Joum D . D . DROSD AND C R O H N - - H A L I T O S I S , T R U E AND F A L S E 79 F~BRUARY, 1942

Fig. 2. Normal appearing stomach. No evidence ()f previous apparent greater curvature deZect.

Accordingly, twelve pulvules of Extralin per day were prescribed. After one month of this therapy, the patient stated that the epigastric burning and gnawing sensation had decreased, and he complained only of a feeling of fullness in the lower abdomen. In May, 1940, the patient volunteered the information that he was proud of the amount of work he was able to do.

Gastroscopic examination on December 4, 1940, after eleven months of Extralin therapy, revealed only a few small areas of mucosa slightly paler than normal. No blood vessels were visualized in the mucosa, indicating a marked reversion of the atrophic changes toward normal. The patient's only complaints at present are occasional lower abdominal distress and flatulence. A barium enema

in August, 1939, and May, 1941, has ruled out the presence of organic disease of the colon and terminal ileum. His weight has been stationary, although about fifteen pounds under his optimum. A complete blood count in May, 1941; revealed normal findings. A re-examination by X-ray in February, 1941, demonstrated a normal ap- pearing stomach (Fig. 2).

COMMENT

From the clinical his tory and X-ray findings, the tenta t ive diagnosis was carcinoma of the stomach. The value of gastroscopy in d is t inguishing in th is case between atrophic gas t r i t i s and carcinoma of the stomach was effectively demonstrated. The importance of repeated gastroscopic examinations is s tressed as an objective check on the results of therapy. Since Konjetzny (6) has presented evidence tha t chronic atrophic gas t r i t i s may be a precursor of gast r ic carci- noma, the value of repeated gastroscopic studies to exclude the presence of early neoplastic changes too small to be recognized roentgenologically, is obvious. The beneficial effects of liver-stomach concentrate therapy on the clinical and gastroscopic picture in this pat ient confirm the observations of Schindler (7) and Schiff and Goodman (5) using s imilar prepa- rations.

CONCLUSIONS

A case his tory has been presented of a pat ient with gastroscopic evidence of chronic atrophic gas t r i t i s oc- curr ing as an isolated condition, responding with marked gastroscopic and symptomatic improvement to the oral adminis t ra t ion of Extral in .

We are indebted to Doctor Mason Light for the gastro- scopic examinations.

R E F E R E N C E S 1. Chevallier, P. et l~Ioutier, Fr. : Les gastrites atrophiques en aires ;

les gastrites atrophiques diffuses. Arch. d. real. d. l'app, dig., 25:193, 1935.

2. Schindler, R.: Gastroscopy. Universi ty of Chicago Press, Chicago, 1937.

3. Schindler, R. and Murphy, H. M,: Symptomatology of Chronic Atrophic Gastritis. Am, J. Dig. Dis., 7:7, 1940.

4. Jones, C. M., Benedict, E. D. and Hampton, A. O.: Variations in the Gastric Mucosa in Pernicious Anemia; Gastroscopic, Surgical, and Roentgenologic Observations. Am. J, M. Sci., 19:596, 1935,

5. Schiff, L. and Goodman, S.: Desiccated Hog's Stomach Ext rac t (Ventriculin) in the Trea tment of Atrophic Gastritis. Am. J. Dig. Dis., 7:14, 1940.

6. Konjetzny, G. E . : Der Magenkrebs, Ferdinand Enk,e Stuttgart , 1938.

7. Schindler, R.: Chronic Gastritis. Rocky Mtn. M. J., 37:570, 1940.

Halitosis, True and False By

RUDOLPH DROSD, M.D.

and

BURRILL B. CROHN, M.D. ~ NEW YORK, NEW YORK

O NE who undertakes to t rea t cases of hali tosis soon realizes that many people who come for t rea t -

ment do not actually bear tha t condition. These pat ients usually suffer more mentally than do those who really have a bad breath. They are painful ly "aware" of thei r bad breath and, as a result, have de- veloped many mannerisms and subterfuges whereby

~From the Medical Services of the Mount Sinai Hospital, New York City.

This study was aided by a grant from the Bristol Myers Co. Submitted Janua ry 20, 1942.

to disguise the i r breath. They are shy and r e t i r ing ; they never speak direct ly to another person, but manage to keep the s t ream of thei r expirat ion di- rected away from the listener. Many become inveter- ate smokers and t ry to disguise the i r breath odors; others are constantly n~unching on scented mints or candy. These people finally become social outcasts of thei r own choosing. The "symptom" becomes as dis- abling as a major infirmity.

I t is easy to demonstrate tha t persons with an of-

80 AMERICAN JOURNAL OF DIGESTIVE DISEASES VOLUME 9 NUMBER 2

fensive breath are rarely aware of it. This common observation becomes apparent to anyone who has the courage to ask the subject of a truly bad breath whether he is honestly conscious of it. The answer is frequently a rather shocked "no!" Or again, how often does the possessor of a reeking breath move about in public ignorant of this social handicap!

Simple experiments were performed to check this observation. Patients who were unaware of the type of medication were given garlic in capsules to swallow. The garlic could not contaminate the mouth when given in this manner. In one-half to one hour the breath of these patients reeked with garlic and was noticeable across an entire hospital ward. These patients noticed a faint garlic odor when they eruc- tated shortly after ingesting the capsules, but there- after were completely oblivious to the odor. No matter how long the odor lasted--12 to 36 hours- - the carrier never recognized the odor on his own breath. When told by others that their breath was foul, these persons found it hard to believe. Those who did not eructate when the garlic was still in the stomach, were com- pletely unaware that they had garlic halitosis. The same procedure was repeated with indoli" skatol, and oil of peppermint with the same results. Neither the pleasant odor of peppermint, nor the stale odor of other drugs could be noticed by the patient. Indol and skatol, incidentally, gave odors similar to the consti- tutional types of halitesis.

The explanation of this negative consciousness is a simple matter. The sense of smell becomes adapted relatively quickly to a constant type of stimulus. Only sudden changes in the intensity of the stimulus can be noticed by the fatigued sense organ. Thus, during eructation, a strong odor rises momentarily from the stomach via the esophagus, and this can be detected even though the breath has been carrying the same odor in a milder degree for some time completely un- known to the patient. This eructation, however, gives the patient no inkling of the fact that his breath was malodorous before, and will continue to be so after- wards, for as soon as the odor due to the eructation is over, the patient will no longer recognize the milder but more constant odor from the breath.

Persons with true halitosis will seldom state that they notice the bad odor themselves; in fact, as soon as the patient states that he notices a bad odor on his own breath, the diagnosis of true halitosis can be seriously questioned. A person who has not, but thinks that he has, halitosis, is a much more unhappy individual than one who has actual halitosis. The subject of true halitosis is not unbearable to himself, but only to others. He is rendered unhappy at rare intervals, and only when told or reminded of his con- dition. The sufferer from false or subjective halitosis "notices" the bad breath constantly. He finds it hard to live with himself. It becomes almost impossible for him to maintain proper social relations.

Some years ago a patient reported himself for observation with the complaint of "bad breath." He was a shy reticent young man who shrank with evi- dent reluctance when one attempted to sniff the odor of his mouth. He volunteered the information that he had been told on one occasion by his fiancee that his breath was "bad." Becoming obsessed with the idea, he had broken his engagement to marry, and retired from social contact. He avoided riding in

public vehicles lest fellow passengers show repug- nance to his presence. He finally resigned his position as bank teller. On no occasion could one smell a dis- agreeable odor from his breath. But no amount of denial of its existence and no protestation of honesty of purpose succeeded in convincing him otherwise. With a sad shake of his head, and exhibiting openly his skepticism, he accepted some well-meant kindly advice, but with evident reservations. It was obvious that the patient was suffering with a "fixed idea," which was either an obsession as part of a compulsion neurosis, or a more serious symptom approaching a delusion. Some time later it was learned that he had committed suicide during a period of depression.

It is of interest to note that as a result of Showing some occupation with the subject of halitosis, three patients have in the last few weeks appealed for help for a supposed condition of obnoxious mouth odor. T~vo of the three patients had perfectly normal sweet mouth odors and breath. One of the individuals had been told twenty-five years previously that his breath smelt badly; he had never to this day forgotten the incident and the resultant shock had left a lasting psychic impression. At this late date he too had an obsession that his breath was bad, and obviously no attempt at denial could convince him otherwise. His "bad breath" was finally conceded; with a diet and a mild intestinal purge, he was discharged happy in the idea that a cure would and could be effected.

VARIATIONS IN THE NORMAL BREATH At various intervals during the day, anyone may

have a moderately disagreeable breath. During sleep the reduced flow of saliva retards the normal cleansing action of the mouth and thus permits "morning mouth" which is fairly universal. Swallowing of saliva does not take place during profound sleep; apparently the secretion of saliva is markedly diminished. I f the person is a mouth breather, the throat will become extremely dry and the voice will be hoarse on awaken- ing. I f saliva does continue to flow, it may drool from the corner of the mouth. But the absence of swallow- ing during sleep has an obvious effect on the waking breath. A person falling asleep with a candy in the mouth is likely to awaken shortly thereafter with his candy or lozenge undissolved in his cheek. The combi- nation of dryness, the putrefaction of food remains in the dental interstices, and the cessation of the swallowing reflex combine to produce the disagreeable smell and taste upon awakening.

Volatile odoriferous foods eaten during the day ap- pear readily on the breath. Most breaths have an unexplained stale odor just before meals when the individual is hungry. There is supposed to be a pre- menstrual disagreeable breath odor that lasts for several days. Certainly constant smokers have charac- teristically bad breaths. I f during one of these normal odoriferous periods a person be told that his breath has an unpleasant odor, he may be so psychically im- pressed that a symptom of a neurosis originates.

BAD TASTE VERSUS BAD BREATH A bad taste in the mouth is not to be confused with

a true bad breath, though many persons may likely fall into such an error. The confusion between taste and odor is an understandable one. Few laymen under- stand the role that the sense of odor plays in the

JOUR. D.D. DROSD AND C R O H N - - H A L I T O S I S , TRUE AND FALSE 81 FB~RUARY, 1942

sense of tas te . Upon a t t e m p t i n g to " t a s t e " a volat i le subs tance , the a roma will r i se in the p h a r y n x and nos t r i l s and be smelt , so t ha t smell is confused wi th tas te . A young female pa t i en t was closely observed under normal condit ions. At f r equen t in te rva l s d u r i n g the day, she was asked to descr ibe the odor in he r mouth , whe the r sweet or sour, neu t r a l or unpleasant , etc. A t the same per iods a desc r ip t ion of he r b r ea th odor was repor ted by an observer . Whenever an un- p leasan t b r ea th odor was present , the pa t i e n t was unaware of i t or descr ibed her b r ea th as "neu t ra l . " Often when the b r e a t h odor was p l easan t or neut ra l , the pa t i en t would descr ibe he r b r ea th as " s l igh t ly sour" or "s ta le ." The only t ime the pa t i en t agreed wi th the observer was immedia t e ly a f t e r meals when the las t i tem eaten could be de tec table on the brea th . These sensa t ions repor ted by the p a t i e n t were in all ins tances , ac tual ly t a s tes and not odors. The con- fus ion between t a s t e and odor accounts for the popu- l a r i t y of f lavored subs tances in a t t e m p t s to mask the odors on the brea th . As long as the t a s t e in the mouth is "sweet , " these pa t i en t s t h ink tha t the b r ea th odor is also sweet. This is not the case, however, fo r the t a s t e f rom a sweet subs tance las ts much longer t han does the odor t he re f rom. The b r ea th in a pa t i en t wi th t rue ha l i tos i s may be h igh ly d i sag reeab le though the bea re r deludes h imse l f into t h i n k i n g t ha t the odor is being covered by a d i sgu i s ing medicament .

Ne i t he r the b~d t a s t e in the mouth, nor the coated tongue, nor ha l i tos i s for t ha t m a t t e r have received adequate scientific a t ten t ion , nor have they been reasonab ly and convincingly explained. A bad tas te in the mouth may be associa ted wi th a coated tongue, but m a y not be such a concomi tan t or r e s u l t a n t ; a coated tongue may be p resen t and ye t the sub jec t ive tas te of the bea re r be unaffected. Cer t a in ly ha l i tos i s may exis t w i thou t e i the r a conscious bad t a s t e or a coated tongue.

Both coated tongue and bad b r ea th are usual ly associa ted wi th some d i s tu rbance of gas t r i c or in tes t i - nal funct ion, r e su l t an t f rom over -ea t ing in bulk or in qual i ty , or f rom const ipat ion. Ju s t wha t is the mechan- ism by which the tongue is th ickened and coated, and the b rea th made malodorous is not known. N e i t he r pylor ic delay nor in tes t ina l hypomot i l i t y can be di- rec t ly ass igned as cons tan t p roduc ing fac tors . But i f t hey a re the mo t iva t i ng forces, ne i the r d i rec t reverse per i s ta l s i s , nor gas t r i c r e g u r g i t a t i o n , nor the reversed act ion of c i l ia ted ep i the l ium can be so impugned or proven.

There is no hes i t a t ion however in conceding the fac t t ha t occasional cases of ha l i tos i s a re a s s o c i a t e d wi th a con t inuous ly coated and f u r r y tongue. Recent ly we had occasion to hospi ta l ize for observa t ion a man who compla ined of "ha l i tos i s . " His i n f o r m a n t was his fond wife who consciously made h im aware of the occasions upon which his b r ea th was bad. D u r i n g severa l days of observa t ion i t was noted t ha t his

b r ea th was obnoxious when his tongue was coated. A h igh fa t , r ich die t p roduced coated tongue and bad brea th . On sc r ap ing and b r u s h i n g the tongue much of the so-called ha l i tos i s d i s a p p e a r e d ; on reduc ing the d ie t and encourag ing mild sal ine laxat ives , his b r ea th became normal .

Severa l f ac to rs may thus combine to produce ba l i - tosis or to be confused wi th i t :

Bad taste alone is a subjec t ive sensa t ion , usual ly founded on an in t e s t ina l or ga s t r i c d i s t u r b a n c e ; i t is not in i t se l f re la ted to, or p roduc t ive of, bad b r e a t h odor.

Coated tongue is only occasional ly the sole cause of hal i tos is , and p robab ly only when a chronic d i s o r d e r of in t e s t ina l ind iges t ion or of f a t me tabo l i sm and ab- sorp t ion exists .

True halitosis exis t s most of ten independent of t a s t e or tongue changes ; i t is unknown to the pa t ien t . I t s exis tence is consonant wi th a pe r fec t ly clean smooth glossal surface . The t rue or essent ia l ha l i tos i s de- pends p robab ly on some fau l t in fa t d iges t ion and i ts i n t e s t ina l abso rp t ion and sp l i t t i ng ; or, pe rhaps in some fau l t in the hepat ic r ea s sembly of f a t t y acid radica ls and soaps wi th newer h u m a n equiva lents of s terols and fa ts . In the course of th i s d i s tu rbance , in tes t ina l or hepatic , volat i le subs tances a re abso rbed into the c i r cu la to ry medium and a re excre ted by the lungs on the expi red a i r , t a i n t i n g the b r ea th wi th a malodor (1) .

S P U R I O U S H A L I T O S I S

A real p rob lem concerns those who wi th an " idee fixe" are possessed wi th the obsession t h a t t hey a re sufferers of a real ha l i tos is when none w h a t e v e r exis ts . The unde r ly ing n a t u r e of the psychic d i s tu rbance is of ten difficult to es tabl ish . Whe the r i t is an obsess ion as pa r t of a compulsion neurosis , or w he the r i t r ep re - sents a more ser ious "fixed idea" r e sembl ing a de- lusion, musk be de t e rmined by psych ia t r i c inves t i - gat ion. Ce r t a in ly i t is the role of the p syc h i a t r i s t , and not t ha t of the in te rn i s t , to de t e rmine the unde r ly ing psychic d i s tu rbances . The g r e a t difficulty is t h a t of convincing a pa t i en t who h e s i t a t i n g l y and wi th t r e - mendous reserve complains of hal i tosis , t ha t wha t he rea l ly needs is p sych iac t r i c t r e a t m e n t .

To r ea s su re such an ind iv idua l wi th the r e i t e r a t e d s t a t emen t t ha t ac tua l ly he has no bad brea th , is com- ple te ly ineffect ive and c rea tes suspic ion and r e sen t - ment in the pa t ien t .

The t ime and pa t ience and expense and pe r seve r - ance necessa ry fo r adequa te p sycho the rapy seems to a skept ical p a t i e n t a f a r c ry f rom his o r ig ina l compla in t of hal i tos is . And ye t wi thou t psychic re l ie f the u l t i - mate fa te of sufferers of spur ious ha l i tos i s is l iable to be a most unhappy one, i f i t does not i t se l f lead to a more t r a g i c finale.

R E F E R E N C E 1. Crohn, B. B. and Drosd, R.: J. A. M. A.