The practice of pediatrics . he underlying maxilla, together with moresuperficial necrosis of the bone. We may find the process extendingupon the bone well up toward the orbit, before there is much breakingdown of the skin. The sloughing begins in the centre of the area, first 190 DISEASES OF THE TRACT appearing upon the lip or cheek, and once begun extends rapidly,destroying the whole lip or cheek, the side of the nose, laying hare thebony parts beneath, and producing the most horrible sight that one iscalled upon to see. With the involvement of the cheek there is analmost constant
The practice of pediatrics . he underlying maxilla, together with moresuperficial necrosis of the bone. We may find the process extendingupon the bone well up toward the orbit, before there is much breakingdown of the skin. The sloughing begins in the centre of the area, first 190 DISEASES OF THE TRACT appearing upon the lip or cheek, and once begun extends rapidly,destroying the whole lip or cheek, the side of the nose, laying hare thebony parts beneath, and producing the most horrible sight that one iscalled upon to see. With the involvement of the cheek there is analmost constant flow of saliva from the corner of the mouth, bearing withit the discharge from the gangrenous area. The odor pervades thewhole room or ward and is very sickening. The process may involveboth sides (Fig. 37). The general condition of these cases varies greatly In some instances,it is said, the children do not appear to be very ill, some even sittingup in bed, apparently undisturbed, ami picking out the loosened teeth Flo. 37. Noma, (Sebamberg.) or bits of necrotic tissue. Usually, however, the patients are markedlyprostrated from the beginning, the temperature is high—102° to 104° F.—and the pulse correspondingly rapid. It is remarkable that there islittle complaint of pain, and the children continue to take nourishmentfairly well. In my experience the disease is very soon complicated bya septic bronchopneumonia, which is evidenced by a higher temperature—105° to 106° F.—more rapid pulse and respiration, greater prostration,and, if the child lives long enough, signs of areas of consolidation,particularly in the lower and posterior parts of the lungs. Death usuallyoccurs from exhaustion. It is not very uncommon to find an extensivediphtheria of the nasopharynx, pharynx, and possibly the larynx as aterminal complication. DISEASES OF THE MOUTH AND PHARYNX 191 Prognosis.—The course of the gangrene is usually rapid, terminatingfatally in from one to three weeks. Instan
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