tion and, apparently, any number of injections may be given with safety. Further, it has been recently shown that 50 cc. of blood, which has been removed one-half hour to one hour after the intravenous injection of salvarsan, contains amounts of arsenic which in terms of salvarsan vary between 25 to 5 mgm.; 0.5 mgm. is now considered to be the largest amount of salvarsan which can be introduced repeatedly with safety into the subarachnoid space. We have had personal experience with neither the method of Ravaut, Wile or Ogilvie, as we have used the Swift-Ellis technic exclusively.

We wish to report briefly our results with the intraspinal injections of salvarsanized serum. While our series of cases is not large, the value of the report may be increased by the length of time that some of the cases have been under observation.

Case I. W. I. S. A young man who had a meningovascular syphilis which had given symptoms for a year. He had had lancinating pains in the legs, and increasing difficulty in walking. When we saw him he had marked ataxia, double vision and a ptosis of the left eyelid. The knee and ankle jerks were absent and there were marked sensory disturbances. The right leg was partially paralyzed. The blood showed a strong positive Wassermann reaction. The spinal fluid showed a great increase in the globulin content, 153 cells to cu. mm., and a Wassermann reaction* which was positive when but 0.2 cc. of the spinal fluid was used. This patient's progress was very slow and was, at times, discouraging. Each intraspinal treatment was followed by terrific explosions of the lancinating pains. He has been under observation over two years, and in that time he has received 12 intravenous injections of salvarsan (a total of 5.4 Gm.) and 7 intraspinal injections of 40 per cent serum strength. In addition, he has received numerous courses of mercury both by injection and by inunction.

Results:

When we began treatment the patient was incapacitated for work, and was suffering greatly from the ever-increasing lancinat

*In performing the Wassermann reaction upon the spinal fluid, we have used 0.1 cc., 0.2 cc., 0.3 cc., 0.4 cc., 0.5 cc., and 1.0 cc. We follow the modification of the original technic which employs one-half quantities of all reagents. The antigens employed have been the alcoholic extract of beef heart fortified by the addition of 0.4 per cent cholestrin.

ing pains. When last examined the blood Wassermann reaction was negative. The spinal fluid showed a normal amount of globulin, 3 cells per cumm., and a Wassermann reaction positive only when 0.8 cc. was used.

In May, 1915, the patient reported that he had but one attack of pain the last year. He is pursuing his business as usual. He walks without difficulty and he has regained the power in his right leg. The ptosis of the left eyelid has disappeared. Otherwise, the physical findings are the same except that the disturbances of sensation have practically disappeared.

Case II. W. M. B. A male of 45, suffering from a moderately advanced tabes. His symptoms had been slowly advancing for two years and consisted of increasing uncertainty in walking, lancinating pains in the legs, and marked numbness of the feet. The pupils were unequal but reacted to light and accommodation. The knee and ankle jerks were absent. There were distinct sensory changes to be made out over the lower extremities and marked hypotonia. Romberg's sign was present. The patient had received three intravenous injections of salvarsan without any improvement in his condition previous to the time at which we saw him. The blood showed a strongly positive Wassermann reaction. The spinal fluid showed a moderate increase in globulin, 75 cells per cumm., and a Wassermann reaction positive in 0.1 cc.

The patient has been under observation for a period of over two years, in which time he has received 20 intravenous injections of salvarsan or neosalvarsan (the equivalent of 10.7 Gm, of salvarsan) and 15 intraspinal injections of salvarsanized serum. Results:

After the first intraspinal injection the lancinating pains disappeared, never to return. The spinal fluid when last examined showed a normal amount of globulin, and a normal cell count. The spinal fluid Wassermann was reduced 50 per cent in strength. Physical examination showed no change in the pupillary reflexes, nor was there any return of the deep reflexes. Sensations over the legs were, however, practically normal and there was no Romberg sign. The patient is now operating his ranch in the west, riding, walking, ploughing and so forth, without any difficulty. It is interesting to note that in this case a serious relapse occurred which was coincident with a course of mercurial

treatment.

Case III. H. O. B. A young man was admitted to the Cleveland City Hospital with the diagnosis of alcoholism. He was delirious and had been drinking heavily for some time. Shortly after admission the patient developed symptoms of meningitis, unconsciousness, rigid neck, Kernig's sign, double Babinski's sign and fever, accompanied by a facial hemi-paresis and a paralysis of the left arm. The spinal fluid was turbid and contained a greatly increased amount of globulin, 550 cells per cumm., and a Wassermann reaction positive in 0.1 cc. of the fluid. The blood Wassermann reaction was also strongly positive. The acute symptoms cleared up under intramuscular injections of Hg. Biniodid, gr. 1⁄2, of which he received 18 injections. His recovery was slow. His mental status suggested paresis. During the next three months the patient received 7 intravenous injections of salvarsan, a total of 4.05 Gm., and 6 intraspinal injections of salvarsanized serum. He left the hospital greatly improved. He reported for examination 8 months later. Except that the pupils reacted a little sluggishly to light and that a slight paresis of the left arm remained, the physical examination was negative. His speech was a little slow, but his mind was clear. The blood Wassermann reaction was negative. The spinal fluid showed a normal globulin content, 3 cells per cumm., and a Wassermann reaction positive only when 0.7 cc. of the fluid was employed. Since leaving the hospital he has returned to his occupation and is now acting as manager of a shoe store.

Case IV. C. H. Z. A man with moderately advanced tabes of several years standing. His chief complaint was of gastric crises, which were severe enough to lay him up about. half of the time. He lost, on the average, two weeks of every month. His general condition was very poor. He had ArgyllRobertson pupils, absent knee and ankle jerks and marked incoordination with definite disturbances in sensation. The spinal fluid showed a great globulin increase, 62 cells per cumm., and a Wassermann reaction positive with 0.2 cc.

This patient was under observation for 11 months. In this time he received salvarsan or neosalvarsan intravenously 9 times, or an amount equivalent to 4.6 Gm. of salvarsan, and 9 intraspinal injections. His improvement has been marked. His gastric crises have disappeared and he has gained in weight and strength. The physical signs are much the same, except that the Romberg's sign and incoordination have disappeared. He is

able to attend to his business and enjoy life, which he had not done for several years before the intraspinal treatment was instituted. At the last observation the globulin content and cell count in the spinal fluid were normal and the Wassermann reaction was negative, even when 1.0 cc. of the spinal fluid was used. It is fair to believe that in this case the process has been arrested.

Case V. Mrs. W. A. D. A young woman who had an early tabes dorsalis. Symptoms had existed for 18 months. She had incontinence of urine and was uncertain on her feet. She had unequal pupils which did not react to light, absent knee and ankle jerks and Romberg's sign. The sensory symptoms were not marked. The Wassermann reaction in the blood was strongly positive. The spinal fluid showed an increase in globulin, 95 cells per cumm., and a Wassermann reaction positive when but 0.1 cc. was used. For a year before consulting us the patient had received a great deal of mercury by injection, with scarcely any improvement in her condition.

The patient was under observation for 4 months, in which time she received 6 intravenous injections of salvarsan or neosalvarsan, equivalent to 3.0 Gm. of salvarsan, and 2 intraspinal injections.

The physical examination reveals no change in the pupillary reflexes or in the ankle or knee jerks. The Romberg's sign is not present. The spinal fluid now shows no increase in globulin content or in the number of cells. The Wassermann is negative in 0.5 cc. of the fluid but positive in 1.0 cc. The patient has no trouble from incontinence and her gait is steady. In her own words, "I can now run up stairs from the basement to the second story, instead of stopping once or twice to take the twist out of my legs as I used to do."

Case VI. D. W. H. A young man with moderately advanced tabes, associated with considerable involvement of the meninges. His symptoms dated back to a nervous breakdown, with stomach trouble, which occurred in March, 1913. On analysis it was found that this stomach trouble was evidently due to gastric crises; 18 months later he began to have pain and stiffness in the back and legs, which advanced so rapidly that he was soon unable to walk. The patient consulted Doctor H. M. Brundage, of Columbus, in December, 1914, from whom he received the early part of his treatment and to whom we are in

debted for the following facts. At that time the blood Wassermann was strongly positive. The spinal fluid showed a marked globulin increase, 150 cells per cumm., and a strongly positive Wassermann in 0.1 cc. of the spinal fluid. When we saw him some months later he showed irregular and unequal pupils which reacted promptly to light and accommodation, absent knee and ankle jerks, Romberg's sign and incoordination. These sensory changes were marked. The sensation of vibration was absent from the middle of the thigh downward on each leg. The patient has received in all 7 intravenous injections of salvarsan, a total of 3.5 Gm., and 7 intraspinal treatments. The first three of these were administered by Doctor H. M. Brundage. While the deep reflexes remain absent, his coordination is practically perfect. His muscle sense is good. The appreciation of vibration and of painful sensation is practically normal. The patient has no pains and no stiffness; he takes exercise and goes about his daily life with zest. The Wassermann reaction is negative in the blood. The spinal fluid shows no increase in globulin nor in the number of cells. The Wassermann reaction in the spinal fluid is negative even when 1.0 cc. of the fluid is employed. This case may be considered as an arrested case, both from the clinical and serological point of view. He has regained his ability to carry on life comfortably and normally and he has no demonstrable signs of an active syphilis about him.

Case VII. H. R. A young man who had a well advanced tabes dorsalis. The patient had suffered attacks of excruciating lancinating pains in the legs and chest for 5 years previous to the time that we saw him. The attacks of pain sometimes lasted 36 hours. There was some incontinence of urine. The pupils were widely dilated and responded to light. The knee and ankle. jerks were absent. A slight Romberg's sign was present. The blood showed a strongly positive Wassermann reaction. The spinal fluid showed a marked globulin increase, 10 cells to the cumm., and a Wassermann reaction positive with 0.5 cc. of the fluid. The patient was under our observation for 10 months, during which time he received 6 intravenous injections of salvarsan or neosalvarsan, an amount equivalent to 2.65 Gm, of salvarsan, and 6 intraspinal injections, in addition to which he received intramuscular injections of the salicylate of mercury with regularity.