ORIGINAL COMMUNICATIONS.

Article I.—Description of the Gangrenous Ulcer of the Mouths of Children. By B. H. Coates, M. D. one of the Physicians to the Philadelphia Children's Asylum, &c.

Having had opportunities of witnessing the ravages and unmanageable character of this destructive disease, I have long and deeply felt the want of some written account, both of the malady, and of a proper mode of treatment. Some research and observation, made in consequence of this feeling, have terminated in the acquisition of more fixed ideas, and of a practice hitherto successful. This convinced me, that it became my duty to lay the result of these inquiries before the public, for the benefit of others. There is, perhaps, no stronger and more peculiar reason for wishing American physicians to write, than the opportunities they possess, of describing and recording many important varieties of morbid affection, which were either unknown to our predecessors, or the descriptions of which, uncombined and uncompared, are only to be found by searching among the more neglected tomes of a public library. Of this, the present case will afford a fair example; as well as an instance of an American physician, who had described the disease from nature, having, from want of encouragement, false modesty, or some other cause, kept it back from publication.

Ever since the establishment of the Children's Asylum, under the care of a committee of the guardians of the poor, of the city and liberties of Philadelphia, in the spring of 1819, this useful institution has been annually visited by the new and distressing scourge of which we are treating. It has here prevailed in a considerable number of cases, forming the principal source of anxiety and trouble during the winter season, and annually sweeping off its little victims, in a manner rendered peculiarly awful by its insidious approach, its loathsome effects, and its apparently uncontrollable progress. Various scattered cases of a similar affection have come within my knowledge, during the last few years; occurring in the practice of several physicians, as well as in my own. In no place, however, near Philadelphia, other than the above, has there existed, so far as I know, a sufficient number of cases at the same time, to enable a physician to examine it in much detail, or to make comparative trials of different modes of treatment, so as clearly to determine the most successful.

References to Authors.—The notices of this complaint given by authors, to which I have been enabled to refer, are few, and generally too scanty to supply much means of forming a satisfactory judgment, or a practice in which confidence can be reposed. They consist, principally, of the mere mention of an affection resembling that of which we treat; and, in some instances, it is even doubtful whether they are describing the same disease. No notice is taken of this affection in any of our common books; with the exception of the last edition of Cooper's Surgical Dictionary,[1] and of Underwood's work on diseases of children. It is there described under the erroneous title of cancrum oris. A reference is given to Pearson's Surgery; and the article in the Dictionary is taken exclusively from that work. As this is the only authority with which I am acquainted, that gives a tolerably full account of a disease somewhat similar to that of which we are treating, I have concluded to extract the whole passage, in the words of the author.

"The canker of the mouth is a deep, foul, irregular, fœtid ulcer, with jagged edges, which appears upon the inside of the lips and cheeks; and is attended with a copious flow of diseased saliva.

"This disease is seldom seen in adults; but it most commonly attacks children, from the age of 18 months, to that of 6 or 7 years. When the ulceration begins at the inner part of the lip, it exhibits a deep, narrow, sulcated appearance, and quickly spreads along the inside of the cheek; which becomes hard, and tumefied externally. The gums are very frequently interested in this complaint, and, in such cases, the teeth are generally found in a loose and diseased state; matter is often found in their sockets, and abscesses sometimes burst externally through the cheek, the lip, or a little below the maxilla inferior: and it is not uncommon to see an exfoliation of the alveolar processes, or even of the greater part of the lower jaw. Among the children of poor people, where this disease is neglected or mismanaged at the beginning, a dreadful gangrene will sometimes supervene.

"The remote causes that give origin to this disease are not very obvious. I think it occurs most frequently among children that live in a marshy situation; that are sustained by unwholesome food; and where a due attention to cleanliness has been wanting. The cancrum oris has been described by some writers, as a complaint very common in England and Ireland, where it is sometimes epidemical among infants. It, however, is commonly seen in other kingdoms, and prevails more especially in those houses where a great number of children are crowded together. I am not able to determine whether it is or is not contagious.

"But adults are not wholly exempted from this morbid affection, and it is not easy in all cases, to distinguish the cancrum oris from a cancerous or venereal ulcer in the mouth; since the uvula, tonsils or fauces may be the seat of each disease. I have seen ulcerations on the uvula and tonsils, with all the marks of a venereal sore, in patients where the presence of such a virus could not be suspected; and by treating them as canker of the mouth, they have been speedily cured.

"The canker of the mouth ought to be distinguished from aphthæ, the epulis and parulis, scurvy, cancerous ulcers, venereal ulcers and exulceration from the use of mercury.

"The mode of treatment.—It will be proper,

"1. To remove the diseased teeth, bone, &c. if possible.

"2. To prescribe a milk and vegetable diet, and to allow a prudent use of fermented liquors.

"3. It will be adviseable to exhibit such remedies as, Peruvian bark; sarsaparilla; elm bark; mineral acids.

"The external applications that I have generally found successful have consisted of such as the following:

"Preparations of copper; a diluted mineral acid; burnt alum; decoction of bark with white vitriol; tincture of myrrh, &c."[2]

Of the above articles, those which we have indicated by italics are omitted in the last edition of Cooper's Dictionary; and, in a former one, they are directly prohibited with strong reprobation. Nevertheless, it is among these that we have found, beyond comparison, the most successful one.

Mr. Pearson prefixes to the preceding article a list of synonymes, with references to authors, in the manner of writers on natural history. They are as follow: Aphthæ Serpentes.—Sennertus; Medicinâ Practicâ. Labrosulcium, seu Cheilocace.—Arnoldus Bootius. Oris Cancrum.—Muys. Stalpaart Vander Wiel. Gangræna Oris.—Van Sweiten. Gangrene scorbutique des Gencives.—Auctores Gallici.

Of these, Sennertus[3] merely mentions, under the article aphthæ, that the latter sometimes spread around the frænum and tongue, occasionally corroding the subjacent parts. He is so far from giving a clear description, under the head of Aphthæ Serpentes, of any affection analogous to that we are about to record, that he quotes Galen as remarking, very properly, that these are not aphthæ at all, but putrid ulcers.

Arnold Bootius, in his little treatise "de morbis omissis," of diseases omitted in the books, published in London, in 1649,[4] gives, from his own observation, an account of a disease, to which he applies the names above attributed to him. It differs from the cases which have attracted our attention, chiefly in its situation. He describes it as an ulcer, soon becoming black and fœtid, corroding the inside of both lips, separating them widely from the gums and allowing them to fall outwards upon the face; thus producing a horrible deformity. Besides this, the author states, that a deep fissure usually extended down each half of the inside of each lip; thus adding four deep and ghastly ramifications to the ulcer. This shocking affection is stated to have prevailed extensively, both in England and Ireland; in which latter country the author practised and held several important offices. It occasionally became epidemic, and then destroyed great numbers of children. It principally prevailed between 2 and 4 years of age; though it was occasionally met with both earlier and later in life. It was frequently, but not always, accompanied with aphthæ.

This disease was, in general, successfully treated by our author, with a decoction of "Chærephyllum, Quinquefolium, Myrrhis, Rosæ et Salvia;" in which was dissolved a "sat magna copia" of white vitriol.—A combination about as precise as some of the prescriptions which have been recommended to me, for the present disease, in this country. With this mixture, he touched the ulcers several times a day; and then washed them with a liniment of acetate of lead, aqua plantaginis, and oleum rosaceum. He also used issues in both arms; and confined the patient, in more obstinate cases, for drink, to a decoction of sarsaparilla, china, and several other articles, which we will spare our readers. To this disease, Bootius devotes about five small 18mo. pages, forming his tenth chapter.

Vander Wiel cites Bootius, and expresses his belief, that the disease described by the latter was identical with one which he saw himself. This last, however, though described in a cursory manner, appears to resemble much more nearly the disease of the Children's Asylum; beginning in the gums, and extending to the adjacent parts. He treats it by the following lotion:

R. Mel. Rosar.℥i
—— Ægyptiaci,ℨij
Olei Vitrioli,gtt. aliquot.
misce.

Under this treatment, and by removing the teeth, when loose, the small number of cases he saw recovered in a few days.

Vander Wiel was a practitioner in Holland; and, though he does not specify the fact, his cases were probably in a marshy country.[5]

Muys, in a little treatise entitled "Chirurgia Rationalis,"[6] published in 1684, has an account of a disease, which is evidently supposed by Pearson to be that which he describes. This also, however, appears to have been a "labrosulcium;" an ulcer between the lips and the incisor teeth. There is but little to be gathered from his paper; as it is principally occupied with an attempt to prove, that this ulcer is owing to an accumulation of acidity in the blood, increased, at this point, by the putrescence of particles of food which collect there. He illustrates this doctrine by an examination of a burnt rag under a microscope; and this he considers as in a state analogous to the gangrene. "Opinionum commenta delet dies," &c. We give his treatment; which is aimed at acidity.

R. Theriaci,ℨijss
Ung. Egypt.ℨiss
Gum. Laccæ, et Spirit. Sal. Armon. aa℈ij
—— Cochleariæ,ℨij
m. ft. ung.

To be softened with a little alcohol, the part washed with the mixture six times a day, and a rag moistened with the same compound left in the ulcer. Here we take leave of the Chirurgia Rationalis.

In the 14th volume of the Memoirs of the French Royal Academy of Surgery, are papers containing accounts of two cases, which have some points in common with the disease of which we treat; but the identity of at least one of which it is hard to establish. The first piece is entitled, "Sur la gangrene scorbutique des gencives dans les enfans. Par feu M. Berthe."[7] The author is described, in a note, as a young surgeon of great promise, who was carried off by an early death. M. Berthe commences by quoting Fabricius Hildanus; who describes a gangrene of the gums, occuring principally at about 4 years of age, and of which all the patients died. Fabricius takes the occasion to give a caution to young surgeons, to avoid being too sanguine in predicting recovery from gangrenes. Next a case is given us, drawn from M. Saviard, in which death was the result. This author seems, subsequently, to have had somewhat better success, but at the expense of horrible disfigurements; such as great holes through the cheek, and the loss of a large piece of the jaw; which, indeed, are described as having been worse than death. In another case, recorded by M. Poupart, in the "Histoire de l'Academie des Sciences," this affection terminated in death; preceded, however, and in the opinion of the author, caused, by the production of two tumours, one by the side of the tongue, the other inside of the cheek. This is not at all unlike the progress, which will be hereafter mentioned to have taken place in many of the Asylum cases.

M. Berthe then remarks, that the greater number of instances of gangrene of the gums had terminated unfavourably.

His own patient was ill from April to September, 1753; and exhibited swelled and bleeding gums, frequently projecting beyond the teeth,—black and fœtid stools, fœtid urine, and ecchymoses over the surface of the body. He treated it with antiscorbutics, internally and externally, and apparently with success. The patient, however, relapsed in January, 1754; when M. Berthe proceeded to a very different, and far more severe treatment. The gums were pared away, in many successive operations; and the wounds were washed with aluminous water. A roll of linen was, during the intervals, kept fastened in the patient's mouth, for the purpose of allowing the escape of the fluids of the part; which he apprehended to possess a putrid character, and to aggravate the original disease, whenever they passed into the stomach. At length, his patient recovered, and continued well.

It appears to the writer of these notes to be hardly necessary to state, that M. Berthe evidently mistook the disease; the latter being in reality scorbutic, and not a single symptom of gangrene being described during its whole history.

The same, however, cannot be said of M. Capdeville; whose "Observations sur les effets rapides de la pourriture des gencives" appear in the same volume with the foregoing, and immediately subsequent to it.[8] This writer's case took place after a fever, and no tumefaction of the gums nor ecchymoses of the skin are mentioned as occurring in it. M. Capdeville attended this case in consultation, in 1764; and complains of too feeble means being employed, as the case was trusted to antiscorbutics. This treatment ended in death. M. C. refers to Van Sweiten, whose correct account we shall mention; and it is evident that it was the disease of the Children's Asylum: though he manifests a strong propensity to connect it with scorbutus, and the "blanchet," or a species of aphthæ, which destroyed a great number of children in the Foundling Hospital, in 1746. Reference is also made to cases which occurred in "La Pitié," under the care of Chopart. Of these, a very scanty account is given. They terminated in death; after a treatment by lotions of honey of roses and spirit of vitriol, with emollient and resolvent cataplasms.

Van Sweiten, in the article devoted to the consideration of gangrene,[9] has left us a far more exact description of the disease, into which we are inquiring. Practising in a marshy country, he had frequent opportunities of meeting with it; and his account of it, and his mode of treatment, though brief, are every way worthy of the close, practical inquirer into nature, and the sound medical philosopher. His description is not unmixed with strong expressions of horror and commiseration at its ravages. He describes it in a manner so similar to that in which it now prevails, that no doubt can exist of the identity of the diseases. He acknowledges, however, "rubedo, calor, dolor," among its symptoms. Cochlearia, theriaca and similar articles, according to him, are almost always injurious. If no fœtor exist, (and, of coarse, no actual mortification,) he applies a solution of sal ammoniac or nitre, with some vinegar or lemon juice; sometimes as a lotion, sometimes by keeping a rag imbued with it always in the ulcer. Hard rubbing he reprobates. If the disease have made progress, and fœtor exist, muriatic acid is used: in the less aggravated stages, diluted with honey of roses and water; in the worst cases, pure. This practice he states never to have failed him, unless where the bone was affected.

In an early edition of Dr. Underwood's Treatise on Diseases of Children, in the library of the Pennsylvania Hospital, no mention is made of this disease; although an article is devoted to "gangrenous erosion of the cheek." The account is wholly borrowed from a work by Mr. Dease, of Dublin, "on the diseases of lying-in women," &c. also in the library. Mr. Dease describes this affection as occurring from 2 to 6 or 8 years of age; especially in unhealthy children, including such as have been subject to worms. The whole body often appeared cold upon the approach of the disease. A black spot then occurred, but without marks of inflammation, on one of the cheeks or lips. The whole cheek was sometimes destroyed, and the lower jaw fell down upon the breast. Muriatic acid, infusion of roses, the effervescing draught, and, in the decline of the disease, bark, broths, jellies, and wine, besides magnesia or rhubarb, to remove the putrid matters swallowed, were the internal remedies employed. The parts were washed and injected with muriatic acid, diluted with chamomile or sage tea; and afterwards dressed with the acid, mixed with honey of roses, and, over this, a carrot poultice. By this practice, Mr. Dease lays claim to almost total success.

In the Philadelphia republication of Dr. Underwood's book, taken from the sixth London edition, there is an article entitled Cancrum Oris. The author appears to have read Pearson's account; but as his description does not at all agree with the disease of which we are treating, nor with that of Mr. Pearson, we shall not stop longer to analyse it.

I have no doubt, from views that will be hereafter developed, that many of the above writers have had cases similar to those which we are about to describe; but have mistaken them, from the want of a sufficiently early and close inspection of the ulcers. In the second stage, this disease much resembles an inflamed sore between the lips and gums, extending to the latter; although I hope to prove that this state of things is secondary.

Locality of the Disease.—The Philadelphia Children's Asylum is situated in South Fifth street, between Prime and Federal streets, in the district of Southwark. The soil is what is called alluvial, or rather diluvial; as is well known to be the case with all that district, lying south of Philadelphia, as well as the southern part of the city itself. The house was built, and for many years occupied, as a mansion, by the head of a most respectable and wealthy family. Its situation possesses some of the qualities usually selected in choosing the site of a country seat. The buildings stand on a swell of ground, leaving an open lawn, now interrupted by several unoccupied streets, and extending, on the right hand, to the banks of the Delaware, and, on the left, to the Navy Yard and part of the suburb of Southwark. Towards the north, it is not far from the edge of a thickly built appendage of the city.

The district immediately south of the Asylum is marshy, and has long been noted for the prevalence of intermittent fevers; but the slightly elevated site of the building had been generally healthy, and continued so, till the universal and distressing epidemic, which infested all the outskirts of Philadelphia, in 1822 and 1823. Even at this period, the persons resident at the Asylum, were far from suffering so severely as the adjacent neighbourhood; and, since those years, it has again become, in general, tolerably healthy. In 1819, 1820, 1821, and 1822, a lot, situated at a short distance, on which were deposited the contents of a number of privies, proved a source of great inconvenience, and some disease, at the Asylum. This focus of effluvia, together with the general and copious use of similar materials in manuring the adjacent fields, occasioned an intolerable stench, and generated diarrhœas, in the early part of the spring. When the grass and weeds, however, were grown sufficiently to protect the surface of the soil from the sun and wind, this effect entirely ceased; and I know not that any other inconvenience was experienced from the same source, unless we attribute to this, as may fairly be done, the destruction of the purity of the well. This formerly afforded very good water; and, since that period, it has much improved. When the corporations of Southwark and Moyamensing shall introduce, as it is to be hoped they will, the Fairmount water into their streets, one remaining cause of inconvenience and ill health, will be removed from the Children's Asylum.

Prevalent Diseases.—Ophthalmias and furuncular eruptions, the latter principally on the face, are epidemic every year; generally in the spring and early summer months. When prevalent in the city, the measles, small pox, and varioloid disease have reached the Asylum; the scarlatina has, at no period, I believe, been peculiarly troublesome there. Intermittents, which were anticipated by many, from the nature of the situation, have seldom, if ever, prevailed in the house, to any very considerable extent. One of the worst visitations which it has experienced, in this respect, was in the autumn of 1823. In many cases, it was in patients who had been labouring under disease of this description, that the ulcer we are about to describe exhibited itself; but it was by no means confined to those who were known to have so suffered. Many, perhaps, most of the children affected, were free from any apparent ailment; although it is by no means impossible that the little, uncomplaining subjects were, at the time, labouring under what has been called "febricula" or "inward fever."

Regimen.—To the impurity of the water we have already adverted. The diet of the children furnishes them with meat every day, with the exception, during a part of the existence of the institution, of two days in every week. Molasses was freely used; indian mush was greatly in demand; and the breakfast and supper were of bread and milk. During the summer months, this diet was abundantly nourishing; but in winter, it was thought that an additional quantity of animal food was desirable; and, accordingly, it was, during the two last winters, given every day.

Description of the Disease.—The ulcer of which we speak, may begin in many parts of the mouth. In by far the greater number of cases, however, it commences immediately at the edges of the gums, in contact with the necks of the teeth, and, most generally, of the two lower incisors. A separation is found here; which exhibits a slight loss of substance at the extreme edge of the gums, and, as far as I have observed, a whitishness of the diseased surface. In some instances, though not very frequently, this is preceded by a slight swelling and redness. In this state, the disease may continue for a long time; and I have reason to believe, that patients have remained thus affected, during the whole period of three months, for which I attended the Asylum. At one time, when the disease was at its height, threatening several patients with destruction, I found upwards of 70 children, out of a population amounting to about 240, more or less affected with these ulcerations. No remarkable change is at this stage observable in the functions of the little sufferer; except a general air of languor and weakness. The appetite and the muscular activity continue, but are somewhat reduced; not sufficiently, however, to disable the child from attending school, taking the air, or continuing his ordinary practices. In this state, no symptoms of irritation have been at all discovered. The skin is cool during the day, no pain is complained of; and no account has ever been given me of any nocturnal paroxysm of fever. It would appear to be purely a state of asthenia. We are, however, by no means certain, that there was no concealed irritation in the system. We were, of necessity, obliged to depend, in a great measure, upon the reports of nurses, and other females; and these were liable to overlook, or mistake for mere weakness, the signs of an obscure disease. In this manner, commencing cases were frequently not discovered, and nothing was done, till the affection had made further progress; and this continued until the ascertained existence of the epidemic in the house, combined with the recollection of its former ravages, had excited an alarm, which led to the inspection of the mouths of all the children in the institution.

The disease, in this form, must be within the curative powers of nature; as, if this were not the case, we should hear of more numerous unfavourable terminations. It has seldom, however, if at all, been within my power to witness this tendency; and, when not controlled by a particular treatment, the cases have almost always either remained stationary, or increased in severity. Its first progress is, most generally, by extending to the edges of the gums round other teeth; frequently affecting a large portion of the dental arches. A very early progress is, however, mostly effected, down the length of the tooth, in the direction of the socket; and, in this way, the disease commits great and unsuspected ravages. When it reaches the edges of the bony socket, the tooth begins to be loose, and when drawn, exhibits portions of the fang, including parts which had been contained within the alveolus, entirely denuded of their periosteum. Indeed, from observation, I should say, that the latter membrane was the part, which was the most peculiarly liable to injury and death from this disease; and it is by no means clear, to my apprehension, that this is not frequently the commencement of the complaint. The injury generally proceeds with augmenting rapidity; especially when it has affected the deeper parts: and it is while in the act of rapidly spreading, that it occasions gangrene.

In the production of gangrenous sloughs, it much resembles the descriptions usually given of sloughing ulcers. A portion of the parts immediately subjacent to the ulcer loses its life; this rapidly separates; and, before or after a complete removal, a fresh slough is formed in the same manner. The sloughs are generally black, with ash-coloured edges. I have not been able to discern a change of colour, the production of vesicles, or any material tumefaction, as antecedent to the gangrene. There is generally, by this time, an increased heat in the parts; with the sensation termed "calor mordens." The discharge now, for the first time, becomes acrimonious; giving pain when it comes in contact with cuts in the finger; and excoriations are produced on all parts in contact with the sloughing ulcerations; as the lips, the cheeks, the tongue, and the adjoining surface of the part where the ulcer is situated.

As soon as the external gangrene has reached the level of the edge of the bony socket, and frequently much sooner, the adjacent portion of the latter is found deprived of its life; forming a necrosis. The death of the periosteum in the socket, at least that of the fang of the tooth, precedes, by some interval of time, that of any portion of the bone itself.

When gangrene is formed, a fever of irritation is generally developed. In regard to the time at which this takes place, there is a great diversity in different constitutions. It has appeared to me to depend, principally, upon the inflammation of the mouth, which is secondary to the original disease, and, in most cases, to arise from the acrimony of the discharge. It is aggravated by loss of rest, want of nourishment, and, probably, by putrid matter finding its way into the stomach. To the latter cause I also refer a diarrhœa, which almost uniformly comes on, towards the close.

There are accounts of a similar disease having begun on the inside of the cheeks. I have, however, never seen a well-marked instance of this; the cases which were supposed to be such having, in every instance, been also found to exhibit ulcerations at the edges of the gums. That the disease spreads from the gums to the cheek, is a fact which have often seen exemplified. It is, indeed, the most usual termination of bad cases. After producing gangrene and necrosis in the gums and alveoli, and after the discharge becomes, as above stated, acrimonious, a gangrenous spot is not unfrequently found about the opening of the Stenonian duct, on the inside of the upper or lower lip, opposite the incisors, in some other part of the inside of the lip or cheek, or in more than one of these situations at the same time. Whether this be owing to excoriation from the discharge, or to some other cause, I cannot say; it has, however, in every instance which I have seen sufficiently early to witness its rise, been subsequent to the symptoms previously described.

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 diarrhœa.

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 œsophagus, 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,ℨij
Pulv. Cinchonæ,℥ss
Aquæ,℥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,ℨi
Aquæ,ℨij Solve.
Dein adde, Mellis Despum. et Tinct. Myrrhæ, aa℥ij

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

R. Sulph. Zinci,ℨij
Aquæ,℥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℥i m.

The same, with the addition of powdered bark.

R. Aluminis,℈ij
Tinct. Myrrhæ, et
Mellis, aa℥ij m.
R. Pulv. Cinchonæ,℥i
Myrrhæ et Pulv. Carbonis. a℥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 fœtor; 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 diarrhœa 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 fœtor. 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.