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Grene of the Vulva, Conjunctivitis and an Ulcerative Dent Purpuric Eruption

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Grene of the Vulva, Conjunctivitis and an Ulcerative Dent Purpuric Eruption Though its symptoms are distinctive, Harris found quently than heretofore into the differential diagnosis the disease confused in the literature with geographic of syphilis, and that familiarity with the various phases tongue, neuralgia of the tongue and lichen planus. of its symptomatology will be required of the derma¬ tologist. The possibility of confusing Vincent's Vincent's disease disease with syphilis is not as remote as might appear, It has been impressed on me by experience that, for the similarity of the lesions to mucous patches may with the return of our troops to their home com¬ be striking in the cases of moderate severity, and munities, Vincent's disease will probably become an search should always be made for the organisms. important factor in the differential diagnosis of lesions The possibility of coexistence of the two diseases of the mouth and other mucous surfaces. Attention should be kept in mind, as well as the fact that mer¬ has been called to the increase in the number of cises curial treatment may arouse to activity quiescent types of Vincent's disease since 1915 in Canada13 and Eng¬ of Vincent's disease in the syphilitic. land, among both the soldiers and the civilian popula¬ tion; but similar statistics as to the prevalence of the disease in this are not available. As it is a country ACCESSORY NASAL communicable and curable affection, its SINUSES OF early recogni¬ CHILDREN tion is a mattter of considerable importance. Vincent's angina has been a widespread, though not common SEYMOUR M.D. disease in this for and OPPENHEIMER, country many years, small, NEW YORK localized epidemics have at times occurred. Among the overseas troops, "trench mouth" has been identi¬ The views that I have expressed in several previous fied as Vincent's disease, and statistics from one Brit¬ publications, dating back to 1912, as to the frequency ish military hospital in France state that it represented of accessory sinus diseases in children, hold at the 23 per cent, of all throat complaints. Most present time with additional emphasis. Subsequent of the patients with this affection whom I have seen investigation of anatomic specimens and references and who had been overseas gave a history of trench to the work of others seems to demonstrate that the mouth, usually described as of moderate severity; accessory nasal sinus development occurs at a much recent attacks were probably recurrent. earlier period than is generally considered by most Vincent's disease may appear on the tonsil as a deep investigators, and it is accepted that their variation ulcération; on the ramus of the lower jaw posterior in size, shape and position at different ages, up to the to the last molar tooth as a localized ulcerating patch ; period when they assume the adult type, is extreme. as a mouth infection almost the general involving SINUSITIS IN THE CHILD entire mucosa, pharynx, and at times the tongue, or From a remain limited to the gums, where it is often careful study of the early anatomic develop- primary ment of the and may be mistaken for pyorrhea alveolaris.14 Mild sinuses, it seems probable that many cases of are the result of cases tending to chronicity occur as tonsillitis or gin¬ meningitis unrecognized inflam- mation of some of the as the givitis of moderate degree, or on the cheeks and lips sinuses, symptoms of in shredlike patches resembling the condition observed sinusitis are more or less obscure in children. That this should be so can be in those who habitually bite the lip or cheek. These readily appreciated from the structure of these at an for are mild types may develop into severe attacks, with the parts early age, they formation of sloughing, serpiginous ulcers covered surrounded by much softer bone than at a later period of life ; there is a more of the with a heavy, pultaceous, creamy, often adherent profuse development and vascular and the mucosa is pseudomembrane. The ulcération may be superficial, lymphatic systems, in most intimate relation with so or and destructive it with the osseous tissue, deep ; may spread rapidity, that inflammation of the former and involve areas of the mucosa. The breath is slight must produce large some in the latter. fetid, the are swollen, and the often pre¬ pathologic change My experience glands patient has been that in the child, chronic sinusitis is sents a pallid or yellowish appearance, even in cases of common, the reaction is and it will be found on careful examination that many moderate severity, though systemic the often than would be instances of postnasal catarrh in child are but less expected. of The disease also ulcération and svmptoms some inflammatory condition of the adja¬ may produce gan¬ cent sinuses. grene of the vulva, conjunctivitis and an ulcerative balanitis. Greeley15 has recorded a case with coinci¬ DEVELOPMENT OF THE SINUSES dent purpuric eruption and bleeding from the nose The reasons for the development of the nasal acces¬ and gums, in several attacks, ending fatally. sory sinuses have been defined by various authors with The spirillum of Vincent and the associated fusi¬ varying théories. Killian believes that the develop¬ form bacillus are recognized as the causative agents ment of this area depends on the inherent biologic of the disease, and can be readily detected in smears. characteristics of the cells which go to form the The organisms are also readily seen in dark-field various structures in this area. Coffin and Frères, preparations, and I have made frequent use of this however, explain the development on a physical basis. method of diagnosis. The clinical resemblance to They believe that the reabsorption of bone is due to diphtheria is occasionally marked, and cultures should variations in air pressure, particularly that of be made in all doubtful cases, as the two diseases may expiration ; that the principal growth of the sinuses coexist. begins after breathing occurs ; that there is a distinct The predicted increase in the number of cases of similarity between the effect of air pressure on the Vincent's disease indicates that it will enter more fre- Read before the Section on Laryngology, Otology and Rhinology Warner Holmes: Canad. M. A. 1919. at the Seventieth Annual Session of the American Medical Associa- 13. Laughlen, and J. 9:345, 1919. 14. McKinstry, W. H.: Brit. M. J. 1: 421 (March 31) 1917. Camp- tion, Atlantic City, N. J., June, bell, A. R., and Dyas, A. D.: Vincent's Angina, J. A. M. A. 68: 1596 The bacteriologic observations contained in this paper were obtained (June 2) 1917. from experiments conducted by Dr. Mark J. Gottlieb, of the Laboratory 15. Greeley, H.: Am. J. M. Sc. 155:742 (May) 1918. for Clinical Research. Downloaded From: http://jama.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/29/2015 sinuses and on the alveoli of the lung, and that a The anterior group is by far the more important, constant change of air pressure in the sinuses, and, as its stornata are found along the semilunar hiatus finally, the direction of the inspired and expired air and the fissure between the ethmoidal bulla and the bear a relation to the anatomic formation of the inferior turbinated body, at a location at which infec¬ nose. These two authors also point out that children tion from intranasal morbid changes most frequently having adenoids present poorly developed sinuses, takes place. The anterior cells are more numerous because of the lack of normal air pressure in the nose than the posterior, although the latter are larger as during expiration. regards the capacity of the individual cells, and their Functions.—The functions of the nasal accessory stornata are much less in size than those of the anterior sinuses have been subject to considerable controversy, mass. As the internal wall of the orbital fossa forms and no particular theory as to the physiology of these the eternal boundary of the ethmoid, the possibility cavities has as yet been universally accepted. Whether of orbital symptoms, as a complication of ethmoidal the sinuses are the remains of rudimentary struc¬ infection, is apparent. In operating on this region, tures, which, in lower animals, serve as adjuvants this relationship must be borne in mind on account of to the act of smelling, or whether these cavities evenly the extreme thinness of the ethmoidal orbital wall, distribute the inspired air and thus help olfaction, and the danger of injuring the contents of the orbital is still open to discussion, as well as the suggestion cavity. that the pneumatization and extension of these cells FRONTAL AND SPHENOIDAL SINUSES serve to lighten the bones of the skull in order that Previous to the seventh or eighth year, the frontal proper poise and counterpoise, may be maintained. sinus is usually not developed, although not infre¬ The contention that they are an adjunct to respiration quently it is present as as the fifth year. Before air early by moistening the inspired is not supported by puberty, it does not extend far up in the frontal bone ; no mucous in histologie findings, as there are glands then a marked change takes place until the eighteenth the mucosa of these cavities. year, when its full development is accomplished. The Early Appearance.—In connection with the anatomic anatomic and surgical relation differs in no way from development, it should be remembered that the maxil¬ that in the adult, except that its relation to the cranial lary sinus is well defined, although rudimentary, at cavity, on account of the thin posterior wall, is most birth, and even in the fetus it is found about the intimate ; and this must be considered in relation to fourth month, so that inflammation of this sinus at inflammatory processes.
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