Synonyms:—Cancrum oris; noma; stomatitis gangrenosa.
Definition:—A grave affection of the cheeks and gums of children (rarely attacking adults), gangrenous in character, tending to spread rapidly, usually asymmetrical, fortunately of rare occurrence.
Etiology:—The disease occurs in children under seven years of age, seldom if ever in nursing infants; most commonly in those from three to five years of age, who are bady nourished, who inherit some dyscrasia, or who are raised in filth and in a bad atmosphere. It occurs more frequently in girls than in boys, and as the sequel of measles, smallpox, scarlet fever, typhoid and other severe, devitalizing disorders, such as typhus, pneumonia and those diseases in which the circulation of the blood, as well as its character, is greatly impaired. Those conditions which impoverish the blood and thus reduce the vitality of the patient may be followed by noma.
The disease is undoubtedly of infectious origin, but no specific cause has as yet been determined. The infection is probably of a mixed character. But little stress is now laid upon the theory that mercurialization is the constant cause of the disease. The contrary is too often proven, but it undoubtedly occurs less often in the practice o£ those who but seldom use mercury.
Symptomatology:—The disease is of insidious approach, without pain or discomfort at first. There appears a violet or purple spot within the cheek, near the corner of the mouth, and there is some swelling and later edema. If the substance of the cheek is pressed between the thumb and finger at this spot, a small, hard nodule is distinctly outlined. This increases in size rapidly, breaks down, and an ulcer appears on the darkened mucous membrane, which is phagedenic in character, sloughs rapidly and has ragged edges. It gives off an ichorous discharge, with a most sickening, intolerable, gangrenous odor, and gangrenous tissue is soon thrown off in shreds. Necrosis progresses rapidly. The induration loses no time in extending to the entire cheek, which is swollen, edematous, and the face is distorted.
The disease may involve one cheek, with the gums and the jaw of that side, but it is seldom that both sides are attacked. The teeth are loosened and sore, the structure of the jaws are eroded, and finally the lips are involved in the destructive process. Usually perforation occurs within the first few days, and in rare cases within a day or two.
The constitutional symptoms develop rapidly and are plainly marked. There is extreme depression almost from the first. The temperature soon rises, the pulse becomes rapid and feeble, and symptoms resembling typhoid quickly appear. The saliva, which becomes mixed with the ichorous discharge and gangrenous shreds, is unavoidably swallowed, and constitutional infection is almost immediate from this source, increased by the inhalation of the gangrenous exhalations. Very soon the temperature rises to 104.5° or 105° F. Diarrhea appears and becomes most troublesome, prostration is extreme, and delirium supervenes, which soon passes into stupor. Often a septic lobar pneumonia, or other septic local inflammation, occurs from the general septic involvement, and the patient rapidly succumbs, usually within from ten to fourteen days.
Diagnosis:—The characteristic phenomena when once developed are unmistakable. The difficulty lies in anticipating the disease and in making an early diagnosis. The location and character of the nodular formation, the gangrenous sloughs, the disgusting odor, the rapid extreme prostration, the high temperature, and other evidences of extreme septic involvement can hardly be misinterpreted.
Prognosis:—It is rare that recovery from this disease occurs, but when such is the case the gangrenous edges of the wound become clean and assume a clear red color, granulations form and cicatrization occurs, usually with considerable disfigurement, and often with deformity and restriction of the movement of the jaw. The return to health extends over a greatly protracted period, and is often interrupted by the appearance of other complicating disorders. The mortality as shown by statistics is about ninety per cent.
Treatment:—The prophylaxis of this disorder is of the utmost importance. It should be anticipated in the severe forms of those exhausting and devitalizing diseases which it more frequently follows. As soon as the nodule appears, stimulation of the circulation should be accomplished and dead tissue or sloughs should be separated and removed when formed. The ulcer should be thoroughly treated with hydrogen peroxid, potassium permanganate, or other active antiseptics, and in some cases it should be touched with nitric acid; it should then be cleansed and thoroughly swabbed with full strength echinacea and packed with gauze saturated with this remedy, and the gauze should be freely applied on the outside of the cheek and kept in place by proper bandages. In some cases the remedy should be injected into the tissues of the cheek. No one will have proper confidence in the power of echinacea to antagonize gangrene and restore the tone of the tissues until he has used it thoroughly. Its influence is little less than marvelous in some cases. The agent should be given internally in from ten to twenty drop doses every two hours. The course above advised will tend to prevent constitutional infection, which is of the utmost importance, and will at once antagonize the influence of the sepsis in the blood.
Other internal measures will be suggested by plain, direct indications, which must be correctly interpreted. The strength must be sustained by stimulants and tonics. To children who are old enough to swallow a capsule, the following will be found valuable: Hydrastin, five grains; quinin bisulphate, thirty grains; extract of nux vomica, two grains; powdered capsicum, three grains. Mix and fill twenty capsules. Give one every two or three hours. With infants quinin sulphate should be administered by inunction twice daily. In other cases other tonics, such as the hypophosphites with strychnin and quinin should be given. The echinacea should be continued through the course of the tonic treatment. An excellent combination can be made of echinacea, hydrastis, avena sativa, and the fluid extract of cola nut. The patient must be fed with concentrated, nourishing food, administered at frequent intervals. Rectal enemata are sometimes demanded.