LE MAL DES CERISES

1318 TEMPOROMANDIBULAR ARTHROSIS DISEASE of the temporomandibular joint may manifest itself in symptoms ranging from simple clicking to pain in the joint radiating to ear and temple, with tinnitus, deafness, and possibly dizziness.’ In an analysis of patients presenting with lesions of this joint Hankey2 found that women aged 20-30 were most commonly affected. 20% of cases were due to extrinsic traumaa blow, a fracture, or a difficult dental extraction. Among the cases due to intrinsic trauma dental disturbances, such as malocclusion and overocclusion, were the commonest causes. Over half the patients complained of a click, which was almost always unilateral, and was associated with pain in thejoint or was referred either along the auriculotemporal nerve or along the second or third divisions of the trigeminal nerve. Movements of thejaw were usually either irregular or restricted. Probably the usual treatment is excision of the intraarticular meniscus ; and excision of the condyle of the mandible, particularly when true arthritic changes are present, is also of value. But these measures were applied in only 20 of the 150 cases described by Hankey, who found that in most cases symptoms were much relieved by rest with or without dental wiring, or conservative dental treatment with the provision of dentures where necessary. With proper dental care disease of the temporomandibular joint might become less frequent. LE MAL DES CERISES UNDER the above title, Verheggen3 has described cases of painful aphthous stomatitis in people who had eaten cherries. We are assured by allergists that stomatitis of this sort is not uncommonly due to allergic reactions to various foods. In this particular instance the story will delight those who are sceptical of allergy " as the explanation of most human afflictions. The tongue, palate, pharynx, and gums were affected with reddish papulovesicular elements, some of which were ulcerated. Eating and swallowing were unpleasant because of pain and a burning sensation, as though the patient had been chewing nettles. The author’s little daughter having observed that each of the incriminated cherries contained a maggot, he was struck by the thought that the maggots rather than the fruit might be culpable. He thereupon crushed two of these maggots and applied the pulp to his own tongue ; this caused a fiery inflammation of the tongue, palate, and pharynx which persisted for eight days. The parent parasite was unfortunately not identified, but it was probably one of two fruit flies common in the district-Rhagoletis derai or Ceratitis capitata. Neither of these is notorious as the cause of more than horticultural dismay. Various larvae are known to cause dermatitis, stomatitis, and conjunctivitis on contact. Prominent among these are hairy caterpillars, such as those of the puss moth which are armed with poison glands prolonged into hollow pointed hairs. While there may be an allergic element in the reactions to such creatures, it is probable, by analogy with the venoms of sea anemones4 and wasps,5that the caterpillar toxin contains histamine or histamine liberators. In the case of the cherry-fly maggot, it seems more probable that the irritant is present in the tissue juices. Such irritants are less well recognised in larvae than in adult arthropods, among which the cantharides beetle is pre-eminent. Livingstone, however, was familiar with the use of the larva of an African beetle, Diamphidia locusta, as a source of an arrow poison ; the toxic principle is absent from the adult beetle. Even the humble "

1. Costen, J. B. J. Amer. med. Ass. 2. Hankey, G. T. Brit. dent. J. 1954, 3. 4. 5.

1936, 107, 52. 97, 249.

Verheggen, J. L. Montpellier méd. 1954, 46, 83. Jaques, R., Schachter, M. Brit. J. Pharmacol. 1954, 9, 49. Jaques, R., Schachter, M. Ibid, p. 53.

white caterpillar is known to contain a juice nauseating taste. Applied to the tongue, this6 causes a burning sensation which is not to be ignored."

cabbage with "

a

THE INTERNAL CAROTID ARTERY BECAUSE of the rapid development of techniques for replacing unhealthy arteries the pathologist is now and sites of disorders in required to define the vessels which hitherto have not been closely studied. Necropsy usually includes examination of the carotid arteries, but this examination may stop short of the commonest site of occlusion-namely, the first half-inch Fisher7 of Montreal, of the internal carotid artery. who has made a special study of this important artery, draws attention to the frequency of occlusion at or near the carotid sinus. He regards angiography as a research rather than as a clinical technique ; but the recent work of Thomson 8 and Ochs et awl. has underlined the value of this investigation, which is likely to be used more widely now that Mr. Eastcott and his colleagues 10 have shown the feasibility of reconstructing a diseased internal carotid artery. The ligation of an internal carotid artery for injury or aneurysm in an otherwise healthy person is not comparable to occlusion by degenerative disease ; for the three other arteries that can be relied on to fill the circle of Willis in the healthy are likely to be themselves involved when a degenerative disorder has blocked the internal carotid artery-though it is surprising how commonly the patient escapes hemiplegia. A further good reason for operating in cases of degenerative disease is that occlusion of one carotid artery may be followed by occlusion of the other ; this sequence was found in two of the three fatal cases described by Ochs and in eleven of Fisher’s forty-five necropsy cases. It would be interesting to learn from pathologists who examine post-mortem cases of senile dementia how often they find occlusion of the carotid arteries. Both Hughes et al.ll and Fisherhave commented on the relation of blood-supply to cerebral deterioration ; Hughes was especially concerned with the smaller arteries, and Fisher with the larger arteries. None of Hughes’s fifteen necropsy cases of chronic cerebral hypertensive disease showed gross carotid block ; but of Fisher’s necropsy cases of carotid occlusion dementia had been a clinical feature in about a third, while hemiplegia had been present in only half. It seems, then, that arteriographic studies of patients, with vascular disease of the brain will bring to light some eases that would respond to relief of carotid occlusion. But the technical problems in a deep dissection of the upper neck are formidable : the occluded segment is sometimes inaccessible ; and angiography may not display the upper part of this segment, though it shows the lower limit. Eastcott, in the case where he operated successfully, was prepared to use a graft ; but an end-to-end anastomosis between the common and internal carotid arteries sufficed ; this measure had previously been successfully adopted by Shea and Harrison 1,. where the carotid bulb was damaged during excision of a maxillary

types

neoplasm. Full understanding of the causes, and the factors determining the localisation, of atheroma and thrombosis still eludes us ; and meanwhile the surgeon is likely to find increasing scope for useful work in the treatment of cerebral vascular disorders. H. Durch Insekten hervorgerufene Krankheiten. Stuttgart, 1949. 7. Fisher, M. Arch. Neurol. Psychiat. 1951, 65, 346 ; Ibid, 1954, 72, 187. 8. Thomson, J. L. G. Brit. J. Radiol. 1954, 27, 553. 9. Ochs L., Sensenbach, W., Madison, L. Amer. J. Med. 1954, 17, 6. Schmidt,

374. 10. Eastcott, H. H. G., Pickering, G. Nov. 13, 1954, p. 994. 11. Hughes, W., Dodgson, M. C. H., 12.

W., Rob, C. G.

Lancet,

MacLennan, D. C. Ibid,

Oct. 16, 1954, p. 770. Shea, P. C., Harrison, J. H. Surgery, 1953, 34, 895.