In his ambitious An American Text-Book of Diseases by American Teachers (1894), Louis Starr (1849-1925), of Philadelphia, called attention to the importance of smelling the child's breath. In the 1890s, the paucity of what we now consider routine laboratory tests made the physician far more dependent on the use of the sense of smell when confronted with a sick child than is the case nowadays.

Starr1 wrote:

The breath may become sour, catarrhal, foetic, gangrenous, ammoniacal, and stercoraceous. Sour breath is present, in infants more especially, when there is gastric fermentation. Catarrhal breath has numerous shades of difference. In chronic catarrh of the pharynx there is a "heavy" odor, not noticeable far from the patient's face. It is always most marked during and after sleep. Should there be associated follicular tonsillitis, the breath, while still heavy, becomes extremely offensive, with a scent somewhat like that of decaying cheese, and is very penetrating. This odor, too, is worse after sleeping. At the onset of acute catarrh of the stomach the breath has a vinous odor, at other times it is sweetish, and again it has the same quality as after an inhalation of ether. Later in the attack it becomes sour or has the odor of sulphuretted hydrogen. What is known as a "feverish breath," has a heavy, sweetish smell. It is met with in diseases of high temperature; thus, it is very marked and rapid in appearance in scarlatina.

Foetor of the breath is observed in its mildest form in such affections as aphthae and ulcerative stomatitis. It is better developed in ozaena and necrosis of the maxillary bones.

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