(2) Re value of a hopeful approach to the therapy of neurosyphilis.
The prognosis of neurosyphilis is not worse than that of the chronic diseases in general. In fact, the prognosis of neurosyphilis quoad vitam is either good or dubious, certainly not bad. The surprising reversals of form which the spirochete shows in certain remissions are always to be awaited. Treatment of neurosyphilis has certainly effected amazing results, not so much by way of Ehrlich’s therapia sterilisans magna as by means of systematic intensive treatment. Even paretic neurosyphilis (general paresis) seems to have been cured. Preparetic phases are theoretically hopeful. Nor is it so certain that paretic neurosyphilis will ultimately prove a perfectly distinct species of neurosyphilis. General paresis seems to us at least to be more closely related to diffuse neurosyphilis than is tabes dorsalis to diffuse neurosyphilis. In any particular case, moreover, during a good part of the early months or years, it is difficult or impossible to tell the paretic from the non-paretic forms of diffuse neurosyphilis by any combination of clinical observations and tests. In the instance of more protracted neurosyphilis, e.g., tabetic, the outlook for vascular complications is such that antisyphilitic treatment directed at prevention of these complications is scientifically warrantable, even if the tabetic process itself proves unassailable. The old distinction of syphilis and parasyphilis, so striking and apparently satisfactory when introduced by Fournier, seems to be a false distinction which should be dropped. Therapeutically, we should approach all cases of neurosyphilis without bias or nihilistic prejudgments.
(3) Re universal applicability of syphilis tests in nervous and mental cases.
The importance of putting every neurosis or psychosis through syphilis tests is not based alone on the frequency of neurosyphilis, though neurosyphilis is surely frequent enough. The importance of universally applying these tests is established by the experience of lingering doubts both in the physician’s mind and (nowadays increasingly) in the patient’s and friends’ minds, so long as these tests are not applied. Nor should the positive serum Wassermann reaction fail to be followed by lumbar puncture and appropriate tests. The general practitioner confronting neuroses or psychoses—and what practitioner does not?—must not expect valuable results from consultation with neurologists and psychiatrists when he does not carry to these specialists the results of at least the serum W. R. in his patient. Not only are practitioners, specialists, and patients subject to discomfiture on the eventual and delayed proof of syphilis or neurosyphilis, but valuable time has been lost to treatment. How often the physician of yore (and really not so long since) had to be regarded as an eccentric virtuoso if he tested urine as routine! Well, for routine use in nervous and mental diseases, the Wassermann serum reaction is at least as important as urinalysis. Nor would we cease our homily with the general practitioner. We know neurologists and psychiatrists who use the Wassermann test only when it is likely to be positive! But they are dying out.
APPENDIX A
In appendix A a brief outline is given of the six tests (W. R. on blood serum and spinal fluid, cell count, globulin test, albumin test, gold sol test). This is not intended as a complete working manual but rather as indicating the methods used in diagnosis in the cases presented herein. For more complete details the reader may be referred to textbooks on the subject of serology, among which may be mentioned Kaplan: “Serology of the Nervous System”; Plaut, Rehm and Schottmüller: “Leitfaden zur Untersuchungen der Zerebrospinalflüssigkeit”; Kolmer: “Infection, Immunity and Specific Therapy,” and, for the Wassermann technique, an article by Dr. W. A. Hinton in M. J. Rosenau’s “Preventive Medicine and Hygiene.”
Our own W. R’s. have been performed at the Wassermann laboratory of the Massachusetts State Board of Health (formerly the Neuropathological Testing Laboratory, Harvard Medical School), under the supervision of Dr. W. A. Hinton. The other tests are performed at the Psychopathic Hospital. It is very important that a close relationship should exist between the clinician and the Wassermann laboratory if the most is to be obtained from the reactions. This relationship has been effectively close between the authors and the above-mentioned laboratory; and has enabled us to get very much clearer ideas about certain cases than could otherwise have been obtained.
Cell Count. In order to obtain the number of cells per cmm., the examination should be made of the fresh fluid as soon as possible after this is withdrawn. The most convenient counting chamber for this purpose is the so-called Fuchs-Rosenthal counting chamber, the ruled spaces of which contain slightly over 3 cmm. (an ordinary blood cell counting chamber may be used). According to the method used by us the cells are stained in a pipette with Unna’s polychrome methylene blue. Using a white-counting pipette, stain is drawn up to the first or second marking and the remainder of the pipette filled with spinal fluid. This makes no change in the dilution for practical purposes. After two or three minutes the staining is satisfactory and the counting may be done. With this stain a differential count may be made. Plasma cells stain a lavender as contrasted to the blue of the lymphocytes. The characteristic halo surrounding the eccentric nucleus is visible. The blood cells do not assume color with this stain; hence it is unnecessary to add any acetic acid.
For permanent preparations, and more accurate differential counts of the spinal fluid, the Alzheimer method may be used. The technique is given in a paper by H. A. Cotton and J. B. Ayer as follows:[[151]]
1. Lumbar puncture in the usual manner.