cosis the Wassermann reaction occurs- for five or ten days. As Dr. Simonds said, the principal modification of the reaction that has been used in this country is the Noguchi. Foreign observers have done nothing with this, and we have nothing but our own reports to rely on. However, the statisties are accumulating, so that from American statistics the Noguchi modification is becoming well established. I would like to say something of my small personal experience with this test, but while I have made about forty tests and they all agreed fairly well with the clinical diagnosis yet my results are not to be relied on, because of the extreme technical skill required in making the test, and the number of errors that are apt to appear. As Dr. Simonds said. Kaplan made 390 tests before he felt competent to draw any conclusions. Naturally this puts the test beyond the ordinary man's power, unless he does the test continually and all the time. DR. C. F. NEU (Indianapolis): Mr. President, and Members of the Association: There does not seem to be much room for doubt that in the test we have a valuable aid to the diagnosis of syphilis, and it holds out prospects that it would be valuable in regulating the treatment of syphilitic conditions. It is unfortunate, however, that in a test that is apparently so valuable, there are so many difficulties in its application. When you take into consideration the details that have to be watched, and the minutia so necessary to carry out the operation, you can readily understand that it opens up a large field. This makes it inapplicable to the ordinary practitioner. It can only be carried out by one who devotes his time and attention to laboratory methods, and even for one in laboratory work it is necessary that he continually carry out this test, because after an interval, in which they have not been carrying out the test, those who have tried it say they are apt to make mistakes. Another feature in connection with the tests, we have to bear in mind that they are negative in from eight to ten per cent. of cases in which there is positive evidence of syphilis, and the positive reaction is given in other conditions besides syphilis. Cases have been reported where the Wassermann was positive in scarlet fever, in tuberculous leprosy, meningitis, and malignant growths. It is true that there might have been some syphilitic conditions present, but the mere fact that in from eight to ten per cent. of cases the Wassermann reaction was negative where there was a positive luetic condition, and the fact that you get a positive reaction in other conditions besides syphilis, makes it very important that those carrying out the test keep these points in consideration. As I said, the process is beyond the reach of one in ordinary practice. It is difficult of appli cation, and the details that have to be considered put it beyond his reach and place it in the hands. of the laboratory worker. Even in the laboratory there are very few who can devote the time and attention necessary to give the strictest consideration to these details. In talking to Dr. Simonds I was pleased to hear him say that he was not able to carry out these tests because in making them he had to use his own blood, and it was not very pleasant to have to withdraw a certain amount. DR. W. R. DAVIDSON (Evansville): I would like to ask the essayists one question, and that is, for a man who is doing clinical diagnosis work from day to day in the laboratory, what is the recommendation for him? The consensus of opinion seems to be that the work should be limited only to expert laboratory workers, and yet almost in the same breath the recommendation is made that everybody who treats lues should make this test. What would you recommend for the possibility of that work being done in such a laboratory as I mention? If the work is good, certainly it should be carried out more extensively; but in the nature of things it would be impossible for me, for instance, to make this test every day. Would it be advisable for me to go on and work with it, on the principle of putting a rifle out of a window at night to shoot at a cat-it might hit and it might not? DR. H. R. ALBURGER (Bloomington): I would like to say a word in connection with this subject. We know that this test is in the developing stage; it is not all worked out, as is evident from what the essayists have said, and it seems to me it would be the part of prudence for the laity and general practitioners to wait a little until this test becomes simpler. It is bound to come. Every laboratory test that is now simple was originally complicated. I think the wisest plan for the man who is doing ordinary clinical diagnosis, if he does want this test, is to put it in the hands of a man who is giving a good deal of time to that sort of work; trust to his experience and let him perfect his technic and give this test the benefit of his experience. I believe it is only a question of a short time until this test will be put on a practical basis, but the general practitioner must depend on the men in the laboratories to do that sort of work for him. I thoroughly agree with the essayist that it is a valuable test so far, but I believe it is still in the stage when it should only be used in the hands of experienced men, because otherwise it will bring the test into bad repute by giving all sorts of conflicting reports from inexperienced workmen. A great many things in medicine. have been given wrong interpretation by incompetent men. I believe the reason we get positive results in cases that are negatively syphilitic, is because we are all of us somewhat immune to syphilis; we As to the absolute necessity of having all the materials exact, it is only necessary to have your luetic liver exact, your serum, your complement and your amboceptor. As to the salt solution, you can put ten drops in a test tube and it works just as well as another amount. You all know that some corpuscles give off more serum than others, so you will not have the exact number of corpuscles anyway. I can assure you that any physician can learn this easily, and can have nurses in the hospitals learn to do this work. You can have it done in your clinic cases, and you will find it a great help in your work. DR. SIMONDS (closing): My experience has convinced me that the serum test for syphilis is by no means a simple one, that it is exceedingly delicate and useful, but that if improperly done may lead to great confusion in diagnosis. The mere mechanical manipulation of reagents and apparatus necessary to making the test is comparatively simple. But in all work in hemolysis the opportunity for error is very great and often comes from sources entirely unexpected. Hence, I do not believe the work of a man who knows only the mechanical side of the test without a thorough knowledge of the underlying principles can be relied on. Unless one has accurate amounts of amboceptor he is likely to get either a positive reaction where he should not have one, or a negative where he should not have one. The only way one can determine what amount is accurate is to restand ardize very often. This applies to the antigen which must be restandardized occasionally. In order to restandardize reagents one must understand the principles of hemolysis. Mere mechan ical skill is not sufficient. It is often stated that reagents dried on filter paper will keep almost indefinitely. At the State Laboratory we had one test tube of the fluid serum and quite a lot of the dried filter paper slips. For some reason, to our great surprise, the serum that was dried on the filter paper deteriorated first. That is entirely contrary to the teachings of the text-books. Our fluid serum had lost very little of its original potency, but had to be restandardized. This experience is an illustration of the unexpected things that may hap pen. As a further illustration of the ease with which a mistake may occur, it has been found that a very slight variation in the acidity of the reagents may entirely change the results of the test. Sachs and Altmann tested serum with reference to the influence of alkalinity on the reaction, and found that if 1/800 to 1/3200 normal sodium hydroxid solution was added, the syphilitic reaction with known positive sera could be abolished. But if to this alkaline serum enough hydrochloric acid was added to bring it back to the proper reaction, a positive result would be obtained. Not infrequently an exceedingly slight variation in the alkalinity or acidity of a serum, such as might be produced by unclean test tubes, may entirely vitiate the result. I must say, however, that Sachs and Altmann found that varying the reaction in non-syphilitic sera would never make them react positively. I cannot agree that the test is such a simple one. I believe that the test done by the average busy practitioner would give results more confusing than enlightening, and that it should, therefore, be done only by regular laboratory workers who are will equipped with all necessary apparatus and who thoroughly understand the principles of hemolysis. Assistant Professor of Surgery, Indiana University School The purpose of this paper involves a question, still unsettled in the minds of a good many practitioners, and is intended as an appeal to them for a more rational therapy in the particular branch of surgery concerned. To this end I beg your indulgence in the recital of a case report, in its full detail, which I believe important, in order to present, most effectively, the common sources of error in the management of like cases, and their misapplied therapy. Mrs. A. F., age 31 years; married. History of past illnesses negative, usual diseases of childhood being mild in character, of uneventful course followed by quick recovery. Menstrual History.-First menstruation at 15 years of age, not painful, five to six days in duration, profuse in character, at irregular periods every three to four weeks. Subsequent menstrual period unaccompanied by pain, until marriage nine years ago, which precedes the flow. Three years after marriage a leucorrheal discharge appeared, accompanied by backache, bearing down pain and other symptoms referred to as "catarrh of the womb" by the patient. This condition has since persisted, with increasing periodical pain, and continuous thin leucorrheal discharge. No vesical symptoms; no history of pregnancy. Present Complaint.-A metrorrhagia of two months' standing, interrupted on April 26, 1906, severe pain in the right pelvic region then develing and lasting two hours, relief coming with |