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have been many and distinguished--have been

favourably impressed with the character of Mr.SPAHLINGER’S work and with his sincere desire to

put his remedies at the disposal of mankind. Theremedy has not yet reached the stage of proved valueand necessity. Mr. SPAHLINGER himself does notpose as a clinician, and the clinical trials of his remedieshave been spread over several countries and havenowhere been carried out under research conditions.It is well known that the British Ministry of Healthis prepared actively to encourage the experimentaltrial of the Spahlinger preparations under scientificsupervision, so soon as supplies of the remedy areavailable for the purpose, and the British Red Crosshas gone so far as to vote a sum of .E30,000 to enable IIMr. SpAHLiNGER to produce his remedies to a larger Iextent so that they may be tried in this country.

The issue being thus clear-cut, it is with the keenestregret that we have noted during the last weekevidences of a press campaign to raise funds in thiscountry on the ground that the reports alreadypublished prove beyond doubt the great national

importance of the movement. A Memorandum,ostensibly prepared by several medical men as anauthoritative statement of facts, contains such

regrettable exaggerations as that the methods ofSPAHLINGER make it clear that tuberculosis can be

prevented, and that when the treatment is over

there is no trace of the disease remaining. There isa suggestion that, had they not been prevented fromdoing so by the fear of " oblique advertisement "

(in the sense of the General Medical Council), manyimportant signatures would have been appended tothis statement. It seems to us improper to infer theweight of medical opinion in such a way. The

Ministry of Health has found it necessary to reissuea statement of its position-namely, that up to the

present the Minister has neither approved, nor dis-approved, of the treatment.The Memorandum justifies the appeal for funds by

the grave danger from financial pressure to whichMr. SpAHLiNGEB’s work is now exposed. We can

only trust that he will submit to the independentinvestigation of his remedy which would put himright with the medical world and relieve him of hisimmediate difficulties. Could some arrangement bemade to carry out this investigation, with the usualcontrols, at one or other of the research institutes inthis country, two objects would be served : (1) themoney could be raised without risk of forfeit ; and(2) the control would bring conviction to those amongwhom it is carried out. We appeal to Mr. SPAHLINGERin the name of humanity, no less than in that of

science, to consent to this course.

EFFICIENT DIAGNOSIS OF CANCER.AT the present time a number of new and hopeful

methods of treatment are being brought to bear uponcases diagnosed clinically as cancer, and the provingof these methods must depend in large degree upon thecertainty of the diagnosis. Surgeons in all countriesfor many years past have been perfecting their powersof clinical acumen to make sure that they onlyintervene when it is needful for them to do so and thento good purpose. In a paper read before the Nebraskabranch of the American College of Surgeons, and nowreprinted in a volume of Collected Papers of the MayoClinic, Dr. WILLIAM C. MACCARTY attempts toanswer the question : Have we, as a profession,

1 Vol. xiii. Published May, 1922. London and Philadelphia:W. B. Saunders Company. 60s.

reached our greatest efficiency in the clinical diagnosisof neoplasms ’1 In order to determine the presentdegree of diagnostic efficiency Dr. MACCARTY hascompared the pre-operative diagnosis of a group ofwell-trained graduates of first-class medical schoolsin America and other countries with the actualcondition found at operation, checked by a surgicalpathologist. Confining his study to the mammarygland, on the grounds that it is easily seen and feltand a frequent site of a variety of neoplasms, he findsthat surgeons are willing to commit themselves to apositive diagnosis in 78-5 per cent. of cases and

unwilling to commit themselves definitely in 21’5 percent. When clinicians are certain enough to say"

malignant " they prove to be correct, Dr. MACCARTYfinds, 94-5 times out of 100. This, as he says, is thepercentage which doctors like to quote, but it is notan index of diagnostic efficiency, for there remain the21’5 per cent. of cases in which the clinician is unwillingto commit himself before operation. Thus the actual

percentage of malignant breasts diagnosed positivelyby the clinician correctly becomes reduced to 77 percent., while the percentage of benign breasts diagnosedpositively by the clinician correctly is only 50 per cent.Now most surgeons have been content to operatefirst and to hear the pathologist’s report afterwardswhen it is too late to guide their action. It was thelate Mr. C. B. LoCKwoOD who suggested in 1899 theplan of cutting frozen sections of every tumour at thetime of operation and Mr. ERNEST SHAW who workedout the details of the method. Mr. SHAw first setout his method in our columns in 1910, and in ourissue for Feb. 3rd, after an experience of 23 years, hesummarised his results. The delay occasioned by hispresence in the operating theatre is not serious ; thewhole process of freezing, cutting, mounting, staining,and examining a section requires five minutes or less.Mr. SHw has made it a rule to prepare paraffinsections to examine at leisure later, and he states thatin every instance-and he is writing of 540 cases-theleisurely has confirmed the hasty picture.The pathologist may thus be a person of some moment

in the operating theatre. Suppose, Dr. AIACCARTYasks, you are the surgeon and have no surgicalpathologist, what are you going to do with a patientwho happens to be one of this 21-5 per cent. In thewhole series of 2100 cases which he studied, not onewas treated too radically, and not one failed to receivea radical operation when necessary, by virtue of thefact that all the clinical diagnoses were checked atoperation by a surgical pathologist. This is hisanswer to his own question. He then sets out certainreasons why all breast cases are not checked, and thelist is worth quoting in his own words :

1. You may not have a pathologist.2. You may not have tried to have a pathologist.3. There may not be a pathologist near you.4. You may think you are a great pathologist, especially

a great gross pathologist, in which case you simply incisethe tumour, immediately after its removal, and passjudgment.

5. You may not believe in frozen sections.6. Your practice may not be large enough to allow you to

pay a pathologist.7. You may be depending upon the hospital to supply

you with a pathologist.8. You may have lost faith in pathologists because you

have had sad experiences with men who call themselvespathologists, or with the so-called intern pathologist whohappens to be sojourning in the hospital for a year or twodoing everything in the categories of tissue pathology,bacteriology, serology, clinical microscopy, and sometimesroentgenology.

Dr. MACCARTY himself believes that it is unfair toperform a radical operation on the mammary glandin doubtful cases, but that it is fair with our present

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knowledge to remove a sector of the gland-bearingstructure for immediate examination. The liningof the ducts and acini of the breasts consists normally Ifof two layers of cells ; if these are present the path- Iologist is dealing either with a normal condition or ’one in which there is at most reaction to some dis- Iturbing factor. Radical operation is then unnecessary. Shouid the hyperplastic cells of the outer row be found ’,to have invaded the stroma, malignant condition ispresent and radical operation should be performed.If after thorough microscopic examination a conditionis found in which the outer cells, although hyperplastic,have not invaded the stroma, his experience indicatesthat the removal of the gland-bearing structure issufficient. He has never seen recurrence after sucha simple operation.

’

This is the type of service which the surgicalpathologist can render. Whether the microscopicaldetermination of malignancy is quite as simple as

Dr. MACCARTY seems to imply is a question which weprefer to leave open. In the case of the breastnumerous layers of cells are sometimes seen in simpleinflammation; in some growths but one layer ofcolumnar cells is present in the alveoli. Probablythe most important point to determine in an early ’,case is whether the basement membrane is or is notintact. Moreover, malignant disease of the breast is ’,usually one of the easier forms of growth to distinguishin frozen sections. It is notoriously difficult to decidebetween some forms of sarcoma and inflammatorytissue even under the most favourable conditions. Andon this decision may depend the amputation of a limb.Frozen sections and rapid staining can hardly solvedifficulties which still vex the skilled pathologist afterthe whole ritual of hardening, embedding, anddifferential staining has been observed. Nevertheless,if all surgeons were to follow out this plan over aseries of years, substantial progress might be madeand an end be put to the fashion of guessing. Guessingshould not be agreeable to the scientific surgeon,nor will it help to assess the value of non-surgicalmethods. The case for exact microscopic diagnosisof neoplasms is very strong indeed, but it wouldinvolve a large staff, and specialisation has gone onamong pathologists to the extent of strictly limitingthose who devote themselves to the study of morbidanatomy and histology. The method of " rapiddiagnosis " has established itself to meet the emergencyof the operating theatre, but it can in no way replacethe careful and detailed pathological examination towhich every breast, and indeed every tumour, removedby operation should be submitted. The pathologistmay still be unable to suggest what course the caseshowing an unusual type of tumour is likely to take.Mr. SHAW’s plea is valid for a national pathologicalmuseum, where examples of every kind of malignancymay be obtained. For microscopic examination isthe only really efficient control to the clinical diagnosis,and until the necessity for adequate controls is as

clearly recognised by the clinician as it is by thelaboratory worker the outlook for progress in diagnosisand treatment will never be as hopeful as it might.

ROYAL SANITARY INSTITUTE.—A meeting will beheld on March 2nd and 3rd, in the Town Hall, Sheffield, whendiscussions will take place on Extraneous Matters in Foodand the Prevention of Disease by Feeding. to be opened byMr. J. Evans, city analyst, and Prof. E. Meilanby, respec-tively. The chair will be taken by Dr. Louis C. Parkes.On March 3rd visits will be paid to the Corporation SewageWorks, at Wincobank, and the works of Messrs. Newton,Chambers and Co., at Thorncliffe.The annual congress will be held at Hull from July 30th

to August 4th next.

Annotations.

WILHELM KONRAD V. RÖNTGEN.

"No quid minis." "

THE death is announced of Prof. Rontgen atMunich, in his seventy-eighth year. Born in 1845at Zennep in Rhenish Prussia, Wilhelm Konradvon Rontgen was educated in Holland and at Zurich,where he became doctor of science in 1869. In 1885,after holding various appointments in Germanuniversities, he became professor of physics at Wurz-burg, where on Nov. 8th, 1895, he discovered X raysin circumstances so well known as to render descrip-tion unnecessary. Although the exact nature ofthese rays has not yet been ascertained, their useimmediately resulted in a great advance in manybranches of scientific work. The medical and surgicalapplication of the rays first took the direction oflocalisation of coarse foreign bodies, as bullets, butalmost immediately a dozen directions were seen inwhich the discovery would advance therapeutics.Apart from its medical uses, great advances in

physical and industrial investigation have also beenmade possible by the discovery. The medical aspectsof Rontgen’s discovery form a story that must betold at some length later.

THE PATHS OF INFECTION.

UNTIL the last few years the accepted theory as tothe dissemination of many of the infectious diseasesof this country was that the victim was alwaysinoculated from a previous case, and that the viruswas conveyed from the one to the other by directcontact or some similar direct transmission, such asthe breath, or by means of fomites. With small-poxit may be said that our experience accords with thistheory, and that action based on the isolation of thesick from the healthy, and on disinfection, has beensuccessful. There are certain other diseases, such asmeasles and chicken-pox, in which the infection alsoappears to be spread directly, although there is not thepractical evidence of the successful application in thecommunity of measures based on the theory. But ourexperience with scarlet fever and diphtheria points inthe opposite direction. If the usual method of spreadwere by direct infection or through fomites, it wouldbe reasonable to expect that prompt isolation in

hospital of nearly every diagnosed case, followedby disinfection of the infected room, clothing, andbedding, which is the method practised in many ofour sanitary areas, would have resulted in a greatreduction in these diseases. It has been the subjectof comment that there is so little evidence of any suchdiminution, and we understand that the practice oftreating the cases in their own homes, which is beingreverted to in some districts and has always been invogue in others, results in no excessive incidence.

It is evident from such facts that, while there maybe no grounds for thinking that the recognised caseof scarlet fever or faucial diphtheria cannot infect asusceptible person directly, yet such direct transmis-sion is not the ordinary way of spread. What theordinary channel of infection may be is unknown.The knowledge of the cause of diphtheria whichbacteriology has afforded has not yet led to the tracingout of this path. But it has shown that only a minorityof the population is susceptible, and that the causativebacilli are to be found in many more persons in aninfected community than the disease itself. The factsmay be explained on the assumption that the infectionis spread broadcast from one naso-pharynx to another,but that only a minority of the infected-those wholack immunity-develop the disease. This has beensuggested as the mode of spread in certain otherdiseases like cerebro-spinal fever, which under present-day civilian conditions exhibits almcst no power ofdirect infection ; and it may well appJy to scarlet fever,