243 displayed in the school. Secondly, this present year has seen the completion of the penultimate stage in the council’s plans for the advancement of the school, whereby it takes its place among those with a muster roll of 400. Yet another event of importance, especially to the boys themselves, was the opening of the new pavilion, while the presence of a large number of old boys among the thousand guests was a pleasant indication of their interest and support. Prince Arthur divided his address, which was essentially for the boys, into two parts : the fine part in life to be played for the welfare of the com- munity by those of them who were destined to become doctors, and the great opportunity offered by emigra- tion to those who had not yet chosen their career. From his own personal experience of South Africa, he could assure them that successful careers could be made in the Dominions and Colonies by public school boys of the right stamp possessed of grit and a capital of 21000 to .81500, who were prepared to take up agriculture. When Dr. Raymond Crawfurd became chairman of the council some five years ago certain plans were formulated, which aimed at the increase in numbers of the boys of public school age from 250 to 400. To achieve this has necessitated an expenditure of over job40,000 in bricks and mortar, but the result is that there are now 387 boys, who have a beautiful chapel, up-to-date chemistry and science classrooms, with many other amenities of public school life that were previously lacking. As regards the pavilion, it is worthy of note that less than a year ago old boys and parents were first asked to subscribe. Within six months, in spite of the general strike and the ensuing coal strike, 92700 had been raised, and within another six months the pavilion had been built. It provides accommodation of modern type in the way of washing, changing, and dining-rooms, seating accommodation for all the college needs for years to come, a " tuck shop," and premises for the ground staff’s accommodation. Messrs. C. E. Barry and Son, the architects, presented the design as a donation to the Pavilion Fund, Mr. Barry, junior, being himself an old boy. The head- master (Mr. A. C. Powell), in his annual report, spoke of a very satisfactory position in school life. Chief among the successes was the senior open science scholarship at Jesus College, Cambridge, won by E. A. Marsh, who achieved the unusual by passing the B.Sc. examination of London University while still at school. As a result of bequests, two new entrance scholarships, one of 2120 per annum and one of 100 guineas per annum, will be made available for open competition. ____ A MEETING OF NEUROLOGISTS. THE American Neurological Association several months ago accepted an invitation from the Neuro- logical Section of the Royal Society of Medicine to hold its annual conference this year in London, and to have a series of joint meetings with English neuro- logists. Thirty-four of the visitors, many of them accompanied by their wives and daughters, arrived in this country on Friday of last week, whilst others were already in this country. The proceedings began on Monday evening with the reception of the visitors at the Royal Society of Medicine. Sir James Berry (President of the Society) and Lady Berry received the guests in the library, and there was a large attendance both of visitors and Fellows. Among the former were Dr. Charles Dana (President of the American Neurological Association), Dr. F. Tilney, Dr. H. A. Riley, Dr. B. Sachs, Mr. Penfield, Dr. Corn- wall, Dr. N. W. Winkelman, and Dr. I. H. Weisenburg (Secretary of the Association). After the reception Sir James Purves- Stewart, this year’s President of the Neurological Section of the Royal Society of Medicine, gave a lecture entitled " Mount Athos," in which he described his visit in 1916 to that remarkable community, and showed many lantern slides of its monasteries. He explained the organisation of the monastic republic, and the exclusion from it of every female, human or animal—’’ no cows, no milk, no hens, no eggs." The architecture of the monasteries, many of which date from the tenth century, was illustrated, and some account was given of life within the walls. The lecturer was impressed by the mental stagnation w thin the community, and the lack of appreciation of the priceless manuscripts which are in their possession. Dr. Charles Dana afterwards pro- posed a vote of thanks to Sir James Purves-Stewart for his entertaining lecture ; this was seconded by Dr. Bernard Sachs, and conveyed to the lecturer by Sir James Berry. The joint meetings of the Association and the Section were continued during the week, and a report of the early proceedings appears on p. 258. WE regret to announce the death on July 26th in London, in his 83rd year, of Sir Bryan Donkin, consulting physician to the Westminster Hospital. A leading criminologist, his outspoken expressions have been of the greatest public value in many social circumstances. A fuller obituary notice will appear in our pages. ____ MEMBERS of the medical profession will also learn with sorrow the death, in his 66th year, of Mr. Alfred C. Taylor, of Peterborough, whose radiological work commenced with Rontgen’s discovery and was carried on assiduously for over 30 years in spite of the serious consequences to his health manifested in dermatitis and the loss of fingers from both hands. THE conferment of a knighthood upon Dr. Wilfred Thomason Grenfell, C.M.G., will give pleasure to his many friends inside and outside the medical profession. Dr. Grenfell is a Fellow of the Royal College of Surgeons of England, who holds honorary degrees of the Universities of Oxford, Harvard, and Williams. As doctor, missionary, and mariner his name will always be associated with life and progress in Labrador. Modern Technique in Treatment. A Series of Special Articles, contributed by invitation, on the Treatment of Medical and Surgical Conditions. CCXXXIV. THE TREATMENT OF ERYTHEMA MULTIFORME AND ALLIED ERUPTIONS. Tms large and relatively common group of toxic erythematous eruptions will for our purposes include erythema multiforme (e.g., iris or target forms), erythema nodosum or contusiforme, and purpura. A simultaneous consideration of these clinical types is justified by what has been termed their rheumatoid characters. The lesions are always evanescent or fleeting, tending to recur, sometimes with seasonal variations, and not infrequently accompanied by fever, constitutional disturbances, and vague rheu- matic pains around the joints and in fibrous planes. Scarring is never produced in uncomplicated cases. A certain similarity in the pathological histology further justifies this grouping. Exudation of serum or blood through a damaged capillary endothelium is the keynote. In all three conditions there is some evidence to support the view that a haemolytic streptococcus may play a part in the causation. It has actually been recovered and grown in pure culture from some of the lesions, especially those of a purpuric type. In a large percentage of the cases there is a history of tonsillar trouble, and it is likely that the organism s or their toxins may enter the circulation a this point. In others, again, there is pronounced dental sepsis, which may be obvious or revealed only by X rays. The possibility of these two sources of blood infection should always receive due consideration, but it has to be admitted that eradication of such foci does not invariably lead to a cure or prevent- relapses.
Transcript
243
displayed in the school. Secondly, this present yearhas seen the completion of the penultimate stage inthe council’s plans for the advancement of the school,whereby it takes its place among those with a musterroll of 400. Yet another event of importance,especially to the boys themselves, was the openingof the new pavilion, while the presence of a largenumber of old boys among the thousand guests wasa pleasant indication of their interest and support.Prince Arthur divided his address, which was
essentially for the boys, into two parts : the finepart in life to be played for the welfare of the com-munity by those of them who were destined to becomedoctors, and the great opportunity offered by emigra-tion to those who had not yet chosen their career.From his own personal experience of South Africa, hecould assure them that successful careers could bemade in the Dominions and Colonies by public schoolboys of the right stamp possessed of grit and acapital of 21000 to .81500, who were prepared to takeup agriculture. When Dr. Raymond Crawfurd becamechairman of the council some five years ago certainplans were formulated, which aimed at the increasein numbers of the boys of public school age from250 to 400. To achieve this has necessitated anexpenditure of over job40,000 in bricks and mortar, butthe result is that there are now 387 boys, who havea beautiful chapel, up-to-date chemistry and scienceclassrooms, with many other amenities of publicschool life that were previously lacking. As regardsthe pavilion, it is worthy of note that less than ayear ago old boys and parents were first asked tosubscribe. Within six months, in spite of the generalstrike and the ensuing coal strike, 92700 had beenraised, and within another six months the pavilionhad been built. It provides accommodation ofmodern type in the way of washing, changing, anddining-rooms, seating accommodation for all thecollege needs for years to come, a " tuck shop," andpremises for the ground staff’s accommodation.Messrs. C. E. Barry and Son, the architects, presentedthe design as a donation to the Pavilion Fund, Mr.Barry, junior, being himself an old boy. The head-master (Mr. A. C. Powell), in his annual report, spokeof a very satisfactory position in school life. Chiefamong the successes was the senior open sciencescholarship at Jesus College, Cambridge, won byE. A. Marsh, who achieved the unusual by passingthe B.Sc. examination of London University whilestill at school. As a result of bequests, two newentrance scholarships, one of 2120 per annum andone of 100 guineas per annum, will be made availablefor open competition. ____
A MEETING OF NEUROLOGISTS.
THE American Neurological Association severalmonths ago accepted an invitation from the Neuro-logical Section of the Royal Society of Medicine tohold its annual conference this year in London, andto have a series of joint meetings with English neuro-logists. Thirty-four of the visitors, many of themaccompanied by their wives and daughters, arrivedin this country on Friday of last week, whilst otherswere already in this country. The proceedings beganon Monday evening with the reception of the visitorsat the Royal Society of Medicine. Sir James Berry(President of the Society) and Lady Berry receivedthe guests in the library, and there was a largeattendance both of visitors and Fellows. Among theformer were Dr. Charles Dana (President of theAmerican Neurological Association), Dr. F. Tilney,Dr. H. A. Riley, Dr. B. Sachs, Mr. Penfield, Dr. Corn-wall, Dr. N. W. Winkelman, and Dr. I. H. Weisenburg(Secretary of the Association). After the reception SirJames Purves- Stewart, this year’s President of theNeurological Section of the Royal Society of Medicine,gave a lecture entitled " Mount Athos," in whichhe described his visit in 1916 to that remarkablecommunity, and showed many lantern slides of itsmonasteries. He explained the organisation of themonastic republic, and the exclusion from it of every
female, human or animal—’’ no cows, no milk, nohens, no eggs." The architecture of the monasteries,many of which date from the tenth century, wasillustrated, and some account was given of life withinthe walls. The lecturer was impressed by the mentalstagnation w thin the community, and the lack ofappreciation of the priceless manuscripts which are intheir possession. Dr. Charles Dana afterwards pro-posed a vote of thanks to Sir James Purves-Stewartfor his entertaining lecture ; this was seconded by Dr.Bernard Sachs, and conveyed to the lecturer by SirJames Berry. The joint meetings of the Associationand the Section were continued during the week, anda report of the early proceedings appears on p. 258.
WE regret to announce the death on July 26th inLondon, in his 83rd year, of Sir Bryan Donkin,consulting physician to the Westminster Hospital.A leading criminologist, his outspoken expressionshave been of the greatest public value in many socialcircumstances. A fuller obituary notice will appearin our pages. ____
MEMBERS of the medical profession will also learnwith sorrow the death, in his 66th year, of Mr.Alfred C. Taylor, of Peterborough, whose radiologicalwork commenced with Rontgen’s discovery and wascarried on assiduously for over 30 years in spite ofthe serious consequences to his health manifested indermatitis and the loss of fingers from both hands.
THE conferment of a knighthood upon Dr. WilfredThomason Grenfell, C.M.G., will give pleasure to hismany friends inside and outside the medical profession.Dr. Grenfell is a Fellow of the Royal College ofSurgeons of England, who holds honorary degrees ofthe Universities of Oxford, Harvard, and Williams.As doctor, missionary, and mariner his name willalways be associated with life and progress inLabrador.
Modern Technique in Treatment.A Series of Special Articles, contributed by invitation,on the Treatment of Medical and Surgical Conditions.
CCXXXIV.THE TREATMENT OF ERYTHEMA
MULTIFORME AND ALLIED ERUPTIONS.Tms large and relatively common group of toxic
erythematous eruptions will for our purposes includeerythema multiforme (e.g., iris or target forms),erythema nodosum or contusiforme, and purpura.A simultaneous consideration of these clinical types
is justified by what has been termed their rheumatoidcharacters. The lesions are always evanescent or
fleeting, tending to recur, sometimes with seasonalvariations, and not infrequently accompanied byfever, constitutional disturbances, and vague rheu-matic pains around the joints and in fibrous planes.Scarring is never produced in uncomplicated cases.A certain similarity in the pathological histologyfurther justifies this grouping. Exudation of serumor blood through a damaged capillary endothelium isthe keynote. In all three conditions there is someevidence to support the view that a haemolyticstreptococcus may play a part in the causation. Ithas actually been recovered and grown in pure culturefrom some of the lesions, especially those of a purpurictype. In a large percentage of the cases there is ahistory of tonsillar trouble, and it is likely that theorganism s or their toxins may enter the circulation athis point. In others, again, there is pronounced dentalsepsis, which may be obvious or revealed only byX rays. The possibility of these two sources of bloodinfection should always receive due consideration, butit has to be admitted that eradication of such focidoes not invariably lead to a cure or prevent- relapses.
244
If we are satisfied that the surgical work has beenthorough, and that the macroscopic and accessible focihave been completely eradicated, we are then facedwith the more difficult and problematical search forsubsidiary foci, a task which may baffle even the mostexperienced. In this connexion it is well to rememberthat the causative toxin may be medicinal or metabolic,as well as bacterial, and that cases are recorded whichappear to have followed the ingestion of tinned foods ;this brings the clinical picture into line with those(like urticaria) for which an anaphylactic explanationis put forward. In urticaria there is considerableexperimental and clinical evidence that histamine, ora chemical substance resembling it, is the actualcausative agent. By analogy there is much to be saidfor the theory that the introduction of certain drugs-e.g., iodine or quinine-in predisposed persons, theexistence of septic and occluded foci, or the ingestionof stale foods, may lead to the formation or splittingoff from tissue molecules of a definite type ofalbuminoid poison which specifically produces theeruptions we call erythema multiforme, erythemanodosum, or purpura. Such a hypothesis is attrac-tive, and whether ultimately proven or not, at anyrate provides a basis for treatment.There are special therapeutic indications in each
of the three members of the group.
Erythema Jlultiforme.In the acute case the treatment should at first be
symptomatic only, for it is never wise to attack evenobvious foci surgically when the whole circulation ispresumably flooded with the causative virus. Thiscaution would seem especially advisable in cases withoral or pharyngeal lesions. These patients are besttreated in bed, with the usual attention to diet,purgation, &c. If gastro-intestinal symptoms occur,calomel, salol, or high rectal washouts with saline orweak permanganate of potash (1 in 5000 or weaker)may be administered. If there is much oral sepsisor eruption of bullse, with rapid formation of erodedor ulcerated areas in the mouth, only the bland andsoothing antiseptics will be tolerated. These includeweak solutions of glycothymolin ( i. to 0 i.), peroxide(5 vols. per cent.), and bicarbonate of soda(gr. x. ad 3i). Pains in the joints should be treatedwith salicylate of soda, but do not respond so wellas the true rheumatic cases. While the patient isunder immediate medical supervision every effortshould be made to discover the source of infection.Swabs may be taken from the tonsils or gums ; abacterial investigation of sterile samples of the urinemay prove useful for the purposes of diagnosis, or forthe preparation of a vaccine at a later stage.
Local treatment of the cutaneous manifestations isa simple matter, for the patient, as a rule, does notcomplain of much more than burning or slight itching.Lead and calamine lotion in equal parts usuallysuffices to give relief. Strong antiseptics shouldnever be used, and lotions and powders are betterthan ointments.
Vaccine treatment is best deferred until the surgicalprocedures are completed. In one case, in which avirulent hsemolytic streptococcus had been recoveredfrom the urine, the faeces, and the apical abscesses atthe roots of many teeth, every injection of theautogenous vaccine was followed on the next day bya fresh eruption of vesicular erythema multiformeover the whole trunk. The phenomenon showed howsensitive some patients are to the virus, and suggeststhe need for caution in the matter of dosage and doseintervals. There is good reason to suppose that inthe case quoted the vaccine helped to promote therecovery of the patient.
Erythema Nodosu7n.In this disease the inflammatory process and the
exudation of serum are at a deeper plane, and occurin tissues, such as the shins, in which pressure effectsgive rise to pain. Pain is indeed usually the symptomthat most urgently requires treatment. Bed isessential, and salicylate of soda or aspirin givesconsiderable relief. The affected members may be
wrapped in cotton-wool over a 10 per cent. ichthyolointment, or lead compresses may be applied.While most authorities are convinced of the presenceof circulating toxins in such cases, there is somedoubt as to their nature. The safest position is.to regard erythema nodosum as a symptom whichmay occur as a manifestation of various poisons, andthat in its aetiology rheumatism, tuberculosis, strepto-coccal infections, certain acute specific fevers, andgastro-intestinal toxaemia may play a part. Duringthe attack the same general measures are applicableas for erythema multiforme ; when the attack is overthere should be instituted a similar process of investi-gation, which must include an examination of thepatient’s personal and family history, especially asregards tuberculosis.
Purpuric Erupt-ions.Purpuric eruptions may be classified broadly into
primary or idiopathic, and secondary. The aetiology ofthe former group is entirely unknown, and its incidenceincreasingly rare. There is ground for the belief thatin the future a bacterial or biochemical cause willbe found for all cases. A blood count and a Wasser-mann test should precede all other investigations,for purpuric eruptions may occur in many blooddiseases of both known and unknown causation.They may also occur in diabetes and advanced renaldisease, and are of grave significance when associatedwith intermittent fever and signs of organic diseaseof the heart. Beyond attention to the points alreadylaid down above, little can be suggested on generallines. The treatment must in the main be symptom-atic and governed by the severity of the case. Whenhaemorrhage from mucous membranes, from thekidney, or from the stomach is a feature, the outlook isserious, and it has been computed that 14 per cent.of such cases proceed to a fatal termination. Threevarieties of idiopathic purpura are described.
(1) P. simple.!:, usually seen in young children as.
small petechial spots on the legs chiefly. There mayalso be joint pains and slight fever. Rest in bed anda light diet is usually all that is required, and recoveryis the rule in from two to three weeks.
’, (2) P. r/MMma<MX<.—In this type the joint symptomspredominate, but occasionally there is an associatederuption of bluish red macules.
(3) P. hcenaorrhagica.-As its name implies, thehaemorrhages, which may be either cutaneous, sub-cutaneous, or general from any mucous surface, are themain feature of the clinical picture. Joint symptomsmay also occur, and treatment by salicylates mayafford some relief.The number of recommendations available for the
treatment of severe cases of purpura is in inverse-ratio to the degree of their reliability. Adrenalinchloride by the mouth or by subcutaneous injectionof 5 to 10 minims of a 1 in 1000 solution three tofour times daily is probably the most valuablesymptomatic agent we possess. In desperate casesblood transfusions from a relative in the corre-
sponding blood group may be tried, while in thoseless dangerously situated the blood may be given intra-muscularly in 20 c.cm. doses in the buttocks. Horseserum (20 c.cm.) at intervals of three or four days hasother advocates, but if used must be given with duecare to the avoidance of the most troublesome andever-present possibility of subsequent serum disease.Calcium salts are generally prescribed for all cases
of purpura, and in the severe types with serioushaemorrhages intramuscular injections of whole bloodare said to have been beneficial. In cases of a chronicrelapsing type, X ray irradiation of the spleen, whichis sometimes felt to be enlarged, may do good, andrecovery has been reported after splenectomy.
In the secondary group of purpura every effort mustbe made to trace out and eradicate a septic focus, for,just as in erythema multiforme and erythema nodosum,.the best results can only be expected by discovery andabolition of the cause.HENRY C. SEMON, M.D. Oxf., M.R.C.P.Lond.,
Physician for Diseases of the Skin, Royal Northernand Hampstead General Hospitals, &o.
