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Treatment

The main goal in treatment of symptomatic late neurosyphilis is to halt progression of the disease, since much of the damage to the CNS is irreversible. Patients who have neurosyphilis or ocular syphilis should be treated with aqueous crystalline penicillin G, 18 to 24 million units per day, given as 3 to 4 million units intravenously every 4 hours or continuous infusion, for 10 to 14 days. An alternative regimen that requires strict assurance of compliance is procaine penicillin G, 2.4 million units IM once daily plus probenecid 500 mg orally four times daily, both for 10 to 14 days. Since the duration of therapy for neurosyphilis is shorter than the 3-week course recommended for latent syphilis, which theoretically may coexist, many specialists recommend an additional intramuscular dose of benzathine penicillin, 2.4 million units, after completion of the 2-week therapy for neurosyphilis to achieve at least 3 weeks of serum penicillin levels.

Syphilitic otitis should be treated the same way as neurosyphilis, regardless of CSF results. Adjunctive systemic steroids are often used in this setting, but the benefit of such therapy has not been proven.

Penicillin Allergy

Ceftriaxone, 2 g IM or IV daily for 10 to 14 days, is an alternative regimen for patients with a penicillin allergy, although there is potential for cross-reactivity. No other regimen has been adequately evaluated for treatment of neurosyphilis. Therefore, if ceftriaxone is not considered a safe alternative, the patient should undergo skin testing to confirm the penicillin allergy and be desensitized if necessary.

Assessing Response to Therapy

Patients with elevated cell counts in the CSF prior to treatment should have repeated lumbar punctures every 6 months until the pleocytosis resolves. Changes in the VDRL-CSF and protein counts may take longer to occur, and persistent elevations may not be significant. As a general guideline, the cell count should decrease after 6 months and the CSF should normalize after 2 years; otherwise, retreatment should be considered.

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The current approach to the treatment of myocardial infarction is first to get the suffering patient to the hospital quickly. After a provisional diagnosis has been made, he is moved into a special area of the hospital called a Coronary Care Unit (CCU), which is staffed and equipped expressly for this type of illness. The patient is usually under the constant supervision of doctors, nurses, and electronic machinery, all of which are focusing their attention on detecting the very first sign of any complication. If complications do develop, treatment is much more effective if it is begun early.

The development of the concept of coronary care units is of recent origin. It is the result of increasing medical knowledge and in particular of increasing knowledge about the natural history of coronary artery disease. To achieve a proper frame of reference, it is of interest that Dr. Paul White reports that in 1910 the diagnosis of a heart attack or myocardial infarct was seldom made in a general hospital in this country. His explanation is that, first, the disease itself was much less common than it is today, and, second, that doctors were not aware of the disease itself. In other words, medicine had not advanced to the point where it was commonly recognized that there was such a thing as a myocardial infarct, or what the symptoms of this illness were. By the 1920s the disease pattern was established as a distinct entity, and by World War II large numbers of patients were being treated for this condition.

By the 1960s statistics revealed that about 60 percent of the deaths of persons with atherosclerotic heart disease (the disease that causes heart attacks) were sudden deaths. Furthermore, about 70 percent of these deaths occurred during the first seven days of the illness. Just before this period, the first human being was successfully defibrillated by an electrical shock across the chest. (Ventricular fibrillation is a situation in which the heart quivers rather than beats, and it is fatal within four or five minutes.) This is a common cause of sudden death in persons with heart attacks.

Shortly after this, the technique of closed-chest cardiac massage was devised. By this is meant the application of pressure repeatedly over the chest of a person whose heart has stopped beating. With the proper application of chest compression, blood is forced into and out of the heart in a near normal fashion. The efficiency does not approach that of the normally beating heart, but enough blood can be induced to circulate to the vital organs of the body to postpone death. Formerly, if the heart stopped beating or fibrillated, death of the brain occurred in four or five minutes. Other forms of heart stoppage cannot be treated by defibrillation, but sometimes drugs or other forms of treatment can be used to start the heart again if the patient can be kept alive until they have a chance to take effect.

In 1767 a society for the revival of persons apparently dead by drowning was formed in Amsterdam. One of the methods recommended was mouth-to mouth respiration. This technique was forgotten until about 1960, at which time its revival provided an improved method for giving artificial respiration.

It was now at least theoretically possible for one or preferably two persons to maintain life in a patient who had suddenly stopped breathing, or whose heart had suddenly stopped functioning. A method was now available to “buy a little time” until a person could be transported to a treatment facility, or until special forms of treatment could be brought to him.

Incidentally, no special tools are necessary to perform this cardio-pulmonary resuscitation; the only requirement is trained personnel. Both forms of assistance are usually necessary in a case of cardiac arrest or stoppage of the heart. The body must be supplied with blood that has an adequate amount of oxygen. When the heart stops functioning, breathing stops within less than a minute. Closed-chest cardiac massage is useless without artificial respiration.

To avoid any confusion, it must be pointed out that people cannot be kept alive very long with these techniques. Some hearts are too diseased to recover, and a certain percentage of cardiac arrests cannot be restarted.

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