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.