end of the period of confinement and who died soon after or showed lesions of hereditary syphilis later in life.

A striking example of the influence of syphilis on the lives of babies occurs in Ohio month after month. There were reported in the state in the first four months of 1918, for instance, 194 deaths from syphilis. Of this number, 57, or 30 percent, were one year of age or younger. These were all live children whose deaths were reported due to syphilis, but during the same period there was a large number of stillborn children reported. How many stillbirths are due to syphilis we cannot say, with no accurate statistics available, but of course a large proportion was caused by this disease. Basing the statement upon the records for past years in Ohio of an average of 250 stillbirths each month, one may safely claim that out of the thousand stillbirths in the four months an unknown but surely a high toll of baby lives is paid to the incidence of syphilis.

The statement that syphilis plays an important part in Ohio's infant mortality is further strengthened by the fact that for the past threeyear period there was a total of 401 deaths of children under one year caused by syphilis 34 percent of all deaths registered as due to syphilis. In this same threeyear period there were 9,926 stillbirths with no record of the syphilis represented in this number. There are, too, the deaths registered under "prematurity" and "inanition," which are in their turn closely related to syphilis.

When we remember that the children who die under one year of age are the fortunate ones, while the ones who go through life as

cripples, as imbeciles or epileptics are those who really pay the penalty, one is brought directly face to face with a problem, the immensity of which is appalling. One has only to study carefully the chart of any of the famous families, such as the Kalikak family, to find that alcohol and syphilis head the list as regards frequency of appearance among its members. These mental and moral wrecks, while not so great in numbers perhaps as the abortions, premature births and deaths in infancy, are almost a greater problem because they become or should become a source of actual expense to the community in which they live, to say nothing of the dangers to which they expose society at large.

When one considers the effect of gonorrhea on the lives of children one has almost the same condition to face. Here we do not record great numbers of deaths, in fact, almost none, but we have to record the long illnesses, in the course of which the child passes from the acute into the chronic sufferer and often is left totally blind or else with the eyesight so impaired that life is at best a very doubtful joy. In Ohio, where there is a law in force to protect the lives of its babies by supplying actual care to children with infected eyes, there were, in 1916, 741 reported cases of specific infection. Of these, twenty lost the sight of one or both eyes and fourteen suffered probable loss of sight in one or both eyes. This serious loss, it must be remembered, occurred in a state where prompt investigation and treatment of cases of eye inflammation in infants, is provided for by law.

In the preceding discussion only

a

the infections directly transmitted to innocent children from diseased or careless parents were discussed, but there is still another angle from which the subject must be considered and that is from the standpoint of the possibility of the spread of specific disease among school children. The possibility of infection by one child with gonorrheal discharge in a public school, where the condition is unrecognized and untreated, is almost unlimited and any physician who has done a fairly large amount of work in a children's dispensary is only too familiar with the kind of case which is found in schools. Another place in which children in the past at least have been much exposed to infection is in the wards of the children's hospitals or the general hospitals. It is not so very rare an occurrence to know of an entire children's institution, whose receiving department is closed until such time as the gonorrheal discharges among the inmates shall be cleared up. With greater knowledge as to the prevalence of vaginitis especially, it is possible to throw sufficient safeguards, in the way of examination and isolation, about newly admitted children to prevent the extreme condition developing.

These are only a few of the facts which bring unquestionably to our attention the influence of venereal disease upon children's welfare. Any statewide scheme to develop a thorough system for the control of venereal disease, to break down. the unfortunate barriers of silence, to institute actual isolation, quarantine and treatment of infected persons, especially if combined with an intensive plan for general educational training for our very young people, will have an enormous influence upon the general

problem of child hygiene. The necessity for the educational training of all young children as well as the adolescent to a frank knowledge and understanding of matters of sex is as important as the purely medical side of the work. This is true because it is chimerical to expect to affect the real situation under several generations. Probably not until the little children of today have children of their own, who will be educated along quite different lines and who will, we hope, be armed with the one greatest necessity-self-control, the result of discipline begun immediately after birth shall we see any very great change. The reason for doing everything possible to improve the situation now, is that the longer the first steps are put off the longer it will be before a single standard of morality and freedom from venereal disease may be brought about. No one single undertaking would do more for the little children than the development and operation of as wide and comprehensive a plan for the control of venereal disease as could be worked out with our present knowledge.

THE PHYSICIAN'S DUTY To insure the success of the Federal Government program for the suppression of venereal disease, it is essential that that program should have the support of every practicing physician in every state. The best thought in the medical profession of today concedes that every doctor should consider himself a health officer without pay. — Public Health Reports.

In February, 1915, it was estimated that Germany had 175,000 cases of syphilis among her soldiers in Belgium alone.

HE venereal diseases, gonor

T rhea and syphilis, have been

and are of great interest to laboratory workers. As with other diseases, the bacteriologist has attempted to find the organism which is responsible for each disease and has worked from a purely scientific standpoint with little or no thought given to the social problems which are so intimately interwoven with the question of venereal disease control.

These diseases which are so vital to the human family have been known for many years. Their manner of transmission and the serious results which follow their inception have been observed but it is only recently that any marked advance in their control has been made.

Gonorrhea

While gonorrhea and its serious effects have been known for many years, it was not until 1879 that Neisser called attention to the constant presence of a peculiar organism in gonorrheal pus. Some few years later Bumm was able to isolate the organism in pure culture. and, together with Welander, Bockhart, Bokai, Brenner, Wertheim and others, demonstrated that the pure culture of gonococcus when inoculated into the urethra of man would set up a typical attack.

After having established a causative agent of the disease it was necessary only definitely to indentify the organism in order to establish a laboratory diagnosis. The

gonococcus has a characteristic and constant form and has certain peculiarities as regards its cultural and staining properties which assist the laboratory worker in its identification and thereby in arriving at a proper diagnosis. Besson gives a very clear picture of its appearance at various stages in the developinent of the disease. of the disease. In pus from the urethra the gonococcus is found in pure culture during the first few days. In the early stages the organisms are few in number and are found almost entirely within the polymorphonuclear leucocytes. Numbers of epithelial cells are seen in the smears, but these contain few gonococci. Towards the third day the number of gonococci increases and a large proportion of the leucocytes contain the organism. A little. later the epithelial cells disappear, and the majority of the gonococci are intracellular and are so numerous that about fifteen to twenty percent of the leucocytes are invaded. At a still later stage of the disease secondary infections take a part in the inflammatory process and as the acute symptoms pass off the epithelial cells again become numerous, but it is only when the disease enters upon the chronic stage that gonococci are again found within them and the pus cells diminish in number.

Knowing the characteristic form and staining properties of the organism as well as its location with regard to other cells, it would seem to be a very simple and definite

thing for the bacteriologist to examine a smear and state that gonorrhea either was or was not present. It is found, however, that certain other organisms are very similar morphologically and are easily confused, in a simple microscopic examination, with the gonococcus.

Jordan states that the behavior of the gonococcus towards the gram stain, together with its coffee bean form and intracellular situation, usually serves to distinguish it from related organisms, such as the common pyogenic cocci found in the urethra or vulvo-vaginal tracts. From the meningococcus, however, it is differentiated principally by the fact that it does not usually grow on the ordinary culture media. In practice, Jordan states, little confusion is caused by the close resemblance of these two organisms, since they are not likely to occur in the same tissues.

McFarland finds that the diagnosis of gonorrhea by observing gram negative diplococci in urethral pus and epithelial cells is a simple matter. The recognition of the microorganisms under other conditions, however, is by no means easy. Thus, when gonorrhea becomes chronic and the cocci are no longer taken up by the phagocytes it raises a little doubt whether gram negative cocci may be true gonococci or not.

Again, when gonococcus-like organisms occur upon the conjunctiva, in the pus taken from the joints, upon the valves of the heart or in the Fallopian tubes, the same difficulty is met. Probably the greatest uncertainty arises when the conjunctiva is involved, for here there can come about the confusion of the gonococcus, the pneumococcus, and micrococcus catarrhalis which very careful staining. and cultural experiments alone can solve.

It will be observed from the preceding paragraphs that it is not an entirely easy thing to demonstrate the gonococcus beyond question by the simple staining methods. In all doubtful cases it is necessary to utilize cultural methods. These are not simple, for the gonococcus has a highly selective action and does not grow readily upon the ordinary culture media. Special media must be prepared in order to secure its proper development. It is important, however, to utilize the laboratory in securing a diagnosis, in order to assist the physician in his clinical study. Not all inflammatory conditions of the urethra are attributable to the gonococcus. Other pus cocci contribute to the inflammation and in secondary inflammations the gonococci may disappear. So long however, as the gonococci persist in the urethra or other superficial tissue, the patient may spread the contagion and after apparent recovery from gonorrhea the cocci may remain latent in the urethra for years, not infrequently causing a relapse. Owing to these peculiar conditions, it is essential that the physician use every means placed at his disposal in order to ascertain as exactly as possible the true condition of his patient.

In addition to the microscopical and cultural methods of diagnosis, complement fixation has recently been suggested as of distinct diagnostic value. This method, however, is handicapped by the difficulty which has arisen in securing satisfactory results. The chief difficulty has been that of securing a satisfactory antigen. One of the peculiarities of the gonococcus is that various strains have been isolated which may or may not be specific for other organisms of the same group. Torrey has shown that not all races of the gonococcus

are antigenically alike. The antigen which he has prepared, and which is used by the New York Department of Health, is made from the original ten Torrey strains which he has isolated and used in his complement fixation work for gonorrhea. Until more work has been done in perfecting a satisfactory antigen, it does not seem likely that this method will come into general use.

Syphilis

While syphilis has been making its inroads upon man for centuries, it was but a few years ago that the exact cause of the disease was demonstrated. In the examination of material removed from syphilitic lesions a peculiar spiral shaped organism had been discovered for may years, by many observers. Bordet studied this organism very carefully and believed it to be the infective agent in syphilis. It was left, however, for Schaudinn and Hoffmann, in 1915, to demonstrate that this particular spiral shaped organism was the cause of syphilis. They gave it the name of Spirochaete Pallida, which name, however, is not generally used now but has been replaced largely by Treponema Pallidum. Schaudinn and Hoffmann were unable to find a suitable medium upon which grow the organism, and so were unable to obtain cultures whereby they could transmit the disease experimentally. Another difficulty encountered was that the disease is not readily transmissible to other animals, it being found that certain apes are most susceptible and most laboratory animals not at all susceptible. Schereschewsky in 1909 discovered a method whereby the organism could be cultivated, but even with the method proposed by him, it was impossible to secure a

to

pure culture. It was certain, however, that the particular organism which was being observed was responsible for the disease as it was found by observers all over the world in lesions of primary and secondary stages. It was always present in lesions of congenital syphilis and was also found in the blood of many persons suffering from the disease. These facts, together with the fact that it was never found in healthy individuals or individuals suffering from other diseases, seemed to be sufficient evidence to show that it was the causative agent. In 1911 Noguchi first cultivated it in pure culture. The report of his investigations, methods of culture and isolation, may be found in the Journal of Experimental Medicine, Vol. XIV, 1911. Additional details as to the cultivation may be found in the same publication, Vol. XV, 1912.

The organisms may be observed in freshly secured material by examining a hanging drop under the dark field microscope. Special staining methods have also been devised for the differentiation of the Treponema Pallidum from other organisms which have a similar appearance. The technic of these staining methods is somewhat difficult, but very accurate results can be secured by the careful laboratory observer. The organisms are always present in the hard chancre. In secondary syphilis they are found in the mucous patches, a few in the rose spots and occasionally in the blood. Seldom are they found in the internal organs. In tertiary syphilis they are generally present but are few in numbers. The largest number are found, and these are observed in practically all organs, in cases of congenital syphilis. These staining methods are