Synonyms.—Cancrum Oris; Noma; Water Cancer.
Definition.—Gangrene of the cheek and gums, affecting delicate and sickly children, rarely the adult, and characterized by a rapid destruction of tissue. The disease is generally fatal.
Etiology.—Predisposing Causes.—Age.—The disease usually occurs between the ages of two and six years, and is more frequently found in girls than in boys.
Climate.—It prevails in low moist, countries, especially in Holland.
Infections Fevers.—While the disease may be primary, it frequently follows the infectious fevers, especially measles, scarlet fever, typhoid fever, typhus fever, and pneumonia. In fact, any disease that lowers the vitality, as well as poor hygienic conditions which impoverish the blood, predispose to noma.
The Exciting Cause.—Mercurialization has been thought, by many, to be responsible for this destructive disease, and from the similarity of symptoms of this and mercurial stomatitis, there are strong grounds for the belief. The microbic theory has its adherents, but as yet no specific germ has been discovered.
Symptoms.—The disease commences with an indurated swelling, usually near the angle of the mouth. On grasping the swollen mass between the finger and thumb, we get the sensation that the induration extends through the entire cheek. Externally the affected side is swollen, and presents a blanched, glassy appearance. Internally, there is a dusky redness, in the center of which the ulcer rapidly forms; phagedenic in character, it rapidly destroys tissue, and may perforate in three or four days, though rarely before seven or eight days. The entire cheek may be involved, the tissues melting away like a snowball in the sun. From the ulcer an ichorous fluid is discharged, and shreds of tissue slough off and are mixed with the changed and vitiated saliva. The odor is peculiarly fetid and that of gangrene. The submaxillary glands are always swollen; usually there is but little pain.
As the disease progresses, the temperature rises to 104° or 105°; the pulse, though feeble, is rapid. In swallowing, more or less of the ichorous fluid and shreds of the gangrenous tissue enter the stomach, and a troublesome diarrhea often follows, or the patient, poisoned by the inhalations from his own necrotic cheek, finds septic lobular pneumonia complicating the already overburdened system; the prostration increases, the mind wanders, or the patient sinks into stupor, and succumbs to general sepsis. Death may occur in a few days, or be delayed three or four weeks. In exceptional cases, the patient recovers, leaving great disfigurement from cicatrization of tissue; the disease is generally confined to one side.
Diagnosis.—When fully established, the diagnosis is not difficult. The hard, indurated nodule near the angle of the mouth, the phagedenic character of the ulcer, the gangrenous tissue and foul odor, and later the perforation, can hardly be mistaken for any other variety.
Prognosis.—This is a very grave disease, and the prognosis is decidedly unfavorable, principally due to the impoverished condition of the blood, and general sepsis.
Treatment.—The local treatment will consist of first cleansing the mouth thoroughly, trimming away the gangrenous sloughs and washing the ulcer with a five per cent solution of pyrozone, or a solution of potassium permanganate. The orifice should then be packed with cotton saturated in echinacea.
Internally, give echinacea three drams, water four ounces; teaspoonful one hour, alternating with a saturated solution of hydrastin or potassium chlorate. Where the tongue is covered with a nasty, dirty, pasty coating, sodium sulphite will be used. The mineral acids will replace the above remedies if the tongue be dry and brown and sordes appear on the teeth. The treatment will be antiseptic throughout.