January 1953 C. S. NICOL: The Treatment of Neurosyphilis 27 Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from i. The age incidence is lower. subsequent excision and, finally, closure. This is 2. The pouches'are often solitary. a protracted and irksome experience for the 3. The pouches are peculiarly liable to cause patient, but there appears to be no alternative. acute symptoms. Acute diverticulitis of the caecum, which closely resembles acute appendi- Diverticula of the Appendix citis in its clinical features, may, in fact, be the Diverticula of the appendix may be demon- first indication of the presence of a pouch. Rarely, strated in about t per cent. of appendices removed chronic inflammation of a diverticulum causes a at operation. They may be associated with mass in the right iliac fossa which is liable to be generalized diverticulosis of the colon or may mistaken for cancer and the true nature of which result from disorganization of the appendix mus- only comes to light after excision. culature as a result of chronic fibrosis. They are not The management of a case of acute diverticulitis in themselves of any notable clinical significance. revealed at operation undertaken on a diagnosis of acute appendicitis will vary according to the find- BIBLIOGRAPHY EDWARDS, H. C. (I939), Diverticula of the Small and Large ings. There have been cases recorded in which Intestine, John Wright & Sons, Bristol. the inflamed diverticulum was readily seen and KRON, S. D., and SPECTER, J. (I95o), Gastroenterology, is, 62. MAYFIELD, L. H., and WAUGH, J. M. (I949), Ann. Surg., was excised. In others there is found a mass of x29, I98. inflammatory tissue and the wall of the caecum MAYFIELD, L. H., and WAUGH, J. M. (I949), Ibid., 130, i86. itself is inflamed. The best for ORR, I. M., and RUSSELL, J. Y. W. (i95x), Brit. 7. Surg., 39, acutely procedure I39. the latter condition is to exteriorize the bowel, with WALKER, R. M. (I945), Brit. J. Surg., 32, 457. Protected by copyright. THE TREATMENT OF NEUROSYPHILIS By 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- A classification of neurosyphilis is always syphilis, it is first necessary to discuss briefly the difficult as the involvement of meninges, vessels incidence, clinical classification and natural history and parenchyma never occurs alone, but one or http://pmj.bmj.com/ of the condition. other type usually predominates. It is almost certain that 'invasion' of the I. Early syphilis (within first four years of nervous system by the treponema pallidum occurs infection): during the primary stage of the disease in all cases, (a) Asymptomatic neurosyphilis. but in the majority these organisms do not survive (b) Acute syphilitic meningitis (may occur in to produce an inflammatory process, thus 'in- secondary stage or later). volvement ' may occur in to per cent. of cases. 2. Late syphilis (after fourth year of 25 35 infection): on September 24, 2021 by guest. This involvement is first manifested by a pleo- (a) Asymptomatic neurosyphilis. cytosis and increased protein content of the spinal (b) Meningeal syphilis of brain or spinal cord fluid in the secondary stage of the disease as (often termed meningo-vascular as there is also demonstrated by the pioneer work of Ravaut involvement of smaller vessels). (I903). Even after involvement of the nervous (c) Vascular syphilis of brain or spinal cord system at this stage spontaneous regression occurs (involvement of medium-sized vessels). in a number of cases so that Bruusgaard's (1929) (d) Parenchymatous: analysis of patients with untreated syphilis seen (i) General paresis.. many years later, gave a figure of 9.5 per cent. for (ii) Tabes dorsalis. those with neurosyphilis, while Rosahn's (1946) (iii) Optic atrophy. analysis of autopsy findings in 77 patients with (e) Gumma of brain or spinal cord. untreated syphilis showed pathological evidence It is important to know something of the natural of neurosyphilis in 7.6 per cent. history of neurosyphilis and realize that reversal 28 POSTGRADUATE MEDICAL JOURNAL January 1953 Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from Early, Syphilis Late Syphilis Asymptomatic Asymptomatic Tabes Dorsalis Neurosyphilis - Neurosyphilis Tabo-paresis Acute Syphilitic Meningeal Syphilis General Paresisx Meningitis (meningo-vascular) ) of the spinal fluid to normal can occur in both indicated if this test remains positive provided the symptomatic and asymptomatic conditions. Pro- cell count and protein revert to normal. A gression is the rule with involvement of the quantitative Wassermann test is helpful as it parenchyma of the brain or spinal cord. This is indicates the gradual fall in titre. False positive indicated in Table I. reactions of the Wassermann test in the spinal fluid In considering the curative effect of any drug in are rare, except in the presence of bacterial neurosyphilis it is most important to realize that meningitis, when the ' reagin ' from the blood may this is very different in inflammatory (meningeal) pass through the choroid plexus provided, of and degenerative (parenchymatous) lesions. There course, that the patient already has latent syphilis. may be complete resolution of inflammatory (d) The colloidal gold test parallels the Wasser- lesions with treatment as one sees in asympto- mann test in the rate of appearance of abnormal matic and meningo-vascular neurosyphilis, on the curves and their modification and reversal to other hand if a degenerative lesion predominates normal with treatment. Dattner (i944) has em- as in tabes dorsalis, signs and symptoms may phasized that the so-called paretic, luetic and remain unchanged. meningitic curves do not necessarily indicate the

In some conditions, such as general paresis or conditions named. They may all occur inProtected by copyright. Erb's spastic paraplegia, both types of lesions may asymptomatic neurosyphilis, and a paretic patient be present. Gummatous lesions are of the in- may have a luetic curve and vice versa. It is flammatory type, while the results of vascular probable, however, that the presence of a paretic neurosyphilis are mainly degenerative. If these curve in a patient with asymptomatic neuro- facts are realized it is easier to assess the response syphilis suggests that that patient, if untreated, to treatment in the various types of neurosyphilis. would develop general paresis. In 1944 Lange It is also a general rule that inflammatory lesions and Harris introduced a new method for the occur -earlier in the course of the disease than colloidal gold test by which the colour changes degenerative lesions, and thus early treatment were constant and the numerical value given to (ideally in the asymptomatic phase) will give the each would be totalled so as to produce a quantita- best results. tive as well as a qualitative test. Examination of the cerebro-spinal fluid is Using these basic tests, spinal fluid findings in essential in neurosyphilis, both in diagnosis and neurosyphilis are usually classified in three groups. in order to assess the results of treatment. This Group I. Cases with abnormal cell count and http://pmj.bmj.com/ involves four tests: (a) the cell count; (b) the total protein with a negative colloidal gold and estimation of total proteins; (c) the spinal fluid Wassermann test. Wassermann reaction; (d) Lange's colloidal gold Group 2. All cases not included in Group I or curve. A test for increase in globulin (Pandy Group 3. test) is not essential as the colloidal gold test is an Group 3. Cases with abnormal cell count and indication of the albumen globulin ratio in the total protein, positive Wassermann test and a spinal fluid. paretic type of colloidal curve. (a) An increase in the cell count above 3 to 5 on September 24, 2021 by guest. per cu.mm. is the earliest indicationof involvement Dattner Thomas Concept of the nervous system by the treponema pallidum, Dattner and Thomas (I942) believe that the and equally it is the first test to revert to normal cure of a patient with neurosyphilis is assured if as a result of treatment. all the tests in the spinal fluid become and remain (b) An increase in the total protein above 40 negative. They assume that this indicates resolu- mgm. per cent. follows an increased cell count, and tion of the meningeal inflammatory process and it also is the next test to revert to normal with believe that while any degenerative process cannot treatment. be reversed, it will not progress. On the other (c) The Wassermann reaction takes longer to hand in tabes dorsalis and optic atrophy this is not become positive and is slow to reverse with treat- always the case. ment; it may take several years to revert to In contrast to the reversal of an abnormal spinal negative. Thus retreatment is not necessarily fluid produced by adequate therapy, the blood January 1953 C. S. NICOL: The Treatment of Neurosyphilis Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from serological tests (Wassermann and Kahn re- syphilis, vascular neurosyphilis and gumma of the actions) remain positive in the majority of cases. brain and cord. Quantitive tests will demonstrate variations in Penicillin plus fever therapy is indicated in titre according to certain patterns (Redmond, general paresis, tabo paresis, primary optic Nicol and Shooter, I952). ' Seroresistance' is atrophy, eighth nerve deafness, syphilitic epilepsy of no prognostic significance and does not indicate and Erb's spastic paraplegia. further treatment of the neurosyphilis. The best type of fever therapy is induced malaria, 8 to I2 paroxysms (40o to 6o or more hours General Considerations of Therapy of fever over 104° F.). Before the discovery of penicillin, neurosyphilis Hahn (1951) summarizes the present trend as was treated with various combinations of neo- follows: arsphenamine, 'bismuth, tryparsamide and fever Although opinions to the contrary are expressed therapy (benign tertian malaria or mechanical the consensus appears to be that in all forms -of fever). Since the introduction of penicillin all neurosyphilis, with the exception of primary optic are agreed that this is the drug of choice. There atrophy, the clinical and spinal fluid results of are still, however, a number of controversial treatment with penicillin alone are comparable to points to be decided. those with penicillin plus fever therapy. I. The type of penicillin, dosage and duration of Early Syphilis (First Four Years of Infection) course. In most clinics at present the procaine (a) Asymptomatic neurosyphilis. Excellent re- salt of penicillin is used. This saves multiple in- sults as judged by spinal fluid reversal are obtained jections and' may be given once daily intra- with penicillin alone. Hahn (I95i) reports Ioo muscularly in dosage ranging from o.s to I.o mega per cent. entirely satisfactory of 25 patients treated unit. A course of injections may last for io to this method. by Protected by copyright. 15 days, giving a range of from 5.0 to 15.0 mega (b) Acute syphilitic meningitis. Moore (1946) units total dosage. reported on io cases treated with intramuscular 2. The mechanism of the Jarisch Herxheimer penicillin in total dosage ranging from 6o0,ooo reaction and possible means of preventing it. units to 4,000,000 units given in 71 to i i days. Heyman, Sheldon and Evans (I952) now consider The follow-up was from 287 to 667 days. The the Herxheimer reaction to be a hypersensitivity immediate symptomatic response was dramatic- phenomenon of the delayed type. This reaction, ally favourable in every case. Headache and stiff as manifested by a rise in rectal temperature neck disappeared in 24 to 48 hours. Cranial nerve above 00oo F. following the first injection of paralysis disappeared in all cases except one in penicillin, is not uncommon in all types of neuro- which a slight residuum remained after 98 days. syphilis and may occur in about half the cases -of Of four patients with eighth nerve deafness, one general paresis treated. It is uncommon, how- showed no improvement (tested by audiometer) ever, to get a severe reaction with exacerbation of after 104 days. Two patients with convulsions symptoms or the appearance of new symptoms. had no further attacks after therapy. Three http://pmj.bmj.com/ In this country the present policy is to give 6 to 12 patients had mild febrile Herxheimer reactions weeks preparatory treatment with intramuscular without any -clinical exacerbation. The spinal bismuth (0.2 to 0.4 g. each injection) in the hope fluid response was entirely satisfactory at the last of preventing a reaction. While the resultant delay observation in nine cases, in the tenth case the in giving the penicillin is not important in most cells had been reduced from I,450 c.mm. to 9 cases of neurosyphilis, it may be thought advisable c.mm. 383 days after treatment, other spinal fluid that acute syphilitic meningitis or general paresis findings were negative in this case. of acute onset should be treated immediately with In one of the io cases there was a muco- on September 24, 2021 by guest. penicillin and the small risk of a serious Herx- cutaneous relapse 287 days after treatment, which heimer reaction accepted. The evidence from the had consisted of only 6oo,ooo units of penicillin in work of Farmer (1948) suggests that giving initial 71 days. small doses of penicillin in no way prevents a The results reported in this group are dramatic Herxheimer reaction, thus when a course of when the small dosage of penicillin given in some penicillin is started initially or after bismuth cases is considered. There is every reason to therapy it may be given in full dosage. expect excellent results with present dosage 3. The indications for adjuvant fever therapy. schedules. In I946 the situation was summarized by Moore as follows: Late Syphilis (More Than Four Years After Penicillin alone is indicated in early asympto- Original Infection) matic neurosyphilis, meningo-vascular neuro- (a) Asymptomatic neurosyphilis. Penicillin alone 30 POSTGRADUATE MEDICAL JOURNAL January I953 Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from is used. Hahn (I95I) reports in I8o cases with in I5 per cent. the results were unknown and 5 94.5 per cent. entirely satisfactory response, 5 per per cent. were treatment failures. cent. unknown and only 0.5 per cent. failure as (d) General paresis. In this condition, whether judged by spinal fluid examination. occurring as a single entity or combined with tabes (b) Meningeal syphilis (including Erb's spastic dorsalis (tabo-paresis), there remains a difference paraplegia). In cases in which there is a pre- of opinion as to the necessity of fever therapy in dominant meningeal reaction, results with peni- addition to penicillin. Analysis of reported re- cillin should be adequate except in Erb's paraplegia. sults should be assessed both in relation to spinal Hahn (I95 ) reports results in nine cases of fluid reversal and in relation to clinical results in meningeal involvement of the brain with cranial terms of the degree of social recuperation. It nerve lesions (excluding optic atrophy and eighth may be interesting to compare clinical results nerve deafness), II.I per cent. were entirely satis- obtained by different workers in different countries factory, 44-4 per cent. significantly improved, in the last few years. Ix.x per cent. results unknown and 44-4 per cent. treatment failures. He also reports I8 cases of CLINICALLY CURED OR GREATLY IMPROVED spinal cord involvement (including Erb's para- (a) Combined penicillin and malaria therapy plegia) giving II.I per cent. entirely satisfactory, Curtis, Kruse and Norton (I949) . 42% of 77 cases 22.2 per cent. significantly improved, I6.7 per cent. Lereboullet and Brisset (I949) · 50% ,, 31 ,, results unknown and 50 per cent. treatment Nicol and Whelen (I95I) .... 65% ,, I4x ,, failures; when he used malaria in addition to Lescher and Richards (I947) .. 66% ,, ,, Hahn (1951) . .. 67% ,, 43 ,, penicillin in three cases there were two failures and Kopp, Rose and Solomon (1948) .. 67% ,, 446 ,, one success. Kierland, O'Leary and Underwood Jones et al. (I95I) in a study of i9 patients (1948) ...... 70% ,, 76 ,, with non-tabetic cord observed the spinal syphilis (b) Penicillin therapy alone Protected by copyright. best clinical results in five patients with meningo Curtis, Kruse and Norton (I949) ·· 47% of I55 cases myelitis with a duration of symptoms of less than Hahn (I95I) .. 55% ,, 70 ,, five months. They stated that the outcome in Lescher and Richards (1947) * 70% ,, ,, three patients with Erb's spastic paraplegia or Delay, Desclaux and Stevenin (x947) 8o ,, 95 ,, syphilitic amyotrophic lateral sclerosis was dis- couraging. The duration of symptoms in these No biostatistical conclusions can be drawn from patients was of more than one year's duration, and this type of comparison. Perlo, Rose, Carmen they concluded that considerable degenerative and Solomon (I95I) were able to compare two changes had taken place before the onset of similar groups of patients with advanced simple therapy. The spinal fluid response in all the cases dementia treated with penicillin only and peni- they reported was comparable to that occurring cillin plus malaria therapy respectively. They in other types of neurosyphilis. summarize the results in three tables, which are (c) Vascular syphilis. Following the occlusion reproduced overleaf. of a medium-sized cerebral or spinal vessel there They concluded that 'clinical results with http://pmj.bmj.com/ is always some degree of myelomalacia. As a penicillin alone proved slightly more favourable result of this there is usually little clinical response than those obtained with combined therapy.' to therapy. It must be remembered that malarial therapy Jones et al. (I95i) describe six patients with necessitates admission to a special hospital with acute transverse myelitis as the result of anterior skilled medical and nursing care, as there are spinal artery thrombosis. None obtained com- risks of grave complications and fatalities have plete clinical recovery after treatment with peni- been reported. Such a centre exists in this cillin. Two of them, however, showed some country-The Mott Clinic, Epsom. on September 24, 2021 by guest. improvement in motor function and became am- Penicillin therapy gives varying results accord- bulatory in spite of severe spasticity, they also had ing to the type of psychosis present in paresis. fair control of the bladder' and anal sphincters. Kopp, Rose and Solomon (1948) report 85 per Two patients showed a poor clinical response with cent. improvement in patients with slight psychic but slight improvement of motor function. Two disturbances, 66 per cent. improvement in affective patients showed no recovery and died two months dementia, but only 25 per cent. improvement in and two and a half years after treatment respec- patients with a paranoid psychosis. tively. Bruetsch considers that total dosage of peni- Hahn (I95i) reports the results of penicillin cillin in paresis should be more than Io mega units, therapy in 20 patients with cerebral and spinal as he found treponema pallidum still present in the vascular syphilis, 20 per cent. were entirely satis- cerebral cortex of patients who came to autopsy factory, 60 per cent. were significantly improved, after having received this dosage. January 1953 C. S. NICOL: The Treatment of Neurosyphilis 3' Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from 122 PATIENTS WITH ADVANCED SIMPLE DEMENTIA (after Perlo, Rose, Carmen and Solomon) CLINICAL STATUS Improved Arrested Worse Penicillin alone, 30 patients .... I9 (63%) 8 (27%) 3 (Io%) Combined therapy, 92 patients .... 48 (52%) 25 (27%) I9 (21%) SOCIAL ADJUSTMENT Good 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 LEVEL Working 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 Herxheimer cludes the effects of penicillin plus malaria therapy reaction in patients with paresis. Heyman, on tabetic symptoms are essentially the same as Sheldon and Evans (95z2) reported this in 23 (52 those of penicillin alone. Asjudged also by overall per cent.) of 44 patients with paresis. Six of these clinical results the addition of malaria therapy 23 patients showed a transient intensification of affords no definite benefit. He also states that in a Protected by copyright. their psychotic manifestations. Putkonen and few patients development or progression of symp- Rehtijarvi (1950) studied the Herxheimer reaction toms occurs after treatment. Koteen (1949) re- in 223 patients with neurosyphilis. All 21 patients ported on 403 patients with tabes including 49 in this series with paresis previously untreated treated with penicillin alone. There was im- showed a febrile response. They stated that provement of symptoms and signs such as im- previous therapy with arsenic and/or bismuth potence (40 per cent.), ataxia (54 per cent.), seemed to reduce this to some extent, while pre- lightening pains (50 per cent.), urinary com- vious malarial or penicillin treatment made the plications (33 per cent.) and paresthesiae (66 per reaction impossible. They also stated that the cent.) as indicated. Gastric and other crises, more active was the spinal fluid the more likely pupillary abnormalities and deep sensibility dis- was the febrile response to occur. It usually took orders remained unaffected. The appearance of a place 12 to I6 hours after the first injection of new clinical sign such as a Charcot's joint might did not serious occur after treatment. Herxheimer reactions are penicillin. They experience any http://pmj.bmj.com/ clinical exacerbations. In a few patients there was uncommon in tabes according to Putkonen and increased confusion during the febrile response Rehtijarvi (1950). and in one patient who had previously had fits, a (f) Optic atrophy. This serious complication is further convulsion occurred at the fever peak. often associated with tabes dorsalis. If un- Lereboullet and Sapin Jalloustre (x947) record a treated the patient may become blind in three to patient with paresis who died in status epilepticus five years from the onset of symptoms, but the after penicillin therapy had been begun and the progression of the condition is very variable. One author has seen a similar case. must emphasize the importance of early diagnosis on September 24, 2021 by guest. (e) Tabes dorsalis. In this condition the problem by the examination of the optic discs, visual acuity again arises as to whether penicillin therapy alone and visual fields (the earliest change). Klauder is adequate. Hahn (I95I) tabulates the results in and Gross (1949) reported in 56 patients given 70 patients treated with penicillin and 31 with penicillin and malarial therapy, that there were penicillin and malaria. The results in the first 32 stabilizations, io aggravations and eight became group were 41.4 per cent. entirely satisfactory, blind. Hahn (195i) reported progression in six of I8.6 per cent. significantly improved, II.4 per 17 patients with primary optic atrophy after treat- cent. results unknown and 28.6 per cent. treatment ment with penicillin alone, and in three of i6 after failures. In the second group there were 48.4 per treatment with penicillin plus malaria. Blindness cent. entirely satisfactory, I9.4 per cent. signifi- occurred in four of the former and two of the latter cantly improved, I2.9 per cent. results unknown group. The total period of observation in both and I9.4 per cent. treatment failures. He con- groups was only 15 months. Similar types of 32 POSTGRADUATE MEDICAL JOURNAL January 1953 Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from patient composed both treatment groups. He (I952) mentioned an investigation which he was concludes that penicillin alone cannot yet be undertaking with Mohr to study the effect of evaluated, and penicillin plus malaria remains the aureomycin and chloramphenicol in I patients treatment of choice. with late asymptomatic neurosyphilis (Group 3 (g) Gumma of brain or cord. This condition is a spinal fluid changes). The dosage given for both clinical rarity and may only be diagnosed at opera- drugs was 6o g. in 15 days. In a graph he showed tion as in the case of a gumma of the cord described the return to normal of spinal fluid cell counts in by Thompson and Preston (I950); their case re- I8o days with a slow improvement in the colloidal ponded favourably to penicillin therapy. It has gold curve. The total protein and complement been stated in the past that a serious clinical fixation test remained essentially unchanged during Herxheimer reaction might occur, especially if the this time. He concluded that the treatment of lesion were in the brain below the tentorium cere- choice for neurosyphilis remained procaine peni- belli and that a pressure cone of the medulla might cillin, 600,000 units daily or every other day to an result in a fatality. Premedication with bismuth approximate total of io million units. should always be given as a prophylaxis against this event. Summary I. In a summary of the present status of treat- Spinal Fluid Relapse ment in the various types of neurosyphilis the Dattner (I949) reported on the spinal fluid out- recent literature concerning clinical and spinal come of 388 patients with various types of neuro- fluid results has been reviewed. syphilis observed for 6 to 56 months, and recorded 2. Penicillin appears to be the drug of choice for only 43 failures to a first course of penicillin. Of neurosyphilis; the newer antibiotics have not been these 43 patients, 24 responded favourably to a proved more effective. second course of higher dosage, of the other I9 The total amount of penicillin given should not failures only three showed a continuous active pro- be less than 6 mega units administered in not lessProtected by copyright. cess indicated by persistent abnormal cell count than io days. Dosage up to 15 mega units in I5 and protein. In I95o Dattner reported concern- days is employed in many clinics. The procaine ing further treatment of these three patients (all salt of penicillin is generally used with an injection cases of asymptomatic neurosyphilis). Two had given intramuscularly once in every 24 hours. reached an inactive state following treatment with This makes ambulatory treatment possible. four courses of penicillin totalling 49.8 and 59 3. Penicillin alone will give as satisfactory spinal mega units respectively. The third case had not fluid reversal and clinical outcome as when com- been followed long enough to evaluate treatment. bined with malarial therapyexcept in optic atrophy. In Hahn's (I95I) whole series of 589 patients with 4. Where malaria therapy is indicated the all types of neurosyphilis, the spinal fluid relapse patient should be sent, if possible, to a special rate was I.25 per cent. for the penicillin group and centre where expert medical and nursing care will 0.93 per cent. for the penicillin plus malaria group. reduce the risk of a fatality to a minimum.

These relapses only occurred in patients whose 5. Spinal fluid relapse rate is low with penicillin http://pmj.bmj.com/ initial spinal fluid contained io or more cells and therapy and retreatment with a larger dosage is who received less than 5 mega. units of penicillin. usually successful. No patient suffered more than one spinal fluid 6. The Jarisch-Herxheimer reaction as mani- relapse. fested by a febrile response is not uncommon especially in general paresis, but serious new Antibiotics Other Than Penicillin clinical symptoms or exacerbation of existing There is as yet no evidence that these prepara- symptoms are rare. In this country, however, it tions are more efficient than penicillin in the treat- is still considered prudent to give 6 to I2 weeks on September 24, 2021 by guest. ment of syphilis, and they remain considerably preparatory treatment with intramuscular bismuth more expensive. They have been used experi- before the administration of penicillin in cases mentally for the treatment of neurosyphilis in a where there is no urgency. In cases of acute limited number of cases. Kierland and O'Leary syphilitic meningitis or in general paresis of acute 'I950) treated I2 patients with neurosyphilis by onset it may be considered best to give penicillin giving oral aureomycin and reported satisfactory initially accepting the risk of a clinical Herxheimer clinical and spinal fluid reversal. Romansky et al. reaction. (I95) treated five patients who had neurosyphilis 7. Giving penicillin in initial small dosage, with chloramphenicol for i5 days. They reported which is gradually increased, in no way modifies reversal of abnormal spinal fluid cell counts. There the incidence or severity of a Herxheimer reaction. was no clinical improvement in a case of tabes Thus when penicillin is administered for neuro- dorsalis or in a case of optic atrophy. Robinson syphilis it may be given in full dosage. January 1953 A. W. LIPMANN KESSEL: Fractures Around the Elbow Joint 33 Postgrad Med J: first published as 10.1136/pgmj.29.327.27 on 1 January 1953. Downloaded from BIBLIOGRAPHY KOPP, T., ROSE, A. S., and SOLOMON, H. C. (1948), Am. J. BRUUSGAARD, E. (I929), Arch. f. Derm. u. Syph., 157, 309. Syph. Gonor. & Ven. Dis., 32, 509. CURTIS, A. C., KRUSE, W. T., and NORTON, D. H. (I949), KOTEEN, H. (i949), Am. J. Syph. Gonor. & Ven. Dis., 33, 364. Am. J. of Syph. Gonor. &f Ven. Dis., 33, 527. LANGE, C., and HARRIS, A. H. (i944), Am. _. Pub. Health, DATTNER, B. (I944), 'The Management of Neurosyphilis,' 34, 1087. Grune & Stratton, New York. LEREBOULLET, ]., and BRISSET (I949), Rev. Neur., 8, 646. DATTNER, B. (1949), Am. Y. Syph. Gonor. & Ven. Dis., 33, 571. LEREBOULLET, J., and JALLOUSTRE, S. (I947), Bull. Soc. DATTNER, B. (I950), Am. Y. Syph. Gonor. & Ven. Dis., 34, 373. Med. Hop., 26, 775. DATTNER, B., and THOMAS, E. W. (I942), Am. J. Syph. Gonor. LESCHER, G., and RICHARDS (x947), Brit. Med. J., ii, 565. & Ven. Dis., 26, 21. MOORE, J. E. (1946), 'Penicillin in Syphilis,' Blackwell, Oxford. DELAY, DESCLAUX and STEVENIN (I947), Rev. Neur., NICOL, W. D., and WHELEN, M. (I9s5), Brit. J. Ven. Dis., July, 515. 27, 132. FARMER, T. W. (I948), Y.A.M.A., 138, 48. PERLO, V. P., ROSE, A. S., CARMEN, L. R., and SOLOMON, HAHN, R. D. with assistance of LEWIS, B., WIGGALL, R. H., H. C. (i95x), Am. J. Syph. Gonor. & Ven. 12is., 35, 559- and CROSS, E. S. (x95s), Am. Y. Syph. Gonor. & Ven. Dis., PUTKONEN, T., and REHTIJARVI, K. (I95i), Acta. Dermat- 35, 433- Venereol., 31, 120. HEYMAN, A., SHELDON, W. A., and EVANS, L. D. (1952), RAVAUT, P. A. (I903), An. de Dermat et Syph., 4, 537. Brit. J. Ven. Dis., 28, 50. REDMOND, A., NICOL, C. S., and SHOOTER, R. A. (1952), JONES, R. W., HEYMAN, A., SMITH, W. A., and WILSON, R. Brit. J. Ven. Dis., 28, 13. (x95I), Am. Y. Syph. Gonor. & Ven. Dis., 35, 72. ROBINSON, R. C. V. (I952), Brit. J. Ven. Dis., 28, 8o. KIERLAND, R. R., and O'LEARY, P. A. (I950), Am. J. Syph. ROMANSKY, M. J., OLANSKY, S., TAGGART, S. R., LAWD- Gonor. & Ven. Dis., 34, 443. MAN, G. S., and ROBIN, E. D. (I95I), Am. J. Syph. Gonor. KIERLAND, R. R., O'LEARY, P. A., and UNDERWOOD, & Ven. Dis., 35, 234. L. J. (I948), Am. Y. Syph. Gonor. & Ven. Dis., 32, 470. ROSAHN, P. (1946), gournal of V.D. Information Supplement 21. KLAUDER,J. V., and GROSS, B. A. (x949), Am. . Syph. Gonor. THOMPSON, R. G., and PRESTON, R. H. (I950), Am. J. Syph. & Ven. Dis., 33, 234. Gonor. & Ven. Dis., 34, 356.

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FRACTURES AROUND THE ELBOW JOINT Protected by copyright. IN CHILDREN By A. W. LIPMANN KESSEL London

The swings and slides of public parks provide opposite elbow must always be X-rayed for our hospitals with a regular week-end clientele of comparison: small boys who have sustained fractures about the Supracondylar fractures-extension and flexion elbow joint. The diagnosis of many such frac- varieties. tures calls for nice judgment and a meticulous Transcondylar-simple and' T '-shaped. attention to the general principles as well as the Epicondylar avulsion, with or without disloca- http://pmj.bmj.com/ details of treatment. The I935 Report of the tion. B.M.A. Committee on Fractures did not analyze Fracture-separation of the external condyle fractures in children, but if it is true that the epiphysis. average incapacity period for a simple fracture of Fracture of the head or neck of the radius. the clavicle in adults who were not treated in an Treatment. Each type of fracture will be con- organized clinic was 22 weeks, as compared to five sidered separately, but there are certain general the treatment of all these weeks for those treated in organized clinics, it principles applicable to on September 24, 2021 by guest. would be a fair assumption that a similar analysis fractures. for the group of more serious and difficult fractures I. Manipulative reduction must always be we are now considering would reveal an even gentle. Only too often does a complication arise greater difference. from the violence of attempted reduction rather Diagnosis and classification. The precise diag- than from the original injury itself. nosis of the type of fracture is essential, but by 2. Wherever possible a 'single attack' should no means always easy because of the complexity be made to achieve reduction by closed manipula- of the ossification of the lower end of the growing tion. It should be carried out under general humerus. Leaving aside for the moment the anaesthesia with X-ray control (not screening), and question of soft tissue damage, this group of the several attempts that may be necessary to fractures may be broadly classified into five radio- achieve satisfactory alignment should be carried logical types. Intermediate as well as complex out at the same session. An examination of some types will, of course, occur. In cases of doubt the of the disasters which have occurred shows only