is possible to read them after an hour's time, but they are usually not so clean-cut after standing at room temperature for a while. This applies especially to weak reactions. In our experience, syphilitic serum rich in antibodies may prevent hemolysis as long as eighty hours.

All our work has been carried on with appropriate controls. These have been as follows: at least two known normal sera; one known active syphilitic serum; one hemolytic system (amboceptor, complement and corpuscles—plus liver extract alone); one cell suspension in normal salt solution alone; and one tube containing all the constituents of the reaction in sterile water instead of normal salt. If it was shown that these controls were at fault then the work was either repeated or wholly discarded.

III.

STUDY OF OUR WORK.-Space does not permit our going into detailed description of each case that we tested. There have been many very interesting, and we might say, surprising, cases. This has, doubtless, been the experience of all those who have worked with the reaction. For the purpose of a rapid survey, we have compiled several tables, which show the scope of the material and in the main, explain themselves.

It will be seen from Table I that of fifty-seven individuals in which a history of syphilis was obtained, for all stages of the disease, and including two cases of hereditary syphilis (female children aged three days and eleven years respectively) fifty-one or eighty-nine percent gave positive reaction. Of the six cases which did not give positive reaction, one was a case of primary syphilis where the antisyphilitic treatment had been pushed; one a case of secondary syphilis without marked manifestations; two were terti

ary syphilis, and from one of these serum several days old was used; one a case of tabes, and the sixth case one of suspected brain tumor, where the reaction was questionable. The relationship of treatment to the manifestation of the reaction may be responsible for some of the negative findings. Those cases where specific measures have been carried out thoroughly seem to react less strongly, to be sure, or not at all. One should, however, bear in mind that the syphilitic infection is far more pronounced in some individuals than in others, and that there may be a corresponding variation in the production of antibodies, which variation may be responsible for weak or absent reactions.

TABLE II.

CASES WITH SUSPECTED BUT NOT POSITIVE HISTORY OF SYPHILIS GIVING POSITIVE REACTION.

In

It will be seen that Table II presents a list of twenty five cases where syphilis was suspected but not positively proven and where the Wassermann reaction was plus. Two cases of acne-so diagnosed—are mentioned. One of these later developed enlargement of the liver and confessed to gonorrhea, although he denied lues. The other presented no evidence of specific disease other than the acne-like lesion. There is one case of old Pott's disease where history was probable but not proven, the patient having gonorrhea also. There were three cases of obscure headaches. one there was strong presumptive evidence of syphilis. In the others there was nothing indicative of the disease. The cases of abdominal tumor were all atypical. In four of them, the suspicion of syphilis was strong. In the fifth, operation revealed only extensive adhesions about gall-tract and liver. The cases of gential involvement denied specific infection, but after the test showed positive, were put on antisyphilitic treatment and improved markedly. This also happened to the patients presenting enlarged lymphatics. The case of suspected throat syphilis (early) also had a specific

vulvovaginitis. The "sore throat" had come on between two and three weeks after suspicious intercourse. The positive reaction in this case was marked, and the patient did well when put upon mercury.

In Table III are noted forty-two cases where there was no history of syphilis and yet positive manifestations was shown by the reaction. In the majority of the cases, with the exception of those having taken the Pasteur treatment, the manifestation of the reaction was slight, but for the sake of fairness was recorded as positive. This was particularly so in the cases of carcinoma, and in one of the acne cases. In the anemics giving positive reaction, the manifestations were quite marked. While in these patients one could not entirely exclude syphilis, there was no suspicion. The anemia of one case resembled pernicious anemia with the exception that nucleated red cells were never seen in four examinations of smears taken at different intervals. One case of dementia precox reacted positively. Syphilis here was not improbable. The reaction in two cases of measles both of which were early in the course of the disease is interesting. Similar observations have been made in other acute exanthemata, notably by Much and Eichelberg" in scarlet fever. It will be noted in Table IV, that a late case (tenth day after appearance of the eruption) did not give positive reaction. We had not opportunity of testing cases further along in the disease. Some of them might react positively. Inasmuch as the exact causative factor in measles is not known, it would appear to be useless to speculate upon the probable cause of the reaction in these cases we report. One case of tuberculosis, with acute febrile exaccerbation and pleural effusion reacted positively. Similar observations in pleural effusion have been mentioned by Weil and Braun.

The positive reactions present in twenty-two out of twenty-eight patients who had been or were being treated for rabies by prophylactic injections at the Pasteur Institute, is worthy of comment. In a recent paper we have offered as explanation of this phenomenon the suggestion that the rabbit's serum after inactivation will give the precipitin reaction with the sensitized human serum of the Pasteurized patient and the guinea-pig complement. This precipitin reaction is due to the presence of amboceptor in the blood serum of the patient who has had the prophylactic injections according to the Pasteur method, and the receptor in the inactivated rabbit's serum. This inactivated serum in the presence of normal complement and sensitized red blood cells gives rise to deviation of complement. There thus follows a more or less complete fixation of complement in both the precipitin reaction and in the process of hemolysis.

It is interesting to note the length of time after patients have received the Pasteur treatment that their sera gives incomplete hemolysis. One case tested more than two years after the prophylactic injections had been completed gave distinct positive reaction. The reaction is usually present as early as the tenth day in patients who are receiving the injections. We

TABLE IV.

CASES WITH AILMENTS OTHER THAN SYPHILIS AND WITHOUT HISTORY OR MANIFESTATION OF SYPHILIS, TOGETHER WITH PATIENTS APPARENTLY WELL, GIVING

CASES

NEGATIVE REACTION.

CLINICAL DIAGNOSIS

Tuberculosis:

REACTION REMARKS

have had a few cases show reaction as early as the fifth day. Inasmuch as Pasteur institutes are being established throughout the country at a rather rapid rate, it would appear that the presence of the reaction in these Pasteurized patients here reported would have a certain practical bearingespecially where cases give positive reaction and there is no history or suspicion of syphilis. It would seem to be advisable to ask such patients whether or no they had ever had Pasteur treatment.

Table IV summarizes some sixty-seven cases. Of these fifty were afflicted with ailments clinically other than syphilis and in all negative findings were observed by the test. In connection with the positive manifestations in tuberculosis, cancer, anemia and acne, as shown in previous tables, it will be noted that in this table there is a goodly number of these classes of cases presenting the negative reaction. In the arteriosclerotics, there was no history or suspicion of syphilis. In one, a small aneurysm was diagnosed.

Table IV also includes negative findings in six patients who were taking Pasteur treatment. These cases, with the exception of one, were all patients who had had but several injections of prophylactic serum. In one case, the patient had had the injections six months previous to the time her blood was taken for the Wassermann test.

The table also shows negative reaction in twelve clinically normal adults. This is, we admit, a small number for control, but when it is remembered that at each running through of the test normals-sera from two to three persons-were used over and over again, without reaction, the presence of positive reaction in other cases would seem to have con siderable significance.

IV.

It might be well to compare our results briefly with those of a few investigators in this and other countries, whose method was practically identical with the one that we used.

Citron examined 108 evident and suspected luetics with 74.7 % positive reactions. Michaelis examined 12 evident and suspected luetics with 75 % positive reactions. Fleischmann and Butler

examined 41 cases lues, all stages with 70.7% positive reactions.

Wassermann and Meier"

Meier
Kroner

examined 39 cases lues, all stages with 69 % positive reactions. examined 118 cases lues, all stages with 81.7% positive reactions. examined 40 cases lues, all stages with 75 % positive reactions. Fischer and Meier 30

Blaschko
Muller

Fox23

Lee and Wittemore
Butler

examined 114 cases lues, all stages with 83.7% positive reactions. examined 270 cases lues, all stages with 87 % positive reactions. examined 197 cases lues, all stages with 94 % positive reactions. (500 controls negative.)

examined 46 cases lues, all stages with 90.1% positive reactions.

examined 150 cases lues, all stages with 82 % positive reactions. (Our experience with positive syphilitics) 57 luetics all stages with 89.5% positive reactions. It would seem that a few words might be said with respect to the much written of "prognostic value" of the Wassermann test for syphilis. Anyone who has worked with the reaction knows how greatly the intensity of