viii, B, 5 Reyes: Noma in the Philippine Islands 399 



and spindle-shaped organisms, and blood culture gave Staphylo- 

 coccus aureus and albus. 



Noma is essentially a disease of children, especially under 10 

 years of age, but it has been met with in adults. Girls are more 

 often affected than boys. 



It usually follows or develops during the course of some debili- 

 tating sickness, like the eruptive fevers, particularly measles and 

 typhoid. It has been met with after scarlet fever, whooping 

 cough, bronchopneumonia, diphtheria, variola, etc. Unhygienic 

 surroundings, underfeeding, and cachexia are strong predisposing 

 causes, but it has been met with where the sanitary, hygienic, 

 and dietetic conditions were most favorable. Usually sporadic in 

 its appearance, the disease has been observed from time to time 

 in epidemic forms, which, together with the fact that it seems to 

 have a special predilection for the lining mucous membrane of 

 the different orifices of the body, strengthens the belief that it is 

 of a specific infectious nature. Formerly the malady was con- 

 sidered to be the result of some vasomotor or trophic disturbance, 

 but in the light of the present bacteriologic researches it must be 

 considered as an infectious disease due to a definite cause, and the 

 isolation of the specific microorganism may be predicted with 

 confidence. 



Blumer and MacFarland, after studying a series of 16 cases, 

 arrived at the conclusion that the disease begins primarily as a 

 simple infection and terminates as a mixed infection, generally 

 with a slim organism of the leptothrix type predominating. 

 Weaver and Tunnicliffe, who have compiled the results of the 

 bacteriologic studies of noma by several investigators, report the 

 almost constant finding of polymicrobic cultures from the super- 

 ficial areas of necrotic tissue, while the deeper portions showed 

 long, thread-, or filament-like bacteria in almost pure culture, the 

 bacteria being easily decolorized by Gram, but not growing on 

 ordinary culture media. 



The disease usually attacks the mouth and cheek, but may 

 occasionally attack the vulva and anus (noma pudendi). Per- 

 haps this may explain, in part, its greater frequence among girls. 



It usually begins as a livid, swollen patch on the mucous mem- 

 brane of one of the cheeks, followed by an inflammatory infil- 

 tration which is rapidly transformed into typical gangrenous 

 tissue. The lesion soon spreads from the cheek, which becomes a 

 foul, ashy gray, pultaceous slough, and the process often extends 



