Part 38

Bruck’s[154] technique is described as follows: “The test is made with 0.5 cc. clear serum in a test tube, to which is added 2 cc. of distilled water, and the whole shaken. Then, with a precision pipette, 0.3 cc. of the ac. nitr. purum of the German pharmacopeia is added and the whole thoroughly shaken and then set aside at room temperature for ten minutes. Then 16 cc. of distilled water at room temperature is added, and closing the tube with the finger, it is shaken up and down three times carefully, not vigorously enough to make it foam. This is repeated ten minutes later, and the tube is then set aside for half an hour. By this time the precipitate is entirely dissolved in the tube with the normal serum, while the syphilitic serum shows a distinct, flocculent turbidity. In two or three hours, or better still, in twelve hours, the gelatinous and characteristic precipitate is piled up on the floor of the test tube.”

The acid is prepared by diluting the Acidum nitricum of the U. S. P. (Sp. gr. 1.403) with distilled water until the hydrometer shows the specific gravity 1.149, which corresponds to the nitric acid of the German pharmacopeia, but since this requires a special hydrometer, a simpler method is to make a 25 per cent solution of the Acidum nitricum, which will give about the proper specific gravity.

The serum is obtained by allowing 10 cc. of blood to stand at room temperature for an hour, and then centrifuging. Serum that has stood for some time may be used as well as the fresh, and even bloody serum does not seem to confuse the results to any great degree. The serum gives the same results with or without inactivation. Post mortem blood gave results as constant as that obtained during life, in the few cases that we had in this series. But the reaction may be influenced markedly by the size of the test tubes. We have found that the 13×1.9 cm. is the most favorable size.

When one first thinks of this test it appears very simple and probably somewhat crude as a chemical reaction, but there are certain precautions that must be observed, and several hundred normal and syphilitic sera should be tried before the investigator can feel that he has a refined routine technique. There is the personal equation which must be watched, for here is probably the greatest source of error, and readily explains why two different persons get widely varying results with the same sera if they have done only a few dozen tests. We must take it for granted that the reaction is a quantitative one, where some positive reactions may differ only slightly from the normal non-syphilitic, and, furthermore, any normal serum may be made to give a positive reaction, and almost any positive serum be made to give a negative by improper manipulation at some point in the test. There are as many places for error to creep in as there are steps in the process. Bruck has omitted many details in his publication, which allow personal variations, and so we have tried to develop a routine process that will eliminate as many of these as possible.

We shall here attempt to explain the methods which we have found most satisfactory and at the same time indicate the places where error is likely to occur. The 0.5 cc. of serum is added to 2 cc. of distilled water, and shaken thoroughly. Now add slowly exactly 0.3 cc. of acid from a precision pipette, care being taken it does not flow down the side of the tube. The tube should be shaken gently while the acid is being added, for this prevents the formation of a flocculent precipitate in normal serum which is difficult to dissolve later. After the acid is added shake each tube gently to make sure that these flakes do not persist. It is difficult to shake each tube in exactly the same manner, as must be done if we expect uniform results.

The first 250 tests of this series were made by allowing the tubes to stand for ten minutes as Bruck advocates. Then we found that practically all sera gave a positive reaction if allowed to stand 15–20 minutes, and so in the other tests of the series an attempt was made to make the reaction more sensitive by allowing the tubes to stand only 6–7 minutes. During this time the tubes should be shaken gently once or twice. The manner in which the 16 cc. of water is added also influences the reaction. If allowed to flow freely in upon the precipitate, the positive may be forced into solution as well as the negative. Both pipette and tube should be slanted and the water allowed to flow down the side of the tube without disturbing the precipitate. If all has gone well up to this point, we may see a marked difference between the normal and syphilitic precipitates, in that the normal will begin to go into solution at once, thus clouding the water, while a positive precipitate will be composed of large flakes which show little or no tendency to go into solution or cloud the water above. It must be remembered that the most flocculent positive precipitate will go into solution if the fluid is splashed or shaken too hard while the tube is being inverted. If any doubt as to the character of the precipitate now exists, it may be allowed to stand ten minutes longer, and again inverted as before, or even repeated several times during the next hour or two. We see no reason why the tubes should be left to stand over night, for during this time a precipitate usually settles in the normal tubes. This, however, differs from the syphilitic precipitate in that it is still finely granular and goes back into solution readily when the tubes are inverted.

In view of these possible grounds for error, it is only logical to run controls of known positive and known negative sera along with each group of unknown bloods, and even then certain tubes will seem doubtful, in which event the test should be repeated with added precaution to see if a definite positive or negative reaction may be obtained.

In the last tests of this series we seemed to aid the reaction by rendering the serum-water solution alkaline by one or two drops of 10 per cent potassium hydroxide before the acid was added. The positive sera have a larger precipitate, while the normal seem to dissolve more readily.

TABLE I

Syphilis: nervous system involved.

General Paresis Wassermann and Bruck agree positively 47 Wassermann and Bruck agree negatively 7 Wassermann and Bruck at variance 10

Tabes Dorsalis Wassermann and Bruck agree positively 3

Cerebrospinal Wassermann and Bruck agree positively 8 Wassermann and Bruck agree negatively 3

Juvenile Paresis Wassermann and Bruck agree positively 1

Summary: Wassermann and Bruck agree positively 59 Wassermann and Bruck agree negatively 10 Wassermann and Bruck at variance 10

TABLE II

Syphilis: nervous system not involved.

Syphilis Wassermann and Bruck agree positively 12 Wassermann and Bruck at variance 5

Congenital Syph. Wassermann and Bruck agree positively 3 Wassermann and Bruck agree negatively 2

Summary: Wassermann and Bruck agree positively 15 Wassermann and Bruck agree negatively 2 Wassermann and Bruck at variance 5

TABLE III

Non-syphilitic: Wassermann reaction negative. Doubtful or positive Bruck 86 Bruck test negative 216

Total for three groups: Wassermann and Bruck agree positively 74 Wassermann and Bruck agree negatively 230 Wassermann and Bruck at variance 101

The tests here reported were made on blood sera obtained from patients admitted to the Psychopathic Hospital and its Out-Patient Department. As a routine Wassermann test is made on each patient who enters the hospital, it was only necessary to take another tube of blood from each patient, and check the results in each instance with the Wassermann reaction. As it takes several days to get the report from the Wassermann laboratory of the State Board of Health, there was no chance of being prejudiced by a previous knowledge of the Wassermann reaction. The cases for the most part were those of mental disease; the majority in good general physical health.

A comparison of the total number with the Wassermann reaction shows that there was a general agreement of 304 of the 405 cases tested, or a percentage agreement of practically 75%. In considering the cases of syphilis of the central nervous system in a group by themselves, we find that the agreement is closer, since 69 of the 79 cases tested, or 87% agreed without any question of doubt. It will be noted that in several cases of general paresis, the Wassermann reaction, which was repeated at intervals, was negative, and in most of these cases the Bruck test was negative also. Our few cases of congenital and latent syphilis also checked very closely with the Wassermann test. In the various groups of mental cases in this series, no factor of interference was discovered. It is also of interest that in the cases where the blood was obtained post mortem, the Bruck test agreed with the Wassermann result obtained on ante mortem blood serum. Further work on post mortem sera will be reported. Some of the patients not included in the syphilitic groups that have a negative Wassermann and no clinical signs of syphilis, give a history of previous infection at some time, which might partly account for the variations in the two tests.

CONCLUSIONS

1. We present results of the Bruck sero-chemical test in 405 cases. In 101 of these cases there were definite clinical manifestations of syphilis, in which the Wassermann and Bruck tests agreed positively in 74 or 75%. The two tests agreed negatively in 12 instances, and were at variance in 15.

2. In the group which showed syphilis of the nervous system we had 64 cases of clinically certain general paresis, of which the Wassermann and Bruck tests agreed in 54 instances, or practically 85%. In other forms of central nervous system involvement the agreement was 100% in the 15 cases tested.

3. In the cases with no apparent involvement of the nervous system the agreement was somewhat less, being 76%. This may be in keeping with the fact that the Wassermann test was not so strongly positive in these cases.

4. The advantages of the test are: (1) the short time required to do the test; (2) the limited amount of apparatus necessary, and (3) the simplicity of the technique.

5. The disadvantages of the test seem, for the most part, to be bound up in the personal variations that are apt to occur.

6. We are here dealing, most probably, with a quantitative chemical difference in the protein content of syphilitic and non-syphilitic sera, the nature of which is not understood by us. It is our hope that this may be brought to light in the near future in the field of chemistry.

APPENDIX B COMMON METHODS OF TREATMENT USED IN CASES OF NEUROSYPHILIS

The =treatment for neurosyphilis= according to the viewpoint of the authors =is treatment for syphilis=. It is necessary in order to cure a case of neurosyphilis to cure the syphilis in the patient. Accordingly, the methods of treatment best adapted for the cure of syphilis are indicated in the treatment of neurosyphilis. As experience shows that it is often more difficult to cure the neurosyphilitic cases, treatment will have to be pushed with greater intensity than in some non-nervous system syphilis. In general, then, the methods that have been applied by the syphilologist will be used in the treatment of cases of neurosyphilis. In addition, methods attempting to bring the drug into local contact with the central nervous system have been devised. The methods of treatment have been in part indicated in Chart 27.

The method chiefly used in treatment of the cases of this book is what we have called =intensive systematic intravenous treatment=. The treatment consists of intravenous injections of salvarsan (or a substitute for salvarsan, as arsenobenzol and diarsenol) given in a dose of about 0.6 gram and repeated twice a week over a period of a number of months. In addition, injections of mercury salicylate averaging 0.065 gram once a week are given and potassium iodid by mouth. As indicated, the important point is to keep up treatment for a long period of time. This method has produced practically no untoward results, certainly no more untoward results than are to be expected with salvarsan in smaller quantities and it has seemed to us that the therapeutic results have been as satisfactory as in any other form of treatment.

Specialized forms of treatment intended to place the drug in contact with the central nervous system may be described under the headings of =spinal intradural treatment= and =cerebral subdural= and =intraventricular treatment=.

Three main therapeutic agents have been largely used. These are (1) salvarsanized serum according to the =method of Swift-Ellis= (=in vivo=). The serum according to this method is prepared as follows: An intravenous injection of salvarsan is given to a patient and blood withdrawn at the end of one-half hour. This is allowed to clot. The serum is removed and after inactivation at 56° C. for one-half hour it is ready for use. The average dose is 15 to 30 cc. of serum. As a matter of fact, it is not necessary to use the blood serum from the same patient to whom the intraspinous injection is to be given. (2) The salvarsanized serum according to the =method of Ogilvie= (=in vitro=). Blood serum is prepared from any patient and to it is added salvarsan in such a strength that the amount to be injected, 10 to 30 cc. of serum, will contain 0.0001 to 0.001 gm. (3) Mercurialized serum according to the =method of Byrnes=. Mercury bichloride is added to blood serum in such proportion that the amount of serum to be injected will contain from 0.00065 gram to 0.0026 gram.

The method of intraspinous injection is to perform lumbar puncture, withdraw an amount of fluid approximately equivalent to the amount to be injected; then allow the serum to be injected to run in by gravity.

For the =cerebral=, =subdural and intraventricular= injections, the same sera may be used as for the intraspinous. Five or six times as much salvarsan may be given, but a smaller amount of serum may be advisable, that is, 10 to 15 cc. To perform injections a trephine opening is made in the calvarium about the size of a dime. The location of choice for the opening is slightly back of the longitudinal prominence just to the right of the median line, to avoid the frontal sinus. For subdural injections a curved needle is thrust between the dura and the brain and the serum allowed to flow in slowly by gravity. For the intraventricular injections a blunted spinal puncture needle is thrust through the brain substance into the 3rd ventricle. When the 3rd ventricle is reached the clear cerebral fluid will flow out; then after withdrawing a sufficient amount, the serum may be introduced by gravity. The trephining may be done under local anesthesia but as a rule it is better to induce general anesthesia. The subsequent injections can be made without recourse to any anesthesia whatsoever, as they are practically painless.

All procedures both in the injections and in the preparation of sera are naturally to be performed under aseptic conditions.

INDEX

Abscess, tonsillar, associated with neurosyphilis, 250.

Addison’s disease in juvenile paretic, 279.

Agraphia, 101.

Albumin test, 474.

Allbutt, Clifford, 257.

Alcoholism, chronic, 227.

Alcoholic dementia, 237. epilepsy, 229. hallucinosis, 225. pseudoparesis, 222, 223, 451.

_Allergie_, 129, 204.

Alzheimer, 428. method, 472.

Amboceptor, 477.

Amnesia, 195.

Anaphylaxis, 129.

Anatomical formulae, 25.

Antigens, 476.

Aortic aneurysm, 35, 439.

—— sclerosis, 41, 46, 135.

Aphasia, 31, 43, 101, 262, 445.

Apoplexy, 197.

Argyll-Robertson pupil, 209, 212, 217, 291, 450. as isolated symptom, 217. in alcoholism, 214, 229.

Arndt, Junius and, 249.

Arsenobenzol, 375, 377, 389, 486.

Arteriosclerosis, cerebral, 101. not a contraindication to intensive salvarsan therapy, 359. radial, 68.

Ascending lesion, 23.

Asymmetrical lesions, 19.

Ataxia, 31, 223.

Atheromatous degeneration, 35.

Atrophy, cerebellar, 39. cerebral, 47, 134, 205. parenchymal, 41. pontine, 39.

Atypical case congenital neurosyphilis, 270.

Ayer, J. B., 472.

Ballet, 72.

Barrett, A. M., 54, 175, 187, 212, 218, 219.

Bechterew, 219.

Binet and Simon, 304.

Binet scale, 277.

Birnbaum, 403.

Blood pressure, high, 70, 262, 124.

Bly, 252.

Bonhoeffer, 404, 415, 417.

Bordet, 427.

Bratz, 278.

Bruck test, 479.

Bruck, C., 479.

Bumke, 214.

Canavan, 256. and Southard, 70.

Cell count, 471.

Cerebral syphilis, see diffuse neurosyphilis.

Cerebrospinal syphilis, see diffuse neurosyphilis.

Cervical hypertrophic meningitis of Charcot, 56, 441.

Chancre, extragenital, 75, 342.

Character change, neurosyphilis, 314.

Charcot, 60, 186.

Choroiditis, 242.

Christian, 407.

Cimbal, 403.

Civilization and syphilis, 76.

Clinical evidences of syphilis, 131.

Clouston, 158.

Collins, Joseph, 145.

Compensation in neurosyphilis, 309, 402, 456.

Complement, 477.

Conduct disorder, 38.

Congenital syphilis, absence of stigmata, 318. as cause of feeblemindedness, 159, 447. involvement of nervous system in, 274.

Congenital neurosyphilis, 270, 395. resembling feeblemindedness, 272.

Conjugal neurosyphilis, 263.

Convulsions, 43, 101, 248, 362. cause of in paretic neurosyphilis, 232. in psychopathic subject with syphilis, 417.

Corneal opacity, syphilitic, 234.

Cotard, 73.

Cotton, H. A., 472.

Craig, C. B., 152, 196.

Cramer, 125.

Cranial neurosyphilis, 140. tenderness, 139.

Crises, gastric, 367.

Cysts, ependymal, 59. of softening, 27, 36, 54.

Cytorrhyctes luis, 381.

Dana, Charles L., 65, 77, 78.

Dazed states, 264.

Deafness, 63.

Decompression, 138.

Defective delinquent—diffuse neurosyphilis, 300, 455.

Dejerine-Tinel, 61.

Delinquency and juvenile neurosyphilis, 298.

Delirium tremens, 332.

Dementia, 137.

Dementia paralytica, see paretic neurosyphilis.

Dementia praecox, 74, 185, 247.

Depression, 95, 126.

Depressive drugs, 189.

Diabetes, and neurosyphilis, 240. insipidus, 190.

Diabetic pseudoparesis, 238.

Diarsenol, 377, 389, 391, 486.

Differential diagnosis, alcoholism and neurosyphilis, 227, 231, 234, 236. brain tumor, diabetic pseudoparesis and neurosyphilis, 238. diffuse and paretic neurosyphilis, 165, 193, 247. manic-depressive psychosis and neurosyphilis, 69. multiple sclerosis and neurosyphilis, 253, 255. neurasthenia and neurosyphilis, 65, 183. senile arteriosclerotic psychosis and neurosyphilis, 262.

Diffuse neurosyphilis, cerebrospinal syphilis, cerebral syphilis, spinal syphilis, 17, 80, 85, 97, 103, 122, 140, 183, 193, 300, 331, 342, 359, 433, 439, 443. premonitory symptoms, 342. prognosis, 80, 103, 124, 433, 443. spinal fluid findings in, 348. symptoms, 99. treatment, 98, 103, 184, 302, 390. treatment, results, 343.

Diplopia, 50, 184, 253, 356. causes, 140.

Donath, 401, 403.

Drastich, 407.

Duco and Blum, 403.

Dupré, 407.

Dysdiadochokinesis, 231.

Ehrlich, 184, 428, 429.

Encephalitis, 27, 248. disseminated, 218.

Endarteritis, 220.

Ependymal cysts, 59.

Ependymitis, 40, 47, 49, 134.

Epilepsy, 192. alcoholic, 229. brought out by syphilis, 415. Jacksonian, 103. parasyphilitic, 194. relation to juvenile neurosyphilis, 277. syphilitic, 103, 194. syphilogenic, 415.

Epileptic neurosis, 195.

Erb’s syphilitic spastic paraplegia, 147. treatment of, 148.

Euphoria, 73.

Excited states, 95.

Exner, M. J., 416.

Exophthalmic goitre, syphilitic (?), 205.

Extraocular palsy, 140, 441.

Eye changes in neurosyphilis, 257.

Eye muscles, paresis of, 17, 50.

Facial paralysis, 53.

Families of neurosyphilitics, 275, 316, 318, 320, 373, 431, 457.

Family of neurosyphilitic, normal-looking, but syphilitic, 318.

Familial syphilis, 299, 306.

Farrar, C. B., 411.

Fearnsides, Head and, 21, 140, 150, 193, 217, 374, 378.

Feeblemindedness, 395. and congenital syphilis, 159.

Fernald, W. E., 159, 273, 396.

Fildes, McIntosh and, 129, 329.

Focal changes, 221. meningitis, 50. softenings, pontine, 54.

Fournier, 142, 222, 186, 194, 381.

Franz, 357.

Froissart, 413.

Fugue, hysterical, 264.

Garnier, 407.

General paresis, see paretic neurosyphilis.

Glands, 270.

Gliosis, 39, 47, 49, 136, 180.

Globulin, 229. tests, 473.

Glycosuria, 238, 241.

Goddard, 397.

Gold sol reaction, 247, 474. in brain tumor, 100. paretic, 85, 98. paretic, other tests negative, 383, 385. in purulent meningitis, 100. syphilitic, 85, 98, 345.

Graham, Thomas, 429.

Grandiosity, 72, 295, 455.

Graves, W. W., 157.

Grilli, 407.

Gross, 257.

Gumma, see gummatous neurosyphilis.

Gumma of tonsil, 250.

Gummatous neurosyphilis, 53, 56, 137, 138, 140, 221, 362, 438.

Hallucinations, 53. in paretic neurosyphilis, 249.

Hauptmann, 348.

Head and Fearnsides, 21, 140, 150, 193, 210, 217, 374, 387.

Headache, 53, 63, 122, 247, 352. causes of, 209.

Hecht, 399.

Hemianopsia in neurosyphilis, 242.

Hemiplegia, 31, 45, 80, 122, 262, 360. causes of, 389.

Hemitremor, 197.

Heredity, neuropathic, 84.

Herxheimer reaction, 152.

Heubner, 427, 428.

Hinton, W. A., 471.

Huntington’s chorea, 258.

Hutchinsonian teeth, 45.

Hydrocephalus, 134, 306.

Hyperreflexia, explanation of, 233.

Hypochondriacal ideas, 133.

Hysteria, 185, 301.

Hysterical symptoms, 18.

Incontinence, vesical in tabetic neurosyphilis, 144. rectal, 56.

Incubation period of neurosyphilis, 152.

Infectiousness of neurosyphilis, 95.

Insight, 95.

Insomnia, 63.

Intracranial pressure, 139, 362.

Intraspinal lesions, 95.

Intraspinous therapy, 122, 366, 486. unpleasant results of, 366.

Intraventricular injections, 389, 487.

Involution-melancholia, 187.

Iodine, untoward results, of, 363.

Iritis, 17.

Järisch-Herxheimer reaction, 72.

Joffroy, 214. and Mignot, 64.

Junius and Arndt, 249.

Juvenile neurosyphilis, 438, 447. relation to epilepsy, 277.

Juvenile paresis, see juvenile paretic neurosyphilis.

Juvenile paretic neurosyphilis, juvenile paresis, 45, 154, 157, 272, 275, 298, 306, 440. age of onset, 158. and Addison’s disease, 279. and delinquency, 298. prognosis, 156, 158, 162, 273, 275. treatment, 154, 161, 278, 299.

Juvenile paretic neurosyphilis, with initial trauma, 306. congenital amputation of toes in, 158.

Juvenile tabetic neurosyphilis, 161, 447.

Kaplan, 255, 471.

Kéraval, 257.

Key, 427.

Knee-jerks, absence of, 223. lively, 75. return of, 24.

Koefod, Solomon and, 243.

Kolmer, 471.

Kraepelin, 65, 66, 69, 88, 91, 95, 187, 225, 249.

Krafft-Ebing, 84.

Laignel-Lavastine, 413.

Lange, C., 428, 429, 474.

Lancinating pains, 92, 141.

Lépine, 408, 413.

Leptomeningitis, 47, 54, 135.

Lewandowski, 210.

Liability of paretic, 295.

Lissauer’s paralysis, 38.

Locomotor ataxia, see tabetic neurosyphilis.

Long, 418.

Lucke, Baldwin, 93, 144.

Lues maligna, 250, 452.

Lumbar puncture, untoward effects, 352. treatment of, 354.

Lüth, 278.

Lymphocytosis, 23, 30, 40, 49.

McDonagh, 381.

McIntosh, Fildes and, 129, 329.

Malaria, cerebral, simulation of paretic neurosyphilis, 245.

Mallory and Wright, 472.

Manic-depressive psychosis, 68, 71, 77, 187, 202, 291, 384, 442.

Marie, Chatelin and Patrikios, 412.

Marie, 408, 414.

Martin, E. G., 313.

Massary, de, 414.

Mattauschek and Pilcz, 347.