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Cabot has the credit of first calling attention to acondition which he described under the heading,<; The Lymphocytosis of Infection." His first casewas that of a septic infection of the finger followed bylymphangitis and enlargement of axillary glands.The blood changes are not given in detail, but astatement from Cabot that there was " throughout a

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well-marked, absolute and relative lymphocytosishas more value than mere figures. Fever continuedfor " several weeks," but the patient recovered andwas in good health 15 years later. This is not thepicture of leukaemia, nor is it that of glandular fever.Yet Dr. Tidy says that " glandular fever and thecondition described as infective mononucleosis are

identical." There is a further aspect of the questionwhich may be considered-namely, that there existsan infective myelocytosis-e.g., that recorded bySimon &mdash;which would appear to bear much the samerelation to myelaemia as infective lymphocytosis doesto lymphaemia. There are good reasons for supposingthat a hyperplasia of the haemopoietic tissues, com-parable to that of leukaemia in all but degree, maycomplicate various septic conditions, and is furtherof such frequent occurrence as to be typical in mumps(in early years of life) and in glandular fever.But it may be doubted whether the recorded cases

warrant any more sweeping assertion than this.I am, Sir, yours faithfully,

Sevenoaks, Kent, July 6th, 1923. GORDON WARD.

TUBERCLE ANTIGENS.

To the Editor of THE LANCET.

SIR,-In your issue of June 30th you draw attentioneditorially to recent work of Dr. A. R. Jentzer and hisfellow-workers regarding the attack on the acid-fastcoat of the tubercle bacillus in vivo. These workersinject or use a proprietary preparation or compound offats, lipoids, and waxes. Prof. G. Dreyer, as is wellknown, removes the fatty and waxy capsule of thetubercle bacillus in vitro by formalin-acetone. Inboth the methods centre on the waxy and fattyprotective coat. According to Dreyer, the removal ofthe acid-fast substances releases the protein antigen.This is thus more readily soluble in trypsin, and afterinjection is more effective in the production of variousantibodies. On the other hand, according to Jentzerand his colleagues, it is claimed that their compound offatty and waxy substances " stimulate the tissues toproduce ferments which not only saponify the fattyand waxy substances introduced by parenteralinjection, but- also the fatty, lipoid, and waxy con-stituents of the tubercle bacillus." This method ofattacking tuberculosis is described as novel, and in asense to some extent as anticipating the work ofProf. Dreyer, but the exact composition and mode ofmanufacture of the compound of the fats, lipoids, andwaxy substances used by Jentzer and his colleagues arenot published. May I point out that the employmentof the fats and lipoids and the theory therefromconstructed is not novel ? P For many years variousaspects of the fat-splitting action of the pancreas hasoccupied my attention. The results of my work, Icarried out in the physiological and bacteriological Ilaboratories, King’s College, have been published in’THE LANCET and elsewhere. 2 The main outcome ofthis work has been to show that a natural and increasedproduction of lipase in the blood and tissues is animportant factor in the protective mechanism of thebody. This is particularly the case in malignantdisease, although I have pointed out that this lipolyticdefensive response is not specific to cancer but iscommon to tuberculosis and other bacterial invasions.This I have expressed in identically the same terms asemployed by Jentzer and his colleagues. Lipase,moreover, lends itself naturally to attacking the fatty

1 Amer. Jour. Med. Sci., 1907, cxxxlii., 389.2 Shaw-Mackenzie, J. A.: THE LANCET, 1919, ii., 825;

Brit. Med. Jour., 1921, i., 402 ; Jour. Trop. Med. and Hyg., 1921,xxiv., 161 ; Med. Press and Circ., 1922, i., 287.

and lipoid coat of the tubercle bacillus in vitro. Aslong known, lecithin is split by lipase and acceleratesalso the activity of that enzyme in vitro and in vivo.In my experiments it was found that fatty acids areliberated by lipase from killed tubercle bacilli in vitro.In this way saponified extracts were prepared andindicated for therapeutic use. Preparations were

made also by extracting tuberculous material with theusual fat and lipoid solvents, alcohol, ether, andchloroform successively, in a Soxhlet’s apparatus inthe usual way, and saponifying the extracted materialor emulsifying. This method in the main differsessentially from that of Jentzer and his colleagues inthat the products of the fats and lipoids of tuberclebacilli are used, together with protein and phosphatederivatives or constituents of the bacillus. The

soaps themselves&mdash;e.g., sodium oleate, organic andinorganic phosphates, and proteins-have markedpower in stimulating tissue lipolytic activity. Similarmethods have been employed in dealing with the fatsand lipoids of the cancer cell and tissues. The idea orprinciple underlying treatment by these extracts isstimulation of tissue lipolytic activity with destructiveaction on the fats and lipoids of the cancer cell, as inthe case of tuberculosis, on the fats and lipoids of thetubercle bacillus.

I am, Sir, yours faithfully,J. A. SHAW-MACKENZIE, M.D. Lond.

London, June 30th, 1923.

DELAY IN GIVING DIPHTHERIA ANTITOXIN.To the Editor of THE LANCET.

SiR,-All medical officers of health will agree withDr. F. F. Caiger that frequently in fatal cases valuabletime is lost by the practitioner. In 17 fatal cases ofdiphtheria occurring in Brighton during 1921 and 1922the time lost by the doctor failing to diagnose thecondition is shown in the following table :-

There is little doubt from a study of the table thatthe case mortality of diphtheria can be greatlyreduced by prompt diagnosis and immediate removalof the patient to hospital. In Brighton probablyone-third of the deaths could have been avoided ;assuming the same conditions for the whole of Englandand Wales the annual loss due to lack of promptdiagnosis by the doctor is some 1800 lives. Whenone considers that diphtheria in the child is easyto diagnose, also that negative swab results give littlehelp, the folly of awaiting swab results is apparent.My own conclusions are : (1) It is the duty of

general practitioners to acquaint themselves with theeasily-grasped clinical signs of diphtheria and theduty of those controlling fever hospitals to give eopportunity to the general practitioner to see typicalcases of the disease ; (2) it is doubtful if local authoritiesshould accept swabs for the diagnosis of acute throatconditions in children.

I am, Sir, yours faithfully,

July 3rd, 1923.DUNCAN FORBES,

Medical Officer of Health, Brighton.

R.A.M.C. MEMORIAL IN DUBLIN.-On July 4thSir John Goodwin, Director-General of the Army MedicalService, unveiled in St. Patrick’s Cathedral, Dublin, amemorial to the officers and men of the Royal Army MedicalCorps who fell in the late war. The memorial is a marbletablet, a replica of that erected some months ago in West-minster Abbey. There was a large attendance at theunveiling ceremony.