ULCERATED AND SWOLLEN GUMS IN

THE NATIVE ARMY.

&Y P. HEHIR,

LIEDT.-COL., I.M.S.,

Medical Officer, 2j8th Gurkha Ilijfas. A FORM ot ulcerated, swollen and spongy

gums of unknown etiology is a condition that is met with in all regiments of the Native Army. Ihe essential pathological state that appears to be present is ulceration and suppuration of the margins ot the gums, and between the gums and the teeth, so that, for want of a better term, one would designate it suppurative gingivitis. Its chief incidence is during the hottest summer and early autumn months, when men have run down from climatic effects, but probably chiefly from an absence of an adequate supply of fresh vegetables which occurs at this time of the year. Some cases ot it are, however, to be found in most regiments at all times of the year. It is specially common during our Indian Frontier campaigns, particularly campaigns lasting over

three or four months. One can recall over 100

cases^ in each of three out of five regiments examined in June in the Deccan some years ago, and I have trequently found from 20 to 30 cases in various regiments in the cantonments in Northern India during the last years. At the end ot the Tirah Expedition some Native regiments had as many as 40 per cent, of men atiected -with it. The condition is very wide- spread in the civil population at the seasons of the year mentioned above, and it is unusually prevalent during periods of drought and scarcity.

Ihe state under reference consists of ulcera- tion, sponginess and swelling of the gums ; the mucous membrane of the tongue, cheeks, and mouth generally may be superficially denuded of epithelium, occasionally small visible ulcers .occur here aud there over these regions, or the papilla) ot the anterior part of the dorsum of the tongue is bare of epithelium, swollen and inflamed.

The condition ot the gums is, as a rule, pain- less, the man otten does not know that anything is the matter with him, and he seldom comes to

hospital spontaneously. In individual cases the actual state ot the gums varies. In some they

, are so swollen that the teeth appear to be almost buried in them. In such cases the gums are

congested and bleed readily on pressure, in others, the margins o? the gums have atrophied, receded, and exposed the whole of the crowns and part of the fangs of the teeth, and present a thin ulcerating margin. Generally a large area ot the gums ot both upper and lower jaws is

involved, thus contrasting with pyavihoea alveo-

laris, in which, except in the advanced stage, the disease is localised to the go111 opposite one or a few teeth.

Occasionally the atrophy of the gums will bo

found associated with the accumulation of masses of dirty greyish or cream-coloured tartar on the outer aspect of the teeth. Such masses may sometimes also be found beneath swollen gums. On scaling off these masses of tartar we expose an ulcerating gum which may be very offensive.

In these tartar cases the cleaning ot the teeth

has been neglected, because the patients have found the ordinary process of using the frayed end of a stick for this purpose, painful. These blocks of

tartar are unlike the small greenish patches of cretaceous material found beneath the pockets of

the gums in some cases of pyorrhoea alveolaris.

In a small percentage of the cases the gums are

tender, and render mastication difficult and painful. These are the only cases that seek treatment ot

their own accord. There is often slight foulness

of the breath, exceptionally a very foul odour is

given off, due probably to the presence ot micro-

organisms which generate indol in the diseased

area. In all cases a small quantity of mixed

creamy pus and mucus exudes between the gingi-

val border and the teeth when the gum is pressed by the finger. The condition itself, if not grossly neglected for a long time, and masses of tartar

have not formed, does not appear to endanger the

integrity of the dental structures. The chief micro-organisms that one has found

in stained smears made from the pus have been

streptococci and staphylococci ; m several cases

one has found an amoeba very similar in morpho- logical characters to the Entamoeba coli, in associa- tion with one or other kind of the bacterial forms

named?this amoeboid organism was never found

to be anything like Entamoeba histolytica; and in three cases a short plump Gram-straining bacillus was seen. The more characteristic cases have, nt first

sight, the general appearance of pyorrhea alveolaris (Rigg's disease, false scurvy, gingivitis expulsiva), which is, however, a very chronic

and somewhat formidable malady leading to

atrophy of the gum, and loosening and falling out of the teeth. The essential condition in

pyorrhoea alveolaris seems to be a purulent in-

flammation of the dental periosteum ; in the

condition under consideration, the dental perio- steum remains intact. In pyorrhoea alveolaris we get swelling and inflammation ot the gum

opposite one or several teeth, the gum which

bleeds on pressure, is tender, such pressure also

causes a discharge of creamy Pus between the

gum an d the tooth. The inflamed gum opposite the tooth forms pockets in which debris of food, accumulates and decomposes ; the gum loses its

attachment to the tooth, small greenish patches of tartar may, as previously stated, form within the margin of the gum, and new bone torms on

the outer and inner edge of the alveolus. The

March, 1911 ] ULCERATED GUMS AMONG SEPOYS. 93

etiology of pyorrhoea alveolaris is unknown, and so far no method of treatment lias proved

_

satis-

factory'. This latter is not the case with the

condition under reference. A week's local treat- ment in mild cases, with proper attention to

diet, proves effectual. The more severe cases,

however, occupy several weeks in treatment, ?specially on field service, where suitable diet is not always available and the men have run down from tlie hardships of campaigning.

It is also similar in some respects to the con-

dition often seen in incipient scurvy, and it is occasionally associated with the more positive manifestations of the scorbutic state, such as anaemia, hemorrhage from the bowels, extravasa- tions into the muscles, dysenteric symptoms, etc. Ijike scurvy, it responds to anti-scorbutic treat- ment plus local measures. It seems in India and in Indian frontier warfare to precede the

appearance of the actual signs of developed scurvy. It was very prevalent in Somaliland amongst Native troops and followers in 1003-04 before the outbreak of actual scurvy. In the vast majority of cases there is little in this state to justify one's calling it scurvy ; one is person- ally disposed to consider it to be an ante-scor- butic condition. It is premature, however, to express any definite opinion as to its nature or

etiology. The peculiar state of malnutrition.closely con-

nected with a defective dietary which gives rise to scurvy may, in its earliest and less pronounced stages, manifest itself in a variety of ways. The condition described here is possibly one of these. Apart from a scorbutic taint and pyorrhoea

alveolaris (which is not a common condition in the Native Army), swollen and spongy gums is generally due to a want of cleanliness of the teeth, and in the Native Army this is seldom an initial cause of the condition described, as most Native troops are extremely clean in regard to the state of their teeth and mouth.

"W hilst it occasionally occurs in emaciated and anremic men, it is most frequently found in those who are fairly well nourished. It is very in- sidious in its onset, and while it last?, renders its victims liable to any one of the numerous maladies of the air-passages and bowel which may be associated with oral sepsis. Apart from the inhalation or ingestion of germs of actual specific disease, and septic and putrefactive germs, the coustant absorption of the products of septic

putrefactive micro-organisms from the diseased surface of the gums must tend to pro- duce a general lowering of vitality, and a reduced resistance to disease causes generally, which is a point for consideration. In the normal condi- tion of the mucous membranes of the lungs and alimentary tract, the disease-germs reaching hem, unless in overwhelming numbers or of unusual virulence, produce no evil consequence ; the reverse may be the case when these mucous membranes are in any way damaged from any cause. The many varieties of bacterial forms

that are frequently present in the mouth, nasal and respiratory passages, and alimentary tract? the bacilli of tuberculosis, dysentery, enteric fever, pneumococcus of pneumonia, streptococci, staphylococci, etc., usually operate on a barren soil in thoroughly healthy men, the cells of these passages being then in their highest state of

physiological defence and antagonism. The con- dition described specially tends to create a

vulnerability of the alimentary tract to invasion by one or other of the micro-organisms associated with bacillaiy dysentery and epidemic infective diarrhoea. "When a large number of these cases are occurring in a regiment, there will

usually be found an unusual number of cases with symptoms of ordinary catarrhal dysen- tery, diarrhoea, or other disturbances of the alimentary tract. It is possible that the irritation of the mucous membrane induced by the septic organisms swallowed, permits of the ordinary intestinal flora, especially the bacilli's communis coli, taking on virulent properties. This is one of the ways in which, I believe, the last-named organism gives rise to symptoms indistinguishable from those of mild epidemic dysentery in the condition under reference. In several of these cases in which the blood serum was tested with both Shiga-Kruse and Flexner strains of the bacillus dysenteric*, there were no indications of acrolutination. The form of dysentery met with in these cases is seldom severe, but the classical symptoms of dysentery?repeated calls to stools with the passage of small quantities of bloody mucus, tormina and tenesmus?are always present; they are of the type we used to designate by the term catarrhal dysentery. It is easy to under- stand that when this condition of vulnerability of the mucous membrane is established, such factois as chills over-fatigue, exposure to inclement

weather, drinking of impure water, improper diet and defective cooking, would still further lower the resisting power of the mucous membrane of the bowel and render the persons so affected an

easy prey'to the attacks of the specific organisms of epidemic dysentery and infective diarrhoea. These are I believe, the explanations of the high proportion of cases of dysentery that occur in

Native troops and followers in Indian frontier, warfare, and of a large proportion of the 31,000 cases of dysentery that occurred amongst our

troops during the South African \\ aiv

mwiouslv stated, the condition under

reference is remediable. Its appearance in a

Native regiment in any numbers is an indication

that there is something defective in the feed- ing of the men, and, as a rule, it will be

found that they are living on a monotonous

diet consisting chiefly of rice or atta ana dhall, with a great deficiency of fresh vegetables^

-

fresh meat. In this connection it is desirable, wherever practicable, that Native regiments should provide themselves with a vegetable garden capable of adequately supplementing the ordinary .

bazar supplv throughout the year, the garden ?

94 THE INDIAN MEDICAL GAZETTE. [March, 1911.

being worked as one of the regimental institutions. One practically never sees the condition in British or Native officers, amongst otlier reasons, probably because of their better diet, which usually contains a sufficient supply of fresh vegetables, fruit, etc.

The periodical examination of the gums of Native troops is important. The most opportune time for carrying this out is during the mobilisa- tion practices, and on other occasions when the whole of the regiment is being inspected as to its state of health.

In an epidemic of this condition in a Gurkha regiment which one had to investigate and report upon some time ago, the following recommenda- tions were made : ?

1. An issue of an ounce of lime-juice daily for a period of a mouth, and if the state of the

gums has not considerably improved by that time, a further issue of an ounce every second day for another month.

2. The daily use of at least eight ounces of fresh vegetables (preferably potatoes and onions), for one month, and a similar quantity at least three times a week after that period.

<5. The use of eight ounces of fresh meat per man wice a week.

4. The issue of half an ounce of amchur

(green mangoes that have been sliced and sun-

dried j, or inili (dried pulp of the tamarind fruit) daily, to be cooked with the food.

5. The compulsory use of atta instead of rice

for at least two days, in the week for the ensuing two months.

6. That the men be advised as to the necessity of thoroughly cleaning the teeth daily.

7. The attendance at the hospital of the 82 cases of swollen, spongy and ulcerated gums for

(local, and if necessary, general) treatment?

these cases need not be admitted into hospital, nor struck off duty for the purpose of attending hospital.

8. The medical officer of the regiment to

make a weekly inspection of the whole regiment, and report the results of the measures suggested.

Such recommendations as these would hold

equally good on field service. The local application which one has found most

useful is either tinct. or liquor iodi once a day in

mild cases, and twice a day in severe cases.

When there is pain and tenderness, one employs a combination of tinct. iodi (3 parts), tinct.

aconiti (2 parts), and chloroform (1 part) ; when

there is much swelling with ulceration of the

gums, a daily application of a strong solution of

protargol appears to do most good. In all severe

cases a mouth wash of chlorate of potash solution, or a solution of listerine or glyco-thymoline, is

jndicated. The condition described is so widespread in

this country, and is a possible predisposing cause

of so many maladies, that it is deserving of com- plete scientific investigation as to its etiology and prevention.