The ulcer is not always seated on the cheek. It may occupy the gum, or be placed at the junction of the gum with the cheek. Wherever it first appears, it soon spreads, and may involve the gum, the cheek, the lip, and perhaps the whole side of the mouth. When the internal slough separates, which it may do on the third or fourth day, it leaves a ragged ulcer. At the same time, in severe cases, the red spot noted on the outer surface of the cheek becomes deeper in colour, and rapidly changes into a dry, black slough. Sometimes the internal and external sloughs are separated by in filtrated and oedematous tissue ; but often the two sloughs come into con tact, so as to involve the whole depth of the cheek. In this case, when the slough separates, a ragged opening is left, of variable size. In the in terior of the mouth the gums are more or less extensively destroyed ; the corresponding teeth get loose, and often fall out, and the maxillary bone may become necrosed. The separation of the slough is often unattended by haemorrhage, but sometimes copious bleeding takes place. The face, on the affected side, where it has not been invaded by the gangrenous pro cess, is swollen and oedematous, and the infiltrated eyelids can no longer be opened.
At this stage the general condition of the child varies. If he have not been exhausted by previous acute illness, although weak, he is not pros trated, and may be able to sit up in bed without assistance. In most cases, however, he is excessively feeble and helpless ; there may be great drowsiness ; the pulse is scarcely perceptible ; diarrhoea may come on, and general oedema may occur. Sometimes the appetite persists, and the child takes liquid food with avidity ; but, usually, towards the end he refuses food, and even drink. If broncho-pneumonia supervene, as often happens, the temperature, which had been normal, or even below the natural level, rises, and the respiration becomes hurried and laborious.
In fatal cases the duration of the illness varies according to the rapidity with which the gangrenous process spreads, and to the condition of the child at the time when the disease begins. In very rapid cases the child may die in five or six days. Usually, death takes place between the tenth and fourteenth day. If the child be in an enfeebled or cachectic state at the time when the first symptoms are noticed, the gangrene usually spreads rapidly, and the end may be reached before the slough has had time to separate. If broncho-pneumonia arise, or a profuse diarrhoea be set up, or septicaemia be induced, or gangrene appear in another part of the body, the illness may end in death rather abruptly.
If recovery take place, it is usually in cases where the gangrene rapidly limits itself, and does not spread through the entire substance of the cheek. The slough is then thrown off, and a reparative process is set up, which ends in more or less puckering of the affected side of the face. The fall of
the slough is, however, not always followed by repair. In some cases the gangrene continues at the borders of the wound, and the morbid process goes on unchecked.
Diagnosis.—Cancrum oris in its mildest form is distinguished from a bad case of ulcerative stomatitis by its rapid progress, the induration of the cheek at the base of the ulcer, and the infiltration of the tissues around. Malignant pustule presents symptoms somewhat similar to those of cancrum oris, but differs from it by always beginning on the external surface and extending inwards to the mucous membrane. In gangrenous stomatitis, the mucous membrane is the first part to be affected.
Prognosis.—The disease is fatal in the large majority of cases. If it lead to perforation of the cheek, especially if the gangrene be widely spread, death is almost certain. I have known one case recover after perforation of the cheek ; but in this instance, the gangrenous process, although it pene trated deeply into the cheek, had no great lateral extension. When re covery took place, a deep puckered cicatrix was left in the cheek at the site of the disease.
If a complication arise, such as broncho-pneumonia or diarrhoea, the child's small chance of recovery is still further reduced. As long as he con tinues to take nourishment well, and to digest it, we may retain some hope of recovery. If he begin to refuse his food, or even. to receive it with in difference, the sign is a bad one.
Treatment:—As in all diseases which result from debility and malnutri tion, measures should be at once adopted to improve the general health, and provide the child with suitable nourishment according to his age and diges tive capabilities. Pounded meat, strong beef-tea, eggs, and milk, should be given in small quantities at frequent intervals, taking care that the stomach is not overloaded, and that the powers of digestion are not overtaxed. Stimulants are of great value. Port wine, or the brandy-and-egg mixture, should be given several times a day with food. In this disease, a child bears stimulants well. Half an ounce of port wine, or two teaspoonfuls of the egg flip, can be given every two, three, or four hours, to a child of five or six years of age. The bowels must be attended to, and if much milk is being taken, a teaspoonful of compound liquorice powder should be administered every other night. Fresh air is also of great importance, and the window of the room should be kept open night and day. On account of the fcetor of the breath, which causes a most offensive odour in the neighbourhood of the patient, the room must be frequently sprayed with a solution of car bolic acid (one part in thirty of water).