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Stomatitis Gangrenosa Noma

disease, process, cheek, observed, probably, ulceration and gangrene

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STOMATITIS GANGR.ENOSA (NOMA.) By noma of the face (see Plate we understand a rapidly progres sive and generally fatal gangrene of the cheek, probably' produced by a specific microorganism.

From the writings of the Hollander Battus (I6th century) the inference can be drawn that the disease was more frequent in ancient times than at present. To-clay, noma is observed very rarely and only in isolated cases. The moist and foggy coasts of the North, as Holland particularly, the coast of Northern Germany, Denmark, and England, appear to be a more frequent habitat of the disease than the southern countries.

Pathogenesis, Local qualities are especially char acteristic of the disease: first, that children exclusively are attacked; and, second, that this process, almost without exception, occurs in a body which has been injured and exhausted by some previous disease. The diseases w-hich may predispose to noma are the following: measles, then diphtheria, typhoid, scarlet fever, severe enteritis and dysentery, cerebrospinal meningitis, pneumonia, and tuberculosis. As has been stated, noma may result from ulcerative stomatitis isolated cases. Genuine cases of idiopathic gangrenous stomatitis are known (Billard, Henoch) to have arisen spontaneously.

The first symptom noticeable externally is a severe swelling of the side of the face, which is marked by a fatty gloss and a waxy pallor. On palpating the affected part, which contrary to the expectation is not very painful, a hard diffuse infiltration in the depth of the tumor is found. On inspecting the oral cavity, a small ulceration, which had its orin in a bleb, and which is covered by a blighted, greenish gray mass, is seen on the inner surface of the affected cheek. Even at the beginning of the disease, a nasty fetor exhaled from the mouth, which increase.s in intensity' as the disease progresses. The submaxillary lymphatic nodes are swollen.

The gangrenous ulceration grows perceptibly from hour to hour, both in breadth and in depth, and soon at the point of the outer cheek corresponding to the deepest part of the ulceration, a rapidly, spreading red spot appears, which becomes darker and takes on a black and blue discoloration and finally changes to a dry, fissured, blighted scab. This

necrotic area may reach to the eye and downward to the neck. A pale red zone of demarcation surrounds the scab, which either becomes perforated in places, or is totally cast off. The resulting defect, from which putrid and bloody masses are discharged, sometimes permits direct VISi011 into the oral cavity.

Meanwhile, as a rule, the progressive gangrene has produced great destruction in the mouth. The neighboring gum rots off, the periosteum dies; consequently, the alveolar process becomes denuded and the teeth loosened, so that they may fall out.

Localization,—It is a remarkable fact that the process is almost always limited to one half of the face. Exceptionally, cases of noma have been observed where the necrotic process began on the outer surface of the cheek. Whether these cases are genuine /Ionia, or some sy-mptom complex which simulates it, can not be decided at present. Rare locali zations of norna are the external ear and the vulva.

General Symptoms, seldom an astonishing contrast. is observed between the wide-spread gangrene and the subjective symp toms of the spreading local process; the children in many cases still find pleasure in play and still have appetite, both undoubted signs that the body is in less danger than is really expected. Soon however the picture changes. High fever sets in and the ingestion of food becomes less and less. cAs a rule profuse diarrhcea supervenes (probably auto toxic); delirium and collapse follow and death results viith the symp toms of general exhaustion; if some complication, as pneumonia or abscess of the lung or other septic process, has not already relieved the patient from its sufferings.* microparasitic nature of [Ionia is to-clay probably beyond question. The endemic occurrence in asylums and the whole course of the disease support this view. Of course, the importance of a strong individual predisposition must be accentuated here more than usual.

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