780 SERUM THERAPY 



After-treatment. The patient should be kept in bed for twenty- 

 four hours and the foot of the bed should be elevated for part of this 



time. 



Usually the temperature reaction is mild. There is frequently some 

 pain in the legs, which appears a few hours after the injection is given. 

 The pain is more often noticed in tabetics than in patients with cerebro- 

 spinal syphilis. It can usually be controlled by means of phenacetin 

 and codein, but occasionally morphin is required. 



In a few instances violent maniacal symptoms have developed, due 

 possibly to the direct irritant action of the drug on the tissues, aided by 

 the sudden liberation of endotoxins from myriads of killed spirochetes. 



Serobiologic Findings in the Cerebrospinal Fluid. In all cases before 

 the treatment is undertaken a Wassermann reaction should be performed 

 with the blood and cerebrospinal fluid of the patient. A total cell count 

 should also be made with a specimen of fluid, the percentage of lympho- 

 cytes ascertained, and a Noguchi butyric-acid-globulin test performed. 

 Normally, the cells number about 8 per cubic millimeter of fluid (counted 

 with a Fuchs-Rosenthal counting chamber) ; the presence of more than 

 15 cells in this quantity of fluid may be regarded as bordering on the 

 pathologic. In tabes and paresis the cells may vary in number from 

 50 to more than 100, and are mostly small lymphocytes. A normal cere- 

 brospinal fluid remains clear or shows a faint opalescence when tested 

 by the Noguchi butyric-acid test. In tabes, paresis, etc., varying de- 

 grees of cloudiness and the presence of precipitates are observed. 



Repeating the Dose. Usually a number of treatments are required, 

 and these may be given at from one to three weeks' intervals, depending 

 upon the condition of the patient. The results are estimated from the 

 subjective and objective symptoms and from an examination of the 

 cerebrospinal fluid. A decrease in the degree of positiveness of the 

 Wassermann reaction and diminution in cells and in globulins are fav- 

 orable signs. Theoretically, treatment should be continued until the 

 Wassermann reaction becomes negative, the cells reach normal propor- 

 tions, and the globulins show no increase. Practically, it may be im- 

 possible to secure these results; in many instances the Wassermann re- 

 action is the first to disappear. A total cell count of the fluid is not to 

 be depended upon without a differential count with stained smears, for 

 the injections may produce a form of aseptic meningitis, accompanied by 

 an outpouring of polynuclear leukocytes. This subject has previously 

 been referred to in a consideration of the serum treatment of epidemic 

 meningitis. 



