Early and thorough treatment of every case of syphilis has also already been mentioned as a measure for the prevention of syphilitic disorders of the central nervous system.
It is not wise to postpone treatment until a positive Wassermann reaction is obtained. The diagnosis should be made as early as possible in the primary period by demonstrating treponemata in the initial lesion with the microscope by the dark field illumination method.
Another point is to perform lumbar puncture, repeatedly if necessary, in the course of treatment of every case of syphilis, whether with or without evidences of involvement of the central nervous system. No case of syphilis should be discharged as cured until serological findings both in the blood and cerebro-spinal fluid have become permanently negative.
In some cases, in spite of active intravenous treatment, positive findings persist in the cerebro-spinal fluid. In such cases intraspinal treatment is indicated.
It is the consensus of opinion among syphilologists that patients, in whom permanently negative serological findings in the blood and cerebro-spinal fluid have been achieved by treatment, are no longer in danger of later development of tabes, general paralysis, or other forms of neurosyphilis.
1 Insane and Feeble-minded in Institutions- 1910.
When general paralysis has developed treatment by anti-syphilitic remedies, at least as ordinarily administered in cases of syphilis, is of no avail, being apt even to do more harm than good. Recently attempts have been made to bring anti-syphilitic remedies more directly in contact with the seat of the lesion by administering them intra-spinally or intracranially1 Somewhat encouraging results have been reported,2 though it is still very doubtful if a permanent arrest of the process has been brought about in any case.
For the rest, the treatment is merely symptomatic. An institutional environment seems to have a beneficial influence in many cases, a calming down and general improvement being often observed soon after admission.
In the last stage great care must be taken to prevent the development of bed sores. This is a matter of proper nursing. The patient must be kept thoroughly clean and dry, especially when, owing to loss of sphincter control or to mental deterioration, he soils and wets himself several times a day. His position in bed must be changed frequently and systematically so as not to expose either one side or the other or the back to continuous pressure and friction; a pad may have to be placed between the knees or the ankles in cases with a tendency to contractures. The bed must be made carefully, avoiding unevenness, roughness, or wrinkles in the bed clothes. The skin over the parts that are exposed to pressure may be somewhat protected by sponging with alcohol, drying, and dusting with talcum powder. An air-or water-bed may be used, but will be found hardly necessary where the above-mentioned precautions are carefully observed. When bed sores develop they are to be treated by frequent and careful cleansing and protected by a simple dressing; the application of a saturated solution of picric acid seems often to promote healing.
1 Swift and Ellis. The Direct Treatment of Syphilitic Diseases of the Central Nervous System. N. Y. Med. Journ., July 13, 1912. - H. S. Ogilvie. The Intraspinal Treatment of Syphilis of the Central Nervous System by Salvarsanized Serum of Standard Strength. Journ. Amer. Med. Assn., Nov. 28, 1914. - D. M. Wardner. A Report of Five Cases of Intracranial Injection of Auto-Sero-Salvarsan. Amer. Journ. of Insanity, Jan., 1915.
2 G. S. Amsden. The Intraspinal Treatment of Paresis. N. Y. State Hosp. Bulletin, Feb. 15, 1915. - H. A. Cotton. The Treatment of Paresis and Tabes Dorsalis by Salvarsanized Serum. Amer. Journ. of Insanity, July and Oct., 1915. - C. A. Neymann and N. H. Brush. The Treatment of General Paresis. Arch, of Int. Med., Aug., 1918.
Broncho-pneumonia is a common complication of general paralysis and is in the majority of cases the immediate cause of death. No doubt the general debilitating effect of the disease renders the patient more liable to develop this complication, and the chances are further increased in the last stage when difficulties of deglutition develop and food is apt to find its way into the respiratory passages. Yet here too, careful nursing can accomplish a good deal, and it is safe to say that the frequency of broncho-pneumonia can be considerably reduced. Demented patients will not complain of feeling cold, and it is the nurse's duty to have the patient at all times comfortably clad, well covered if in bed, and protected from draughts; special care must be observed when the patient has occasion to sit up in his bed, or leave his bed, and in bathing. Patients having to take their meals in bed should be placed in an easy, natural position, propped up with pillows, and not so as to have to reach over the side of the bed to get the food or to have to eat while partly reclining; when deglutition becomes. difficult or uncertain they must not be allowed to feed themselves, but must be fed by a nurse or attendant slowly with finely divided food.
There is nothing ordinarily to be done for convulsions beyond protecting the patient against injury. Continued convulsions are sometimes successfully combated by a high enema followed by the administration of 30 grains of potassium bromide and 20 grains of chloral hydrate per rectum, repeating the dose in an hour if necessary.