in the air-passages, or a vomica lined with a pyogenetic membrane, necessarily load the sputum and breath with pulmonary fetor, often so horrid as to resemble sulphuret of potassium; and pulmonary gangrene makes the breath so revoltingly and peculiarly offensive, especially after coughing, as to make the sufferer an object of disgust to himself and to all around, filling a whole room with a fetid and intolerable stench, reinhaling which must be an actual poison. I have seen but two cases of it and these are quite enough.

Tuberculosis may sometimes be recognized by the peculiar odor it communicates to the breath; and unclean teeth,. decaying tooth substance, tartar and the leptothrix buccalis, about their roots, particles of food in cavities and in the dental spaces, and lowered vitality of the gums in scrofulous persons, can each cause an extremely foul or putrid breath; but whether bad teeth are the sole cause of any case of halitosis, or only an accessory, is an important question, so much so that we must never promise too much from the application of the dental forceps.

The mucous membrane covering the tongue is often seen to be catarrhal, furred and desquamating in otherwise. healthy persons, the material on the tongue consisting of an excessive shedding of epithelium, pathological though superficial, besides mucus and swarms of bacteria; here the fetor is due to the decomposition of these three products. Besides, when the tonsil, pharynx, etc., become inflamed from any cause whatever, the tongue also becomes furred and thickly coated with altered saliva andˇ· buccal mucus, and readily becomes a cause of foul breath, and the mucus and other debris scraped from it emit a repulsive odor.

The excessive use of tobacco can also give the breath a vile odor; and in marked cases of chronic alcoholism, the breath has a characteristic odor well known to all physicians, and in all seriousness I state my belief that the seriocomic cases we see reported of spontaneous combustion, or catching afire of rotten alcoholic breaths, result not so much

from the breath being loaded with alcohol, as to its chemical decomposition, and atomic mingling of the resulting carbon and hydrogen, creating inflammable carburetted hydrogen.

Dyspepsia and gastric catarrh may also give rise to marked halitosis, and when due to these it seems to be caused by vicarious pulmonary elimination, united with tongue catarrh and a peculiar tendency to decomposition of the oral and nasal secretions.

Diseases of the nose and throat are responsible for a large percentage of the stinking breaths encountered, for, besides their being the chief avenues of respiration, there is a close connection between the diseases of these avenues and the general health of the body.

Among the affections causing halitosis that naturally fall within the province of the throat and nose specialist, ozena holds first rank. It is characterized by certain well marked pathological features, and is usually associated with atrophy or destruction of the nasal mucous membrane and its glands, and possibly with the presence of polypi or dead bone.

Besides the muco-purulent secretions of ozena, there are pus cells, mucus, and enormous quantities of bacteria. Some other varieties of halitosis may be present one day, week or month and absent the next, but ozena is both omnipresent and disgustingly malodorous, as though a thousand varieties of buzzard-nest bacilli, rotten-egg micrococci, cess-pool spirilla and garbage-box bacteria were holding an endless stink convention in that miserable victim's nasal fossae.

Nasal and post-nasal catarrhs, with their diseased membranes and stale secretions, are also the cause of very many stinking breaths.

Adenoid vegetations of the nasal vault, with the resulting mouth-breathing in children, is another affection that causes foul breath, in a way that is easily understood.

Imperfect development of the turbinated bones, and decomposing secretions in the sphenoidal and ethmoidal cells, all tend to favor the retention of secretions and to create an acid that under

goes a special ferment, with halitosis. I have seen numerous cases of chronic enlargement of the tonsils, chiefly in scrofulous youths and children, with foul breath, that was due to decomposing inspissated secretions in the follicles.

Either simple or follicular stomatitis, and gingivitis, can create fetor, and specific lesions and growths of the mouth, nose, larynx and trachea are also well known sources of halitosis; and the mercurial stomatitis sometimes induced in their treatment creates a very fetid cadaveric and characteristic breath. So also the free use of phosphorus, arsenic, antimony, lead, etc., may cause a phosphoric, phosphuretted, or even a fecal odor of breath.

Masses of necrosed bone anywhere in the mouth, throat, nose, antrum or frontal sinuses, cause an extremely offensive breath, often clearly recognizable several feet away.

Follicular pharyngitis, commonly called clergyman's sore throat, due to debility, over-use of the voice, repeated colds, or downward extension of inflammation from the mouth or nose, creates a penetrating, unbearable breath. In this affection, although the mucous lining of the posterior nares is diseased, the chief seat is in the follicular pouches of the mucous membrane of the pharynx, which becomes filled with inspissated mucus and epithelial debris, resembling cheese in consistence; and these are the source of the halitosis.

In chronic follicular tonsillitis, the crypts are the parts most affected, and their mucous linings being in an unhealthy catarrhal condition, pour out a secretion that tends to become inspissated and cheesy, and afterwards to decompose and stink. We frequently see their points protruding from the surface of the glands like firm, yellowish-white masses, that may be squeezed from their crypts. These have a fetid odor that is positively sickening.

Purulent and muco-purulent rhinorrhea, due to rhinoliths, salivary calculi or foreign bodies--beans, peas, shoe-buttons, cherry seeds, pebbles, masses of food, etc. may also be the unsuspected cause of bad breath in children, some

times even amounting to a horrid

stench.

Cancerous, syphilitic or benign ulceration of any of the linings of the upper air-passages, mouth, pharynx, larynx, trachea or bronchial tubes, may easily cause halitosis; and chronic ulcerative inflammation of the turbinated bones, inspissated material, desiccated mucus, cheesy deposits or purulent collections. due to inflammatory action anywhere in the nasal cavities, or in any of the sinuses opening into the nose, may cause halitosis, especially when, owing to stenosis, the nasal secretions are compelled to pass backward into the pharynx.

I might say here, that independent of special lesions, fetor due to the upper air-passages may result either from the excessive production of epithelium, or to dryness from diminished activity of the neighboring glands, as we see in atrophic catarrh.

Some persons seem to have a peculiar congenital tendency to decomposition of their nasal secretions, and tainted breath ensues in them very readily.

Mouth-breathing from nasal stenosis or any other cause may either create halitosis or increase one already existing; and every person on earth, and especially those with foul breath, should keep their mouths closed and breathe through the nose. In fact, man, with all his boasted superiority and intelligence, is the only being that can violate the natural law and breathe through the mouth; all other animals, domestic and wild, the horse, the cow, the dog, the cat, the wolf, the lion, the rabbit, all breathe through the healthful channel provided by nature-the nose; and not doing so is not only a cause of halitosis, but is one of the chief reasons why man is the most sickly of beings; and were some angel of power to give me the privilege of saying nine words that would be heard by every human being on earth, these words would be: except when eating or speaking, keep your mouth shut.

Can a foul breath be due to odors rising from the stomach through the esophagus? Certainly not. Because, except during deglutition and eructa

tion, the stomach is closed by the sphincter at its junction with the esophagus, and no odor can pass upwards.

Some persons through their own olfactories are conscious of the fact that their breath is foul, and others are ignorant of the fact, and may not discover it for years, unless they are told. Whoever has a peculiar pasty taste in his mouth should suspect that his breath is foul.

In every case of halitosis, and especially in those of an unusual character, our first duty should be to search out the exciting cause, and if possible remove it; and to insure against possible error, and

to ascertain whether the odor results from the condition of the lungs, the stomach, the bowels, the teeth, the nose or the throat, the buccal and the nasal cavities should be throroughly examined, and even though there is no cognizable disease of either, the mouth should be washed thoroughly, and the teeth cleaned before beginning further examination; for in cases of halitosis as in all other diseases requiring a discriminating diagnosis, it is well to follow Davy Crockett's wise motto, "Be sure you're right, then go ahead."

In

THE nervous symptoms are more manifest in proportion to the absence of cutaneous symptoms. All the nervous symptoms are not always dependent on syphilis. A number of nervous diseases have their origin in this malady. In diagnosing the disease, the medication method is unreliable, some other affections being improved by it. The nervous symptoms may be developed in each stage of the disease, but it is in the tertiary stage principally that the gravest lesions of the nervous system appear; and since it is especially in those cases where the ordinary secondary manifestations were wanting that we are to expect these complications, it is important for physicians, in making such a diagnosis, to be prepared to recognize the first danger signal that may be manifested. The primary stage has no prominent nervous symptoms, those symptoms, those present being referable rather to the concomitant anemia than to the action of the specific poison. The secondary stage presents more marked evidences of implication of the nervous systemvarious neuralgias, dyspepsia of nervous origin, cardiac palpitations and meningitis, cerebral or spinal, being characteristically present. The tertiary stage The tertiary stage

gives evidences of numberless shades and varieties of nervous affections and in this period of the disease the nervous symptoms manifested are due solely to the influence of the specific virus circulating in the blood and irritating the delicate nervous structures.

The symptoms produced may be those due to an inflammation or degeneration of the nerve centers themselves, or to the effects produced by pressure upon the nerve centers or trunks by product of this same form of inflammation located in contiguous structures--the symptoms all showing lesions either of the intracranial organs or of the spinal cord, less frequently of the spinal nerves.

The diagnostic symptoms detailed are also diagnostic of other diseases. It is by association that we determine the disease, as locality, etc. There are periodic occipital headaches in nearly every case, absent in the forenoon, returning most frequently at night and becoming worse. I have never found any tenderness on pressure. The diagnostic nervous manifestations of syphilis are: 1. Headache, which disappears if paralysis occur. 2. Insomnia, nearly always associated with headache and disappearing with the appearance of con

vulsions or paralysis. It differs from the insomnia of neurasthenia and melancholia in that it occurs in the early night, the victim arising in the morning ready for his daily labor. 3. Vertigo, occurring usually with the headache. It may be transient, but becomes worse as the disease progresses. 4. Convulsions. In the adult they are not preceded by convulsions in youth. 5. Tremor, present in one-half of cases. It occurs most often, in the order named, in the hands, tongue and over the whole body, and is accompanied by headache. If it occur in a limb, it is the precursor of paralysis of the limb. 6. Hemiplegia. 7. Erratic distribution of paralysis, as aphasia with or without hemiplegia ; ptosis; insanity or epilepsy with paralysis of one arm or leg. It is suggested that ptosis occur

UNEXPECTED RESULT OF TAPPING THE HEART.- Sloan (Medicine) reports a case of accidental puncture of the heart after respiration and heart action had stopped, followed by resumption of heart action and recovery. The patient was a female, aged 19, a sufferer from erysipelas of the face. In previous years she had three attacks of acute rheumatism with mitral endocarditis. The erysipelas subsided, but a few days later there was evidence of pericarditis and of an aggravation of the endocardial affection. Marked effusion followed the pericardial inflammation, but the patient refused aspiration, though it was deemed advisable from her critical condition. Three weeks after the pericardial friction had developed, death seemed approaching. The pulse was very rapid, barely perceptible. The physician was ready to aspirate, but still it was refused. As the physician stood ready to perform the operation, respiration ceased and the heart stopped. To quote the author's own words: "In a moment of excitement I jumped up, seized the aspirator, and plunged the needle into the fourth interspace, about half an inch to the left of the sternum and a little below the left nipple. To my astonishment, from eight to ten ounces of pure blood flowed rapidly into the bottle of the

As

10.

ring suddenly points nearly always to syphilis. 8. The use of electricity to determine central or peripheral lesions. 9. The presence of great physical weakness and mental dulness. This is one of the most valuable of the nervous manifestations, being out of proportion to the seeming condition of the patient. History of the case. In women the history of many abortions in succession would point to syphilis. In the treatment of syphilis the iodides should be given in sufficiently potential doses in Carlsbad or other waters. The cases I report show how easy it is to overlook the disease in the tertiary stage, when the first and second were not noticeable. In conclusion, let me say we could often abort syphilis by studying the nervous system and giving treatment in time.

aspirator, then suddenly stopped, and to my dismay I found I had penetrated the cavity of the heart. As I was slowly withdrawing the cannula, regretfully telling the nurse it was all over and to close the patient's eyes, to my surprise the heart made first a feeble, irregular movement, then a sudden jump, and then finally, like a pendulum regaining its swing, it started to beat again." A somewhat rapid convalescence followed; within seven weeks the patient was in apparently perfect health.

In his conclusions the author raises the question whether if accidental cardiac tapping was in this case, as in some others, followed by recovery, there is not a class of cases where it should be tried as tried as a deliberate remedy, e. g., in cases of asphyxia, suffocation by drowning, accidental hanging, chloroform asphyxia, etc.

TREATMENT OF BUBOES.-A practical method of securing compression in the treatment of buboes is recommended by Neebe (Therapeutic Gazette). He uses a ball of wool, half again as large as a man's fist, which he places over the enlarged gland and binds in place by a firmly applied spica of the groin. To avoid slipping from its proper position a few large safety-pins are placed in the bandage.

MARYLAND

smallpox or some such disease and which is really not, he runs the risk of a suit for damages and in the case where that patient is re

PUBLISHED WEEKLY.

TERMS OF SUBSCRIPTION, $3.00 a year, payable in advance, including postage for the United States, Canada and Mexico. Subscriptions may begin with any date.

DATE OF PAYMENT.-The date following the subscriber's name on the label shows the time to which payment has been made. Subscribers are earnestly requested to avoid arrearages. CHANGES OF ADDRESS.--When a change of address is ordered, both the old and new address must be given. Notice should be sent a week in advance of the change desired.

TO CORRESPONDENTS.-Original articles are solicited from members of the profession throughout the world. Reprints will be furnished in payment of accepted articles if the author's wish is so stated at the time.

CORRESPONDENCE upon subjects of general or special interest, prompt intelligence of local matters of interest to the profession, items of news, etc., are respectfully solicited. Marked copies of other publications sent us should bear the notice "marked copy on wrapper.

Address: MARYLAND MEDICAL JOURNAL,
209 Park Ave., Baltimore, Md.

WASHINGTON OFFICE:
Room 22 Washington Loan and Trust Co. Building.

BALTIMORE, JULY 27, 1895.

THE law enforced in many States, cities and countries requiring an early notification of contagious diseases has Early Notification and suffered a setback in EngDoubtful Diagnoses. land by a recent court

decision and an award

for damages against a physician for calling a disease smallpox which was not that disease. Every one knows the extreme difficulty of recognizing many diseases at the outset and in the abortive and peculiar types of the eruptive diseases the difficulty after the time the eruption ought to appear is even much greater. Out of 1263 cases in London certified as smallpox 155, or 12.2 per cent., were found not to be suffering from that disease..

Now the question is what shall the medical man do when in doubt? If he fails to report what appears to be one of the dangerous contagious diseases he runs the risk of a fine and also of spreading the disease. Should he, however, report a case which appears to be

actually bring on that very disease or one equally dangerous when such would not have otherwise occurred.

The difficulties are still greater when the negro population is large for, as is well known, scarlet fever in the dark-skinned race is hardly of a scarlet hue and all other eruptive diseases have a peculiar appearance in the African race which experience alone will help to recognize. If persons are allowed to bring suits for errors in notification and if courts will allow damages for these errors, all the benefits of the notification act will be lost. The average physician does not, as a rule, report a case of one of the contagious diseases because it is the law but because as a conscientious physician and a good citizen he feels that by so acting he is doing the greatest good to the greatest number.

All this points to the importance of detention hospitals or wards where doubtful cases may be kept until the diagnosis is certain. In the case of the wealthy citizen who may wish to be treated at home, it has been proposed to set apart in the house of the wealthy a room which shall be known as the hospital room and which shall be used for all cases of illness. This has not a very cheerful effect when all are in health, but in such doubtful cases perhaps an isolation room could be arranged so that the patient can be cut off from the rest of the family until the decision as to whether he is dangerous or not has been reached.

Obstacles in the way of notification in the average American city are also the fact that the health department is usually in the hands of politicians, and inspectors are generally men appointed, not by the health officers, who should be best able to judge of the fitness of such men, but they are persons with little or no education, and often with no experience, who are appointed at the request of some ward politician and their work is in too many cases done in a perfunctory manner or not at all. The notification act in most cities needs a careful revision before it can do the good it should do.

Since, however, notification is unpopular both with the physician who is not paid for this work and the householder who dreads