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 Trep onema Pallidum. Schaudinn and Hoffmann were unable to find a suitable medium upon which to 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

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 diseases, seemed to be sufficient or individuals suffering from other 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 ex- . amining 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

used by pathologists and have proved of distinct value in establishing a correct diagnosis as well as assisting in the establishment of the reliability of the Wassermann

test.

One of the greatest aids to the physician in the diagnosis of syphilis is the so-called Wassermann reaction. This is an extremely interesting laboratory procedure and one which has assisted greatly in the proper diagnosis and treatment of the disease. In 1901, Bordet and Gengou, while studying complement observed that under certain conditions the complement became fixed and was thereby made unavailable for further reaction with the materials which they were using. Wassermann and Bruck took advantage of this particular phenomenon for the diagnosis of syphilis. They observed that the blood or spinal fluid of persons suffering from syphilis contained a so-called antibody. This antibody, when brought in contact with an antigen, served to fix the native complement present-in the serum. Owing to the fact that complement is readily destroyed or made inactive by heat they concluded that if a known amount of complement could be added to an inactivated serum and its specific antigen also introduced, the three substances would unite, fixing the known amount of complement. By introducing a second amboceptor and by also adding washed blood corpuscles, it could be easily ascertained as to whether the complement had been fixed or not. This reaction while appearing to be very simple, is quite complicated, as the various reagents used must be carefully prepared and standardized, and the conditions under which the test is made must be accurately controlled.

Since Wassermann first presented his serum diagnosis for syphilis many modifications have been suggested. At present a large number of antigens are in use, some being preferred by one observer and some by another. Other details of the method have also been modified to correspond with the experiences of various observers. In general, however, the original method of Wassermann is still in use.

Here again we are confronted with the problem as to the relative merits of the various methods of diagnosis. The physician must understand the limitations of the laboratory worker and should familiarize himself to as great an extent as possible with the methods in use at the laboratories where he submits specimens. With this knowledge at hand he will be much more able to interpret the results. furnished him and correlate his clinical findings with the laboratory results. As has been so often pointed out, it is only by such correlation - that the greatest benefits can be secured. The physician certainly must realize his limitations of diagnosis, but at the same time he should not base his conclusions entirely upon the laboratory findings.

Quite frequently a physician is unable to establish a definite history of syphilitic or gonorrheal infection; at the same time the condition of the patient is such that he is unable definitely to establish a diagnosis. He is reasonably positive that the patient is suffering from either one or the other of these two diseases. I have in mind at the present time a case which was under observation by an Ohio physician who was unable definitely to establish a diagnosis. Repeated examinations of the blood and spinal fluid gave negative results

for syphilis-nevertheless the physician was reasonably certain that the difficulties were caused by a syphilitic infection. After consultation with the patient he decided to try the syphilitic treatment, to which the patient responded very satisfactorily. Such cases as these are bound to arise but should not detract from the value of having the blood tested for syphilitic infection. It is also possible to secure false positive results by the Wassermann test. The physician, however, should become familiar with those conditions which may cause a false positive and be particularly careful not to collect blood from persons who are suffering from diseases or other conditions which may influence the examination. By co-operation between the attending physician, who has an opportunity to study the patient, and the laboratory, very satisfactory results, and results which should be of distinct. value to the physician studying the case, should be secured.

FIVE PERCENT OF MEN

IN U. S. HAVE SYPHILIS It is certainly a conservative estimate, in the face of such statistics as we have, to place the percentage of syphilitics among the adult male population of the United States at more than five percent.

If syphilis is five times as frequent among men as among women, more than one percent of the women are syphilitic, and more than three percent of the entire population are syphilitic. That is, there are now approximately 1,200,000 adult syphilitics in this country. And these figures probably considerably underestimate the facts. This gives some intimation of the widespread extent of syphilis, and of its enormous importance.

It means that as a result of its late. manifestations it causes in the aggregate an enormous wreckage of human life.-W. A. Pusey, "Syphilis as a Modern Problem."

RESOLUTIONS PASSED AT U.S. HEALTH CONFERENCE

State and territorial health officials, meeting in their sixteenth annual conference with the United States Public Health Service, at Washington in June, passed resolutions as follows:

Urging extension of Federal aid. to states for improving rural sanitary conditions.

Advocating a Federal system of supervision of health in war industrial centers, to be established by co-operation of the Public Health Service with state and local health and labor authorities.

Congratulating the State of Arkansas on having its compulsory vaccination law sustained by the state supreme court.

Endorsing the Chamberlin-Kahn bill providing Federal aid for venereal disease prevention work of the

states.

Recommending that the surgeongeneral of the Public Health Service appoint a committee to study the problem of sanitary disposal of human excreta in unsewered communities.

Recommending that the Public Health Service ascertain by questionnaire the number of public health workers in the states who have left for Federal service and the number who probably will leave in the next few months, the results to be used as the basis of a statement by the proper authorities on the Government's attitude toward such depletion of state health organizations.