ESSAY 
ON 
THE GANGRJENOPSIS 
OR 
GANGRENOUS EROSION OF THE CHEEK. 
BY SAMUEL JACKSON, M. D., 
Of NORTHUMBERLAND, PENNSYLVANIA. 
-quaeque ipsa miserrima vidi.-Vihgil. 66 
Jackson on Erosioti of the Cheek. 
PRIZE ESSAY. 
The following is a Prize Essay which comes under the offer made in 1825, 
leaving the choice of subjects to candidates themselves: such essays as 
might be approved of, being entitled to a premium of fifty dollars, in 
books. 
Art. III.-On the Gangraenopsis or Gangrenous Erosion of 
the Cheek. By Samuel Jackson, M. D., of Northum- 
berland, Pa. 
The science of medicine, however great the fabric, may, 
in one respect, be compared to the ant-hill; it is the aggre- 
gate labour of time, and of many successive generations; 
not raised by power and genius, but rather by the minute 
industry of those who are willing to bring what they can, and 
contribute their mite to the general stock, thus imitating the 
humble care of the myrmidonian race : 
quxque ipse miserrima vidi.-Virgil. 
Parvula, nam exemplo est, magni formica laboris 
Ore trahit quodcunque potest atque addit acervo 
Quem struit, baud ignara et non incauta tuturi. 
Horat. lib. 1. sat. 1. 
We, therefore, venture to offer some observations, with the 
hope of drawing the attention of medical men to a disease 
either very little known or too much neglected ; and of thus 
imposing on your numerous readers an obligation to commu- 
nicate whatever they may have seen or learned, concerning the 
history and cure of a most intractable and deplorable malady. 
This is the " Gangrenous Erosion of the Cheek," described 
by Underwood, by Burns, in his "Principles of Midwifery," 
by Van Swieten, in his Commentaries, art. gangrene, and 
possibly by many other writers with whose works we are yet 
unacquainted. We have ventured to say that it is very 
little known, because it is not generally mentioned by syste- 
matic authors, and also, because we have conversed with 
many respectable physicians who had never seen or heard of 
it. It has not even received an appropriate name; and as 
names, and even synonyma, are of the utmost importance in 
describing a disease, we beg leave to propose the term gan- 
grsenopsis, from gangrene, and the face; the 
most prominent pathognomonic of the disease being a gan- Jackson on Erosion of the Cheek. 
67 
grene of at least a portion of the face. We confess that this 
title does not entirely satisfy our wishes; but we are unable, 
even after considerable research, to invent a better. We shall 
first relate a few cases of the disease, and then offer some 
thoughts on its nature and method of cure. 
Case I.-Mary, aged six years, daughter of John Eisely, 
of Sunbury, was seized, in Sept. 1822, with an epidemic re- 
mittent fever, which, in a few days, and before they ob- 
tained medical aid, had resolved itself into the intermittent 
form. I was called about the tenth day of her disease, when 
one side of her face was greatly swelled, pale, and shining; 
eye-lids of the same side so cedematous as to close the eye 
entirely; lips, and particularly the upper one, tumefied; 
saliva streaming from her mouth : breath highly offensive. 
My first impression was, that she was affected witli mercury; 
but they assured me, as indeed they always did afterwards, 
that she had taken no other medicine than the common parg- 
ing salts, which they had given without medical advice.* 
Upon opening the mouth, 1 found on the inside of the tume- 
fied cheek a patch of gangrene, about as large as a crown 
piece, and without any thing like a line of separation. It 
exhibited a singular ash colour, approaching to whiteness, 
but it was plainly the substance of the check which was dead 
and disorganized to a considerable depth. The teeth were all 
fast, the gums sound and not the least sore on pressure, nor 
did her breath smell precisely like that of a salivated patient. 
This affection had begun two or three days before, and had 
been steadily increasing. The disease was totally unknown 
to me; but the mere indications of cure were not supposed to 
be at all mysterious, though 1 am far from certain of having 
fallen on the most successful means of fulfilling them. 
An epispastic was applied to the cheek, the mouth w as very 
frequently washed with a succession of gargles, strong alum- 
water, Huxham's tinct, diluted muriat. acid ; and bark, wine, 
elixir vit., and tonic diet were given as freely as the patient 
could bear them. The intermittent was checked at once, and 
the patient's health began to improve before the swelling of the 
cheek subsided in the least, or any line of separation could be 
seen. The tonic medicines and diet were continued, and another 
blister drawn as soon as the first was healed. But the state 
of the cheek meliorated slowly, and I was particularly struck 
with the obstinacy of the swelling and the inability of the 
* As the question, whether mercury has any agency in this mischief, must 
come before us for discussion, we shall print in italics all that relates to the 
use of this mineral, in every case. 68 
Jackson on Erosion of the Cheek. 
system to form a line of separation. About the 20th day 
from the time I was called, the slough came away, leaving a 
healthy ulcer which had nearly penetrated the cheek. The 
teeth and gums were not in the least affected at any period of 
the disease. 
Case. II.-About the same time George Gaus of Sunbu- 
ry, called me to visit his family, three of whom were ill of 
intermittent fever and dysentery. His daughter, about four 
or five years old, had also the cheek disease precisely similar 
to that of the above child, unless that there was very little, if 
any discharge of saliva. The father assured me that she 
had not taken one particle of mercury in any form ; nor can 
I possibly believe, that either he or Eisely deceived me, or 
that they were deceived themselves: nor indeed ought this 
cause of itself to have excited any inquiries concerning this 
mineral, since it was not attended with any flow of saliva; 
and moreover, as in the above case, the teeth and gums were 
in a healthy state. Iler dysentery was cured with large 
doses of calomel, jalap, and other purgatives; and at the 
same time a sufficient quantity of bark was given to check 
the fever. During this time probably not less than a hundred 
and fifty grs. of calomel wrere given, notwithstanding the state 
of the cheek. For the gangrene she was treated precisely as 
Eisely's daughter. She soon recovered her health, but writh 
a frightful ulcer which, howrever, did not quite penetrate the 
cheek. How the ulcers, in these two cases, healed I know 
not, as I was soon taken with the epidemic myself, and con- 
fined for several weeks. I went to see these patients since 
writing the above : Eisely's daughter is dead, but the other 
is a blooming girl, without the least deformity. It is not pro- 
bable that these sphacelations could have been arrested without 
medical aid, though it must be confessed that their character 
appeared to be rather indolent and obstinate, than inflamma- 
tory and phagedenic. They gave me no uneasiness at the 
time, but subsequent experience has convinced me, that had 
the debilitation of the primary diseases proceeded a few days 
longer, the patients might have been brought into the utmost 
danger. 
Case. III.-This occurred September, 1823, in a child of 
Hannah Smith of Northumberland. He was a robust boy of 
three years old, who had been taken with epidemic remittent 
fever, for which he was treated with venesection, cathartics, 
antimonials, cold water to the bead, and probably with some- 
thing more that I cannot now recollect. He appeared to be 
going on well till about the tenth day, when he was taken Jackson on Erosion of the Cheek. 
69 
with an incessant agitation of all his limbs, his brain and mind 
being at the same time apparently quite unaffected. An epis- 
pastic was applied to each limb, and nauseating doses of 
tartar emetic, conjoined with laudanum were given every 
hour, with the hope of obtaining both an antispasmodic and 
a diaphoretic effect: the exact doses I do not recollect.* 
This troublesome symptom subsided in about forty-eight 
hours, when the dreadful disease of which we are treating, 
was observed in the cheek. Its prima facies is so peculiar 
that we recognised it in one moment, as the same disease we 
had seen the year before, in the two preceding cases : a swell- 
ing and hardness of one cheek, with the upper lip slightly 
tumid, led us at once to suspect the existence of mischief 
within : nor were we disappointed. A little cineritious spot 
or rather tumour was seen behind the opening of the stenonian 
duct, without any symptom of inflammation near it, or in any 
other part of the mouth. As we were alive to the operations 
of mercury, it was not a little gratifying to find the teeth and 
gums apparently quite sound, and not the least sore on pres- 
sure ; and also, that the saliva was not increased nor the breath 
offensive. By this time I had learned from Underwood and 
Burns, what I had no doubt read long before and forgotten, 
the history of the gangrenous erosion of the cheek; but having 
treated two cases successfully by blisters, a remedy these 
authors do not name, I felt comfortable hopes with respect 
to this. 
The fever continued and therefore general tonics were not 
admissible. A blister was drawn on the cheek, and the mouth 
washed frequently with a strong solution of alum. At this 
time the swelling was very moderate and the mortification con- 
fined to a mere point. But the face swelled rapidly on that 
side and the gangrene proceeded without giving any hopes of 
a line of separation. In two days the pulse became soft and 
slow, and the fever being now arrested, we forthwith used 
tonic diet, bark, and elixir vit. with the bark poultice to the 
• Of this peculiar convulsive affection, which I compared to St. Vines' dance, 
I saw three cases that season, supervene on remittent fever. They were all 
in patients about the same age, and were all cured in a few days by the same 
means. In none was the brain affected, nor did the agitations subside for 
one single moment. They all appeared to die away very slowly under the 
continued use of laudanum and tartar emetic, given in as large doses as the 
patient could bear without too much puking. This was continued day and 
night, for the patient slept none, till the disease was observed to be on the 
decline, when the dose was gradually diminished. Blisters to the limbs were 
also applied in every case; perhaps they were useful in breaking the fever, 
if not in removing the convulsive affection* 70 
Jackson on Erosion of the Cheek. 
face. The mouth was washed alternately with Huxham's 
tinct. and muriatic acid diluted with four times its weight of 
water, and the sphacelated part was circumscribed twice a 
day with the nitrate of mercury according to the plan of Mr. 
Kirkland, until it was fairly ascertained to be utterly useless. 
The disease continued its deadly progress till the poor child 
was relieved of life about the twenty-fifth day of the gangrene. 
During all this time he suffered very little if any pain, and 
he had a ravenous appetite till the last two or three days, 
though much poisonous matter must have been continually 
passing into his stomach. In fact we were greatly surprised 
to find him livingso long, when we considered the deleterious 
effects of mortification on the general system, which in this 
case we did nothing to counteract after we found it impossible 
to preserve a tolerable visage. 
One side of this poor child's face was literally destroyed as 
high as the frontal sinus ; the teeth, maxillary, malar, palate, 
nasal, and orbitar bones were cast off or were picked away 
by the patient; one whole side of the face, including the 
mouth, chin, nose, and one eye were eaten away-a horrible 
sight which even to name is a revolting duty. Yet even in 
this deplorable state of things, many parts of the face put 
on signs of healing; and as the patient had a good appetite, 
we felt no little alarm lest he might continue tolive in this 
awful condition. This child had taken some purges of cal. 
jal. and scamm. in composition, all which operated freely; 
the breath was not that of a salivated patient, there was no 
How of saliva as in the first case, nor did he take any calomel 
which was not combined with the above mentioned active ca- 
thartics. We gave him large doses of laudanum in order.thathe 
might sleep away in comfort the remainder of his life, and that 
the mother might attend to the rest of her family, all of whom 
were sick ; and it is a little surprising that, towards the last, 
he would take more than half an ounce in 24 hours, without 
procuring more than ordinary sleep. 
Case. IV.-In August, 1825, we saw a case exactly simi- 
lar to this in the town of Milton, 12 miles above us. It was 
in a boy of four or five years old, the son of one Miller who 
still resides in that borough. The patient had been treated 
for bilious fever and had, like the little Smith, taken purges 
containing calomel: and like hinj too, nearly the whole face 
was eaten away, after the sphacelation had lasted several 
weeks. We believe that no calomel was given which had 
not been combined with more active cathartics: but we. have 
no means of getting at the exact history of the case. Jackson on Erosion of the Cheek. 
71 
Case. V.-This was the next that came under my own 
care, and horribile dictu, it was in my own child. This little 
girl, less than two years old, was debilitated by a variety of 
diseases in too rapid succession; an attack of habitual inter- 
mittent, cynanche-tonsillaris, measles, inflammation of the 
lungs, influenza, and finally her intermittent again, all which 
confined her about ten weeks, and had nearly brought her to 
the grave. When she was in a state of extreme weakness, 
we observed one side of her face a little swelled. I recognis- 
ed the tumour at once, and heard, with the utmost dismay, 
the little sufferer say cheek, cheek, while at the same time, 
she put her hand to the affected part. On opening her mouth 
I found the characteristic gangrene; but it was not larger 
than a dime piece, and was nearly circumscribed with a 
healthy periphery. Her catenation of maladies having ended 
in her old intermittent, we were ready to give quinine and 
tonic diet. 
This case was attended with an odour of the breath al- 
together peculiar and indescribable. Only one dose of calomel 
had been given as a purge, and there was no affection what- 
ever of the teeth or gums, nor any flow of saliva. 
Case. VI.-In July 1826, I attended a little girl of five 
years old, the daughter of Jacob Troxell, two miles above 
Northumberland. The primary disease was epidemic remit- 
tent fever, which proved rather stubborn, though not appa- 
rently very severe. She was bled twice, took two doses of 
calomel with jalap, and afterwards castor oil, jalap with 
scammony, and sometimes small frequent doses of gamboge. 
Nauseating doses of tartar emetic were used freely whenever 
they could be given without interfering with the operation of 
cathartics. She had constantly a severe pain in her head, 
and therefore cold water was frequently poured upon it from 
a pitcher, a remedy from which my patients have always 
derived great advantage in headach from bilious fever. 
All appeared to go on pretty well till about the tenth day, 
when we observed a swelling of the cheek and lip, with the 
lower eye-lid (Edematous; and upon opening her mouth, I 
beheld with horror the fatal gangrene, occupying the same 
place as it did in the preceding cases. The teeth and gums 
were not affected in the least degree, nor was there any dis- 
charge of saliva. Her breath had the same indescribable 
odour, as had that of my own child. 
The fever still continuing, rendered tonics inadmissible. 
An epispastic, assisted by Dr. Hartshorne's terebinth in ate 
decoction of flies, was applied to the cheek; the mouth was 72 
Jackson on Erosion of the Cheek. 
washed with strong gargles of alum-water; the gangrenous 
spot was circumscribed by a liberal application of lunar 
caustic. 
The second day I found that the epispastic had drawn free- 
ly, but that the cheek was more swelled; and that the gan- 
grene had passed the cauterized line on every side. The 
caustic was again applied, the blister dressed with basilicou, 
and it was directed that the mouth should be washed very fre- 
quently with muriatic acid, diluted with six times its bulk of 
water. She was also directed to take a teaspoon-ful of the 
diluted acid every two hours, but still further diluted and 
mollified with sugar. 
The third day her face was still more swelled, the gangrene 
had spread on all sides, but particularly towards the mouth, 
the whole face wore rather a livid hue, the cheek was nearly 
penetrated, the fever was so far gone, that quinine and tonic 
diet were given, the mouth was injected with the diluted acid 
and with undiluted Huxham's tinct., alternately used, the 
acid was still given internally, a poultice of the strongest 
Lima bark was applied to the face. 
The fourth morning all the symptoms were more unfa- 
vourable. A black spot appeared on the cheek opposite to the 
sore within, and the gangrene had spread rapidly towards the 
mouth. Until this morning I could not find that the teeth 
and gums were at all affected, but now the caninus and mo- 
lares, on that side of the upper jaw, were loose, and the gums 
were cast off from the teeth and completely livid. The tonic 
diet and medicine were continued, and given, we believe, as 
liberally as the stomach would bear them, for the unfortunate 
little sufferer was always ready to take any thing that was 
offered her. 
The fifth day all the symptoms were more distressing, and 
hope was now reposed in death rather than medicine. It is, 
therefore, not necessary to trace the progress of the disease 
from day to day; suffice it to say, that it advanced with a 
steady pace till it reached the mouth and nose, and she died 
about the sixteenth day of the gangrene. During the whole 
progress of the disease, there was no heat, no pain, no red- 
ness either within or without, no symptom of inflammation 
but the swelling. There was no diarrhoea either in this or 
the preceding fatal case, which is a little remarkable under 
such circumstances, for much putrid matter must have been 
continually passing into the stomach. 
Case VII.-A few weeks after this case terminated, Har- 
riet, aged five years, daughter of J. Hepburn, Esq., of this Jackson on Erosion of the Cheek. 
73 
town, had a pretty severe attack of bilious remittent fever, 
which was converted into intermittent about the eighth day, 
and cured by quinine. Hardly was this accomplished, when 
her father came to me in the greatest alarm, lest his daughter 
had been salivated. I was horror-struck with this intelli- 
gence, supposing that it was the same disease of which I had so 
recently lost Troxell's child. My anticipations were realized : 
her cheek presented the diagnostic swelling, the saliva stream- 
ed from her mouth, her breath had that peculiar smell which 
so strongly characterized that of my own and Troxell's child, 
there was a foul looking ulcer at the usual place of the gan- 
grene. 
As the fever was conquered, and the patient improving in 
health, under the use of quinine, wine, and soup, all which 
she had been taking for the last twenty-four hours, I enter- 
tained but little fear for the event, and, therefore, gave the 
parents no further insight into the disease till it was cured. 
The patient was strengthened by every means in our power, 
as quinine, vitriol, wine, and soup; the mouth was washed 
with diluted camphorated spirits, the face frequently bathed 
with warm, camphorated oil, and wrapped in flannel. The 
symptoms meliorated daily, and the patient was soon restored 
to health. Now, had the gangrene supervened a few days 
earlier, while the fever was still raging, and, therefore, the 
debilitation still going on, it would most probably have ended 
in death, or in a deformity worse than death. In this case 
only ten grains of calomel had been given, and the operation 
of this was promoted by small, frequent doses of gamboge, 
and purgative injections. And here the intelligent advocate 
of calomel will, no doubt, be surprised that we did not use 
this medicine more freely, in several of the above cases. But 
it must be remembered, that the mind is not always equally 
able to resist the force of impressions, as a man is sometimes 
startled in the dark, who was frightened with ghosts when a 
child: 
Nam veluti pueri trepidant atque omnia cxcis 
In tenebris metuunt, sic nos in luce timemus. 
Luchet. 1. II. 
And thus sometimes, under temporary feelings of dismay, we 
gave less calomel than we had been accustomed to do, before 
we saw Smith and Miller's children perish of the cheek dis- 
ease. 
The malady of which we are treating is no doubt, the gan- 
grenous erosion of the cheek, described by Underwood, in his 
Vol. xii.~ 10 no. 39. 74 
Jackson on Erosion of the Cheek. 
work on the diseases of children ; and as your paper may pass 
into the hands of persons unacquainted with that useful book, 
we shall here insert the whole of the chapter on this interest- 
ing subject. 
"This complaint has some resemblance to the canker, 
though it is much more dangerous, and is not a mere local 
disease. I have seen no clear account of it in any late writer 
but Mr. Dease of Dublin, who seems to have met with the 
disorder pretty frequently, and describes it very accurately in 
his tract on the Diseases of Lying-in Women, &c. to which I 
am very much indebted on this occasion. Mr. Hurlock, indeed, 
in his Treatise on Dentition, printed in 1747, mentions a 
complaint that seems to be of this kind, though he docs not 
appear to be well acquainted with it. 
" It usually attacks children from two to six or eight years 
of age, especially the unhealthy, and such as have been sub- 
ject to worms. The whole body often feels cold on the ap- 
proach of the disease; after which a black spot appears on one 
of the cheeks or lips and spreads fast; but without any marks 
of inflammation. Oftentimes the whole side of the face is 
eaten away, together with the lip, so that the bare jaw-bone 
and inside of the mouth appear. In the end, the entire lower 
jaw falls down on the breast, and the whole side of the face is 
dissolved into a putrid mass; a colliquative diarrhoea taking 
place from the offensive matter that is continually swallowed, 
especially by very young children. 
"In the cure, internal as well as external remedies are re- 
quired ; but only such as correct putrescency, and support 
the strength, seem to be of any use. A few drops of the 
acidum muriatic, therefore, taken inwardly, in the infus. rosae, 
or in the child's drink; the saline draught in effervescence: 
and in the end, the bark, in doses suited to the age, with good 
broths, jellies and wine, are the proper remedies. The parts 
should be washed, and likewise injected with muriatic acid in 
chamomile, or sage tea, and afterwards dressed with the acid 
mixed with honey of roses, and over all a carrot poultice. 
The child should in the mean time be gently purged with 
magnesia or rhubarb, to carry down the putrid mattersit may 
have swallowed. By this treatment, Mr. Dease informs us, 
he has recovered every patient except one, since he had re- 
course to this plan, which the world is much indebted to him 
for making public ; though fortunately this complaint does 
not appear to be, by any means, a common one." 
There is also a chapter in Burns' Principles of Midwifery, 
which we shall insert, in order to render this essay more Jackson on Erosion of the Check. 
75 
complete and satisfactory. These chapters will show, that 
however deplorable those distinguished authors considered 
the disease, they did not adopt a very active method of cure, 
and that a laudable routine of remedies is still greatly to be 
desired. 
''Another corroding disease begins in the cheek itself, orthe 
lip. It commences with some degree of swelling, which is 
hard, and firm, and shining. It generally begins on the cheek, 
which becomes larger than the other, and the upper lip be- 
comes rigid, swollen, and glossy. On some part of the tumi- 
fied skin, generally on the cheek, we observe presently a 
livid spot, which ulcerates and spreads, but laterally and 
downw ards. Being generally seated near the mouth, it soon 
reaches the gums; and even the tongue partakes of this dis- 
ease, which is of horrible aspect. We often find a great part 
of the upper or under lip destroyed, perhaps only a flap or 
portion of the prolabium left, all the rest being eaten away. 
The gums are foul, the teeth loose, the tongue thickened, 
partly destroyed, and lying so close on other diseased parts, 
that we cannot say what is tongue or what gum, except by 
the child moving the tongue ; and the mouth itself is filled 
with saliva. The ulcer is foul, shows no granulations, but 
appears covered w ith a rough irregular coat of brown lymph. 
The surrounding parts are somew hat sw elled : near the ulcer 
they are hard and red ; farther out on the cheek, they are 
paler, and have more of an (Edematous look. These local 
appearances are accompanied w ith emaciation and fever, and 
the child is either restless, or lies moaning in a drowsy state. 
This disease often proves fatal; sometimes, indeed, the parts 
cicatrize, or the patient recovers after an exfoliation of part 
of the jaw-bone. This ulcer is best managed with stimulants, 
such as diluted muriatic acid, solution of nitrate of silver, 
camphorated spirit of wine, tincture of opium, &c. but some- 
times it is necessary to give these up for a carrot or a 
fermenting poultice. The bowels are to be kept open, the 
strength supported by milk, soups, and wine; and acids, 
with ripe fruit, given liberally. Before ulceration takes place, 
the best application is camphorated spirit of wine, or we em- 
ploy friction, with camphorated liniment. A course of gentle 
laxatives is useful. 
"Another disease, destroying the parts, is called noma, 
which differs from the former, in destroying rather by gan- 
grene than ulceration. It attacks chiefly the cheeks and labia 
pudendi of children, and begins with a livid spot without 
pain, heat, or swelling, or with very little; and is not pre- 76 
Jackson on Erosion of the Cheek. 
ceded by fever. It ends in gangrene, which destroys the 
part, and the patient often dies in a few days. It is to be 
treated with saturnine applications, or a fermenting poultice, 
whilst opium and wine are given internally, with or without 
bark, according as the stomach will bear. The bowels must 
also be excited to action." 
This erosion, and this noma, are no doubt one disease, and 
the very same as that of which we are treating. We have 
however, never seen the tongue affected, nor the gangrene 
begin on the outside of the cheeks, nor on the lips. The noma, 
Mr. Burns tells us, "attacks the cheeks and labia pudendorum 
of children."-"It sometimes takes place after measles 
and scarlet fever, and may be conjoined with the induration 
of the cheek or lip previously described." This loose way of 
writing upon an important subject, gave us no satisfactory 
information, and therefore, we turned to the dictionary. Parr 
says that "Noma, from to eat, is a phagedenic ulcer, 
sometimes a species of herpes." The definition in Rees' Cy- 
clopsedia amounts to the same. Hooper's Quinsy says, " that 
nomse are ulcers that sometimes attack the cheek or vulva of 
young girls, that they appear in form of red and somewhat 
livid spots, are not attended with pyrexia, pain, or tumor, and 
in a fewT days become gangrenous." This reminds us of a 
most interesting paper in the Eclect. Repert. vol. 7th, on the 
"history of a very fatal affection of the pudenda of female 
children," by Kinder Wood, Esq. And since this useful 
paper is buried in the mass of an obsolete periodical, we shall 
endeavour to abridge it, for the use of your numerous readers; 
but particularly because we believe it must be the real noma 
alluded to above, a malady that appears to be very little known. 
The author saw twelve cases in nine years, all of them in 
children between one and six years old. Ten of them proved 
fatal, owing as he supposed, to his being called too late. 
The common symptoms of fever precede the local disease 
about three days ; the bowels are torpid and the patient lan- 
guid. She is now observed to have pain in passing water, 
and the labia are found covered with inflammation of a dark 
tint. Vesicles are soon formed both within and without, 
which burst and the consequent ulcers quickly spread and 
run into each other. A copious and offensive discharge irri- 
tates the adjacent parts, and spreads the disease to the anus 
and even over the mons veneris. 
After the inflammation commences the pulse is quick and 
irritable ; the face soon becomes of a peculiar pallid hue, or of 
a singular wrhiteness; the bowels, are torpid, and cathartics Jackson on Erosion of the Cheek. 
77 
uniformly bring away dark, slimy, offensive stools ; the pain 
on moving the pelvis is excruciating, and therefore the patient 
lies constantly on her back with her knees thrown open ; the 
urine is retained on account of pain in passing it, a circum- 
stance that should never be overlooked by the medical at- 
tendant. 
As the disease advances, it forms a deep, foul ulcer, that 
rapidly destroys the external organs of generation; the dis- 
charge increases with the increasing ulcer, and becoming 
more and more offensive, the patient is finally exhausted. If, 
however, the disease meets with early and proper attention, 
the ulcers are healed, but not without leaving the constitution 
debilitated and injured ; for there follows a copious discharge, 
which hinders the patient from recovering strength, and fa- 
vours the recurrence of the disease-a circumstance that 
occurred to the writer in two cases, one of w hich proved fatal. 
The duration of the disease is uncertain; in one case the 
patient became better in tw enty-three days, in the second she 
recovered in seventeen ; but the consequent mucous discharge, 
and general debility, continued from six to eight w eeks. He 
once saw it end in mortification, and in this case, which 
proved fatal, strong stimulants had been used, under which 
the parts swelled greatly and sphacelated. 
His treatment consisted, 1st. In moving the sluggish bowT- 
els with calomel and rhubarb, which uniformly brought away 
dark and offensive stools. 2d. In washing with weak lead- 
water, slightly aired, and covering the parts immediately 
with warm poultices, made of the same lotion, and crumbs 
of bread. These remedies were used till ulceration wras 
checked, and longer, if tenderness, excoriation, or apthse 
appeared on the adjacent parts. 3d. The ointment of white 
lead w as used when the ulcerating process was stopped. 4th. 
Bark in decoction with confect, aromat. and tinct. columb., 
with small doses of laud. 5th. The bowels receive the 
necessary attention, and red wine is given according to cir- 
cumstances. 
Though we have never seen this malady, we cannot help 
considering the doctor's remediate measures as rather ineffi- 
cient; and we are not at all surprised that he found himself 
called too late in ten of the twelve cases, the whole number 
that he had seen at the time of his writing. Whether he used 
any other means in these ten fatal cases we are not informed, 
and this we consider as a very great defect in his truly lauz 
dable and well-written history. We w ould particularly * 78 
Jackson on Erosion of the Cheek. 
inquire, why he did not use the catheter, since the passing of 
urine was so painful as to induce the patient to retain it, even 
to his manifest injury. If the local disease prevented him, 
we ought at least to have been told so. Sed non omni omnia- 
he must be a wise physician who never errs; and this little 
maxim we would thank the reader to remember, during his 
perusal of the present pages. 
In one respect, a knowledge of this disease may prove of 
the utmost importance to the safety of individuals. It not 
unfrequently happens, when young girls are diseased in these 
parts, that some one is supposed to have committed violence, 
or to have communicated a contagious disease; and that in- 
nocent persons are thus brought to the bar on charge of a rape 
or other misdemeanor. The author relates one case in which 
the circumstances appeared so strong against a young lad, 
and the disease so suspicious, that he himself deposed before 
the coroner's inquest, that he believed it to have come by 
external violence; whereupon a verdict of murder was given, 
and the accused person fled. The occurrence of a few more 
cases, however, soon convinced him of his error; the boy was, 
therefore, encouraged to return and surrender, whereupon the 
judge charged the jury in his favour, and he was instantly 
acquitted. 
The writer thinks it necessary to show, that this disease is 
different from intertrigo and from infantile erysipelas, but we 
cannot help fancying that he might have spared himself the 
trouble. He thinks it probable that Armstrong had seen 
some similar cases, as might be gathered from his work on 
the diseases of children. Whether it be the noma we know 
not; but if it have any cognation with diseases of the mouth, 
we would rather associate it with canker. This last disease 
we have often seen after the measles; and scarlet fever is 
often followed, as every one knows, by a spongy, swelled, 
and hemorrhagic state of the gums, that is sometimes suc- 
ceeded by ulceration, and sometimes also by tumid lips, thus 
showing a susceptibility of these parts, which attracts and 
fixes the relics of the general affection. Mr. Wood's disease 
sometimes runs into mortification ; so does the canker of the 
mouth, thus exuberating, as it were, into the gangrjenopsis. 
We must confess, however, that we know not any reason for 
associating the disease of the mouth with that of the genital 
organs, unless what is derived from the above definition of 
Vminsy, and from the above mentioned careless assertion of 
□Burns. Their noma, when it affects the genital organs, is 
most probably nothing more than foul ulcers, resulting from Jackson on Erosion of the Cheek. 
79 
the state of these peculiar parts, acted on by the peculiar 
irritation of the general disease. Thus, it ought not to sur- 
prise us, if ulcers of the labia should sometimes follow scar- 
latina, or even the measles, when they are of a low type, and 
particularly if strict cleanliness be not regarded; for exces- 
sive heat, the natural discharges, some friction, all conspire 
to attract the general disease to that part; and when ulcers 
are once begun, the state of the system, at this time, must 
contribute greatly to propagate, and to render them phage- 
denic and incurable. If Mr. Burns had known the noma of 
the labia conjoined with that of the mouth, he ought to have 
said so ; if he had read the history of such cases, he ought to 
have given his author; but his phrase, "may be conjoined,'* 
is altogether unsatisfactory, in a disease concerning which so 
little has been written. 
From these considerations, then, the following propositions 
will rationally follow : 
1. That Mr. Wood's disease is the real noma. 
2. That in scarlatina, and even rubeola of a low type, 
there may arise an ulceration of the genital organs, if clean- 
liness be not observed. 
3. That this may exuberate into something malignant, and 
be, therefore, denominated, with strict propriety, the noma. 
4. That this noma may have no relationship with diseases 
of the mouth. 
5. That the gangrsenopsis may often take place in the scar- 
let fever, and even in the measles of a low type, as well as in 
dysentery and remittent fever. In the case of my own child 
it followed the measles. 
6. That, should the noma of the labia pudendi be, by 
chance, attended with the cheek disease after measles and 
scarlet fever, this coincidence does not prove an identity, un- 
less it can be shown that the disease may be translated from 
one part to the other. 
Etiology of the gangrsenopsis.-We very cordially agree 
with the prince of poets in hx^felix qui potuit rerum cognos- 
cere causas ; but to this happiness we cannot, in the present 
case, make any pretensions. This ignorance, however, is 
the fate of medical men. We are not unfrequently troubled 
no little to answer the question, what is the cause; and we 
must either confess honestly, that we do not know, or run 
into a disquisition that neither ourselves nor the patient can 
possibly understand. Yet it is truly surprising what satis- 
faction this semblance of knowledge, however delusive, affords 
to the ignorant multitude. The learned and the unlearned, 80 
Jackson on Erosion of the Cheek. 
the wise and the simple are equally delighted with a catena- 
tion of words, which conveys no more meaning to their minds 
than the whistling of winds. I once remonstrated with a 
learned physician for using language which our patient could 
not understand, he jocosely replied, "1 did not understand it 
myself." 
In the present case, however, we must discuss the question 
whether mercury has any agency in the mischief; and with this 
intention before us we have printed in italics, the quantity of 
calomel that was given to each of the patients. Underwood 
and Burns do not name this mineral: it is true they do not tell 
us that they ever saw the disease, and it is most probable that 
at least Underwood never did, since, as Dr. Coates informs 
us, his chapter " is wholly borrowed from a work by Mr. Dease 
of Dublin, on the diseases of lying-in women." That it may 
take place without the agency of mercury we do not hesitate 
to aver in the most positive terms. In my two first cases, I 
made such inquiry as would have resulted in satisfying the 
most obstinate sceptic, that not one particle of the medicine 
could have been taken ; and this inquisition was the more per- 
severing because my first impression was, thatEisly's daugh- 
ter was salivated. It is true that all my other patients took ca- 
lomel as a purgative, but it was conjoined with, or immediately 
followed by some more active cathartic which generally ope- 
rated freely ; and it is equally true that physicians are in the 
daily practice of giving more calomel than w as given to these 
unfortunate children, and that too, without any consequent 
mischief. That rule of philosophizing, therefore, which refers 
the same phenomena to the same cause, excludes calomel as a 
direct agent in the gangrtenopsis: we shall now inquire 
whether it can be considered as a predisposing cause. 
All the cases that we have seen w;ere preceded by bilious 
fever, a disease that generally has a tendency to spend its 
violence on some particular part; and therefore, if any irri- 
tation, and particularly one that debilitates, should attract and 
fix the morbific influence, a mortification may be the conse- 
quence. In one case of this fever, we knew blisters to mor- 
tify, and in several instances we have known a lingering 
sphacelation of the soft parts, covering the lumbar vertebrae. 
Upon this principle then can mercury have an indirect agency 
in the gangrsenopsis ? It is well known that children cannot 
be easily salivated ; but is it not reasonable to suppose that 
mercury has even in them its specific tendency to the jaws; 
and if so, may it not predispose these parts to this fatal gan- 
grene, and create that morbific attraction that brings upon Jackson on Erosion of the Cheek. 
81 
them the whole weight of the general disease ? Pars dolens 
trahit is a maxim in medicine as true as any of the Newtonian 
Principia, and is of wonderful efficacy in explaining the mys- 
teries of morbid catenations. In confirmation of the above 
opinion we have to relate the case of a little girl, about eight 
years old, who perished of this disease after her face was 
almost wholly destroyed. 
She was first taken with an epidemic remittent fever, and 
her physician, a man of more than ordinary talents, told me, 
that finding her head affected beyond the reach of ordinary 
remedies, he attempted to salivate her : that after some days 
a pimple appeared on the inside of the lip which soon after be- 
came gangrenous, spread to the gums, and ended in the dis- 
ease of which we are treating. The parents refused to have 
a blister drawn, by which, the physician had hoped to arrest 
the gangrene. 
The same physician, in conjunction with another, attended 
a man about the same time, for remittent fever, for which 
they thought proper to salivate. The medicine did not operate 
to their satisfaction nor produce ptyalism ; but while they 
were still giving it, a gangrenous patch appeared on the inside 
of the lower lip, and assumed an alarming appearance. 'They 
very dexterously wrapped up the whole lip and chin, in an 
epispastic which arresWMUe gangrene, and effected a healthy 
sloughing, though the patient was already sinking under the 
primary disease. 
Now these cases might lead a prejudiced mind to refer the 
mischief to mercury, but it is clear to any rational, unprepos- 
sessed understanding that this mineral might have had no 
agency in the matter. In both cases ther^ was a certain fe- 
brile erithism which perverted the just operation of medicine, 
and mercury appeared to be the only agent capable of deob- 
structing the system, and of restoring healthy excitement. It is 
most likely that the system felt not its influence at all, and 
that the gangrene was, in both cases, the result of the general 
disease now thrown on the jaws by some unknown influence. 
While these two cases were the subjects of discussion to those 
interested, one of the medical gentlemen was called to a little 
girl in the same town, who had been attacked with bilious re- 
mittent fever, and had taken no mercury whatever : she too 
had the cheek disease. But a large blister to the face and 
other appropriate treatment, which I do not now recollect, 
very quickly arrested its progress. I can vouch for the honour 
and integrity of the medical gentlemen who gave me the out- 
lines of these three cases. 
VOL. XII. -11 NO. S9. 82 
Jackson on Erosion of the Check. 
I well remember that Dr. Rush used to caution the students 
of his numerous class, against attempting to salivate patients 
under six years old, lest the mercury should produce a morti- 
fication of the jaws; and we believe that he was accustomed 
to add this very phrase, which has long been familiar to our 
ears-"several cases of which have happened in this city, 
attended by circumstances of great distress." In turning to 
some notes which we took of his Therapeutics, and of that part 
of them which treated of salivation, 1 found the following 
words :-" it is forbidden in children under six years old, as 
their tender jaws are not able to withstand this powerful 
stimulus; they run into gangrene." Such a caution from this 
undaunted practitioner, must have heen founded either in ob- 
servation or reading. This, therefore, leads us directly to 
a very important part of our essay, which may serve to con- 
firm the utility of the professor's injunctions. Though I am 
well satisfied that mercury has no direct agency in the gan- 
gramopsis, yet I have met with three cases of exfoliation of 
the alveolar processes in children, which may have been owing 
to the perverted operation of this mineral. 
Case I.-A child of three years old I bled frequently for 
inflammation of the lungs, which had run on too long with- 
out medical aid. Tartar emetic was constantly given in 
nauseating doses, blisters were used'fl'eely, and finally, when 
no more blood could be let, the calomel was given in doses of 
five grains, twice a day, as an expectorant, and the tartar 
emetic was given during the intervening hours, as fast as the 
stomach and bowels could bear it. The cough became loose 
in a few days, and the fever abated; but the child's breath 
was now intolerab*[offensive, and upon examination, I found 
the lower teeth on one side loose, and the gums fallen off. 
The teeth were easily removed, and the mouth was washed 
with charcoal and diluted IIux. tinct. The alveolar pro- 
cesses came away, and the ulcer healed without difficulty. 
The breath was not mercurial nor was there any ptyalism. 
Case II.-A little boy, eight years old, had the epidemic 
remittent fever, for which he took, towards the decline of the 
disease, several doses of calomel, each ten grains, without 
any other cathartic. After a few days he complained that 
his upper jaw was sore, and, upon examination, I found that 
his teeth were loose, and the gums fallen off". As in the above 
case, there was no ptyalism, and the breath was offensive but 
■ not mercurial. The mouth was washed with diluted Hux. 
tinct., and, as he complained of headach, a blister was drawn 
on the back of his neck. Before the next day the gums were Jackson on Erosion of the Cheek. 
83 
gangrenous and the cheek was swelled, but it did not assume 
the appearance of gangraenopsis. The teeth were very easily 
removed, a blister was drawn on the cheek, and the gargle, 
continued. 
Before, the third day, the mortification had spread to the 
inside of the cheek; but it is not necessary to trace the daily 
progress of the disease; suffice it to say, that a large piece 
of the maxillary bone exfoliated, and not without great dis- 
tress and general febrile irritation for several weeks. He 
finally recovered his health, but a little depression is still seen 
below the malar bone. This boy was repeatedly blistered on 
the cheek, the mouth was attentively washed with alum water, 
Hux. tinct., diluted muriatic acid, in succession and rotation, 
all carefully injected every hour with a syringe; and bark, 
with vit. and tonic diet, were given liberally, till a line of 
separation was distinctly formed, and the exfoliated portion 
found to be loose. In this case let it be remembered that the 
disease did not begin in the cheek, but that it spread thither 
from the gums. 
Case III.-This, too, began with remittent fever, in a boy 
about eight years old. He took calomel several times as a 
purgative, and, towards the twelfth day of the disease, the 
teeth on one side of the lower jaw fell out, or were removed 
by the patient himself, and the socket exfoliated. There was 
ulceration but no sloughing of the soft parts. He recovered 
under the same treatment that was used in the preceding case, 
without any external deformity. In none of these cases was 
there any thing similar to that characteristic swelling of 
the check, by which the gangraenopsis was instantly recog- 
nized. 
Though these three cases cannot certainly be referred to 
the use of mercury, yet, it must be confessed, they have ren- 
dered me no little fearful of using this medicine in children, 
as freely as I formerly did. But when we consider how 
extensively it is used in cases of croup, worms, fevers, hydro- 
cephalus, and how generally innoxious it has proven to chil- 
dren, I am almost ready to refer even this exfoliation to some 
latent attraction of the fever to the diseased part. It has, 
however, been observed, that emet. tart., whether given to 
nauseate or to produce full emesis, is apt to determine the 
operation of calomel to the jaws; now, in cases of worms, 
we do not give the tartar in conjunction with calomel, in 
croup, the time is too short to effect this mischief, and in hy- 
drocephalus, we can hardly touch the system with mercury 
in any form. 84 
Jackson on Erosion of the Cheek. 
In the gangrienopsis, therefore. I do not admit the direct 
agency of mercury; in this exfoliation I have some fears. 
Nauseating doses of emet. tart, were given in every case 
daily, for many days, and it is very possible that it might 
have determined the operations of the mercury in this unfor- 
tunate way. Nor can this hypothesis be overturned by any 
argument derived from the general innoxious use of the me- 
dicine. The common practice with calomel is safe and salu- 
tary; but there is no rule in the uncertain sciences to which 
there is not an occasional exception. We all know that a 
single dose of calomel, even when purged off very briskly, 
will sometimes salivate an adult with great severity. The 
most distressing salivation that I ever saw, was effected by 
four grains of calomel, in such combination, as to purge and 
puke the patient with the utmost vehemence. In the present 
state of our knowledge, we consider this an aberration from 
the laws of nature-why should nature not prove a little ca- 
pricious in children also, and sometimes produce a deter- 
mination of mercury to the jaws contrary to her accustomed 
operations ? 
If the reader inquire why we gave calomel as a purge, 
without any more active cathartic, we shall answer that, in 
our opinion, it is by no means a laudable practice; and here 
let us remind him that it was not done in any of the cases of 
gangreenopsis. Children are often so unmanageable, or their 
nurses so tender, that it is with the utmost difficulty we can 
find means of giving them any thing else. I have lately been 
in the practice of giving the calomel first, and afterwards the 
jalap mixed with water; in this way it can be forced down 
their throats, and the portion that is lost can be easily sup- 
plied from another dose. This method I have found more 
satisfactory than that of mixing the compound medicine with 
jelly. To purge off calomel we have also tried gamboge in 
small, frequent doses, according to the method of Dr. Fer- 
riar, but it very seldom operated to our satisfaction. But 
upon reviewing the practice of giving calomel uncombined, 
we have probably imagined many evils that seldom obtain. 
It is a heavy mineral that may settle to the bottom of the 
stomach, and becoming involved in the mucus of the first pas- 
sages, it may lie dormant till brought into action when the 
quantity is greatly accumulated. Thus we have somewhere 
read, that an examination after death demonstrated, that the 
whole quantity of calomel given was then imbedded in the 
intestinal mucus. This we cannot but consider as one of the 
most important facts in modern medicine, as every thing must Jackson on Erosion of the Cheek. 
85 
be important, which throws any light upon the apparent 
aberrations of this most noble mineral. But whatever phy- 
sician is frightened from a liberal use of calomel, his practice 
will be far less satisfactory to himself, and less beneficial to 
his patients. The wonderful powers of this medicine in 
many diseases of children, and particularly in those attended 
with bile, can never be sufficiently praised. A little child 
labouring under languor, dejection of spirits, slow fever, and 
diarrhoea, with offensive, bilious discharges, may sometimes 
be treated with the whole routine of the old school, rhubarb 
raw and spiced, magnesia, crab's eyes, and much more that 
we need not name; and after all these are given unavailingly, 
behold ! a dose of calomel carries off the whole disease, and 
the next day the little sufferer has natural stools, and calls 
for food. In a few weeks he is attacked again, another dose 
of this noble cholagogue is given, and the patient purged and 
puked into health in one single day. But it appears from the 
experience of the few last years, that we have heretofore known 
but little of the wonderful virtues of this article, and that in the 
future knowledge of this and of tart, emetic, lies hidden one 
half of the expected improvements of practical medicine. 
Why the croton oil was not given in some of the above 
cases 1 know not, for I have found it next to calomel, the 
most useful cholagogue medicine in children, and by far the 
most easily given to a refractory child. It is not a little un- 
fortunate that this excellent medicine should come at so high 
a price; but this ought to be no obstacle when danger stares 
us in the face. The price too is not a little enhanced by the 
present inferiority of the oil. When it first reached us, a single 
drop was sufficient for an adult, but no sooner is the reputa- 
tion of the medicine established, than ten are required for the 
same person. 
We have now laid all the facts before the reader, and his 
opinion will, notwithstanding, be determined by his preju- 
dice : if he has learned any thing further, let him communicate 
freely on the subject. For our own part, we believe that 
mercury has no direct agency in the gangrsenopsis. It may 
possibly irritate and predispose the part, and thus establish 
a catenation of morbid attraction, and so may any other local 
and debilitating irritation. Upon this principle we have sup- 
posed that the disease may arise from any injury done to the 
part, while the system is pervaded by a sphacelating influence, 
as no doubt it is in many cases of fever. As to my own child, 
I fancied that she injured the part between the molar teeth, 
and I had thoughts of removing at least one of them : from this 86 
Jackson on Erosion of the Cheek. 
however, I was deterred by fear of attracting the disease to 
the jaw. In the remittent fever, children are very often 
seized with convulsions, in which it is evident they might 
bite and bruise the part on which the gangrene usually begins. 
There is now a justice of the peace in this town, a man of 
great respectability, whose grand child in Virginia is dis- 
figured by the gangrsenopsis. It appeared in her cheek im- 
mediately after convulsions from fever. She lost none of her 
teeth, but the cheek was corroded quite through its substance. 
It has already been said, that I have frequently seen the re- 
mittent fever produce a mortification of the soft parts cover- 
ing the lumbar vertebrae-as a counterpart to this, I observed 
that Troxell's child, who died of the gangramopsis, lay con- 
stantly on the side afterwards diseased, with her hand under 
her cheek. About the period of life at which this disease 
sometimes occurs, the patients arc about cutting their first 
permanent teeth ; this circumstance had nothing to do with 
any of the above cases. 
To the usual question then, what is the disease, permit us to 
answer that we do not know. Neither do we know what is 
pleurisy, gout, rheumatiom, or any of the numerous maladies 
to which we are subject. There are many diseases of the 
human body that may be associated, because a long succession 
of observations on their character and methods of cure, has 
rendered it probable, that they are of similar, if not of an 
identical nature :-is there no disease, then, with which to 
associate the gangrsenopsis? We answer that we know of 
none; nor do we consider it a matter of any importance, 
whether it stands in our books as an isolated disease, or 
w hether it finds some congruous place in Dr. Good's nosology. 
The canker of the mouth sometimes runs into gangrene of 
the face, but this is a very different disease ; and lest any of 
our readers should be of a different mind, we shall here give 
the reasons of our opinion ; and this will be most effectually 
done by laying before them a short history of the canker, 
which we shall abridge from Dr. Coates' truly excellent essay 
on that disease, in the third number of the North America 
Medical and Surgical Journal. 
It commences at the edges of the gums and generally in 
those of the lower incisores. The gums are more or less 
separated from the teeth, and, in the great majority of pa- 
tients, they have a whitish discoloration ; in a very few 
cases, they have been found a little inflamed. In this state 
the disease often continues for a long time, even for several 
months ; and so common was it in the children of the Asylum, Jackson on Erosion of the. Cheek. 
87 
that of 240 inmates, no less than 70 were found affected with 
it at the same time. In this early stage, and until the local 
disease makes further progress, there is no apparent general 
irritation, no nocturnal fever, nothing to be observed but 
loss of appetite and other symptoms of general debility. If, 
however, the disease be not checked either by medicine or the 
powers of nature, it spreads to the adjacent gums and passes 
down into the socket; the teeth become loose and when drawn 
they are found denuded of periosteum. The Dr. is even of 
opinion that this membrane is the primary seat of the malady. 
If the disease be of the worst kind, it often proceeds rapidly, 
the ulcers become of the sloughing kind and necrosis involves 
the socket. Now for the first time a fever from irritation is 
manifest, and it appears to arise from inflammation of the 
mouth-a secondary symptom, apparently caused by the ac- 
rimony of the discharge. 
So much for the canker before it reaches the cheek ; but 
from this account, which comes from the best authority, we 
can form no image of the disease of which we are treating. 
We have often seen the canker in children of the poor, and 
uniformly cured it very quickly, by extracting the teeth, and 
applying white vitriol pulverised with an equal portion of 
sugar. We have never seen it run into gangrene, owing per- 
haps to the more salubrious air in wdiich we reside. 
We shall go on to abridge the Dr's, history. He has often 
seen the gangrene spread from the gums to the cheeks and lips, 
and bad cases generally end in this way. Symptoms of in- 
flammation are now manifest, the whole cheek swells and 
assumes a smooth, polished, dense, white appearance, resem- 
bling the effects of a violent salivation. A black spot is now 
frequently seen on the outer surface of the tumour, which 
spreads rapidly, and this has been, in Dr. Coates' manifold 
experience, the immediate harbinger of death. " 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 and falling out; the whole lining membrane of 
the mouth suffering a violent excoriation ; the wdiole adjacent 
external cellular substance hard and swelled ; large gangre- 
nous spots on the inside of the cheek or lips, sometimes extend- 
ing quite through to the outer surface; a total incapability of 
sleeping or of taking the least food; fever; a swelled abdomen 
and diarrhoea." 
Now in all this train of evils, we can see no likeness to the 
disease of which we are treating. It is true that it ends in 
mortification of the check, which is preceded by a swelling 88 
Jackson on Erosion of the Cheek. 
very similar to that which ushers in the gangrsenopsis; but 
this fact only proves the truth of Dr. Coates* observation, 
"that there is a great liability to gangrene in more than one 
part of the mouth." Our malady seems to begin at the point 
where the canker is about to end ; but even suppose that they 
end alike, this circumstance no more proves their identity than 
it proves that all diseases are one, which end in mortification 
of the same part. Gangrene of the cheek, was the immediate 
harbinger of death in the canker, but in the gangraenopsis 
it was almost the first symptom, and it continued for several 
weeks, till the greater part of the face was destroyed. The 
mortified check from canker appears to arise from a local 
disease at the roots of the teeth-the gangraenopsis is the fatal 
termination of a general fever. In one the labour of the phy- 
sician generally ends where the gangrene begins-in the 
other, his care and sorrow only then commence. So that 
neither in their history, nor their methods of cure can they 
be considered as the same disease. 
We have run into this digression because we find that one 
of the diseases, as described in books, may possibly be mis- 
taken for the other. Even Dr. Coates supposes that the dis- 
ease described by Van Swieten, in his article gangrene, is 
plainly the canker of the mouth. We thank the doctor for 
directing our attention to this book: it has lain upon our shelves 
for fifteen years without our having even looked into this part 
of it. We beg leave to dissent, however, from the doctor's 
opinion, that the commentator describes the canker " in a 
manner so similar to that in which it now prevails, that no 
doubt can exist of the identity of the disease." We, on 
the contrary, fancy that we see the gangrsenopsis very plainly 
delineated : we see a general disease, that is the scurvy, con- 
centrating its malignant influence in the cheek, one of the parts 
which Dr. Coates considers as peculiarly liable to gangrene. 
We shall here insert Van Swieten's history of the disease, 
premising however that the reader ought to bear in mind, that 
in this case, it is supposed to supervene on scurvy, or at least 
to occur in scorbutic habits. This will explain the reason of 
its affecting the mouth more generally than it did in our cases; 
though let it be observed that the author mentions the cheek 
first, in his catalogue raisonne of the parts affected. 
There first arises on the inside of the cheeks, gums, lips, 
tongue, tonsils, &c. as light redness, not very painful, and a 
more than ordinary heat; soon afterwards a white spot shows 
itself in the middle of the red part, which the surgeons are apt 
to mistake for the first appearance of a suppuration. The Jackson on Erosion of the Cheek. 
89 
pain then increases and particularly in the place where the 
white spot is, as also in all the parts around it, which at this 
time look very red. In the mean while the exulceration sinks 
deeper, till the whole white spot, which is nothing else than 
a true gangrenous eschar, falls off, which it will do if the 
distemper be not severe, and the patient be a person grown 
up. But, if the case be very malignant, and the person af- 
fected very young, the mischief spreads, and the white spot 
enlarges itself to a considerable extent; at the same time the 
breath smells very offensively and a large discharge of very 
fetid saliva is continually distilling from the mouth. 
"I have seen very terrible instances of this kind, which 1 
cannot think of without horror, in the children of poor people, 
where the case has either been neglected in the beginning, or 
ill treated. For the gangrene of the gums has not only spread 
so far as to destroy the teeth which have already shown them- 
selves, but has also so corrupted the rudiments of the future 
teeth within the sockets, that the poor wretches have, from 
their infancy, been obliged to undergo the inconveniences of 
age, and become toothless. And yet this is but a slight part 
of their sufferings ; for I have seen where the gums have been 
so corrupted that almost the whole bone of the lower jaw has 
been cast off, the tongue eroded, the lips, cheek, and chin 
almost entirely eaten away, till death has at last put an end 
to their misfortunes."* 
Now this does not appear to be a disease that begins at the 
roots of the lower incisors, and in the periosteum of the fangs. 
The great physician, whom Dr. Coates designates as "the 
close practical inquirer into nature and the sound medical 
philosopher," would not have failed to detect incipient cases, 
and to trace the disease from its origin at the roots of the 
teeth. But he mentions the cheek first among the parts first 
affected; whereas Dr. Coates tells us, that he has never seen 
a well marked instance of the cheek being affected, by the 
canker, without previous ulceration at the gums. Van 
Swieten's disease occurred also in adults. "I wTas once 
called in to a corpulent man, in one of the worst kinds of 
a putrid scurvy, whose lower jaw was almost entirely eaten 
away with the disease." Now it is hardly probable that 
a little disease at the roots of the teeth, would have thus de- 
stroyed an adult subject: rather let us consider that it was 
the malignity of the scurvy fastening on the jaw. Again, in 
loco cit. " as this disease frequently arises from the scurvy, it 
• Comment. Sect. 432. 
Vol. xil.-12 no. 39 90 
Jackson on Erosion of the Cheek. 
is usual to wash, &c." Now this disease of the face is no more a 
part of the history of scurvy than it is of the remittent fever: 
in both cases it appears to be a concentration of general dis- 
ease on parts peculiarly susceptible of mortification. It is 
true the commentator mentions redness, heat, and pain, none 
of which occurred in our cases. But let it be observed that 
the general disease was scurvy, which probably produced all 
these symptoms, before the gangrene supervened. We are 
not contending for a precise similarity of symptoms, which 
always vary under varying circumstances, but merely that 
the gangramopsis is the issue of a general disease, and that 
this was the fact in Van Swieten's cases.* Thus it some- 
times results from dysentery. In my second case the pa- 
tient had intermittent fever and dysentery combined; and 
there is a young man, one John Davis, lately of this neigh- 
bourhood, who has a large scar, occasioned by the destruction 
of part of the cheek. His jaws are so closely locked that 
he feeds altogether on fluids, and his articulation is very indis- 
tinct. I learned from his parents that he had taken mercury for 
the dysentery when about eight years old, and that it brought 
on mortification. All this however was a mere assump- 
tion, for upon a closer inquisition, they appeared to know' 
nothing of the matter. He must have taken mercury, but, to 
use their own language, they could not swear that he took any. 
He had lost none of his teeth, though the ulcer must have been 
very extensive, the cicatrix now making part of the lips. 
Synopsis of Symptoms.-Whenever then, in the course of 
our attendance on children debilitated by fevers, we perceive 
the least swelling of the cheek, it is time to take the alarm. 
According to our very limited experience a little cineritious 
spot will be found on the inside of the cheek, even at this early 
stage. This, as Van Swieten observes, "is nothing else than 
a true, gangrenous eschar." Now what physician wrould a 
priori suspect from this, that any serious evil w as impending; 
and this fact we w7ould desire every inexperienced reader to 
impress on his mind. If the case is not seen till it has made 
a progress of twro or three days, the face will be found pale, 
the cheek tumefied, hard, and shining, the mouth distorted, 
the lower eye-lid oedematous, the saliva sometimes profuse, in 
some cases not at all increased. We have already mentioned 
that in three cases the odour of the mouth wras altogether pe- 
• Whether Van Swieten mentions this gangrene when treating of scurvy 
we cannot ascertain, as our copy of his work does not reach beyond the tenth 
volume. Jackson on Erosion of the Cheek. 
91 
culiar. At this time the gums and teeth arc, to human eyes, 
entirely unaffected, but the gangrene will even now be found 
to have made alarming ravages in the cheek; and spreading 
sooner or later through continuous parts, the gums are seized, 
the teeth become loose, and necrosis involves the socket. 
The further progress of the sphacelation can be more easily 
conceived than described. There is no general inflammation 
of the mouth, none very evident even at the margin of the gan- 
grene, the parts seem to pass immediately from life to death. 
The first spot of gangrene appears cineritious and even whit- 
ish, but in the progress of the disease, the dead parts are 
nearly black. The patient appears to suffer very little, he lies 
quiet, desires to be left to himself, in fact he appears both in 
body and mind to have passed into another state of existence. 
In one case, which I have already mentioned as having 
occurred under the care of another physician, the gangrene 
began in form of a small pimple on the inside of the lower 
lip, the gums at the same time being not the least affected, 
though mercury had been given for the express purpose of 
salivation. This pimple very quickly became gangrenous, 
the parents refused to have a blister applied ; what was done 
I cannot certainly recollect, but the case ended in death, after 
several weeks, the face being nearly destroyed. In the other 
case, which was that of an adult whom they were endeavour- 
ing to salivate for remittent fever, the disease began on the 
inside of the lip, and exhibited a patch of perfect gangrene. 
They enveloped the lip and chin in an epispastic, which ar- 
rested the disease and produced a healthy sloughing; though 
the patient was gradually sinking under his first disease. We 
have not forgotten that we told this story some pages back ; 
but it is useful, and worthy of being told again. 
Of the. Cure.-If in the whole history of medicine there is 
an appalling and heart-rending spectacle, it is that of a little 
child, suspended between life and death, with a portion of his 
face destroyed. Happy, thrice happy the man who shall 
discover the means of averting this evil! The present writer 
knows no remedy that he can recommend with confidence; 
the routine of Burns and Underwood is wholly inadequate; 
and so will the method of Van Swieten be found in the sever- 
est cases. 
Blisters.-The utility of this remedy in mortification, led 
me at once to prescribe it in the cheek disease. The two first 
cases were cured by the force of nature or of medicine, and I 
am inclined to believe that the blisters were of essential service. 
In the two patients that died they did not, as we believe, re- 92 
Jackson ou Erosion of the Cheek. 
tard the disease in the least; but whether any mortal means 
could have stopped the career of these cases we are altogether 
incredulous. We are sorry to confess that we have not found 
this remedy as useful in common sphacelation, as we at one 
time fondly anticipated. The application, in some cases, 
requires a degree of acumen which few possess; and however 
salutary it may have proved in the hands of the illustrious 
American surgeon who first brought it into notice, we fear 
that in common hands it is frequently of mischievous ten- 
dency. It may sometimes turn the wavering balance of na- 
ture in favour of a separation ; but whenever the sphacelating 
action is strong in a part, and the general system brought 
under its influence, we fear that blisters are not unfrequently 
hurtful. In the cheek disease, however, I cannot but recom- 
mend them, though it be rather from analogy than experience. 
Their use must be confined to the earlier stages, or to those 
cases in which the gangrene is confined to a small circle, and 
in which the adjacent parts are possessed of sufficient vitality 
to rise into life, under their revivifying stimulus. If the first 
epispastic do good, or, indeed, if it have evidently done no 
harm, and the gangrene be not too far advanced, we should 
be decidedly in favour of a second application, even before 
the first blister might have entirely healed. This method, we 
presume, would prove more efficacious than that of drawing 
the part with any dressing more stimulating than common 
basilicon. We consider it as of primary importance, that 
the plaster should be as powerful as possible, in order that it 
might draw quickly, and thus tend to subdue, rather than to 
irritate, the disease, beneath. As slow blisters often feed the 
flame, we are accustomed to use Dr. Hartshorne's terebin- 
thinate decoction of flies, whenever a rapid effect is particu- 
larly desired. It would be well to consider, whether a blis- 
ter drawn by the nitric acid, or boiling water, would promise 
to be more efficacious. In fine, whatever produces the greatest 
discharge, in the shortest time, and with the least irritation, 
ought to be applied without unnecessarily losing one single 
moment. In that exfoliation of the alveolar process of which 
three cases have been mentioned, we do not hesitate to re- 
commend blisters as superior to every other remedy. Here 
the disease lies deeper, and they act by attracting the malady 
from bones and periosteum to the flesh and skin of the cheek. 
Caustic.-If, in the earliest stage, the mortified part could 
be fairly circumscribed by the actual cautery, and the peri- 
phery deeply burnt, at the same time an epispastic applied, 
assisted by the decoction of flies, we should certainly leave Jackson on Erosion of the Cheek. 
93 
the patient with some hope of success. In this case our busi- 
ness would be, to make such a decided impression on the part 
as would certainly subdue all the previous sphacelating ex- 
citement. Of course the physician must not consider, how 
much he is about to destroy, but rather the dreadful destruc- 
tion that will follow, if the disease transgress the bounds of 
his cautery. This would be a hard task to fulfil, and a sub- 
ject of melancholy reflection were it not to succeed. When 
there is no debilitating fever present in the system, and gene- 
ral tonics can therefore have their just operation, we presume 
there is little danger; but should another case come under our 
care, in which the system is possessed by any debilitating 
disease that thwarts the operation of tonics, we shall cer- 
tainly try the cautery, unless, in the mean time, we hear of 
something more promising. 
But this brings to our mind a circumstance of no pleasing 
recollection. I lanced the gums of a child six months old, 
that was greatly reduced by the summer complaint; the ves- 
sels did not contract, and blood continually passed into the 
stomach from whence it was discharged by vomiting. After 
ten or twelve hours the parents became alarmed, and fancied 
that their child would bleed to death. The patient was 
sinking with her original disease, and I had now no doubt 
but that she would die in a short time; but to render the 
matter more satisfactory to those concerned, I undertook to 
stop the hemorrhage. Vitriol, white and blue, was utterly 
useless, and so was plugging the incisions. A hot wire was 
then applied freely, but the more it was burnt, the more it 
bleed ; there was not vitality enough left to react under the 
cautery. If then the gangrsenopsis should begin in a patient 
already very greatly reduced, it might become a question, 
whether the actual cautery would not prove equally useless, 
however distressing to the patient, his physician, and friends. 
A resolute mind, however, that is possessed of the people's 
confidence, will endeavour to do something heroic in such 
desperate cases: a doubtful remedy is better than none-it 
may do good, and things standing thus, can hardly do harm. 
Success would be a source of lasting comfort, and failure 
would not prove to him any considerable detriment in public 
estimation. 
In the gangr?enopsis we cannot but consider the actual as 
far more promising than any potential cautery. It is supposed 
by old authors, and indeed by some among the moderns, to 
afford a more brisk, enlivening, tonic influence to the adjacent 
parts; and certainly its action can be more accurately limited. 
Dr. Coates informs us that M. Marjolin, author of the article 94 
Jackson on Erosion of the Cheek. 
gangrene de la bouchedes enfans, in the Dictionaire de la Me- 
decine, and therefore no doubt a man of reputation, has cured 
two cases of that disease, one by the actual cautery, and a 
second by the caustic potash. The same Marjolin cites three 
of his countrymen who have cured the said gangrene de la 
bouche by the actual cautery. The Dr. supposes that this 
disease was the canker; when the hot irons were used it is 
more than probable it had passed to the cheek or lips. 
Cataplasms.-Whether any benefit is to be derived from 
tonic and stimulating poultices, we are very doubtful. We 
cannot, however, suspect they would do harm, as they very 
often do in common gangrene, since there is here no evident 
inflammation. We cannot think that in the early stage they 
promise as much as the blister, but after the cheek has become 
largely corroded and the adjacent parts sink below the epis- 
pastic point, we strongly suspect that poultices of bark, wetted 
with Huxham's tinct., camphorated spirits, or some more 
enlivening corroborant medicine, might not be employed in 
vain. We used them in our two fatal cases, but as we ex- 
pected, without retarding the gangrene. But when matters 
have come to this pass the physician is fairly at a stand; he 
docs not know whether he can conscientiously endeavour to 
save life and to rescue from an early grave, an innocent 
child, to travel the long journey of life, an object of disgust 
to himself and of heart-rending sympathy to all around him. 
Expertus loquor, never were my feelings so harassed as 
with the dread that my two little patients would survive, 
and it was well for f , that I was incessantly and 
usefully employed in more manageable cases of those afflict- 
ing epidemics. But here another consideration presses on 
the mind. We know not how great may be the powers of 
nature even when all would appear to be lost and the patient 
certainly sinking. If then after abandoning him to his fate, 
in order that he might hide his horrid deformity in the grave, 
we should find him revive with a mutilation still greater on 
account of our benevolent neglect, what would be our feel- 
ings? Upon the whole we shall find it most conducive to 
peace of mind, and most accordant with the principles of our 
profession, to do every thing in our power, till we find the 
pulse irrecoverably sinking and the patient in the grasp of 
death. 
Local Stimulants.-We arc well convinced that with re- 
spect to this class of remedies, we did not use preparations 
of sufficient power. Underwood recommends that the part 
be "injected with muriatic acid in chamomile or sage tea." 
Burns says, that the ulcer is best managed with stimulants, Jackson on Erosion of the Cheek. 
95 
such as diluted muriatic acid, solutions of nitrate of silver, 
camphorated sp. of wine, tinct. of opium. But Van Swieten 
used undiluted muriatic acid in bad cases with great success. 
He says, "it presently stopped the gangrene and soon after 
the eschar has separated from the parts in which there was 
life. Nor have I ever known this application to fail me, 
except where the gums being entirely putrid, the jaw bone 
was affected ; for then I could not prevent its being carious ; 
but if the soft parts only in the inside of the mouth are the 
parts that are gangrened, it will certainly cure them."* 
This is no doubt overwhelming authority and it ought to 
claim the attention of every reader. We remember that 
Dr. Rush used to say, Van Swieten ought to be read for the 
sake of his numerous useful facts. 
The means ought to be energetic in proportion to the viru- 
lence of the attack; and, therefore, in every case which 
threatens to advance, we should recommend, after cauteriza- 
tion, a liberal use of the Baron's remedy. The nitrate of 
mercury we used without any advantage, but it was in a 
case of uncommon malignancy in which no human means 
would have been efficacious; and as the medicine according 
to Mr. Kirkland has done wonders in at least one case of 
mortification, we should be rather encouraged to use it 
again. An argument in its favour may be derived from the 
peculiar operation of citrine ointment, in many inflammatory 
cutaneous diseases and ulcers. 
In the canker Dr. Coates has found a strong solution of the 
blue vitriol, 30 grs. to the ounce of water, to prove far more 
efficacious than any other medicine that was tried in the 
Children's Asylum. We have already mentioned that in 
the same disease we have found white vitriol, pulverized 
with an equal portion of sugar, to afford, after extracting 
the teeth, the most distinguished relief. If any cases of the 
gangnenopsis should appear rather ulcerous than sphacelat- 
ing, these remedies would no doubt prove beneficial. 
Mr. Kinder Wood, in the disease of the genital organs, 
used lead water and poultices wetted with the same; but he 
found this medicine utterly useless where the disease was far 
advanced. This does not surprise us, for lead is among 
the last remedies we should think of using in a malignant 
ulcer, attended with general debility. Had he used some 
tonic applications he might not have been called too late in 
ten cases out of the twelve, to which his experience was 
limited. It is true he tells us that one case, in which sti- 
• Comment, Sect. 432. 96 
Jackson on Erosion of the Cheek. 
mutants had been used ran into mortification ; but what these 
stimulants were he does not inform us, and therefore we shall 
take the liberty of inferring, that they were not of the tonic 
kind. 
Ablutions.-The mouth ought to be well cleansed many 
times in the twenty-four hours ; and if the little sufferer is not 
able or willing to do it himself, the parts may be injected with 
a syringe. We have used strong alum-water, diluted muriatic 
acid, Huxham's tinct. We presume they were of little use 
except in washing away the putrid matter. The mouth 
ought to be held downward in order that the noxious fluid 
may pass out freely, lest a convulsive deglutition should con- 
vey some portion of it into the stomach. 
Constitutional Treatment.-It is evident that much poi- 
sonous matter must be continually passing into the stomach, 
that its primary operation on this organ must be very dele- 
terious, and that its long course through the bowels, cannot 
be altogether innoxious. To correct this evil, I gave targe 
doses of calcined charcoal to Troxell's child, a scruple of the 
powder frequently in the twenty-four hours. With respect 
to the use of general tonics, we are not aw are of any pecu- 
liarities that obtain in this disease: the physician must be 
* li d by those general principles which he may have de- 
rived from reading and practice. 
If the original disease be already subdued or have assumed 
the intermittent form, his way will be plain and he cannot, 
under such circumstances, fail to remedy a common case, 
■without any severe measures, or uncommon skill. But if the 
gangrene and the debilitation of the fever are'going together, 
let him remember our two fatal cases. Let him be assured 
that he is about to contend with an enemy of no ordinary viru- 
lence, one which may for a long time haunt his most occupied 
moments, and which may entail upon his patient during a long 
life, a digusting deformity, which even himself would be glad 
to bury in the grave. 
We have now very freely communicated all that we have 
seen, read, or thought on the subject; and we have done so 
rather with the hope of exciting the attention of others than 
of doing any direct good by the present essay. 
On perusing the foregoing essay and comparing the description of this formidable disease with 
our reminiscences we were forcibly struck with the graphic accuracy displayed by the author; and 
in confirmation of his views we shall state the results of our own experience. 
In the summer of 1824, while engaged in practice with our esteemed friend Dr. Spencer of N. J. 
we encountered several cases of this affection, which invariably occurred as the sequela of inter- 
mittents and other febrile diseases. 
From similar pathological views to those of Dr. J we were induced to rely principally on epispas- 
tics, a wash of acet, znci, together with tonics; and speedy recovery was the uniform result. Though 
mercurial cathartics had in every case preceded the affection of the cheek, we are doubtful of their 
having had any agency in its production, as the gtrms were not affected in the slightest degree. 
C. B. M.