds, no doubt, very much to the fetor. The bad breath from lead-poisoning is more easily removed than that produced by any other mineral. It often disappears when the bowels have been completely emptied by appropriate ca- thartics. Two or three drops of croton-oil, mixed with mucilage or sweet-oil, is a com- mon remedy where obstinate constipation 106 THE BREATH. exists. The dose may be repeated in an hour if the first fails. Elaterium may be giv- en in quarter-grain doses, repeated at inter- vals of an hour until free evacuations are produced. Warm water, with an ounce or two of castor-oil, may be used in the form of an enema for the same purpose. Iodide of potassium is considered by many the best elimmative. It joins with the lead in the system to form a soluble iodide of lead, which is carried out through the different evacuations. Sulphuric acid is often administered for the same purpose. The paralyzed limbs may be healed by fric- tion, electricity, and cold water. Any of the disinfectants mentioned on page 55 may be employed in these cases. ANTIMONY Produces a bad breath by increasing the waste and destructive metamorphoses of tis- sue, and by disordering the functions of di- gestion. When it has been taken in small ANTIMONIAL FETOR. 107 doses for two or three weeks, the strength be- gins to fail. There are loss of appetite, nau- sea, pain in the abdomen, and looseness of the bowels. The pulse becomes very small and feeble. As soon as the kidneys and bowels fail to get rid of the drug, and the detritus of nitrogenized decay—the mucous membrane of the mouth and lungs—the skin and salivary glands both fail in their work, and the breath is made fetid. The foul odor is sometimes associated with a metallic taste in the mouth. The principal medicine em- ployed as antidotes to antimony are the vege- table astringents, such as tannic and gallic acid, and strong infusions of green tea. One teaspoonful of tannic acid may be added to half a pint of water, and taken in repeated doses in the course of three or four hours. Green tea is probably the best remedy in chronic poisoning, because, in addition to its antidotal character, it acts as a stimulant. Where there is much nausea, mustard-plasters should be applied over the epigastrium, and iced champagne taken continually. Stimu- 108 THE BREATH. lants and tonics are always necessary to .sup- port the strength of the patient. Any of the preparations of iron and quinine may be employed with benefit. PHOSPHORUS. Chronic poisoning from this substance usually occurs among the employes in match- manufactories, from inhalation of phosphor- ous vapor. Like the preceding, it usually manifests itself first by dyspeptic symptoms, such as loss of appetite, weight, and heat in the epigastrium and prostate. The breath is affected early in the disease, not so much by the drug, as it is carried out of the system, as by the failure of nutrition and conse- quent increase in destructive metamorphoses. When necrosis of the jaw sets in, the fetor becomes unbearable. Tonics, change of air, and exercise, are necessary to restore the general health. The constant use of disinfectants will be neces- sary until recovery takes place (see page 55). THE END. MEDICAL TEXT-BOOKS, FOR THE STUDENT AND THE PRACTITIONER, Published by D. APPLETON & CO., 549 & 551 Broadway, New York, Complete Catalogues will be forwarded upon application. All com- munications promptly answered. Analysis of the Urine, with Special Keference to the Diseases of the Genito- urinary Organs. By K. B. Hofmann, Professor in the University of Gratz, and R. Ultzmann, Docent in the University of Vienna. Translated by T. Barton Brune A.M., M.D., and H. Holbeook Curtis, Ph.B. 1 vol., 8vo. Cloth. 269 pages. With Eight Colored Plates. 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SOPHOCLES.............................Professor Lewis Campbell. DEMOSTHENES........................S. H. Butcher, M.A. EURIPIDES..............................Professor Mahaffy. [Ready. LATinST- VIRGIL...................................Professor Nettleship. HORACE.................................T. H. Ward, M.A. CICERO...................................Professor A. S. WiLkins. j_jVY......................................W. W. Capes, M.A. Other volumes to follow. D. APPLETON & CO., New Yobk. Spencer's Synthetic Philosophy. -------•—♦-♦—•------- THE DATA OF ETHICS. By HERBERT SPENCER. 1 vol., 12mo. Cloth. 238 pages. - Price, $1.50. "Every year seems to widen the influence of that philosophical inquirer, in whom, long ago, J. S. Mill recognized one of the most vigorous as well as boldest thinkers that English speculation has produced. As the majestic outlines of his design have been disclosed, there has been a growing willingness to recognize not only the breadth and solidity of his conclusions, but their regulative bearing on human conduct and the practical concerns of life. It remained for the author to define the final outcome of his philosophy, and this has been done in the present work."—New York Sun. " Mr. Spencer's main purpose is to ascertain and describe the objective qualities of right conduct, the external signs of the highest virtue, and to show their coincidence with the results of progressive evolution. This he has done in the course of the pro- found and exhaustive analysis, of which he is so consummate a master, of vigorous but singularly lucid reasonings, and of ample and impressive illustrations from every department of Nature."—New York Tribune. 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"As examples of lucid, elegant style, Mr. Spencer's writings deserve careful study; but beyond and above mere form he is deserving of higher praise. Lucid style ac- companies a wonderfully trained brain, filled with almost all kinds of contemporary knowledge, thoughts that reach, surround, and master the loftiest subjects, a love of symmetry that connects masses of heterogeneous and conflicting thoughts into perfect order and harmony, and an almost miraculous patience that is an attribute of genius alone."—Boston Gazette. " This book is constructed upon a clear and symmetrical plan, and is a model of lucid and terse treatment. Such are the author's richness and variety of knowledg' that he is able to illustrate at every step the abstract principles which he lays down by concrete instances cited from Sociology or the physical sciences. In no chapter does his grasp of the subject appear more firm than in that on the ' Evolution of Conduct.'" —Baltimore Gazette. For sale by all booksellers; or. sent by mail, post-paid, to any address in the United States, on receipt of price. D. APPLETON & CO., Publishees, 549 & 551 Broadway, New Yoek. HeolthServ.ee » Be.hesdo, Md | U.S. Deportment of » Heolth. Educot.on. * ond Welfore. Pubhc S Heol.hServ.ee « Bethesdo. Md J US Deport, A7 S V\^Av Heolth Service *> Belhesdo Md ■* U.S.Deportment of *> Heolth. Educot.on. * ond Welfore, Public *> Heollh Service ^ Belhesdo. Md =° U S Deportment of NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBR/ 3NIDIQ3VV JO AMVaan TVNOUVN 3NIDIQ3W JO AHVaail TVNOUVN 3NIDIQ3W JO o. 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