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experience of the military medical boards mayhelp the Industrial Health Research Board intheir investigation of a problem which hasexercised their minds from the start of their work.

GENERALISED STAPHYLOCOCCALINFECTION

EvER student knows that a staphylococcalinfection usually results in a localised abscess, incontradistinction to the spreading or invasivelesion characteristic of the streptococcus. But attimes the staphylococcus produces a generalisedinfection which from the occurrence of metastaticabscesses is usually called pyaemia, although thegeneric term septiemmia-indicative of a wide-

spread infection of the tissues and not merelythe occasional spilling of organisms into the blood-stream from a local focus (bacteraemia)—may bejustifiably used. Staphylococcal lesions in twosites-the face and the bones-are particularlyapt to be followed by a generalised infection, andthe results are usually disastrous. The case-

fatality rate of staphylococcal septicaemia hasvaried in different series from 66 to 90 per cent.;the prognosis is worse after carbuncle than osteo-myelitis, in the very young and the aged than inadolescents, and in the presence of complicatingdisease, especially diabetes. But, as the late Dr.A. P. BEDDARD used to say, in staphylococcalsepticaemia the betting is on the staphylococcusevery time.Treatment of staphylococcal septicaemia aims

at (a) eradicating the source of infection and

(b) sterilising the blood-stream. It is not alwayseasy to deal with the local focus, particularly inlesions about the face, and in such cases ligatureof the angular vein is recommended to preventthe spread of infection to the cavernous sinus.In osteomyelitis, too, there is a school of thoughtthat advocates non-operative treatment, but in

general the principle of removal of the infectingfocus which is feeding the blood-stream with

septic emboli must be regarded as sound.Attempts at sterilisation of the blood have in thepast been mostly unsuccessful, although repeatedblood transfusions or the injection of staphy-lococcal antitoxin has sometimes seemed to do

good.It was natural, therefore, that the sulphon-

amide group of drugs should be tried in thesesevere infections. Experimentally, in staphy-lococcal infections of mice, M. & B. 693 and

possibly Uleron have been more effective than

sulphanilamide itself, and this finding is now beingsupported by clinical observation. MITCHELL 2

reported the successful treatment of five severecases of osteomyelitis (in two of which the affectedbone was not drilled) with uleron; on the otherhand, WADE 3 has recorded a case of staphy-lococcal septicaemia which failed to respond touleron but appeared to react to M. & B. 693. Inour present issue Dr. ABRAMSON and Dr. FLACKSreport six cases of severe carbuncle of the face,

1. Mendell, T. H., Arch. intern. Med. June, 1939, p. 1068.2. Mitchell, A., Brit. med. J. 1938, 2, 1200.3. Wade, H. J., Lancet, April 1, 1939, p. 756.

of which the first four patients-three of themtreated with proseptasine or uleron-died, whereasthe other two who were given M. & B. 693, andhad the angular vein on the affected side tied,both lived. Staphylococcus antitoxin was givento one of the patients who recovered (and also toone who died), and in view of the part whichantitoxic immunity possibly plays in limiting thespread of staphylococcal infection,4 a combinedserum and chemotherapy would seem worth a

more extended trial in this as in other bacterialinfections. In the fifth case of this series and inthe case reported by Dr. GALEWSKI and Dr.STANNUS on p. 1067, Staphylococcus albus wasthe organism recovered from the blood. Whilewhite variants of Staph. pyogenes do occur, thepossibility of such strains being non-pathogeniccontaminants must be considered, and it becomesessential to test their pathogenicity, which canbe done by the simple coagulase test.5

Isolated instances of cure apparently effectedby a particular treatment may not mean much,but the clinical evidence now accumulating aboutthe benefit of chemotherapy in staphylococcalsepticaemia encourages a more optimistic prog-nosis. Its comparatively long course, however,must not be allowed to tempt the clinician to

give these new drugs for longer periods than havebeen found safe in other infections.

GENES AND HORMONESFEW are qualified to discuss the relationship of

genetic and endocrine factors and the ways inwhich their complex interaction in the highervertebrates may have arisen. As an endocrino-logist who is also a geneticist Professor DANFORTHof Stanforth University, California, is able to treatthis difficult subject in a particularly refreshingand stimulating manner. s Dealing first with

genes, he emphasises the modern tendency tothink of the whole gene complex as a unit, inwhich, for the production of a given trait, anyparticular gene has perhaps no more intrinsic

importance than many others. Under conditionsother than those holding in a particular organism,the seemingly significant gene for the same traitmight be an entirely different one, and one shouldno longer speak of the gene for a trait as thoughthat gene and no other could or does produce theeffect studied. Genes and cytoplasm are relatedin a kind of functional symbiosis; the actualanatomical and physiological reactions are a func-tion of the cytoplasm, but the behaviour of thecytoplasm is conditioned by the genes. The reac-tivity of the cytoplasm to the genes may be theresult of gradual cytoplasmic evolution, and thecytoplasm may adjust itself to already existinggenes, some of which become effective inindividual development only when the cytoplasmhas gone through certain preliminary phases.This adjustment of cytoplasm or of tissue to

4. Downie, A. W., J. Path. Bact. 1937, 44, 573.5. Cruickshank, R., Ibid, 1937, 45, 295.6. Danforth, C. H., Harvey Lectures, 1938-39. Baltimore:

Williams and Wilkins Co.; London: Baillière, Tindall andCox. 1939. Pp. 279. 18s. (p. 246).