broad smile without demonstrable reason. The disturbance in the somatopsychic sphere is most prominent and interesting. He spends much of the time on the bed, because when he stands the left side of his chest "jumps so." He repeatedly complains of his heart, fears it is going to stop, says it has no more ambition than he has. Complains of a great variety of paresthesias in surface areas, such as burning, warmth, electric touches, pains and numbness. These often are fleeting in duration, and very localized in extent. Cephalic pain and girdle sensation, he often mentions. He complains of a mental dullness, and that things feel strange to him, or that he cannot think at all and doesn't want to.

In the physical examination the right pupil was more active than the left, and irregular in outline. The excursion of the left under torch-light was diminished. Accommodation reaction is also sluggish and restricted. All the deep tendon reflexes are increased. The extremities are usually cold and moist. There is a very slight grade of cyanosis. In the seven months the patient has been under observation there has been very slow, yet obvious, deterioration, consisting chiefly of affect dementia, an intellectual narrowing and a fixation of the somatopsychic complexes.

CASE III.-Male, 27, single. The only son of cultured and intelligent parents. After puberty he evidently showed marked psychopathic predisposition. He was admitted to the Sheppard and Enoch Pratt Hospital in May, 1908. His psychosis was said to have commenced several months previously. The principal feature was the occurrence of mental states characterized by marked disorientation and dissociation in the autopsychic sphere. There were active hallucinations, both visual and auditory. All varieties of delusions of reference paranoid in character were expressed. There were also prominent somatopsychic disturbances, which were, however, at all times present to a lesser extent. Such a phase as the above would last on the average several days to a week, when the auto- and allopsychic disturbance would clear entirely with the return of a good insight and appreciation of having been through some kind of a mental attack. As previously mentioned there would persist, when in his best condition, some somatopsychic disturbance which resembled a neurasthenic reaction. The patient often complained of paresthesias similar in quality to those shown by Case II.

Physical examination was negative except for pupillary anomalies, which were an irregular left pupil and a sluggish light reaction and diminished excursion. Similar attacks to the one described occurred at regular intervals during his stay at the hospital. Between attacks patient's general reaction to the casual observer was practically normal. He was discharged improved, and when heard from recently was able to do some work in the jewelry business, and was considered in good condition by his family. Evidently so far there has been but little deterioration, and if we are right in assuming that the process is a dementing one, the progress is evidently very slow.

CASE IV.-Male, single, 23. Admitted in July, 1905. The psychosis of this patient is strikingly like that of Case III. The attacks, however, have occurred at more regular intervals, and last a week or 10 days, to be followed by a fairly normal interim of about the same duration. The transition into the attack usually takes a few hours. This patient left the hospital in 1907, but has been seen at intervals since then. He shows a well-marked physical and mental deterioration. Formerly an expert stenographer, during his well periods he is still able to do a little work along this line, but the quality of his work has obviously degenerated.

The cyclic-nature of the disturbance in Cases III and IV seem to support the theory of the primary importance of the "X" or toxin of Jung, especially as no complex of pathogenic importance could be discovered in either case.

Cases II and III exhibit peculiar interest from the standpoint of differential diagnosis, inasmuch as a single examination during several phases might easily lead to a diagnosis of neurasthenia. The importance of a correct estimate of such cases is obvious.

THE APPLICATION OF IMMUNITY REACTION TO

THE CEREBRO-SPINAL FLUID.*

By J. W. MOORE, M. D.,

Assistant Physician, State Hospital, Central Islip, N. Y.

Time does not allow of a preliminary explanation and discussion of the various theories of immunity by which modern investigators have sought to explain the changes which occur in the serum of an animal which has been inoculated with some foreign cell or toxin. Suffice it to say that the hypotheses of Ehrlich have so well withstood the assaults of critical experimentation that they have come to be tacitly accepted as, at least, a convenient working basis until chemistry in its rapid strides shall have come to our aid and simplified what are now merely to be expressed as properties possessed by a serum into definite colloid or proteid formulas. In the following paper the use of technical terms has been avoided so far as possible, but such as do occur are among those which were introduced by Ehrlich and are still in constant use.

One of the ingenious applications of an immunity reaction to diagnosis has been the so-called "complement-fixation test" introduced by Bordet and Gengou in 1901. The immune property of a serum, e. g., the immunity which a typhoid patient's serum acquires against the typhoid bacillus, by reason of which it agglutinates and destroys the bacilli in the Widal test, is known to consist of two parts. One part, called antibody, represents that peculiar property of the serum which makes it immune to that organism and to no other. This antibody is thermostabile, that is, it is not affected by heating the serum to 56 C. The other part, complement, is a constituent of all sera whether normal or immune. It is thermolabile and is driven off by heating to 56 C., but can be restored by simply adding a small quantity of fresh, unheated, normal serum from the same or from another suitable species. So, if we first heat the typhoid patient's serum and then add it to an extract made from a broth culture of typhoid bacilli, the organisms will not be destroyed, for the serum has been inacti

* Read at the sixty-fifth annual meeting of the American Medico-Psychological Association, Atlantic City, N. J., June 1-4, 1909.

vated by the loss of its native complement. But by adding a few drops of serum, from, let us say, a guinea-pig, the patient's serum is at once re-activated and the lysis of the bacilli takes place.

If we have a patient on whom we wish to make a specific diagnosis of typhoid, we have the direct method of demonstrating the bacilli in the patient's blood or excreta, usually a difficult task, or the indirect method of determining the existence of antibody to typhoid in the patient's serum. For the latter procedure we may do the well-known Widal test, or resort to the complement-fixation test, which is somewhat as follows: In a test-tube which we will call tube No. 1, we place a suitable amount of the serum to be tested and of an extract of typhoid bacilli. Next we add a small quantity of fresh guinea-pig serum as complement. If the complement in this guinea-pig serum is absorbed, we can tell that the patient was suffering from typhoid and that an antibody to the typhoid bacillus had formed in his serum, otherwise the complement would remain free, for it is bound only where the serum is specifically immune to the organism present. But there is nothing in the appearance of the fluids in the test-tube to indicate what has taken place; how are we to prove that complement has been absorbed? For this we use, as an indicator, an immune reaction which also requires complement for its fulfillment, but which is easily visible to the naked eye-namely, hemolysis. A rabbit is injected repeatedly with increasing quantities of sheep blood from which the serum has been washed and the corpuscles suspended in physiological salt solution. As a result of this there is generated in the serum of the rabbit an antibody for sheep red-blood cells— a fact which can be demonstrated by bringing the two together, when the suspension of sheep erythrocytes will change in appearance from a bright, opaque red to a clear, transparent cherry color, due to the destruction of the corpuscles and the liberation of their hemoglobin. A small quantity of this rabbit's serum is heated to drive off its complement and placed in a test-tube, which we will call tube No. 2, together with a suspension of sheep red-bloodcells. This gives the potential for hemolysis, complement alone being needed. If the contents of tube No. I be added to that of tube No. 2 and hemolysis occurs in the latter, it indicates that free complement existed in tube No. I and means that the patient's serum did not contain typhoid antibody. On the other hand, if

hemolysis does not occur, we can say that typhoid antibody did exist in the patient's serum and, acting specifically on the extract of typhoid bacilli, caused the absorption of complement. This is known as the complement-fixation or complement-absorption test. In syphilis, however, we deal with an organism which has not been cultivated and concerning whose very morphology we are not yet clear. In 1906, Wassermann, Neisser and Bruck' published their method of using the complement-fixation test in the diagnosis of syphilis. For an analogue of the extract of typhoid bacilli they used a watery extract of the liver and spleen of a syphilitic fœtus, after first ascertaining by smears that the organs contained large numbers of spirochetes. They added to this the heated serum of a syphilitic and found that complement was absorbed. Conversely, when they used serum from a person who did not have syphilis, complement was not absorbed. Later in the same year Wassermann and Plaut' performed the test in general paralysis and tabes, using, instead of the blood-serum, the cerebrospinal fluid. They obtained the same results as with syphilitic serum, with the same negative controls. The blood serum in these diseases also sometimes gave positive reaction but in a very much smaller per cent than the spinal fluid. Thus it appeared that we were about to be given a new diagnostic criterion for general paralysis and a proof of its specific relationship to syphilis.

It was soon found, however, by other investigators, that an extract from normal livers could be used just as satisfactorily as that from syphilitic organs and that an alcoholic extract did quite as well as a watery one. So it is now known that the presence of syphilitic organisms in the Wassermann extract had nothing to do with the reaction, but that the latter depended upon certain lipoid bodies which are abundant in the liver.

Although the specificity of one element in this so-called Wassermann reaction has been thus exploded, the test remains a valuable one, for a very high percentage of blood-sera from syphilis and spinal fluids from metasyphilitic diseases evince this peculiar property of absorbing complement in the presence of lipoids, while sera and spinal fluids from other disorders are practically always negative in this regard. The sharing of this characteristic by that group of disorders is significant of their relationship.