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The Treatment of Neurosyphilis 27 Postgrad Med J: First Published As 10.1136/Pgmj.29.327.27 on 1 January 1953

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The Treatment of Neurosyphilis 27 Postgrad Med J: First Published As 10.1136/Pgmj.29.327.27 on 1 January 1953 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.).
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