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or the blood. The blood was infected by 1’l’ypanosomalewisi. The rats were well nourished and showed nosign of disease.

It is of interest to compare these results with therecent investigations of Profs. W. Schuffner and W. A.Kuenen into the condition of rats in Holland. G Theyexamined, by dark-ground illumination, the kidneyscrapings of a large number of rats in Amsterdam.Out of a total of 209 of the species Mus decurnanics.27 per cent. were found to be infected ; of 29 of thespecies lYIus l’attus, only one contained the organism.They concluded that in comparison with other townsthe percentage of infected rats in Amsterdam wasfairly high, about equal to that of London (Stevenson).They also examined for Trypanosoma le1Visi and foundthat 14 per cent. of the ilI us decumanus and 7 per cent.of the 11I us rattus were infected. In the case of oldrats, the spirochsetes were found in a much greaterproportion of cases than among young rats (45 percent. against 2-5 per cent.) ; the relative incidence oftrypanosomes was 11 per cent. against 16 per cent. inyoung rats. Like Stevenson, they found the spiro-chsetes in the kidney collected in foci, not in thekidney-substance but in the tubes. In the case ofthe rat the investigators hold that the infectiongradually increases in virulence. Cases of Weil’sdisease in Holland are rare and the high infectionpercentage among rats came as a surprise to theinvestigators. -

SECONDARY INFECTIONS IN PULMONARY

TUBERCULOSIS.

Prof. Paul Courmont and Dr. Boissel,7 of Lyons, Istate that until recently it was generally held that Ithe tuberculous lung was almost always invaded ata certain stage of the disease by other organismsthan the tubercle bacillus, and particularly by pyo-genic germs. A considerable proportion of thepatients’ symptoms were attributed to secondaryinfection, especially the hectic fever and the aggrava-tion of the general condition. The therapeuticalconsequences of this view were that mixed vaccinesconsisting of the principal pyogenic organisms weresystematically employed in all cases of active pul-monary tuberculosis with frequently disastrousresults. In opposition to this theory of the frequencyof secondary infection Besancon and Biros, at theStrasbourg Congress in 1922, maintained that thetubercle bacillus played a predominant part through-out the course of pulmonary tuberculosis, and thatthe role of secondary invaders was reduced to a fewcases of pneumococcal infection or insignificantbronchitis. The present writers carried out investiga-tions on 188 patients presenting all varieties of pul-monary tuberculosis, and found that while secondaryinfections were much less frequent than was formerlysupposed, they were present in a considerable pro-portion-viz., 20 per cent.-while in the remaining80 per cent. the tubercle bacillus was sufficient toproduce every form of anatomical lesion in thelungs and all the clinical varieties of the disease,including hectic fever. The secondary infectionswere divided into two groups. In the first group,which consisted of 13 cases, the infection was poly-microbial, there being a collection in more or lessvariable quantity of different organisms, such as

streptococci, pneumococci, B. col-i, and diphtheroidorganisms. Cases of this kind were almost alwaysvery severe, with pulmonary cavities, and it wasdifficult to say whether these secondary infectionsmerely represented the last stage of the disease, orwhether they played a part in the evolution of thelesions. In the second group, which consisted of23 cases, the associated infection was due to a singlemicro-organism, such as the pneumococcus (2 cases,1 death), pneumobacillus (2 cases), enterococcus(1 case), streptococcus (3 cases, 1 death), tetragenus(2 cases, both fatal), B. ci<tis commune (4 cases, allfatal), catarrhalis (1 case, fatal), Pfeiffer’s bacillus

6 Nederl. Tidschrift voor Geneeskunde, 1923, ii., 2018.7 Paris M&eacute;dical, Jan. 5th, 1924.

(5 cases, 1 death), and various cocci (3 cases). Inthe second group the secondary invaders appear tohave played an important part. The prognosisindeed in many cases seemed to depend on thenature of the associated micro-organism. While thepneumobacillus and Pfeiffer’s bacillus proved to beof little danger, the streptococcus, enterococcus, andtetragenus were found in the severe and rapidly fatalcases. A Paris thesis to which attention was drawnrecently sets out the sinister relation of tetragenusto fatal tuberculosis. The practical outcome of theLyons studies is that if vaccine treatment is to beemployed in pulmonary tuberculosis it should be

specific. In most cases vaccine treatment by otherorganisms than the tubercle bacillus is not required,but in cases of secondary infection vaccine-therapyshould be tried, and is all the more likely to besuccessful when the tuberculous lesions are notsevere or extensive.

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THE FUNCTIONAL CAPACITY OF THELIVER.

NN7HiLE the efforts of clinicians are continuallydirected towards the study of the functional capacityof diseased organs, the study of the hepatic functionshas been somewhat neglected, although it is far moreinteresting and necessary than the mere physicalcondition of the liver. This state of things may beimputed to the fact that the results obtained havebeen at variance, often unexplainable and uselessfrom a clinical point of view. Prof. Giuseppe Sabatini, 1of the Institute of Clinical Medicine in the Universityof Rome, has published the results of his own investiga-tions which seem to us to shed some light on thesubject.

Prof. Sabatini recognises that the liver has notone, but five functions, the biligenetic, glycogenetic,ureopoietic, antitoxic, and proteopexic : he investi-gated them all by the usual well-known laboratorymethods in 12 cases of hepatic disease, includingdiabetes mellitus, various forms of cirrhosis, jaundice,and gall-stones. In none of the cases were all thefive functions affected simultaneously, nor was it

possible to say whether in definite diseases therecorresponded definite types of functional insufficiencyeither singly or gathered into special groups. In thecase of cirrhosis this question could be with certaintyanswered in the negative, while the cases of diabetesshowed an almost identical behaviour of the variousfunctions. On the other hand, there was a profoundand extensive disturbance of the hepatic functionsin calculous cholecystitis. It must therefore beadmitted that in this disease, apparently localisedbut which may cause grave disturbance of the generalhealth, certain conditions come into play whichseriously impair the action of the liver, perhapsthrough reflex nervous stimuli, and perhaps alsothrough slight general infection. Investigations ona far larger scale and perseveringly carried out in thisdisease may help to solve this problem. The biliary

function was always found altered in these patientsto a slight extent, but in the diabetics it was normal,the glycogenic function was altered in some cases,normal in others-for example, in three out of fourcases of cirrhosis it was found to be normal. Theureopoietic function gave results in accord withpathological conceptions ; it was altered in three casesof true atrophic cirrhosis, and normal in a case ofcardiac cirrhosis. In the diabetics there was invari-ably a disturbance of this function, probablv in relationwith altered metabolism not only of carbohydrates,but also of proteids. It is not improbable, however,that this function is altered in diabetics because thereis in these patients a greater production of ammonia(a defence against acidosis) which necessarily changesthe value of the coefficient of ureogenetic inadequacy.The proteopexic function, judged by the digestivehsemoclasis of Widal, did not give any definite or

serviceable results, the haemoclasis being sometimespositive and sometimes negative without reasonable

1 Il Policlinico, Practical Section, xxxi., Jan. 14th, 1924.

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explanation. The antitoxic function, at least inthe form of Roger’s induced glycuronuria showed avariable behaviour of no clinical value or particularinterest for diagnosis.The conclusion which may be derived from these

interesting researches is that if it has hitherto beenadmitted that there is a parallelism of all the functionsof the liver and a complete association between them,this view will have to be modified. Even assuming,according to the general laws of physiology, theharmony of the various hepatic functions, we havenow evidence to show that this association is correctonly within physiological limits. Under the actionof different morbid conditions, the various functions,which perhaps have different anatomical sites in thecomplex and obscure architecture of the organ,do not all suffer simultaneously nor in an equal degree.So that we always find in functional exploration ofthe liver one or several functions more or lessprofoundly altered side by side with others which areabsolutely normal and intact. Prof. Sabatini pleadsfor further studies of the many hepatic functions inorder to arrive at an estimation of the functionalefficiency of the organ by the adoption of definite andidentical methods, so that results may be obtainedwhich leave no gaps and are intelligible and comparableand lead to the determination of constant relationshipbetween types of hepatic lesions and types of functionalefficiency. ____

FUNDAMENTALS OF THE CANCERPROBLEM.

AT this stage of the cancer problem a criticalselection from the enormous mass of material nowcollected, presented mainly in pictorial form, cannotfail to be of interest to students and practitioners. Itis therefore not surprising that the Governors’ Hall atSt. Thomas’s Hospital was filled with an audience ofnearly 400 people on the occasion of the first of the fourlectures on cancer being delivered under the auspicesof the University of London by Dr. J. A. Murray.This lecture was a survey of the main features commonto malignant growths, preliminary to the discussion ofexperimental and other research work in subsequentlectures. Dr. Murray’s main conception of cancer isthat of an aberration of the process of repair. Whethercancer arises in the covering epithelium of any portionof the body, whether it arises in the subcutaneoustissues, or from linings of the blood vessels, the sameprocess is at work, the differences in the histology of thegrowth being due to differences in the tissues of origin.Dr. Murray showed lantern slides of primary andsecondary growths in man and other mammals, andalso in amphibians and fish, and of histological prepara-tions demonstrating characteristic features of malignantgrowths. In a carcinoma which has developed from aglandular tissue the glandular structure is sometimesentirely lost, and a solid mass of cells results, but thisdifferentiation can be reversed under suitable experi-mental conditions. Such a growth can be made togrow in a solid mass or made to return to glandularstructure without having altered its characteristics asa growth. The superficial similarity between thehistology of a carcinoma of the skin and of the develop-ment of an embryo has given rise to many of thenow untenable hypotheses of the nature of carcinoma.In the early stages of malignant growths several fociof independent growth are to be found, and manygrowths have arisen by the coalescence of these foci ;but it is interesting to note that this coalescencedoes not take place by the transformation of the inter-vening portions into cancer. It is on the interpreta-tion of pictures as active processes-not as a

final stage-that the diagnosis and interpretation ofthe histology of malignant new growths must rest.If cancer remained localised tissue there wouldbe no necessity for the elaborate amount of investi-gation and study which we apply to it; verysimple remedies would be sufficient, such as itsremoval when it became troublesome-or dangerous.But it is the capacity for passing beyond the original

site in the body and disseminating to the distantparts which makes cancer so serious a disease.Dr. Murray proceeded to discuss the occurrence anddistribution of cancer. Here individual experience,he said, is of very little value. The experience ofcommunities is required. Of all the causes of death,cancer is responsible for one-tenth or one-twelfth ofthe general mortality. Recoveries from cancer arepractically negligible from the point of view of statisticsin this country. The age-incidence of cancer, both inman and animals, is suggestive, for as we go up inyears we find that the proportion of those dying fromcancer, to the total of people living, rises swiftly.Comparison of the incidence and mortality of cancerin different countries is not easy. The difficulty isthat we have no good grounds for believing that anumber of cases of cancer recorded in any countryrepresents truly the number of deaths in that countryfrom cancer. There may be more deaths or fewer.There is no means of knowing what other diseases weretermed cancer, or whether cancer was always diagnosed,and thus we have to read international statistics with

a certain reservation. The significance of the apparentincrease of cancer found in this and other countriesis very difficult to interpret. It is extraordinary thatthe increase is not in those regions of the body-for example, cancer of the uterus-where the diseaseis commonest. Again, while females of 75 and upwardsduring the period 1851-1909 show progressive andrapid increase in the proportion of deaths due to cancer,in women of 35-45 the increase has been much less.Dr. Murray considers that we are justified in takingcomfort from this observation by deducing that thefactors which can produce cancer are apparentlytaking longer to produce it now than in the past. Ifthe increase of cancer is significant at all, not merelydue to improvement in diagnosis or the like, then ittakes longer for the disease to develop than 40 years sago. That is one of the most hopeful features ofotherwise ominous figures.

EPIDEMIC DROPSY IN CALCUTTA.

RECENTLY Calcutta has experienced an outbreakof epidemic dropsy, which has been the substanceof an inquiry by the workers at the Calcutta School ofTropical Medicine, under Lieut.-Colonel J. W. Megawand the staff of the Health Office, Calcutta. As aresult of careful investigations, the ingestion of injuredrice has been suspected as an astiological factor inthe outbreak. The disease first appeared among thewomen students of a medical school, who made theirown messing arrangements. It was found that theirrice supply came from a small dealer in a differentlocality. An interesting fact was discovered-namely,that the family of the dealer was suffering fromgeneralised oedema, and that a number of people inthe neighbourhood who obtained their rice from thesame source were also affected. About 75 cases inall were detected. Colonel Megaw reports that allthe effects which were observed went to show thatthe disease originated from the consumption of rice,and it was quite possible that one consignmentof rice might have been responsible for all the cases.There have been many different views as to the natureand cause of epidemic dropsy. ’. In 1914, Lieut.-Colonel E. D. W. Greig, I.M.S., classified epidemicdropsy as one of the deficiency diseases, similar toberi-beri. It has also been regarded as an infectiousmalady, and in support of this view Dr. BepinBrahmachari, I.M.S., has published a paper in a

recent issue of the Calcutta Medical Journal. 2 Again,it has been widely held in Calcutta that a poisoncontained in an adulterated mustard oil is responsiblefor the condition, but no evidence of the presence of anypoison has been obtained on scientific investigation.The opinion which now holds the field on the aetiologyof epidemic dropsy is that rice which has been damagedby improper storage develops a mould which, when

1 THE LANCET, 1920, ii., 1234.2 Calcutta Medical Journal, December, 1923, p, 519.