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January 1953 C. S. NICOL: The Treatment of Neurosyphilis 27
i. The age incidence is lower.2. The pouches' are often
solitary.3. The pouches are peculiarly liable to cause
acute symptoms. Acute diverticulitis of thecaecum, which closely
resembles acute appendi-citis in its clinical features, may, in
fact, be thefirst indication of the presence of a pouch.
Rarely,chronic inflammation of a diverticulum causes amass in the
right iliac fossa which is liable to bemistaken for cancer and the
true nature of whichonly comes to light after excision.The
management of a case of acute diverticulitis
revealed at operation undertaken on a diagnosis ofacute
appendicitis will vary according to the find-ings. There have been
cases recorded in whichthe inflamed diverticulum was readily seen
andwas excised. In others there is found a mass ofinflammatory
tissue and the wall of the caecumitself is acutely inflamed. The
best procedure forthe latter condition is to exteriorize the bowel,
with
subsequent excision and, finally, closure. This isa protracted
and irksome experience for thepatient, but there appears to be no
alternative.Diverticula of the Appendix
Diverticula of the appendix may be demon-strated in about t per
cent. of appendices removedat operation. They may be associated
withgeneralized diverticulosis of the colon or mayresult from
disorganization of the appendix mus-culature as a result of chronic
fibrosis. They are notin themselves of any notable clinical
significance.
BIBLIOGRAPHYEDWARDS, H. C. (I939), Diverticula of the Small and
Large
Intestine, John Wright & Sons, Bristol.KRON, S. D., and
SPECTER, J. (I95o), Gastroenterology, is, 62.MAYFIELD, L. H., and
WAUGH, J. M. (I949), Ann. Surg.,
x29, I98.MAYFIELD, L. H., and WAUGH, J. M. (I949), Ibid., 130,
i86.ORR, I. M., and RUSSELL, J. Y. W. (i95x), Brit. 7. Surg.,
39,
I39.WALKER, R. M. (I945), Brit. J. Surg., 32, 457.
THE TREATMENT OF NEUROSYPHILISBy C. S. NICOL, M.D., M.R.C.P.
Medical Officer in Charge, Special Treatment Centre, St.
Bartholomew's Hospital:Assistant Physician. Whitechapel Clinic,
London Hospital
In a paper dealing with the treatment of neuro-syphilis, it is
first necessary to discuss briefly theincidence, clinical
classification and natural historyof the condition.
It is almost certain that 'invasion' of thenervous system by the
treponema pallidum occursduring the primary stage of the disease in
all cases,but in the majority these organisms do not surviveto
produce an inflammatory process, thus 'in-volvement ' may occur in
25 to 35 per cent. of cases.This involvement is first manifested by
a pleo-cytosis and increased protein content of the spinalfluid in
the secondary stage of the disease asdemonstrated by the pioneer
work of Ravaut(I903). Even after involvement of the nervoussystem
at this stage spontaneous regression occursin a number of cases so
that Bruusgaard's (1929)analysis of patients with untreated
syphilis seenmany years later, gave a figure of 9.5 per cent.
forthose with neurosyphilis, while Rosahn's (1946)analysis of
autopsy findings in 77 patients withuntreated syphilis showed
pathological evidenceof neurosyphilis in 7.6 per cent.
A classification of neurosyphilis is alwaysdifficult as the
involvement of meninges, vesselsand parenchyma never occurs alone,
but one orother type usually predominates.
I. Early syphilis (within first four years ofinfection):
(a) Asymptomatic neurosyphilis.(b) Acute syphilitic meningitis
(may occur in
secondary stage or later).2. Late syphilis (after fourth year of
infection):
(a) Asymptomatic neurosyphilis.(b) Meningeal syphilis of brain
or spinal cord
(often termed meningo-vascular as there is alsoinvolvement of
smaller vessels).
(c) Vascular syphilis of brain or spinal cord(involvement of
medium-sized vessels).
(d) Parenchymatous:(i) General paresis..(ii) Tabes
dorsalis.(iii) Optic atrophy.
(e) Gumma of brain or spinal cord.It is important to know
something of the natural
history of neurosyphilis and realize that reversal
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28 POSTGRADUATE MEDICAL JOURNAL January 1953Early, Syphilis Late
Syphilis
Asymptomatic Asymptomatic Tabes DorsalisNeurosyphilis-
Neurosyphilis
Tabo-paresisAcute Syphilitic Meningeal Syphilis General
Paresisx
Meningitis (meningo-vascular) )
of the spinal fluid to normal can occur in bothsymptomatic and
asymptomatic conditions. Pro-gression is the rule with involvement
of theparenchyma of the brain or spinal cord. This isindicated in
Table I.
In considering the curative effect of any drug inneurosyphilis
it is most important to realize thatthis is very different in
inflammatory (meningeal)and degenerative (parenchymatous) lesions.
Theremay be complete resolution of inflammatorylesions with
treatment as one sees in asympto-matic and meningo-vascular
neurosyphilis, on theother hand if a degenerative lesion
predominatesas in tabes dorsalis, signs and symptoms mayremain
unchanged.
In some conditions, such as general paresis orErb's spastic
paraplegia, both types of lesions maybe present. Gummatous lesions
are of the in-flammatory type, while the results of
vascularneurosyphilis are mainly degenerative. If thesefacts are
realized it is easier to assess the responseto treatment in the
various types of neurosyphilis.It is also a general rule that
inflammatory lesionsoccur -earlier in the course of the disease
thandegenerative lesions, and thus early treatment(ideally in the
asymptomatic phase) will give thebest results.
Examination of the cerebro-spinal fluid isessential in
neurosyphilis, both in diagnosis andin order to assess the results
of treatment. Thisinvolves four tests: (a) the cell count; (b)
theestimation of total proteins; (c) the spinal fluidWassermann
reaction; (d) Lange's colloidal goldcurve. A test for increase in
globulin (Pandytest) is not essential as the colloidal gold test is
anindication of the albumen globulin ratio in thespinal fluid.
(a) An increase in the cell count above 3 to 5per cu.mm. is the
earliest indication of involvementof the nervous system by the
treponema pallidum,and equally it is the first test to revert to
normalas a result of treatment.
(b) An increase in the total protein above 40mgm. per cent.
follows an increased cell count, andit also is the next test to
revert to normal withtreatment.
(c) The Wassermann reaction takes longer tobecome positive and
is slow to reverse with treat-ment; it may take several years to
revert tonegative. Thus retreatment is not necessarily
indicated if this test remains positive provided thecell count
and protein revert to normal. Aquantitative Wassermann test is
helpful as itindicates the gradual fall in titre. False
positivereactions of the Wassermann test in the spinal fluidare
rare, except in the presence of bacterialmeningitis, when the '
reagin ' from the blood maypass through the choroid plexus
provided, ofcourse, that the patient already has latent
syphilis.
(d) The colloidal gold test parallels the Wasser-mann test in
the rate of appearance of abnormalcurves and their modification and
reversal tonormal with treatment. Dattner (i944) has em-phasized
that the so-called paretic, luetic andmeningitic curves do not
necessarily indicate theconditions named. They may all occur
inasymptomatic neurosyphilis, and a paretic patientmay have a
luetic curve and vice versa. It isprobable, however, that the
presence of a pareticcurve in a patient with asymptomatic
neuro-syphilis suggests that that patient, if untreated,would
develop general paresis. In 1944 Langeand Harris introduced a new
method for thecolloidal gold test by which the colour changeswere
constant and the numerical value given toeach would be totalled so
as to produce a quantita-tive as well as a qualitative test.
Using these basic tests, spinal fluid findings inneurosyphilis
are usually classified in three groups.Group I. Cases with abnormal
cell count and
total protein with a negative colloidal gold andWassermann
test.Group 2. All cases not included in Group I or
Group 3.Group 3. Cases with abnormal cell count and
total protein, positive Wassermann test and aparetic type of
colloidal curve.Dattner Thomas Concept
Dattner and Thomas (I942) believe that thecure of a patient with
neurosyphilis is assured ifall the tests in the spinal fluid become
and remainnegative. They assume that this indicates resolu-tion of
the meningeal inflammatory process andbelieve that while any
degenerative process cannotbe reversed, it will not progress. On
the otherhand in tabes dorsalis and optic atrophy this is notalways
the case.
In contrast to the reversal of an abnormal spinalfluid produced
by adequate therapy, the blood
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January 1953 C. S. NICOL: The Treatment of Neurosyphilis
serological tests (Wassermann and Kahn re-actions) remain
positive in the majority of cases.Quantitive tests will demonstrate
variations intitre according to certain patterns (Redmond,Nicol and
Shooter, I952). ' Seroresistance' isof no prognostic significance
and does not indicatefurther treatment of the neurosyphilis.
General Considerations of TherapyBefore the discovery of
penicillin, neurosyphilis
was treated with various combinations of neo-arsphenamine,
'bismuth, tryparsamide and fevertherapy (benign tertian malaria or
mechanicalfever). Since the introduction of penicillin allare
agreed that this is the drug of choice. Thereare still, however, a
number of controversialpoints to be decided.
I. The type of penicillin, dosage and duration ofcourse. In most
clinics at present the procainesalt of penicillin is used. This
saves multiple in-jections and' may be given once daily
intra-muscularly in dosage ranging from o.s to I.o megaunit. A
course of injections may last for io to15 days, giving a range of
from 5.0 to 15.0 megaunits total dosage.
2. The mechanism of the Jarisch Herxheimerreaction and possible
means of preventing it.Heyman, Sheldon and Evans (I952) now
considerthe Herxheimer reaction to be a hypersensitivityphenomenon
of the delayed type. This reaction,as manifested by a rise in
rectal temperatureabove 00oo F. following the first injection
ofpenicillin, is not uncommon in all types of neuro-syphilis and
may occur in about half the cases -ofgeneral paresis treated. It is
uncommon, how-ever, to get a severe reaction with exacerbation
ofsymptoms or the appearance of new symptoms.In this country the
present policy is to give 6 to 12weeks preparatory treatment with
intramuscularbismuth (0.2 to 0.4 g. each injection) in the hopeof
preventing a reaction. While the resultant delayin giving the
penicillin is not important in mostcases of neurosyphilis, it may
be thought advisablethat acute syphilitic meningitis or general
paresisof acute onset should be treated immediately withpenicillin
and the small risk of a serious Herx-heimer reaction accepted. The
evidence from thework of Farmer (1948) suggests that giving
initialsmall doses of penicillin in no way prevents aHerxheimer
reaction, thus when a course ofpenicillin is started initially or
after bismuththerapy it may be given in full dosage.
3. The indications for adjuvant fever therapy.In I946 the
situation was summarized by Mooreas follows:
Penicillin alone is indicated in early asympto-matic
neurosyphilis, meningo-vascular neuro-
syphilis, vascular neurosyphilis and gumma of thebrain and
cord.
Penicillin plus fever therapy is indicated ingeneral paresis,
tabo paresis, primary opticatrophy, eighth nerve deafness,
syphilitic epilepsyand Erb's spastic paraplegia.The best type of
fever therapy is induced
malaria, 8 to I2 paroxysms (40o to 6o or more hoursof fever over
104° F.).Hahn (1951) summarizes the present trend as
follows:Although opinions to the contrary are expressed
the consensus appears to be that in all forms -ofneurosyphilis,
with the exception of primary opticatrophy, the clinical and spinal
fluid results oftreatment with penicillin alone are comparable
tothose with penicillin plus fever therapy.Early Syphilis (First
Four Years of Infection)
(a) Asymptomatic neurosyphilis. Excellent re-sults as judged by
spinal fluid reversal are obtainedwith penicillin alone. Hahn
(I95i) reports Iooper cent. entirely satisfactory of 25 patients
treatedby this method.
(b) Acute syphilitic meningitis. Moore (1946)reported on i o
cases treated with intramuscularpenicillin in total dosage ranging
from 6o0,ooounits to 4,000,000 units given in 71 to i i days.The
follow-up was from 287 to 667 days. Theimmediate symptomatic
response was dramatic-ally favourable in every case. Headache and
stiffneck disappeared in 24 to 48 hours. Cranial nerveparalysis
disappeared in all cases except one inwhich a slight residuum
remained after 98 days.Of four patients with eighth nerve deafness,
oneshowed no improvement (tested by audiometer)after 104 days. Two
patients with convulsionshad no further attacks after therapy.
Threepatients had mild febrile Herxheimer reactionswithout any
-clinical exacerbation. The spinalfluid response was entirely
satisfactory at the lastobservation in nine cases, in the tenth
case thecells had been reduced from I,450 c.mm. to 9c.mm. 383 days
after treatment, other spinal fluidfindings were negative in this
case.
In one of the io cases there was a muco-cutaneous relapse 287
days after treatment, whichhad consisted of only 6oo,ooo units of
penicillin in71 days.The results reported in this group are
dramatic
when the small dosage of penicillin given in somecases is
considered. There is every reason toexpect excellent results with
present dosageschedules.Late Syphilis (More Than Four Years
AfterOriginal Infection)
(a) Asymptomatic neurosyphilis. Penicillin alone
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30 POSTGRADUATE MEDICAL JOURNAL January I953
is used. Hahn (I95I) reports in I8o cases with94.5 per cent.
entirely satisfactory response, 5 percent. unknown and only 0.5 per
cent. failure asjudged by spinal fluid examination.
(b) Meningeal syphilis (including Erb's spasticparaplegia). In
cases in which there is a pre-dominant meningeal reaction, results
with peni-cillin should be adequate except in Erb's paraplegia.Hahn
(I95 ) reports results in nine cases ofmeningeal involvement of the
brain with cranialnerve lesions (excluding optic atrophy and
eighthnerve deafness), II.I per cent. were entirely satis-factory,
44-4 per cent. significantly improved,Ix.x per cent. results
unknown and 44-4 per cent.treatment failures. He also reports I8
cases ofspinal cord involvement (including Erb's para-plegia)
giving II.I per cent. entirely satisfactory,22.2 per cent.
significantly improved, I6.7 per cent.results unknown and 50 per
cent. treatmentfailures; when he used malaria in addition
topenicillin in three cases there were two failures andone
success.
Jones et al. (I95I) in a study of i9 patientswith non-tabetic
spinal cord syphilis observed thebest clinical results in five
patients with meningomyelitis with a duration of symptoms of less
thanfive months. They stated that the outcome inthree patients with
Erb's spastic paraplegia orsyphilitic amyotrophic lateral sclerosis
was dis-couraging. The duration of symptoms in thesepatients was of
more than one year's duration, andthey concluded that considerable
degenerativechanges had taken place before the onset oftherapy. The
spinal fluid response in all the casesthey reported was comparable
to that occurringin other types of neurosyphilis.
(c) Vascular syphilis. Following the occlusionof a medium-sized
cerebral or spinal vessel thereis always some degree of
myelomalacia. As aresult of this there is usually little clinical
responseto therapy.
Jones et al. (I95i) describe six patients withacute transverse
myelitis as the result of anteriorspinal artery thrombosis. None
obtained com-plete clinical recovery after treatment with
peni-cillin. Two of them, however, showed someimprovement in motor
function and became am-bulatory in spite of severe spasticity, they
also hadfair control of the bladder' and anal sphincters.Two
patients showed a poor clinical response withbut slight improvement
of motor function. Twopatients showed no recovery and died two
monthsand two and a half years after treatment respec-tively.Hahn
(I95i) reports the results of penicillin
therapy in 20 patients with cerebral and spinalvascular
syphilis, 20 per cent. were entirely satis-factory, 60 per cent.
were significantly improved,
in I5 per cent. the results were unknown and 5per cent. were
treatment failures.
(d) General paresis. In this condition, whetheroccurring as a
single entity or combined with tabesdorsalis (tabo-paresis), there
remains a differenceof opinion as to the necessity of fever therapy
inaddition to penicillin. Analysis of reported re-sults should be
assessed both in relation to spinalfluid reversal and in relation
to clinical results interms of the degree of social recuperation.
Itmay be interesting to compare clinical resultsobtained by
different workers in different countriesin the last few years.
CLINICALLY CURED OR GREATLY IMPROVED(a) Combined penicillin and
malaria therapyCurtis, Kruse and Norton (I949) . 42% of 77
casesLereboullet and Brisset (I949) · 50% ,, 31 ,,Nicol and Whelen
(I95I) .... 65% ,, I4x ,,Lescher and Richards (I947) .. 66% ,,
,,Hahn (1951) . .. 67% ,, 43 ,,Kopp, Rose and Solomon (1948) .. 67%
,, 446 ,,Kierland, O'Leary and Underwood
(1948) ........ 70% ,, 76 ,,(b) Penicillin therapy aloneCurtis,
Kruse and Norton (I949) · · 47% of I55 casesHahn (I95I) .. 55% ,,
70 ,,Lescher and Richards (1947) * 70% ,, ,,Delay, Desclaux and
Stevenin (x947) 8o ,, 95 ,,
No biostatistical conclusions can be drawn fromthis type of
comparison. Perlo, Rose, Carmenand Solomon (I95I) were able to
compare twosimilar groups of patients with advanced simpledementia
treated with penicillin only and peni-cillin plus malaria therapy
respectively. Theysummarize the results in three tables, which
arereproduced overleaf.They concluded that 'clinical results
with
penicillin alone proved slightly more favourablethan those
obtained with combined therapy.'
It must be remembered that malarial therapynecessitates
admission to a special hospital withskilled medical and nursing
care, as there arerisks of grave complications and fatalities
havebeen reported. Such a centre exists in thiscountry-The Mott
Clinic, Epsom.
Penicillin therapy gives varying results accord-ing to the type
of psychosis present in paresis.Kopp, Rose and Solomon (1948)
report 85 percent. improvement in patients with slight
psychicdisturbances, 66 per cent. improvement in affectivedementia,
but only 25 per cent. improvement inpatients with a paranoid
psychosis.
Bruetsch considers that total dosage of peni-cillin in paresis
should be more than Io mega units,as he found treponema pallidum
still present in thecerebral cortex of patients who came to
autopsyafter having received this dosage.
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January 1953 C. S. NICOL: The Treatment of Neurosyphilis 3'
122 PATIENTS WITH ADVANCED SIMPLE DEMENTIA(after Perlo, Rose,
Carmen and Solomon)
CLINICAL STATUSImproved Arrested Worse
Penicillin alone, 30 patients .... I9 (63%) 8 (27%) 3
(Io%)Combined therapy, 92 patients .... 48 (52%) 25 (27%) I9
(21%)
SOCIAL ADJUSTMENTGood Fair Poor Not known
Penicillin alone, 30 patients . 5 (7%) 9 (30%) I. (50%) I
(3%)Combined therapy, 92 patients .. 13 (I4%) 26 (28%) 48 (52%) 5
(6%)
WoRK LEVELWorking Not Working Hospitalized
Penicillin alone, 30 patients....
II (37%) 6 (20%) I3 (43%)Combined therapy, 92 patients .... 38
(41%) x6 (I8%) 38 (41%)
Lastly, there is the problem of the Herxheimerreaction in
patients with paresis. Heyman,Sheldon and Evans (95z2) reported
this in 23 (52per cent.) of 44 patients with paresis. Six of
these23 patients showed a transient intensification oftheir
psychotic manifestations. Putkonen andRehtijarvi (1950) studied the
Herxheimer reactionin 223 patients with neurosyphilis. All 21
patientsin this series with paresis previously untreatedshowed a
febrile response. They stated thatprevious therapy with arsenic
and/or bismuthseemed to reduce this to some extent, while pre-vious
malarial or penicillin treatment made thereaction impossible. They
also stated that themore active was the spinal fluid the more
likelywas the febrile response to occur. It usually tookplace 12 to
I6 hours after the first injection ofpenicillin. They did not
experience any seriousclinical exacerbations. In a few patients
there wasincreased confusion during the febrile responseand in one
patient who had previously had fits, afurther convulsion occurred
at the fever peak.Lereboullet and Sapin Jalloustre (x947) record
apatient with paresis who died in status epilepticusafter
penicillin therapy had been begun and theauthor has seen a similar
case.
(e) Tabes dorsalis. In this condition the problemagain arises as
to whether penicillin therapy aloneis adequate. Hahn (I95I)
tabulates the results in70 patients treated with penicillin and 31
withpenicillin and malaria. The results in the firstgroup were 41.4
per cent. entirely satisfactory,I8.6 per cent. significantly
improved, II.4 percent. results unknown and 28.6 per cent.
treatmentfailures. In the second group there were 48.4 percent.
entirely satisfactory, I9.4 per cent. signifi-cantly improved, I2.9
per cent. results unknownand I9.4 per cent. treatment failures. He
con-
cludes the effects of penicillin plus malaria therapyon tabetic
symptoms are essentially the same asthose of penicillin alone.
Asjudged also by overallclinical results the addition of malaria
therapyaffords no definite benefit. He also states that in afew
patients development or progression of symp-toms occurs after
treatment. Koteen (1949) re-ported on 403 patients with tabes
including 49treated with penicillin alone. There was im-provement
of symptoms and signs such as im-potence (40 per cent.), ataxia (54
per cent.),lightening pains (50 per cent.), urinary com-plications
(33 per cent.) and paresthesiae (66 percent.) as indicated. Gastric
and other crises,pupillary abnormalities and deep sensibility
dis-orders remained unaffected. The appearance of anew clinical
sign such as a Charcot's joint mightoccur after treatment.
Herxheimer reactions areuncommon in tabes according to Putkonen
andRehtijarvi (1950).
(f) Optic atrophy. This serious complication isoften associated
with tabes dorsalis. If un-treated the patient may become blind in
three tofive years from the onset of symptoms, but theprogression
of the condition is very variable. Onemust emphasize the importance
of early diagnosisby the examination of the optic discs, visual
acuityand visual fields (the earliest change). Klauderand Gross
(1949) reported in 56 patients givenpenicillin and malarial
therapy, that there were32 stabilizations, io aggravations and
eight becameblind. Hahn (195i) reported progression in six of17
patients with primary optic atrophy after treat-ment with
penicillin alone, and in three of i6 aftertreatment with penicillin
plus malaria. Blindnessoccurred in four of the former and two of
the lattergroup. The total period of observation in bothgroups was
only 15 months. Similar types of
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32 POSTGRADUATE MEDICAL JOURNAL January 1953
patient composed both treatment groups. Heconcludes that
penicillin alone cannot yet beevaluated, and penicillin plus
malaria remains thetreatment of choice.
(g) Gumma of brain or cord. This condition is aclinical rarity
and may only be diagnosed at opera-tion as in the case of a gumma
of the cord describedby Thompson and Preston (I950); their case
re-ponded favourably to penicillin therapy. It hasbeen stated in
the past that a serious clinicalHerxheimer reaction might occur,
especially if thelesion were in the brain below the tentorium
cere-belli and that a pressure cone of the medulla mightresult in a
fatality. Premedication with bismuthshould always be given as a
prophylaxis against thisevent.
Spinal Fluid RelapseDattner (I949) reported on the spinal fluid
out-
come of 388 patients with various types of neuro-syphilis
observed for 6 to 56 months, and recordedonly 43 failures to a
first course of penicillin. Ofthese 43 patients, 24 responded
favourably to asecond course of higher dosage, of the other
I9failures only three showed a continuous active pro-cess indicated
by persistent abnormal cell countand protein. In I95o Dattner
reported concern-ing further treatment of these three patients
(allcases of asymptomatic neurosyphilis). Two hadreached an
inactive state following treatment withfour courses of penicillin
totalling 49.8 and 59mega units respectively. The third case had
notbeen followed long enough to evaluate treatment.In Hahn's (I95I)
whole series of 589 patients withall types of neurosyphilis, the
spinal fluid relapserate was I.25 per cent. for the penicillin
group and0.93 per cent. for the penicillin plus malaria group.These
relapses only occurred in patients whoseinitial spinal fluid
contained io or more cells andwho received less than 5 mega. units
of penicillin.No patient suffered more than one spinal
fluidrelapse.Antibiotics Other Than PenicillinThere is as yet no
evidence that these prepara-
tions are more efficient than penicillin in the treat-ment of
syphilis, and they remain considerablymore expensive. They have
been used experi-mentally for the treatment of neurosyphilis in
alimited number of cases. Kierland and O'Leary'I950) treated I2
patients with neurosyphilis bygiving oral aureomycin and reported
satisfactoryclinical and spinal fluid reversal. Romansky et
al.(I95) treated five patients who had neurosyphiliswith
chloramphenicol for i5 days. They reportedreversal of abnormal
spinal fluid cell counts. Therewas no clinical improvement in a
case of tabesdorsalis or in a case of optic atrophy. Robinson
(I952) mentioned an investigation which he wasundertaking with
Mohr to study the effect ofaureomycin and chloramphenicol in I
patientswith late asymptomatic neurosyphilis (Group 3spinal fluid
changes). The dosage given for bothdrugs was 6o g. in 15 days. In a
graph he showedthe return to normal of spinal fluid cell counts
inI8o days with a slow improvement in the colloidalgold curve. The
total protein and complementfixation test remained essentially
unchanged duringthis time. He concluded that the treatment ofchoice
for neurosyphilis remained procaine peni-cillin, 600,000 units
daily or every other day to anapproximate total of io million
units.
SummaryI. In a summary of the present status of treat-
ment in the various types of neurosyphilis therecent literature
concerning clinical and spinalfluid results has been reviewed.
2. Penicillin appears to be the drug of choice forneurosyphilis;
the newer antibiotics have not beenproved more effective.The total
amount of penicillin given should not
be less than 6 mega units administered in not lessthan io days.
Dosage up to 15 mega units in I5days is employed in many clinics.
The procainesalt of penicillin is generally used with an
injectiongiven intramuscularly once in every 24 hours.This makes
ambulatory treatment possible.
3. Penicillin alone will give as satisfactory spinalfluid
reversal and clinical outcome as when com-bined with malarial
therapy except in optic atrophy.
4. Where malaria therapy is indicated thepatient should be sent,
if possible, to a specialcentre where expert medical and nursing
care willreduce the risk of a fatality to a minimum.
5. Spinal fluid relapse rate is low with penicillintherapy and
retreatment with a larger dosage isusually successful.
6. The Jarisch-Herxheimer reaction as mani-fested by a febrile
response is not uncommonespecially in general paresis, but serious
newclinical symptoms or exacerbation of existingsymptoms are rare.
In this country, however, itis still considered prudent to give 6
to I2 weekspreparatory treatment with intramuscular bismuthbefore
the administration of penicillin in caseswhere there is no urgency.
In cases of acutesyphilitic meningitis or in general paresis of
acuteonset it may be considered best to give penicillininitially
accepting the risk of a clinical Herxheimerreaction.
7. Giving penicillin in initial small dosage,which is gradually
increased, in no way modifiesthe incidence or severity of a
Herxheimer reaction.Thus when penicillin is administered for
neuro-syphilis it may be given in full dosage.
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January 1953 A. W. LIPMANN KESSEL: Fractures Around the Elbow
Joint 33
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VFRACTURES AROUND THE ELBOW JOINT
IN CHILDRENBy A. W. LIPMANN KESSEL
London
The swings and slides of public parks provideour hospitals with
a regular week-end clientele ofsmall boys who have sustained
fractures about theelbow joint. The diagnosis of many such
frac-tures calls for nice judgment and a meticulousattention to the
general principles as well as thedetails of treatment. The I935
Report of theB.M.A. Committee on Fractures did not analyzefractures
in children, but if it is true that theaverage incapacity period
for a simple fracture ofthe clavicle in adults who were not treated
in anorganized clinic was 22 weeks, as compared to fiveweeks for
those treated in organized clinics, itwould be a fair assumption
that a similar analysisfor the group of more serious and difficult
fractureswe are now considering would reveal an evengreater
difference.
Diagnosis and classification. The precise diag-nosis of the type
of fracture is essential, but byno means always easy because of the
complexityof the ossification of the lower end of the
growinghumerus. Leaving aside for the moment thequestion of soft
tissue damage, this group offractures may be broadly classified
into five radio-logical types. Intermediate as well as complextypes
will, of course, occur. In cases of doubt the
opposite elbow must always be X-rayed forcomparison:
Supracondylar fractures-extension and flexionvarieties.
Transcondylar-simple and' T '-shaped.Epicondylar avulsion, with
or without disloca-
tion.Fracture-separation of the external condyle
epiphysis.Fracture of the head or neck of the radius.Treatment.
Each type of fracture will be con-
sidered separately, but there are certain generalprinciples
applicable to the treatment of all thesefractures.
I. Manipulative reduction must always begentle. Only too often
does a complication arisefrom the violence of attempted reduction
ratherthan from the original injury itself.
2. Wherever possible a 'single attack' shouldbe made to achieve
reduction by closed manipula-tion. It should be carried out under
generalanaesthesia with X-ray control (not screening), andthe
several attempts that may be necessary toachieve satisfactory
alignment should be carriedout at the same session. An examination
of someof the disasters which have occurred shows only
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