Chapter 3

When the gangrene reaches the cheek or lip, however, very active inflammatory symptoms are uniformly developed. In the cellular substance of these parts, they assume the well known characters which have been attributed to the _phlegmonous_ species. We have a great thickening, forming, in the cheek, a large, rounded, prominent tumour, with great heat and pain. Sometimes redness is perceived externally; but, more frequently, the great distension of the skin of the cheek seems to empty the cutaneous vessels; giving to the part, a smooth, polished, dense, white appearance, very much resembling the effect of a violent salivation. I have no doubt that this is the tumour described by POUPART, and alluded to in an earlier part of this paper. Great thickness and hardness have always occurred, in the other situations where this gangrene has approached the external cellular masses of the face; in the lip, however, they are less remarkable, perhaps from the smaller amount of cellular matter. After reaching this stage, a black spot is frequently seen on the outer surface of the swelling. This spreads rapidly; and has always been, in my own experience, the immediate harbinger of death. It is proper to state, however, that I have heard it said, that cases had recovered in this city, in which the gangrene had produced a hole through the cheek. Under what physician's care this occurred, I have never learned.

In two cases it commenced in the fauces; and was marked by the same unsuspected progress. In one of these, the little patient was remarked to be languid, but had no positive external marks of disease. The mouth was examined, and found healthy; but no suspicion of the real situation of the disease was entertained, till after 3 or 4 days more, when he complained of a slight sore throat. A large gangrene of the tonsils, half-arches and pharynx, was now found; and the event need hardly be told.

The closing stage of this affection is marked by large gangrenous patches in the gums; deep fissures between these and the teeth; the latter loose, or falling out; large pieces of the alveolar processes, often containing the roots of several teeth, in a state of entire necrosis; the whole lining membrane of the mouth suffering a violent excoriation; the whole adjacent external cellular substance, hard and swelled; large gangrenous spots in the inside of the cheek or lips, occasionally extending quite through to the outer surface; a total incapability to sleep, or to take the least food; fever; a swelled abdomen, and diarrhoea.

_Dissection._--The inspection of the body after death had never thrown much light upon this obscure affection. Since I began to prepare materials for this paper, I have been able to dissect but one subject. The appearances were as follow:

_Exterior_, emaciated.

_Alimentary canal_, externally and internally, altogether in a natural state, except what appeared to me to be owing to the subsidence of blood to depending portions of the intestines. The mucous membrane was carefully examined throughout its whole length; but not being at that time aware of the importance, attached, by some pathologists, to small rednesses in this organ, it is highly probable that some such may have been overlooked.

_Liver and Spleen_, enlarged, but of a natural appearance.

_Heart, thoracic oesophagus, and one kidney_, (the other not examined,) natural.

_Lungs_, containing much mucus in the bronchial cavities. The fore part of their substance contained much hepatization.

_Pathology._--The nature and production of this disease are certainly very obscure. We may, however, as in other branches of knowledge, attempt to develop and record what knowledge we possess respecting it; carefully separating truth and reason from conjecture. We have already said, that its access was very frequently preceded by no marks of visible disease, or at least none that attracted attention. The little subjects were, apparently, in merely a drooping or enfeebled state. In other instances, the ulceration followed a common remittent or intermittent fever; insomuch that, at one time, whenever a child was brought to the nursery for fever, it was expected, as a matter of course, that his mouth would become sore. In the other cases, as we have already had occasion to say, it is quite possible that a concealed "inward fever" may have existed; and this is rendered the more probable, by the circumstance of their losing their appetites. In the instance where the body was opened, we have seen that the original disease was hepatization of the lungs; and yet it is quite probable, that this affection had caused, as it often does, that species of disease, which a rapidly spreading pathology refers to a slow inflammation of the stomach and intestines. With regard to marks of this last not having been detected by me, it is evident that I am in the same situation with a very numerous body of other observers.

The local appearances, at the commencement, did not appear to be of an _inflammatory_ nature, at least generally. If the gums were really the first part affected, it was not so; as these parts when inflamed, as they frequently are in affections of the teeth, exhibit decided soreness, pain, swelling, and an increase of redness. The ulcerated part was, in about nine cases out of ten, paler than natural; and then neither soreness nor increased heat was perceptible, except in a few cases, in which the mouth was generally hotter than natural, though it was not, in a striking manner, referrible to the gums. In a few cases, distinct redness, and a slight swelling, were perceptible round the ulcer. These patients generally did better than the others.

If, on the other hand, we suppose the original derangement to have taken place in the periosteum, we shall be enabled, more easily, to explain some of the phenomena. We then reason thus: The whole of the body had shrunk considerably, from disease, and, the circulation being deprived of a part of its usual vigour, the periosteum, a part possessed of little vitality, was unable to bear the additional extension, which it underwent, across the unyielding bone of the tooth. The blood ceased to circulate in it, and it died. Ulceration of the adjacent parts followed, as a matter of course; and these parts, especially the periosteum, being possessed of but little sensibility, the sympathies of the other parts of the system were but little interested, until an extensive portion of the mucous membrane of the mouth, or a mass of cellular substance, became affected. We certainly see that, in every case but two, the disease commenced in contact with the teeth. This doctrine will also explain the rapid and deep penetration of the ulcer along the roots of the teeth; and the destruction of the bone. We may recur to the statement, that a portion of the fang of every loose tooth was always found deprived of its periosteum.

In the two cases excepted, we have seen it apparently begin in the mucous membrane of the fauces; and indeed the manner in which it generally spreads from the gums to the cheek and lips, seems to me, unquestionably, to indicate a greater liability than common to gangrene in more than one part of the mouth.

The soreness and pain of the socket, which forms a part of most tooth-achs, might have been reasonably expected here; but neither was ever complained of, even when the teeth were loosening: and, as no fever existed at this time, the original irritation can hardly be considered as inflammatory; excepting perhaps the cases which exhibited redness, and slight swelling of the gums.

_Is this disease scorbutic?_--I never observed ecchymoses, nor in more than a single instance any the minutest red specks upon the cutis, which might be thought to resemble petechiæ. The patients never fainted; the gums were never spongy, nor did they bleed more than those of any other child would have bled, under an equal degree of violence. I however requested my friend, Dr. HARRIS, who has had ample opportunities of making himself acquainted with scorbutus, to see some patients with me. He complied, with his usual kindness, and pronounced their disease not at all to resemble the scurvy.

_The teeth._--But few cases occurred during the second dentition; and it is doubtful whether any one took place during the first. It should be remarked, however, that children under 2 years, were not admitted to the institution, unless by deception on the part of the parents. No child ever lost a tooth of the second set; and, indeed, the second dentition seemed often to cure the complaint. The greater number of cases occurred between 2 and 5 years of age, but some as late as 8 or 10. In several instances, the ulcer destroyed a portion of the enamel capsule; and the teeth were then cut, with _very perfect enamel_ upon the lower part, while the bone was entirely bare at the ulcerated portion of the capsule. This singular fact proves that no inflammation of the capsule, sufficient to interrupt the function of its remaining portion, took place in consequence of the opening of its cavity.

_Prevalence of this disease in our own country._--Many elderly persons remember during different periods of their lives, a tradition and particular instances of a formidable disease of the mouth, by the name of "Black Canker."[10] Round Philadelphia, it appears to have been rare. Having been informed by a friend, that the disease had prevailed extensively at Salem, New Jersey, under the notice of my friend, Dr. THEOPHILUS R. BEESLEY, I addressed a letter to that gentleman, to which he furnished me with an obliging and instructive reply, which I have unfortunately mislaid. Numerous cases have occurred, in that vicinity, within the last 30 years; and were, in general, successfully treated by the women. Cases seldom came under the view of physicians, until gangrene had commenced; and of these, many died: so that the old women were generally more in vogue for its cure, than the regular practitioners. Dr. BEESLEY, Dr. VANMETER, and my friend Dr. E. Q. KEASBEY, had met with much of this complaint; and the result of many of their observations had been combined in a thesis, written, but, according to our unfortunate custom, not published, by the younger Dr. VANMETER. It was there considered as a sequela of intermittent and slow remittent fevers, and seldom occurred but in marshy districts, and among the poor. It generally prevailed between the ages of 2 and 10 years. Of the remedies employed we shall again speak. Dr. SAMUEL TUCKER has also seen it in marshy situations near Burlington. I have heard of its existence on the Schuylkill. Dr. PARRISH has for several years noticed a stage of this complaint, under the name of "a disease resembling the effects of mercury," in his private lectures. Drs. PHYSICK, HARTSHORNE, HEWSON, MEIGS, WOOD, RHEA BARTON, and REMINGTON, and several others who will pardon me for omitting their names, have also met with cases.

_Prevention._--Our precautionary measures should be directed to the predisposed or commencing state already described; to the prevention and cure of fevers, to the removal of "febricula," and other internal disorders, and to the general restoration of strength. Finally, its commencing stage should be watched, and promptly met; and success, I believe, will always attend our endeavours.

At the Children's Asylum, all the weakly children were made to take bitters, of different descriptions; and Dr. SYLVESTER'S antiscorbutic drink, composed of cream of tartar and juniper berries, infused in water. As the disease declined in the house, under this administration of bitters, it is highly probable that they had a preventive agency. I much question, however, whether Dr. SYLVESTER'S drink was productive of any advantage.

One question of some importance yet remains. _Has mercury any agency in producing this affection?_ The salivary glands have never been observed to be affected in it. Dr. PARRISH informs me, that, after a strict examination, he has come to the conclusion that the previous use of mercury does not bring on, or aggravate this complaint, as he has noticed it. I have made the same observation; and, not being peculiarly sparing of the use of calomel in fevers, have had opportunities to verify it. I think I can add, that, in some cases, by shortening and moderating an attack of fever, calomel has been useful in preventing the ulceration. Given during the progress of one, and that a fatal case, it did not appear to aggravate it.

There is no evidence whatever tending to excite the suspicion of _contagion_.

_Treatment._--A variety of remedies had been tried within my knowledge; most of them with but little success, and one or two with somewhat better. Feeling much disappointed with the results of my practice, in the small number of cases which fell under my care in the spring months at the Asylum, as well as elsewhere, I wished to exchange with another physician for a period when the disease was more prevalent; for the purpose of studying it, and making comparative trials of different remedies. Dr. JOS. G. NANCREDE was so polite as to indulge me. Having then a large number of patients under my care, I was enabled to make more extensive observations, and with more precision; the results of which course gave me the first satisfaction I had ever felt relative to this disease. Trials were made of every thing that was suggested by friends, and generally upon 4 or 5 selected patients at a time. Thus, choosing them in the ulcerative stage, and having several at a time before our eyes, the result was seen in a very few days, much sooner than if patients had been successively subjected to the remedies; and no material time was lost in appealing to the article which appeared to answer best.

The remedy which beyond all comparison succeeded best, was sulphate of copper. The usefulness of this substance, though known at Salem, New Jersey, was discovered, at the Asylum, by the mistake of a nurse. It had been previously used, in lotions of the strength of gr. ij or iij to the ounce of water; and with little advantage. Observing that the empirical remedies said to have succeeded, were, as I considered them, immoderately strong, I furnished the nurse with a common solution of sulphate of copper, and with a vial containing 72 grains of the sulphate in an ounce of water, for the purpose of being progressively added to the other at different periods. This stronger solution was applied, by mistake, instead of the diluted one; and it was the first remedy which had produced a rapid tendency to a cure. I finally settled down, after various trials, in the employment of the following:

R. Sulph. Cupri, [Symbol: dram]ij Pulv. Cinchonæ, [Symbol: ounce]ss Aquæ, [Symbol: ounce]iv _m._

S. To be applied twice a day, very carefully, to the full extent of the ulcerations and excoriations.

The cinchona here is not absolutely necessary; but operates by retaining the sulphate longer in contact with the edges of the gums.

Simple ulcerations and small gangrenes, as well as the troublesome excoriation, when not in the last stage, yielded promptly to this remedy; the good effect being generally visible from the first application.

Dr. FOX, my friend and fellow-labourer in the Asylum, had already taught me that it was important early to extract the teeth. I was not, however, sensible of the full extent of this rule, till after examining the fangs of some of them which were drawn. The separation of a portion of the periosteum from the fang, within the socket, which was universally found whenever the tooth was loose, among two or three hundred specimens, proved the existence of the disease in a deep, narrow crevice, into which it was impossible, by any contrivance, to insinuate the lotion. This cavity was laid open by extracting the tooth; and when the remedy was applied, the sanatory effect was surprisingly prompt. From this period, forwards, the universal rule was to extract all teeth, the moment they were discovered to be in the slightest degree loose; and "the blue wash" above described, became the standing remedy.

It is at all times a dangerous boast for a physician to make, to say that, in the treatment of any complaint, he has always succeeded. He is frequently not credited; and he can never know at what moment disbelief may be borne out by his subsequent failures. A faithful adherence to fact, and justice to the medical art, oblige me to say that it was owing to the observation of these means, that I never had an opportunity of making a dissection, after the one mentioned in a preceding page. Upwards of 120 ulcerated gums came under my notice in the course of three months; of which 70 were affected at one time. Of these, by far the greater number would, unquestionably, have escaped gangrene. The experience of past winters, however, and that of the preceding autumn, justifies the belief that there would have been several gangrenous cases, and some deaths; unless interrupted by remedial means. Some 3 or 4 suffered small spots of mortification, and one, by the delay arising from the tardy report of a nurse, suffered necrosis in a portion of an alveolus; but they were speedily arrested, and the production of more such cases, I believe, prevented, by the employment of the above means.

I have been once, since then, called in consultation to a case in which this remedy failed; but this was only two days previous to death, and during the existence of swelled cheek, and of a thick gangrenous eschar, and it was in fact only once imperfectly applied.

The farthest advanced of all the cases which I have seen, since that time, relieved by this remedy, was in the practice of my friend, Dr. R. M. HUSTON. He aided it by the application of a poultice with lead-water to the external surface of the cheek. This was thought to be productive of much relief.

Great attention and care are requisite on the part of the physician, to see that every part of the ulceration and excoriation is made visible, and brought under the influence of the applications employed. Without this entire knowledge of the extent of the evil, the result will be failure. The disgusting sloughs and discharge, and the fear of an imaginary _contagion_, make the nurses very unwilling to introduce their fingers into the reluctant little patient's mouth, and without this scrutiny all is in vain. The physician is compelled to set the example, to try the looseness of the teeth with his own fingers, and to ensure the nurse's entire knowledge of the extent of the disease.

Dr. BEESLEY writes that the women in his neighbourhood, frequently used considerable _roughness_ in applying the lotions. _Certainty_ is absolutely necessary.

After the remedy had been thus accidentally discovered in the Asylum, and used for a few days, I received Dr. BEESLEY'S letter mentioned above; and I then learned that the sulphate of copper was the principal dependence of the physicians at Salem. As, however, I had never seen Dr. VANMETER'S thesis, the use of it at the Asylum was new to me.

An excellent remedy, and one on which the sole dependence should be placed, were we not in possession of one which possesses a decided superiority, is one which was communicated to me by Dr. PARRISH. It is as follows, including a slight correction made by the apothecary:

R. Sulph. Zinci, [Symbol: dram]i Aquæ, [Symbol: dram]ij Solve. Dein adde, Mellis Despum. et Tinct. Myrrhæ, aa [Symbol: ounce]ij

To be used in the manner described above. Some bad cases yielded to the following:

R. Sulph. Zinci, [Symbol: dram]ij Aquæ, [Symbol: ounce]i _m._

It is useful to record failures and unsuccessful trials; as they serve to deter others from unnecessary risk. We therefore record the following as not having succeeded in our hands:

R. Mellis et Tinct. Myrrhæ, aa [Symbol: ounce]i _m._

The same, with the addition of powdered bark.

R. Aluminis, [Symbol: scruple]ij Tinct. Myrrhæ, et Mellis, aa [Symbol: ounce]ij _m._ R. Pulv. Cinchonæ, [Symbol: ounce]i Myrrhæ et Pulv. Carbonis. a [Symbol: ounce]ss _m._ et adde Succ. Limonum, q. s. ad massam faciendam, quâ illineantur gingivæ.

Caustic potassa; and nitrate of silver.

Pyroligneous acid, both pure and variously diluted with water. This had but a very limited effect, even in destroying the foetor; and I am by no means sure that it was of any use in arresting the disease.

Muriatic acid, though praised by such high authorities, did not seem productive of any distinct useful effects. Nitric acid, variously diluted, and sulphuric acid, which was tried in one case, diluted with an equal quantity of water, were entirely useless.

Of _constitutional_ treatment, the disease seemed to admit very little. In the early stage, the means employed, were the same mentioned above as means of prevention. It was by no means evident that any of these were useful in retarding the progress of the complaint. Towards the decline of the worst cases, aromatic sirup of rhubarb, with magnesia, were employed, to remove the putrid matters swallowed; and to relieve the diarrhoea which generally took place, by the astringent operation of the first mentioned medicine. It is extremely doubtful whether these means were productive of any benefit.

* * * * *

While the above was in press, I have met with the article, "_Gangrene de la bouche des enfans_," in the Dictionnaire de Medicine; written by M. MARJOLIN. The author in the Dictionnaire des Sciences Medicales, has given nothing material but references to some of the writers mentioned above; with one or two which were not within my reach. M. MARJOLIN has evidently identified the disease. He cites FABRICIUS HILDANUS, though we have not found a distinct account of it in that writer's works. He remarks that it is identical with the _necrosis infantilis_ of SAUVAGES. He also refers to SAVIARD, VAN SWEITEN, whom he justly mentions with the highest praise, UNDERWOOD, BERTHE, CAPDEVILLE, M. BARON, and the inaugural thesis of M. ISNARD. As we have no means of referring to the two last, we must judge of them by M. MARJOLIN'S statements. He observes the dissimilarity of BERTHE'S case. From the thesis of M. ISNARD, he gives us an account of the disease which corresponds very nearly, indeed, with that of VAN SWEITEN, and with the appearances observed at the Children's Asylum.

"Almost all the infants affected with this disease in the hospitals of Paris," says M. MARJOLIN, "sink under it." He recommends, after VAN SWEITEN, the use of muriatic acid, which he mixes with honey in equal proportions. Thick sloughs he cuts away with a bistouri or with scissors. MM. JADELOT, GUERSENT, and BARON, have employed the actual cautery with success in several instances. M. MARJOLIN has cured three cases; one by the actual cautery, one by caustic potassa, and a third by _muriate of soda!_ which, he believes, will always destroy the foetor. It would be interesting, undoubtedly, to make repeated trials of this simple remedy; and we shall endeavour to do so in cases which admit of delay.

FOOTNOTES:

[1] Vol. I. p. 319, Anderson's edition.

[2] Principles of Surgery; by JOHN PEARSON. Lond. 1788. p. 262, et seq.

[3] Opera omnia. Vol. II. p. 271. In the Loganian Library.

[4] Ibidem.

[5] See CORNELII STALPAART VANDER WIEL Observationes Medico-Anatomicæ. p. 167. Note by the editor, P. STALPAART VANDER WIEL. Amsterdam, 1687. In the Loganian Library.

[6] In the Loganian Library.

[7] Page 193.

[8] Page 217.

[9] Commentaria.--Edit. Lugd. Bat. 1742. Vol. I. pp. 766, 767.