Furthermore, the recent discoveries of bacteriological research are very coniincing, inasmuch as they agree in essential points; an anaerobic bacillus has been found by all investigators. This microorganism usually grows in spiral threads (clailothrix); it exists in large numbers, especially in the inflamed tissues of the zone of demarcation, and, conse quently, is generally regarded as the exciting causative agent (Schmorl, Perthes, Hofmann and Kilster, Seiffert, etc.). The cultivation of this microorganism and inoculation experiments have also been successful. This discovery has become still more significant since these bacilli, morphologically and biologically, have been shown to resemble Laffler's microorganism, which causes nomatous gangrene in domestic animals (so-called calves' diphtheria).
Histological examination of the affected parts reveals the signs of a necrotic disintegration of the, tissues. Very remarkable is the heavy deposit of "norna-threads" around the muscle fibres which are thus encircled by bacteria and the nutrition is thereby impeded. Another peculiarity is found in the growth of a luxurious fungus-sod on the walls and in the lumen of the blood vessels (Bruning).
Diagnosis.—A typical case presents no difficulty in diagnosis. The genuine gangrene, without any antecedent severe inflammatory process is a singular manifestation of noma and plainly distinguishes the dis ease. But the onset of noma does not always take such a rapid course. Occasionally the swelling of the cheek is present for several (lays before gangrenous changes of the tissues ensue. Especially after ulcerative stomatitis, which is often attended by a considerable infiltration of the cheek, the onset of noma may not easily be recognized. This is really
unfortunate as according to all evidence early therapeutic measures are very desirable.
The prognosis of noma is always grave. Very few cases recover (about 15 per cent). Severe deformities and functional derangements, which need surgical treatment, are the constant results of the disease.
The prophylaxis is naturally limited to a careful hygiene of the mouth during the designated infectious diseases and proper medical treatment of ulcerative stomatitis.
views in regard to the methods of treatment stand opposed to each other. Most of the authors favor an early radical operation (Perthes, Hanke, Springer) others advise an expectant treat ment and recommend surgical intervention only after the process ceases to spread (Soltmann). The excellent results of Ranke behooves us to recommend the early operation, while the value of the expectant treatment does not seem to be sufficiently proven.
The surgical treatment consists in excision of the affected parts through the healthy' tissues and the immediate cauterization of the edges with the thermocautery.
The medical treatment is restricted to sponging and flushing with antiseptic remedies, of which hydrogen peroxide (2 per cent.) is compara tively the most effective. In addition pencilling with tincture of iodine or silver nitrate (10 per cent.) with a local tamponade of iodoform gauze may be tried. Recently, the daily brushing vdth a one per cent. solution of pyoktanin has been warmly recommended (Poljakoff).