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and lower gums, you may observe, exhibit the characteristic streak. Among the reasons for suspecting that the indication is in this instance correct, I may mention a decided reduction of weight, and the presence of a peculiar form of indigestion. There is much pain of forehead ; giving the countenance an appearance of great oppression ; the tongue is furred, and the appetite greatly impaired. This condition is not persistent, but recurs from time to time, without any obvious cause, and yields only partially to treatment. No modification of diet has any apparent effect either in relieving or aggravating this condition. It differs materially from ordinary dyspepsia ; and I cannot help referring it to a morbid state of blood, by which it is rendered incompetent to supply the proper secretions for accomplishing healthy digestion. If, as I believe, such a condition often ceases when tubercular disease is established in the lungs, is not the change attributable to the partial elimination from the blood into the lungs of the morbid element ? This patient has appeared to me to derive more benefit from yeast than from all the alteratives and tonics previously administered; but the variety of phthisical dyspepsia, which it seems to me to illustrate, usually requires such medicines; for example, you may administer an occasional dose of mercury with chalk, combined with carbonate of soda, and followed by a powder containing a drachm of bisulphate of potash (sal polychrest), and ten grains of rhubarb. The good effects of this plan will be promoted by the subsequent administration of fluid extract of sarsaparilla combined with taraxacum. It is unsafe, in such cases to give mercury at all continuously, and the muriate of lime has been supposed to be a suitable substitute for mercury as a deobstruent. I prefer the muriate of ammonia, in doses of from five to ten grains three times a day. On the whole, I know no medicines better calculated than a combination of chalybeates with saline aperients, to obviate hepatic congestion, and to correct the condition of blood which may be assumed to characterize such cases For those who are able to obtain the mineral waters, whether at the natural spring or factitiously prepared, a course of the Kesselbrunnen of Ems is appropriate ; or if there be any tendency to hæmoptysis, the Saratoga Congress Spring of America may be given in preference. When these remedies are not accessible, a substitute may be obtained by administering, every morning, two grains of sulphate of iron, a drachm of sulphate of soda, a scruple of carbonate of soda, and ten grains of dinner salt, in half a pint or a pint of warm water. Exercise in the open air, the shower-bath, and friction of the skin, are important auxiliaries in treatment.
But to return from this digression. I have mentioned that the streak on the gums is not always present in consumption ; let me add that its absence may be regarded as belonging to the class of favourable circumstances. Apply your stethoscope under the right clavicle of W. J. when he speaks. You probably hear what you may be inclined to call bronchophony ; but bid him whisper, and I think you will be satisfied that the voice resounds as it were in a little cavity ; that, in short, it is cavernulous. The expectoration, although chiefly mucous, is variegated with little purulent spots, which strengthen the suspicion of the existence of a cavity. He is, however, improving in condition, and says that since he obtained his order for admission he has “ got well.” His gums are without margin.
The next patient, M. A. B., has gums free from the margin, and you will recollect her as an example of most gratifying progress from serious disease to convalescence.
When the gingival margin is strongly defined, it is not uncommon to find hypertrophy of the border of the gum, suggesting an analogy to the tightened and deepcoloured skin around the border of the nails, attending even slight degrees of clubbing of the fingers. Of thirtyeight men lately examined in reference to this analogy, twenty-three had the fingers more or less clubbed, and none in whom this appearance was obvious were free from the margin on the gums. Of thirty-eight women, twenty-two had clubbed fingers, and of these twentytwo, only one was without the streak on the gums. The altered aspect on the gums would seem to precede any obvious change in the fingers ; ten of the thirtyeight men, and ten of the thirty-eight women, having marginated gums, but not clubbed fingers.*
In some patients, as in M. M., you have seen the gingival margin deep in colour, and more than a line in breadth. Under such circumstances, patches of a similar colour are occasionally observed in the mucous membrane, at a short distance from the lower incisors, particularly where the mucous membrane of the lip is
* I am indebted to the courtesy of my colleagues, Dr. Hamilton Roe and Dr. Cursham, in allowing me to avail myself of their cases in this investigation, so as to extend the field of observation.
reflected on the gums, sometimes also about the roof of the mouth, and inside of the cheeks. In such instances, the disease is usually in the third stage, and the patient's strength rapidily failing, a result to which the co-existence of diarrhea often contributes. Under more favourable circumstances, with the assistance of soothing and refrigerant remedies, these patches may disappear, and the margin become fainter; but, whether in the early manifestations or the more confirmed conditions, I have never yet observed the line entirely to disappear. In addition to the cases which I have arranged on the table, and recorded in this lecture, I have examined some hundred patients with special reference to this appearance, and the result is in harmony with the deductions to which the tabular view would conduct us.
The greater constancy of the margin in the male patients is remarkable, and the cause not easy to assign. The habit of smoking was at first suggested as a possible explanation, but I have occasionally noticed the absence of the line in consumptive patients addicted to this habit, and have repeatedly found it present in those who do not smoke.
Habits of cleanliness are not a preventive. The margin under consideration may usually be distinguished from the irregular discoloration occasioned by the irritation of accumulated tartar. The discoloration thus induced is commonly rather livid, and the border on which it appears ragged or uneven. In such instances the presence of the line around the gums, where tartar is not deposited, and its continuance after scaling the teeth (an operation which my ingenious friend Mr. Harrison has been so obliging as to perform
in some uncertain cases with a view to settle the question), may conduct us to a positive conclusion.
A large proportion of our hospital patients are the subjects of advanced disease, and afford, therefore, little opportunity of exhibiting to you a very common appearance at the early period of the disease, I mean a delicate, pearly, transparent aspect of the border of the gums, probably in part the result of fineness of structure. When congestion of the membrane, from whatever cause, occurs in such individuals, the red line may be expected to appear, but it probably varies in vividness in the same individual, under circumstances which modify the circulation, or produce congestion of the mucous membrane ; but I believe the pearly condition to be very significant and peculiarly valuable, as occurring frequently at a very early period of disease, and not liable to the fallacies with which shades of colour may be associated.
It seems reasonable to inquire how far the activity of the catamenial function might lessen the tendency to the formation of the streak in women. In the list before you this point is recorded with a view to this question : whilst on the one hand I met with a considerable portion of marginated gums in patients with the catamenia regular, on the other hand I found a large proportion without the margin amongst those with whom the catamenia were irregular or absent. The instances under our notice are, as you may observe on reference to the table, equally inconsistent with any idea of the existence of a connexion between liability to the production of the margin, and hereditary predisposition.