452 DISEASES OF THE MOUTH. 



fects parts which have been greatly altered by previous changes of their 

 nutrition, entire death of the part may quickly result." ( Virchow.) 



The disease is almost exclusively encountered among children, 

 especially among those who have become cachectic from want of care, 

 insufficient or spoiled food, and bad dwellings ; or among those who 

 have just recovered from severe illness that has greatly weakened 

 them. Noma is most frequently seen as a result of measles, more 

 rarely after other acute exanthematous affections, or after typhus, 

 pneumonia, etc. Misuse of mercurials in the treatment of the above 

 affections appears to have much to do with the occurrence of noma as 

 a sequel ; it often begins simultaneously with mercurial stomatitis. 

 In the north of Germany, and especially in Holland, it is more fre- 

 quent than in the south. It seems never to be epidemic. 



ANATOMICAL APPEARANCES. The affection almost always begins 

 on the inside of the cheeks. Over a spot hardened by infiltration, the 

 mucous membrane becomes red, then discolored ; a vesicle filled with 

 cloudy serum, often forms on this. The affected part soon blackens, 

 softens, and disintegrates. The gangrene spreads, destroys the gums, 

 the lips, the base and edges of the tongue on the affected side ; the 

 maxillary bones are exposed and exfoliate, the teeth become loose and 

 fall out. Progressing, the gangrene reaches the outer surface of the 

 cheeks, spreads rapidly, and finally changes the entire cheek, part of 

 the nose, the lower eyelid, often even half the face, into a ragged, 

 pulpy, moist mass, or to a dry, black slough. The blood-vessels resist 

 the destruction longest ; on post-mortem examination, they are found 

 still preserved, but filled with fibrinous coagula. In the few cases that 

 recover, the gangrenous masses are thrown off and the loss of sub- 

 stance is filled with granulations, so that a firm, fibrous cicatrix finally 

 results from a new formation of connective tissue. Adhesions in the 

 mouth and frightful disfigurement always remain. 



SYMPTOMS AND COURSE. According to the excellent description 

 of MiUiet and Barthez, while the gangrene commences, usually with- 

 out pain, on the inner surface of the oral mucous membrane, a soft, 

 regular, circumscribed oedema occurs in the affected cheek and lip, 

 and gradually spreads. A hard, round nucleus forms in its centre, over 

 which the skin appears shining, pale, or mottled violet. Even when 

 the inside of the cheeks and a great part of the gums have become 

 gangrenous, the child often sifs quietly in bed. A sanguineous, or 

 even black saliva, runs out of his mouth ; but he plays, demands food, 

 takes it eagerly, and with the food swallows the sloughs that fall off 

 trom the gangrenous parts. At the same time the skin is pale and 

 cool, the pulse small and moderately frequent, and there is delirium at 

 night. Occasionally, mostly at the fifth or sixth day of the disease, n 



