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160

CONCLUSIONS REGARDING GINGIVAL MARGIN.

to the suggestions of minds more apt to detect objections than to perceive evidence ; avail yourselves, therefore, of such assistance, whilst steadily aiming to attain a habit of seeking truth with an unprejudiced and discriminating mind.

Should further investigation confirm the opinion which I have ventured to express regarding the significancy of the mark on the gums, the facility with which the symptom can be observed must tend to enhance its practical value, whilst its physiological relations suggest a wide and instructive range of inquiry, and serve to impress the important truth, that consumption is not exclusively, or even essentially, a local disease, but rather a constitutional condition, requiring for its satisfactory elucidation and successful treatment far more than an acquaintance with the science of auscultation.

LECTURE XI.*

Diseases presenting some symptoms resembling those of con

sumption, asthma, cancer - Consolidation from chronic inflammation-Hysterical affections simulating phthisis.

THERE are at present in the wards of the hospital several patients who were supposed by their friends to be consumptive, but in whom the reasons for suspecting the existence of such disease are by no means conclusive. These patients may serve to illustrate a class of cases requiring much care in their discrimination. The responsibility incurred in speaking decidedly respecting the nature of some of these conditions is so considerable, that a few suggestions on the subject may not be unseasonable.

A few years since it was not uncommon to find cases of asthma, especially when occurring in debilitated subjects, and associated with chronic bronchitis and copious expectoration, mistaken for phthisis. It is unnecessary on this occasion to expatiate on the distinctions between these conditions. Some remarks in reference to such diseases were made in the introductory lecture; and you are sufficiently acquainted with the physical signs

* This Lecture did not form a part of the course in 1851, but was delivered subsequently.

162

CONDITIONS RESEMBLING PHTHISIS.

to avoid confounding them together. Infiltrated cancer of the lung, in consequence of the marked dulness and increased resistance on percussion by which it is accompanied, sometimes suggests the idea of tubercular affection; but various circumstances will assist you in forming a diagnosis, such as the aspect and previous history of the patient, and particularly the state of the pulse, which, as in a patient lately in the hospital, may be considerably slower than is usual in health. A pulse preternaturally quick is seldom associated with cancer of the lungs, excepting as the result of anæmia, or intercurrent inflammation. When the pulse is quick in consequence of anæmia, it contrasts with the pulse of the consumptive by the great range of its variations under changes of posture. When, in addition to the particulars above specified, you observe among the attendant symptoms a peculiar expectoration resembling prune juice, or currant jelly, fulness of the superficial veins on the affected side of the chest, induration of the cervical glands, ædema of the arms, or of the face, with protrusion of the eyeball, all ambiguity respecting the existence of cancer is removed.

The cases which you will probably find it most difficult to discriminate are—first, those of partial consolidation of lung, occurring in delicate individuals as a result of chronic inflammation; and secondly, instances of limited congestion in the chest of hysterical subjects. Patients affected with the first of these conditions often remain for a long time without material change, irrespectively of treatment, and even gain weight.

C. M. affords an example of this affection. He is a delicate nervous subject, and his apprehensions so

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much exceed the absolute indications of disease, that you might at first sight be inclined to regard his complaints as fanciful; but, on percussion over the apex of the right lung, you may detect some "dulness, which will be more obvious if you compare the sound on the two sides during full inspiration as well as expiration; the difference in clearness of the percussion sound during full inspiration, as compared with that during expiration, being much greater on the left side than on the right. At the end of inspiration, you may observe slight pleuritic rubbing sound at the upper part of the right side of the chest. This patient has been a tavern waiter, and has led an irregular life. His sleep is much disturbed, and his countenance has an expression not unlike what is observed at the commencement of delirium tremens. The pulse varies greatly from change of posture; and, in the absence of any constitutional symptoms of a phthisical character, although the seat of the local mischief might suggest suspicion, it is reasonable to hope that the deposit is not tubercular. In such instances when, as in this patient, the history is incomplete, especially as regards the appearance of the expectoration, and the indications afforded by auscultation, you will sometimes find it prudent to avoid expressing a positive opinion until the progress of the case, and the effects of treatment, assist your diagnosis. The improvement of C. M. is proceeding so rapidly, under a soothing and cautiously tonic plan, as to confirm the impression that he is free from tubercular disease.

Let me now more particularly invite your attention to a source of fallacy, which you will not find clearly de

ale

fined in systematic treatises; namely, the occurrence of a sort of pseudo-phthisis in hysterical subjects. The hospital affords some examples, but it is in private practice that such cases åre most frequently encountered. There is scarcely any part, the function of which hysteria may not disturb so as to excite the suspicion of organic disease, and there is probably no class of cases in which errors of diagnosis are more frequent. You will scarcely be prepared to expect that even pulmonary consumption is included in the list of diseases which this Protean malady may simulate or complicate; but patients are continually presenting themselves affected with debility, disordered digestion, and variously impaired health; and who consider themselves consumptive, because they are getting weak and thin, are teased with cough, and with uneasiness in what they call the chest. Other individuals, in many respects answering to this description, preserve their plumpness, and it is among such patients that the hysterical condition is usually most decided. With a little attention, such instances can, for the most part, be readily distinguished from those of true consumption. The cough, instead of being short, irregular, and attended with more or less expectoration, is loud, barking, urgent, and dry. The breathing is more hurried than is proportionate to the local signs of pulmonary affection; and the somewhat loquacious complaints of varied disquietude are often amusingly inconsistent with a countenance either expressive of indifference, or animated with sprightliness; there is often a drooping appearance of the upper eyelid, and the aspect altogether is very different from the settled demeanour usually observed

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