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Test for Syphilis Performing the Wassermann Different Methods of A A Comparative Study of Different Methods of Performing the Wassermann Test for Syphilis This information is current as of September 28, 2021. J. Wheeler Smith, Jr. and Ward J. MacNeal Downloaded from J Immunol 1916; 2:75-93; ; http://www.jimmunol.org/content/2/1/7 5 http://www.jimmunol.org/ Why The JI? Submit online. • Rapid Reviews! 30 days* from submission to initial decision • No Triage! Every submission reviewed by practicing scientists by guest on September 28, 2021 • Fast Publication! 4 weeks from acceptance to publication *average Subscription Information about subscribing to The Journal of Immunology is online at: http://jimmunol.org/subscription Permissions Submit copyright permission requests at: http://www.aai.org/About/Publications/JI/copyright.ht ml Email Alerts Receive free email-alerts when new articles cite this article. Sign up at: http://jimmunol.org/alerts The Journal of Immunology is published twice each month by The American Association of Immunologists, Inc., 1451 Rockville Pike, Suite 650, Rockville, MD 20852 Copyright © 1916 by The American Association of Immunologists, Inc. All rights reserved. Print ISSN: 0022-1767 Online ISSN: 1550-6606. A COMPARATIVE STUDY OF DIFFERENT METHODS OF PERFORMING THE WASSERMANN TEST FOR SYPHILIS J. WHEELER SMITH, Jm, AND WARD J. MAcNEAL Downloaded from From the Laboratories of the New York Post-Graduate Medical School and Hospital Received for publication, November 9, 1916 The Wassermann complement-fixation test for syphilis was at first regarded as an immunity test depending upon a reac- http://www.jimmunol.org/ tion between antibodies specific for Spirochaeta pallida, on the one hand, and the specific protein constituents of this patho- genic organism, on the other hand. This conception had to be given up several years ago and at present it is quite generally believed that the test is not a specific one in the usual immuno- logic sense, but that it is a somewhat analogous reaction, which finds its justification in its practical value attested by experience, rather than in logical theoretical considerations. As a neces- by guest on September 28, 2021 sary corollary it results that a proposed antigen or a proposed technic finds favor not according to its theoretical specificity, but only through extensive and satisfactory use upon a large series of patients. Although clinical satisfaction, especi~lly in a short series of cases, cannot, without reserve, be accepted as final proof of scientific accuracy, yet, in the long run, it is a very safe criterion. A modification of the Wassermann antigen, which has gained very enthusiastic and almost general adoption, is that involved in the addition of cholesterin to the tissue extracts formerly used. In 1910, Browning, Cruikshank and McKenzie (1) showed that the quantity of complement absorbed by a mixture of lecithin (watery emulsion of an alcoholic solution of lecithin) and inactivated syphilitic serum could be greatly increased by the admixture of cholesterin. Gilmour (2) in 1911, maintained that the use of cholesterinized antigen furnished the most deli- 75 76 J. WHEELER SMITH, JR., AND WARD J. MAcN-EAL cate and most reliable method for the serum diagnosis of syphi- lis. Browning, Cruikshank and Gilmour (3) found lecithin de- rived from liver or heart to be more useful than that derived from egg-yolk or brain. Browning and Cruikshank (4) inves- tigated a number of cholesterin derivatives, which they tested in combination with lecithin as antigens for the Wassermann reac- tion, but they found that none of these derivatives is as useful Downloaded from as pure cholesterin itself. Sachs (5) found that alcoholic ex- tracts of normal tissues, when combined with cholesterin, possess antigenic properties equal to those of the extracts of syphilitic organs. J This view was confirmed by McIntosh and Fildes (6), who further concluded that in this combination the require- http://www.jimmunol.org/ meats of a standard antigen were finally fulfilled. Walker and Swift (7) ascertained by comparative tests that the most favor- able concentration of eholesterin is 0.4 per cent added to the alcoholic extract of human heart muscle or guinea-pig heart. There can be no question that the addition of cholesterin to the alcoholic extract renders the latter more powerful as an antigen and that considerably more positive results are thus ob- tained in the practical testing of human sera. The accuracy and by guest on September 28, 2021 reliability of these additional positive results have, however, been questioned. Thus Kolmer (8) pointed out that eholester- inized alcoholic extracts may give some inhibition of hemolysis with normal sera and must, therefore, be very carefully con- trolled. However, he places them first in order of practical efficiency in diagnosis. Zinsser (9) also has sounded a warning against too implicit reliance upon the eholesterinized antigen, as follows: From the experience of many investigators it now seems unquestion- able that additions of eholesterin increase the delicacy of the reaction in that more eases react positively with such an antigen than with the uneholesterinized preparations. The experience of Hopkins and Zimmermann, however, would indicate that great caution must be 1 "Es scheint dass die Differenz, welche zwischen Extrakten aus normMen und syphilitischen 0rganen in ihrer Brauchbarkeit fuer die Wassermann'sche Syphilis-reaktion besteht, durch die Cholesterierung dcr normalen Extrakte aufgehoben wird." THE WASSERMANN TEST FOR SYPHILIS 77 exercised when the reaction is done in this way, since occasional posi- tive results are obtained with cases clinically not syphilitic. These workers believe that cholesterinized antigen is extremely t~seful, but advise its use only parallel with the ordinary lipoidal antigens and together with careful study of the clinical aspects of the case. McClure and Lott (10) have also concluded that cholesterin additions render the alcoholic extracts more sensitive but also Downloaded from somewhat less specific and that they are, therefore, of ques- tionable value in the practical diagnosis of syphilis. Snow and Cooper (11) have reported partial to complete complement fixation with cholesterinized antigen in 31 per cent of sera from non-syphilitic tuberculous patients, although they obtained reli- http://www.jimmunol.org/ able results with the simple alcoholic extracts. In practical work one is compelled, therefore, to perform the test with both kinds of antigen and to regard as somewhat doubt- ful those sera which give positive fixation with the cholesterin- ized antigen and not with the alcoholic extract. With the prog- ress in diagnosis and treatment of syphilis and the more fre- quent appeal to the Wassermann test to aid in deciding about sufficiency of treatment, existence of latent syphilis or about the by guest on September 28, 2021 nature of low-grade pathological changes of slow evolution and slight extent, the proportion of instances in which there is defi- nite disagreement between the results given by the two kinds of antigen has shown a tendency to increase. Frequently, in a case where the result of the Wassermann test is awaited with the greatest interest by the clinician, the serologist is unable to be of much assistance, because of this fact. We are convinced that the simple alcoholic antigens fail to detect syphilis in many instances of this kind in which a syphilitic lesion is actually present, but we are equally convinced that the cholesterinized antigen sometimes gives positive fixation in non-syphilitic pa- tients suffering from other diseases, such as acute articular rheumatisnl, pneumonia, jaundice or tuberculosis. The ap- pended tabulations show this very clearly. Another matter of considerable importance in the Wasser- mann test is the temperature and the length of time employed for the first part of the reaction, the time during which takes 78 J. WHEELER SMITH, JR., AND WARD J. MACNEAL place the union between antigen and serum antibody and the binding or destruction of complement. Wassermann and most students of the subject have allowed this part of the reaction to take place at 37°C. Against this common practice may be urged the well recognized fact that complement spontaneously loses its power very much more rapidly at 37°C. than at 8 ° or 10°C. and the further well-known fact that antigen and specific immune Downloaded from body unite readily even at a temperature of 0°C. McNeil (12) has presented the results of comparative tests upon 466 persons, most of whom were presumably syphilitic, em- ploying for each case an incubation at 37°C. in one test and an incubation at ice-box temperature in the other. The an- tigen was the crude alcoholic extract. At 37°C. he obtained 176 http://www.jimmunol.org/ positive reactions, 273 negative and 17 doubtful. At tile ice- box temperature he obtained 224 positive reactions, 212 negative and 30 doubtful. This amounted to an increase in positive results of 10.3 per cent. Coca and L'Esperance (13) have also obtained positive fixation by the ice-box method with luetic sera which gave negative results in the incubator. They also report instances in which a syphilitic serum failed to give posi- by guest on September 28, 2021 tive fixation in tile ice-box while giving positive fixation at 37°C. In this communication we wish to present the results of 496 Wassermann tests upon 477 patients by three different methods, together with brief clinical notes upon those in whom the diag- nosis of syphilis was doubtful In each ease the test has been performed with an antigen of simple alcoholic extract at 37°C., a cholesterinized alcoholic extract at 37°C. and a simple alco- holic extract at 8°C. (ice-box temperature). The tubes for the tests at 37°C. were set up in the same rack, four tubes being used for each serum. Tube 1 received 0.04 cc.
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