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But, as we have pointed out, even when the Wassermann test is carried out by identical methods, th4results obtained in different laboratories may diffe:very considerably-in as many as 25 per cent. of thfcases. E. Joltrain and 0. Naegeli lay especial stresion the importance of making a thorough and carefuexamination of the patient and not relying solely 01the pathological findings. With this we are in fulagreement, although it must be admitted that sometimes clinical methods of investigation will fail t<discover any objective sign of syphilis-in

" latenlinherited " syphilis, as well as in the acquired diseaseIf, besides a positive blood Wassermann reaction, :;positive spinal fluid reaction is obtained, the diagnosisof syphilis is almost certain, and it is almost certainlyalso an active syphilis of the central nervous systerrwhich demands prolonged treatment. A. Marie calls apositive spinal fluid a " danger signal," which may bediscovered quite early by systematic examination oithe cerebro-spinal fluid, and which, if properly treated,may enable us to avert the very serious nervoussystem complications of the disease, to which thepositive cerebro-spinal fluid shows the patient to bepredisposed. This is of the utmost practical import,-ance. Most of the replies expressed the view that apositive serological reaction--even in the absence ofall clinical signs-calls for specific treatment, but thatthe actual method and details of treatment varywith the age of the patient. In the young, andespecially in the pregnant woman (as H. Montlaurpoints out) a positive reaction should mean a prolonged.and intensive course of treatment, aimed at makingthe reaction negative ; whereas in elderly people-who, as S. Bergel says, have passed the age of syphiliticaortitis, general paralysis or tabes-treatment shouldbe moderate and cautious. In considering the valueof the serological tests in hereditary syphilis, Morhardtin his summary suggests that the Wassermannreaction of the blood is not of great value, but thatmore importance attaches to parental antecedentsand to clinical signs in the patient. This brings intorelief the great difference between the prevalentFrench view of the incidence of hereditary syphilis.and that current in this and most other countries.In France a child born of syphilitic parents, if itsuffers from epilepsy, debility, an unexplained.anaemia, dystrophies, or almost any conceivablesymptom, is commonly regarded as being the victimof hereditary syphilis, even though the serologicalreactions are persistently negative. The sequel isoften a course of intensive treatment, and E. Joltrainutters a warning against such indiscriminate medica-tion, since he has seen it do harm in children whenapplied without any valid reason. In this countrynearly every syphilologist treats apparently healthychildren in syphilitic families, who have no othersign or symptom of the disease than a positiveWassermann reaction, in an endeavour to make theblood reaction negative and to prevent trouble in thefuture. It must be admitted that the attempt tomake the Wassermann negative in cases of hereditarysyphilis is not always successful, but granting this, it isdesirable to treat the patient by giving alternate fullcourses of arsenic, bismuth or mercury and iodides,without troubling too much about the blood test.

Lastly, there are the two conditions known asWassermann-relapse and Wassermann-fastness. Theformer refers to a syphilitic in whom the reaction ofthe serum is rendered negative but subsequentlybecomes positive again. It is usually the result ofinefficient treatment. Such patients if young andstrong, require intensive and continuous treatment fortwo or three years with arsenic, bismuth, mercury andiodides ; if they are elderly but apparently well, andthe syphilis is of long standing, they should be treatedwith care, and preferably with intramuscular or

subcutaneous injections of soluble salts of bismuth ormercury (L. Hudelo). Wassermann-fastness, on theother hand, implies that at no time during the courseof the disease has the serum reaction been negative.

1 THE LANCET, 1929, i., 453.

Fortunately this condition is uncommon, and inspite of various explanations of its causation-suchas the administration of the remedial agents (arsenicand bismuth or mercury) concurrently instead of

alternately, or the giving too many or too stronginjections whereby the reacting tissues are exhausted-its pathology is still undecided. No one is able toforetell at the outset of the treatment which patientwill show the condition, and this reminds us once morethat medicine is not and probably never will be anexact science, because it deals with bodies whosechemical and physical make-up differs. Treatmentwhich is usually difficult, though occasionally a

spontaneous reduction to a negative has been reported,is well summarised by Hudelo. In the case of oldsyphilitics, 50 to 60 years of age without clinical signs,and apparently in perfect health, it is unnecessaryto persist in treatment ; for these are essentially casesof benign syphilis, and there is no need to upset theequilibrium of the patients by exposing them to thereal risks of an indefinite course so as to avoid thedangers, often exaggerated, of a Wassermann-fastcondition (Ravaut). With younger patients the caseis different and serum Wassermann-fastness is oftena sign of involvement of the central nervous system (inhereditary as in acquired syphilis) leading eventuallyto tabes or general paralysis. These patients shouldbe carefully watched and periodically examined-the blood being tested every three months and thespinal fluid once a year. Oral or rectal administrationof drugs may be helpful in such cases if intensiveinjections have to be stopped (Schulmann andG. Levy) ; and the advice of Milian and others thatattention must be paid to general hygiene and tonicconditions, including a stay at the seaside or in thecountry should not be overlooked. There is stillmuch difference of opinion about the value of non-specific protein therapy, malaria-therapy, injectionsof sodium thiosulphate in Wassermann-fastness,though in general paralysis the efficacy of malarialtreatment is now well established.

MEASLES IN MANCHESTER.

THE Registrar-General’s return has recorded an

average of 12 deaths a week from measles inManchester during the past month. The epidemicreached its height in the week ending Feb. 8th,although the attack-rate in the city is not accuratelyknown, since only the first case of measles occurring ina household is compulsorily notifiable by the doctorin attendance, and the others are reported as theycome to the notice of the school medical officer andin other ways. During the past five years the measlesmortality-rates per 1000 living in the city have been0-17, 0-20, 0-21, 0-16, 0-08, the figures being onlyslightly higher than those for the country generallyover the same period. The disease is now moreprevalent and the mortality is higher in the centraland more crowded districts of the city. A largeproportion of the deaths occur in children under fiveyears of age, as is indicated by the following figures.In 1925 there were 129 deaths, 123 of which were ofchildren under five years of age ; in 1926 there were156 deaths, 151 of which were under five ; in 1927there were 164 deaths, 156 of which were under five ;in 1928 there were 123 deaths, of which 121 wereunder five ; and in 1929 there were 60 deaths, of which58 were under five. Every known case of measlesis visited by a health visitor, who advises the publichealth authority as to the arrangements for nursing.In any case where poverty prevents the provision ofproper nourishment for the patient, free or cheapmilk is provided by the corporation. Wards areset apart at the infectious hospital for the receptionof cases of measles in which the home conditions areunsuitable. The number of beds so allocated varies ;at the present time the number is 40. Duringepidemic times as many beds as can be spared areset apart for this purpose, as it is believed in Man-chester that this provision is of the utmost value in

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the nursing and treatment of bad cases. The subject Iof measles is dealt with in popular lectures which are Igiven from time to time by medical officers of thepublic health staff. During times of epidemic, also,the aid of the district nursing association is called in,and cases are referred to it for nursing, a grant forthis service being made by the corporation.

THE STOCKHOLM P&AElig;DIATRIC CONGRESS.

THE second International Psediatric Congress willbe held at Stockholm on August 18th-21st, as hasalready been announced in our columns. The CrownPrince and Crown Princess of Sweden are the patronsof the Congress, and a Swedish organisation committeehas chosen the following subjects for discussion :-

(a) The biological effect of direct and indirect ultra-violetirradiation:

(b) The physiological and pathological significance of thethymolymphatic system ;

(e) The psychology and pathopsychology of childhood ;their significance as a branch of psediatric research andteaching, and their application in medico-social work.The names of the introducers of these subjects will beannounced in the near future, as well as the names ofthose announced in advance by their respectivenational committees as intending to take part in thediscussion. Free debate will follow the introductoryaddresses by the announced speakers. We havealso received an intimation that notification of " freelectures " should be in the hands of the organisingcommittee by April 1st. It is evidently expected that,apart from reports and discussions which have alreadybeen arranged for, members of the Congress maydesire to initiate debates on particular subjects, when,if the committee approve, from 15 to 20 minutes willbe allotted to such " free lectures."

All communications are to be addressed to Dr. I.Jundell, Second International Psediatric Congress,Stockholm, Sweden, and application for tickets ofadherence should preferably be accompanied by thefee, sent as a cheque or money order, and all names andaddresses should be printed in block capitals. The feeis 20 Swedish crowns for adherents, and half that sumfor accompanying members of their families-a"Swedish crown is Is. I ’5d. For these special pleasuretrips have been planned.

AMSTERDAM CONGRESS OF CYTOLOGY.

THE second International Congress of Cytology isto. be held in Amsterdam on four consecutive daysearly in August, either at Amsterdam or Groningen,the precise details to be decided later. The firstsubject will be the cell and its properties, whenA. Gurwitsch (Moscow) will deal with the problem of imitogenetic radiation, and A. Krontowski (Kiev) willspeak on carbohydrate metabolism in tissue culturesand its changes under various conditions. The thirdsubject will be the properties of the living cell, eitherwhen stained vitally or on micro-section. Possiblythere may be time to take up radio-sensitiveness atthe same session, and a film by R. Canti (London)will be shown. On one of the other days A. Timofe-jewsky (Tomsk) will speak on the properties of theblood and connective tissue in culture, while W. Bloom(Chicago), successor and pupil of Maximow, will takeas his chief subject the formation of blood in tissueculture. W. von M&ouml;llendorff (Freiburg) will dealwith the potency of fibrocytes in culture and tissues.For another session the subject of growth and itsrelations to differentiation and regeneration has beenchosen, and among individual contributors are

mentioned H. C. Fell (Cambridge) on bone-tissue inculture, A. Policard (Lyon) on cartilage in tissueculture, and L. Doljanski (Paris) on cultivation ofliver-tissue and the maintenance of its properties inculture. The subject will be closed with a contribu-tion by A. Fischer (Berlin) on regeneration in tissueculture. A proposal has been made from various

quarters to devote the fourth day of the Congress toa discussion on the significance of tissue culture inrelation to the culture of bacteria and viruses. Thesuggestions are as yet provisional and any who wishto take part are invited to communicate beforeApril lst with the general secretary of the Inter-national Preparatory Committee, Frau Prof. Rh.Erdmann, Berlin-Wilmersdorf, Nassauische-str. 17.It is understood that the Histological Institute ofProf. G. C. Seringa in Amsterdam will provide thescientific centre for experimental work.

PRELIMINARY TRAINING FOR NURSES.

THE latest gift of the Rockefeller Foundation toUniversity College Hospital is a preliminary trainingschool for nurses, which was opened by Prince Georgeon Wednesday afternoon. Such a school has beenin existence for many years, but it has beeninadequately housed. With increase of the numberof beds has come a need for more nurses, and theadmirable aim of the authorities is to enlarge thetheoretical background of practical instruction, andincidentally encourage a better type of entrant.The variety and increasing scope of a nurse’s lifemake a broad professional outlook more and moredesirable, and the Rockefeller Foundation is anxiousto support institutions which are likely to turn outcompetent administrators, teachers, and supervisorswho can spread the best traditions and methods.The new school is well equipped for the work it hasto do. It is on six floors, with separate dining-roomand practice kitchen, a laboratory department, and ademonstration room which is fitted like a ward, sothat the students will not feel lost on going into themain hospital. Like the students, nurses in trainingwill have access to the anatomy school. Two sistertutors and a staff nurse will have their quarters in theschool, and there is room for 20 students, besides thedomestic staff. The period of preliminary trainingis two months. During the second month thestudents will visit the hospital daily and engage inward work, and at the end of their term they will beexamined in the theory and practice of nursing.If successful, they will then be accepted as

probationers. Provision is to be made for Rockefellerstudents from abroad, who, having been awarded ayear’s Fellowship, come to England for furtherexperience.

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THE SURGICAL TREATMENT OF DEAFNESS.

MIDDLE-EAR deafness, or " conduction-deafness,"’consists of three principal groups, those due tosuppuration and its results, those due to chronicnon-suppurative middle-ear catarrh, and otosclerosis.Much interest attaches to measures for the relief ofdeafness due to the last-named disease, for it frequentlyadvances to a very severe degree, and may be accom-panied by excessive tinnitus, and is uninfluenced byany form of treatment. In the last two decades of thelast century there was a considerable degree of activityin this direction, and numerous intratympanicoperations were designed for the relief of all forms ofmiddle-ear deafness, but the distinction between thevarious forms were not so well understood then asnow. The essential lesion of otosclerosis is the growthof new spongy bone in the capsule of the labyrinth,with consequent fixation of the stapes and often alsowith occlusion of the fenestra rotunda. It is not to beexpected that excision of the drum-membrane, orthe establishment of a communication between theantrum and the meatus, as suggested by Malherbe in1899, would achieve any permanent good in such cases,and they have not, in fact, been found to be successful.Kessel in 1876, and Lucas in 1885, reported theresult of removal of the malleus and incus ; incases of stapes ankylosis the ankylosis was in mostinstances the result of suppurative disease; in deafnessdue to otosclerosis the results were unsatisfactory.Extraction of the stapes has been tried by many