Although we have a long list of diseases which are recognized to have as their causative factor specific bacteria, yet, in so far as the diseases of man are concerned, a rapid technique, suitable for diagnosis early enough to be of value in a given case, has been practically successful in but four or five diseases.

In times of epidemics, such as several countries are now having with influenza and bubonic plague, and as was the case several years ago with Asiatic cholera, especial laboratory facilities have been kept in readiness by the municipalities of the countries concerned, so as to enable the laboratory workers to place the given micro-organisms under conditions by which their biological characters could be ascertained in twenty-four to forty-eight hours. These are exceptional instances, however, and under ordinary conditions these diseases would take as long as most others to establish their identity bacteriologically. But in the following four diseases, which are of frequent occurrence in every general practice, bacteriology offers an easy and a ready solution to the ofttimes perplexing question of diagnosis. These diseases are tuberculosis, gonorrhoea, diphtheria and typhoid fever.

The methods and technique of examining sputum for tubercle bacilli are familiar to every one and need only be touched upon here. A rapid diagnosis may be made by selecting a suspici

this acid solution may readily decolorize the bacilli if they have been stained by the quick method, and thus they may easily be overlooked.

A method which takes a little longer, but which gives more trustworthy results, is to soak the coverglass, fixed in the usual way, in an aniline water solution of fuchsin for twenty-four hours. This solution is made by adding 11 c. c. of a saturated alcoholic solution of fuchsin to 100 c. c. of aniline water. After a twentyfour-hour bath in this mixture, the bacilli will hold the stain much better when subjected to the acid decolorizer. The aniline solution has to be made up fresh every two or three weeks, but otherwise the method is executed just as in using the carbolfuchsin and gives much more safe results. In cold weather the stain and the cover-glass should be set in a warm place, as in an incubator, the warmth aiding in fixing the dye.

An extremely important point in the examination of a sputum in a suspicious case, seen in the very earliest stages of the disease, and when the bacilli, if present, would be present in small numbers only, is the proper use of one or another of the concentration methods. One that gives excellent results is as follows: To every half ounce of sputum add one-half dram of a mixture of equal parts of pancreatin and sodium bicarbonate. The mixture is then placed in an incubator for four or five hours, until it is digested. Neither the elastic fibers nor the tubercle bacilli are interfered with by this process. The vessel and its contents are then removed, and the residuum obtained either by the centrifuge or by sedimentation is stained and examined for the tubercle bacillus. It is

often possible to detect these bacteria by this method when a careful and painstaking examination by the other methods has failed to reveal them.

In reference to the microscopical examination in cases of suspected gonorrhoea, there are four cardinal points to be borne in mind: 1. The morphology of the gonococcus. 2. The position of the specific micro-organism within the pus cells. 3. The fact that the gonococcus decolorizes when treat. ed by the Gram method. 4. The characteristic grouping of these organisms.

In a case of acute discharge, the diagnosis of this disease microscopically presents no difficulty, no matter what stain is used; but in case of chronic urethritis, and especially when a pa tient desires to marry or renew suspended marital relations, one is never justified in giving an opinion unless the Gram method has been used. The details in technique of this most important characteristic of the gonococcus are as follows:

The preparation, carefully dried and fixed in the usual manner, is immersed in a mixture composed of 11 c. c. of a saturated solution of gentian violet added to 100 c. c. of aniline water. The specimen is immediately colored intensely, and two or three seconds suffice for the staining. Then the preparation may be washed and examined in water. If organisms with the typical morphology of this micro-coccus are discovered, the cover-glass is removed and placed in a solution of iodine and iodide of potassium for two or three minutes. The exact composition of this solution is: iodine 1 part, iodide of potassium 2 parts, water 300. When the slip is removed from this solution it is given two baths in absolute alcohol, about one minute in each bath.

When the specimen is reëxamined, if the organisms first seen were gonococci, they will have become completely decolorized.

I have found it useful to lay three or four cotton fibres on the cover-glass when spreading the specimen and to fix these with the preparation. This gives one, as it were, several places of well-known topography in the various fields which he will have to again place under his vision so as to be sure that he is observing the same fields in which he demonstrated the stained diplococci.

The gonoccus is an extremely difficult organism to cultivate, and since we are largely dependent on, as it were, the physiological reaction between the protoplasm of this micrococcus and the various stains, one is never justified in making a diagnosis of this important disease bacteriologically without having exhausted all the means at his command. When one considers the long list of complications which this micro-organism often brings in its train, such as sterility, lifelong blindness for a helpless offspring, gonorrheal rheumatism, a pericarditis which may be fatal, and the ever multiplying pelvic troubles of the female, it behooves the physician to be as absolutely sure as the best methods at his hand will allow him to be, before he gives a patient with a chronic urethral trouble permission to marry. The Gram method is not difficult. It entails a certain amount of time and skill, but it is within the reach of every physician who does microscopical work.

The explanation of the Gram stain is that the protoplasm of the microorganism, the basic aniline, and the iodides form a compound which in

the case of the gonococcus is soluble in alcohol. In numerous other bacteria, as, for example, the pus cocci, the compound formed is insoluble in alcohol and the cocci retain their stain.

In protracted cases, particular attention should be given to the shreds which appear in the urine, as these are composed of pus and epithelial cells and often harbor the gonococci. These are to be examined as carefully, as earnestly, and as repeatedly as one would examine a sputum for the tubercle bacilli. Pus cells containing these organisms may be often demonstrated in the residuum of the centrifuged urine.

In the examination for the diphtheria bacillus we are compelled to go a step higher in bacteriological technique and make use of cultures. Here, fortunately, thanks to the tireless research and the brilliant results of Prof. Löffler's work, we have a medium which is practically a specific for the growth of the diphtheria bacillus. The inoculated tube, when placed in the incubator, is ready for examination on the following morning, when it becomes simply a question of familiarity with the form or morphology of the diphtheria bacillus.

Some confusion exists as to the differences in form between the genuine diphtheria bacillus, the pseudo-diphtheria bacillus of Hoffman, and also between the genuine organism and the xerosis bacillus which is found originally in a disease of the eyes with this name. When there is an important doubt about which micro-organism is under consideration, a culture of the organism in bouillon will place it in its proper category, as the genuine diphtheria germs give an acid reaction, which again becomes alkaline,

while the "pseudo" forms do not change the reaction of the medium.

Guinea pig inoculations will also generally settle the matter, as both the "pseudo" forms and the xerosis bacillus are non-pathogenic for these animals.

Typhoid fever is a disease which has been known since 1882 to have as its special etiological factor the bacillus typhosis; yet so difficult is this microorganism to isolate from the feces, that until within the past four years the knowledge of this specific bacillus has been of as little practical use in the diagnosis of typhoid fever as if it did not exist. From the time of the discovery of the typhoid bacillus until to-day there have been over 365 different media devised for the isolation of the typhoid bacillus from stools, but not one of them is of sufficient practical utility to be of aid early in the diagnosis of this ofttimes difficult disease.

With the advent of the Widal test into clinical laboratory methods, this state of affairs has been changed. The Widal test offers a method by which typhoid fever can be diagnosed in from 90 to 96 per cent. of cases. Continued

use of the method in the laboratories has shown that the method is the most reliable test which has yet been offered for the diagnosis of this disease. In a recent article by Dr. Abbott, of Philadelphia, the claim is made that there is 3 per cent. more of error in using the dried blood method than in using the serum. This statement is borne out by other observers.

In a series of cases examined in private work and at the Denver Bureau of Health laboratory, out of fifty cases which were finally thought to have been typhoid fever, the Widal reaction was obtained in forty-four cases. This

gave a per cent. accuracy of 88. Out of forty-two cases which were suspicious at first, but were finally diagnosed as not being typhoid fever, there were forty-two negative results, giving a per cent. accuracy of 100 in the negative

cases.

The method of conducting the test is as follows:

From stock cultures of the typhoid bacillus which are kept growing on agar-agar, inoculations are made into bouillon daily or whenever it is desired to make the test, so that one shall have on hand a pure culture of a 12 to 20-hour-old bouillon culture of this organism. If the serum from a typhoid case is given for examination, one part of the serum is mixed with ten parts of the culture, and the mixture is examined in the hanging drop under the microscope for agglutina tions. If dried blood is to be investigated, one part of an emulsion of the blood in water is mixed with five of the culture and examined in the same way. This is the easiest and the only practical bacteriological method of examination of a case of typhoid fever at the present time. A large number of scientists, however, are still at work endeavoring to perfect methods by which the bacteriological examination of typhoid fever shall eventually be made as easy as we now have it in cases of tuberculosis, gonorrhoea and diphtheria.

Mary Steinhaus, 16 years old, who puzzled medical experts of New York and Philadelphia by sleeping nineteen days, has become a raving maniac and is in Bellevue hospital.

There are now ten deaconesses at work in the Colorado field.

As fundamental to the consideration of the five subjects for discussion, proposed by the Medico-legal Society (especially the second, "The Most Successful Methods of Treatment"), I wish to draw attention to the fact that the basis of judgment at the present time is defective. Unless this is remedied, any conclusion will be likewise defective and unsatisfactory. This defect of judgment arises from the premise that the bacillus of tubercle is the sole cause of tuberculosis. Probably 90 per cent. of medical men now living rest their faith in treatment upon this belief. The function of the seed is allowed almost to ignore the condition of the soil as a causative factor in tuberculosis. Consequently, the origination of the complex disease called consumption is not understood or is prac tically disregarded. The security which the physician feels in not finding the tuberculosis germ in the sputum is unfortunate, and his possible self-deception invalidates his diagnosis. The right which a patient has to a more fundamental regime is denied him, and thus he is made to miss a most important avenue of cure that of prevention.

The point I want to emphasize is, that the matured bacilli do not appear until late in the disease.. This latent condition of the germ, or a like effect, is manifest in adenoid tissue and scrof ular gland growth.

The demonstration of a blood dyscrasia by reaction in tuberculosis to the Widal typhoid fever test1 is remarkably suggestive of how limited our knowledge of the pretubercular state is. It encourages the hope that new and definite means of diagnosis will be forthcoming, other than the tuberculin test. This latter valuable diagnostic means, however, is quite sufficient to make known these scrofular and other proofs of the tubercular dyscrasia long before there is any ocular demonstration of the germ. Therefore, I submit that the subject should be divided, namely, into, first, tubercu losis before microscopic proof of the existence of the mature germ, and second, tuberculosis after such proof. Then under such a ruling most all of the "Methods of Treatment" at present in vogue can be relegated to the second division, just named, and with few exceptions are confined to the second and third stages of the disease, because usually it is only during the breaking down of the tuberculous tissue, i. e., during these two, the softening and excavation stages, that the germ evidence is found. At this period in treatment we are then dealing with results always accompanied by a certain degree of auto-infection. For this advanced condition and its complexi

1 As shown by the experiments of Dr. S. H. von Ruck, described in the October number of the "Journal of Tuberculosis."