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AN APPEAL TO MEDICAL BENEVOLENCE
784
CORRESPONDENCE AN APPEAL TO MEDICAL BENEVOLENCE To the Editor of THE LANCET
SiR,—It has been my privilege for many years to appeal to your readers for contributions to enable the Royal Medical Benevolent Fund to distribute Christmas gifts. I desire to express my personal gratitude to my many medical colleagues who have so generously responded to the appeal in recent years, and especially to the medical societies and panel committees who, together with branches and divisions of the British Medical Association, have arranged collections at their meetings in aid of this particular need. In a short letter it is impossible to give any details of the sorrowful lives of those we endeavour to help ; in a great many cases tragedy has befallen them. I write on behalf of over 650 beneficiaries, for that is the number on our books, and I feel therefore a
great personal responsibility as to whether my appeal will suffice to persuade your readers of the urgent need of a generous response. One medical practitioner, a married man, wrote recently to the Fund that at the age of 66 he had suffered a complete breakdown in health and further work was out of the question. He had done all that was possible to keep going, and was still not in debt as he had drawn on his endowment policies. But he had now come to the end of his resources and had been forced to take his little girl, aged 14, away from school as he could not meet the next term’s fees, his income being 960 a year. The Fund is now helping this colleague with a yearly maintenance grant, but we want at Christmas to give him and many others the unlooked for Christmas gift. We try to distribute 30s. to each. I ask your readers to help us to do so. Donations will be gratefully acknowledged by the hon. treasurer, Royal Medical Benevolent Fund, 11, Chandos-street, London, W. 1.-I am, Sir, yours faithfully, THOS.
BARLOW,
President of the Royal Medical Benevolent Fund.
Sept. 24th.
ERYTHEMA NODOSUM To the Editor of THE LANCET
SIR,-A study of the literature of erythema nodosum brings out two striking points connected with the age of the patients : first, that in childhood the sexes are about equally affected, whereas among adults, females form the great majority of the cases ; secondly, that in childhood the setiological factor is most often tuberculosis, whereas rheumatism is the causative factor in the vast majority of adults. Where contagion has been proved, it has usually been in children, and has been shown to be tuberculous. Recurrences have been noted in both children and adults, which fact is probably in favour of the rheumatic theory of its aetiology. Dr. J. 0. Symes has referred (THE LANCET, 1929, ii., 1033) to four sisters who each had erythema nodosum over a period of 26 years, usually accompanied by tonsillitis ; their parents were both rheumatic, and the mother had also suffered from erythema nodosum. Another of his cases had seven attacks between the ages of 18 and 37. These facts support the theory of rehumatic aetiology in adults. Dr. A. Hope Gosse, who has analysed (Practitioner, 1913, xci., 240) 100 cases among children, rejected both the rheumatic and the tuberculous theory. Yet his figures show that 48 per cent. of his cases had one or more of the symptoms arthritis, tonsillitis, or
chorea, and only
19 per cent. failed to show one or of his accepted manifestations of rheumatism. In my own study of 35 cases in adults, 33 were females. The youngest patient was 19, and the oldest 69. The third and fourth decades each accounted for 11 cases, the fifth for 8, and the sixth and seventh for 4. None of the cases gave a previous There was a previous history of tuberculosis. history of rheumatism in 13 cases, and of tonsillitis in 13 cases ; six of these overlapped. Included in these 20 are one case who had suffered from chorea, and 2 who had previously had erythema nodosum, one of them twice. Concurrent with the erythema nodosum there were 25 instances of arthritis and 20 of tonsillitis ; 15 of these overlapped, giving 30 cases out of 35 who showed one or both symptoms at the time of the erythema nodosum. Seven of the 30 had endocarditis. These data support the theory that in adults erythema nodosum is usually a manifestation of acute rheumatism.-I am, Sir, yours faithfully, A. HILLYARD HOLMES. Manchester, Oct. lst. more
To the Editor
of
THE LANCET
SiR,-Hebra’s remarks on the treatment of erythema nodosum were to the effect that a drop of tincture of arnica in a bucket of water would not do any harm. It is most likely that this is the correct attitude towards the treatment of a symptom, which, as Dr. Collis points out, is self-limited in duration. Nobody who has studied the symptom called erythema nodosum would deny that as a symptom it occurs in response to various toxins. In England this nonspecificity of erythema nodosum has blinded our eyes to the fact that out of all these various toxins tuberculosis stands first in frequency and importance. When this fact is fully and generally realised much ill-health will be prevented, andI am in entire sympathy with Dr. Collis when he states that he would willingly give up mentioning streptococcal erythema nodosum if thereby he could persuade people to regard every case as potentially tuberculous. It is in great trepidation that I am shortly publishing some cases of aphthous stomatitis associated with recurrent erythema nodosum-and not due to tuberculosis. I am, Sir, yours faithfully, Guy’s Hospital, S.E., Sept. 28th. G. P. B. WHITWELL. THE CANCER PROBLEM OF TO-DAY To the Editor of THE LANCET
SIR,-In an annotation under the above heading in your last issue you say in effect that the belief that cancer is a disease of civilisation is a facile and superficial generalisation founded on wrong premises, the outcome of modern hurry and has been disproved over and over again. As a matter of fact the opinion referred to has been held for over a hundred years, was mentioned with approval by Walshe in 1845, and was afterwards accepted by some of our greatest In these circumstances the terms oncologists. "hurry," "slogan," " facile " seem peculiarly inappro-
priate. far from this generalisation having been the evidence in its favour has so grown disproved in the course of years that it is to-day no longer a mere opinion but a widely recognised fact. For confirmation of the truth of this statement there is no need to seek outside our own country or this present century. It is not likely that anyone will dispute the assertion that during these last 33 years
Then
so
CORRESPONDENCE AN APPEAL TO MEDICAL BENEVOLENCE To the Editor of THE LANCET
SiR,—It has been my privilege for many years to appeal to your readers for contributions to enable the Royal Medical Benevolent Fund to distribute Christmas gifts. I desire to express my personal gratitude to my many medical colleagues who have so generously responded to the appeal in recent years, and especially to the medical societies and panel committees who, together with branches and divisions of the British Medical Association, have arranged collections at their meetings in aid of this particular need. In a short letter it is impossible to give any details of the sorrowful lives of those we endeavour to help ; in a great many cases tragedy has befallen them. I write on behalf of over 650 beneficiaries, for that is the number on our books, and I feel therefore a
great personal responsibility as to whether my appeal will suffice to persuade your readers of the urgent need of a generous response. One medical practitioner, a married man, wrote recently to the Fund that at the age of 66 he had suffered a complete breakdown in health and further work was out of the question. He had done all that was possible to keep going, and was still not in debt as he had drawn on his endowment policies. But he had now come to the end of his resources and had been forced to take his little girl, aged 14, away from school as he could not meet the next term’s fees, his income being 960 a year. The Fund is now helping this colleague with a yearly maintenance grant, but we want at Christmas to give him and many others the unlooked for Christmas gift. We try to distribute 30s. to each. I ask your readers to help us to do so. Donations will be gratefully acknowledged by the hon. treasurer, Royal Medical Benevolent Fund, 11, Chandos-street, London, W. 1.-I am, Sir, yours faithfully, THOS.
BARLOW,
President of the Royal Medical Benevolent Fund.
Sept. 24th.
ERYTHEMA NODOSUM To the Editor of THE LANCET
SIR,-A study of the literature of erythema nodosum brings out two striking points connected with the age of the patients : first, that in childhood the sexes are about equally affected, whereas among adults, females form the great majority of the cases ; secondly, that in childhood the setiological factor is most often tuberculosis, whereas rheumatism is the causative factor in the vast majority of adults. Where contagion has been proved, it has usually been in children, and has been shown to be tuberculous. Recurrences have been noted in both children and adults, which fact is probably in favour of the rheumatic theory of its aetiology. Dr. J. 0. Symes has referred (THE LANCET, 1929, ii., 1033) to four sisters who each had erythema nodosum over a period of 26 years, usually accompanied by tonsillitis ; their parents were both rheumatic, and the mother had also suffered from erythema nodosum. Another of his cases had seven attacks between the ages of 18 and 37. These facts support the theory of rehumatic aetiology in adults. Dr. A. Hope Gosse, who has analysed (Practitioner, 1913, xci., 240) 100 cases among children, rejected both the rheumatic and the tuberculous theory. Yet his figures show that 48 per cent. of his cases had one or more of the symptoms arthritis, tonsillitis, or
chorea, and only
19 per cent. failed to show one or of his accepted manifestations of rheumatism. In my own study of 35 cases in adults, 33 were females. The youngest patient was 19, and the oldest 69. The third and fourth decades each accounted for 11 cases, the fifth for 8, and the sixth and seventh for 4. None of the cases gave a previous There was a previous history of tuberculosis. history of rheumatism in 13 cases, and of tonsillitis in 13 cases ; six of these overlapped. Included in these 20 are one case who had suffered from chorea, and 2 who had previously had erythema nodosum, one of them twice. Concurrent with the erythema nodosum there were 25 instances of arthritis and 20 of tonsillitis ; 15 of these overlapped, giving 30 cases out of 35 who showed one or both symptoms at the time of the erythema nodosum. Seven of the 30 had endocarditis. These data support the theory that in adults erythema nodosum is usually a manifestation of acute rheumatism.-I am, Sir, yours faithfully, A. HILLYARD HOLMES. Manchester, Oct. lst. more
To the Editor
of
THE LANCET
SiR,-Hebra’s remarks on the treatment of erythema nodosum were to the effect that a drop of tincture of arnica in a bucket of water would not do any harm. It is most likely that this is the correct attitude towards the treatment of a symptom, which, as Dr. Collis points out, is self-limited in duration. Nobody who has studied the symptom called erythema nodosum would deny that as a symptom it occurs in response to various toxins. In England this nonspecificity of erythema nodosum has blinded our eyes to the fact that out of all these various toxins tuberculosis stands first in frequency and importance. When this fact is fully and generally realised much ill-health will be prevented, andI am in entire sympathy with Dr. Collis when he states that he would willingly give up mentioning streptococcal erythema nodosum if thereby he could persuade people to regard every case as potentially tuberculous. It is in great trepidation that I am shortly publishing some cases of aphthous stomatitis associated with recurrent erythema nodosum-and not due to tuberculosis. I am, Sir, yours faithfully, Guy’s Hospital, S.E., Sept. 28th. G. P. B. WHITWELL. THE CANCER PROBLEM OF TO-DAY To the Editor of THE LANCET
SIR,-In an annotation under the above heading in your last issue you say in effect that the belief that cancer is a disease of civilisation is a facile and superficial generalisation founded on wrong premises, the outcome of modern hurry and has been disproved over and over again. As a matter of fact the opinion referred to has been held for over a hundred years, was mentioned with approval by Walshe in 1845, and was afterwards accepted by some of our greatest In these circumstances the terms oncologists. "hurry," "slogan," " facile " seem peculiarly inappro-
priate. far from this generalisation having been the evidence in its favour has so grown disproved in the course of years that it is to-day no longer a mere opinion but a widely recognised fact. For confirmation of the truth of this statement there is no need to seek outside our own country or this present century. It is not likely that anyone will dispute the assertion that during these last 33 years
Then
so