The Third Great Plague A Discussion of Syphilis for Everyday People online

lose 5 or 10 pounds in weight, have severe or mild headaches, usually
worse at night, with pains in the bones and joints that may suggest
rheumatism. Nervous disturbances of the most varied character may
appear. Painful points on the bones or skull may develop, and there may
be serious disturbances of eye-sight and hearing. A few are severely
ill, lose a great deal of weight, endure excruciating pains, pass
sleepless nights, and suffer with symptoms suggesting that their nervous
systems have been profoundly affected. As a general thing, however, the
constitutional symptoms are mild compared with those of the severe
infectious fevers, such as typhoid or malaria.

+The Secondary Eruption or Rash.+ - The eruption of secondary syphilis is
generally the feature which most alarms the average patient. It is
usually rather abundant, in keeping with the wide-spread character of
the infection, and is especially noticeable on the chest and abdomen,
the face, palms, and soles. It is apt to appear in the scalp in the
severer forms. The eruption may consist of almost anything, from faint
pink spots to small lumps and nodules, pimples and pustules, or large
ulcerating or crusted sores. The eruption is not necessarily
conspicuous, and may be entirely overlooked by the patient himself, or
it may be so disfiguring as to attract attention.

+Common Misconceptions Regarding Syphilitic Rashes.+ - Laymen should be
warned against the temptation to call an eruption syphilitic. The
commonest error is for the ordinary person to mistake a severe case of
acne, the common "pimples" of early manhood, for syphilis. Psoriasis,
another harmless, non-contagious, and very common skin disease, is often
mistaken for syphilis. Gross injustice and often much mental distress
are inflicted on unfortunates who have some skin trouble by the
readiness with which persons who know nothing about the matter insist on
thinking that any conspicuous eruption is syphilis, and telling others
about it. Even with an eye trained to recognize such things on sight, in
the crowds of a large city, one very seldom sees any skin condition
which even suggests syphilis. It usually requires more than a passing
glance at the whole body to identify the disease. If, under such
circumstances, one becomes concerned for the health of a friend, he
would much better frankly ask what is the matter, than make him the
victim of a layman's speculations. It is always well to remember that
profuse eruptions of a conspicuous nature, which have been present for
months or years, are less likely to be syphilitic.

+The Contagious Sores in the Mouth, Throat, and Genitals.+ - Accompanying
the outbreaks of syphilis on the skin, in the secondary period, a
soreness may appear in the mouth and throat, and peculiar patches seen
on the tongue and lips, and flat growths be noticed around the moist
surfaces, such as those of the genitals. These throat, mouth, and
genital eruptions are the most dangerous signs of the disease from the
standpoint of contagiousness. Just as the chancre swarms with the germs
of syphilis, so every secondary spot, pimple, and lump contains them in
enormous numbers. But so long as the skin is not broken or rubbed off
over them, they are securely shut in. There is no danger of infection
from the dry, unbroken skin, even over the eruption itself. But in the
mouth and throat and about the genitals, where the surface is moist and
thin, the covering quickly rubs or dissolves off, leaving the gray or
pinkish patches and the flattened raised growths from which the germs
escape in immense numbers and in the most active condition. Such patches
may occur under the breasts and in the armpits, as well as in the places
mentioned. The saliva of a person in this condition may be filled with
the germs, and the person have only to cough in one's face to make one a
target for them.

+Distribution of the Germs in the Body.+ - The germs of syphilis have in
the past few years been found in every part of the body and in every
lesion of syphilis. While the secondary stage is at its height, they
are in the blood in considerable numbers, so that the blood may at these
times be infectious to a slight degree. They are present, of course, in
large numbers in the secretions from open sores and under the skin in
closed sores. The nervous system, the walls of the blood-vessels, the
internal organs, such as the liver and spleen, the bones and the
bone-marrow, contain them. They are not, however, apparently found in
the secretions of the sweat glands, but, on the other hand, they have
been shown to be present in the breast milk of nursing mothers who have
active syphilis. The seminal fluid may contain the germs, but they have
not been shown to be present either in the egg cells of the female or in
the sperm cells of the male.

+Fate of the Germs.+ - The fate of all these vast numbers of syphilitic
germs, distributed over the whole body at the height of the disease, is
one of the most remarkable imaginable. As the acute secondary stage
passes, whether the patient is treated or not, by far the larger number
of the spirochetes in the body is destroyed by the body's own power of
resistance. This explains the statement, that cannot be too often
repeated, that the outward evidences of secondary syphilis tend to
disappear of themselves, whether or not the patient is treated. Of the
hordes of germs present in the beginning of the trouble, only a few
persist until the later stages, scattered about in the parts which were
subject to the overwhelming invasion. Yet because of some change which
the disease brought about in the parts thus affected, these few germs
are able to produce much more dangerous changes than the armies which
preceded them. In some way the body has become sensitive to them, and a
handful of them in course of time are able to do damage which billions
could not earlier in the disease. The man in whom the few remaining
germs are confined largely to the skin is fortunate. The unfortunates
are those who, with the spirochetes in their artery walls, heart muscle,
brain, and spinal cord, develop the destructive arterial and nervous
changes which lead to the crippling of life at its root and premature
death.

+Variations in the Behavior of the Germ of Syphilis.+ - Differences in
the behavior of the same germ in different people are very familiar in
medicine and are of importance in syphilis. As an example, the germ of
pneumonia may be responsible for a trifling cold in one person, for an
attack of grippe in the next, and may hurry the next person out of the
world within forty-eight hours with pneumonia. Part of this difference
in the behavior of a given germ may be due to differences among the
various strains or families of germs in the same general group. Another
part is due to the habit which germs have, of singling out for attack
the weakest spot in a person's body. The germ that causes rheumatism has
strains which produce simply tonsillitis, and others which, instead of
attacking joints, tend to attack the valves of the heart. Our recent
knowledge suggests that somewhat the same thing is at work in syphilis.
Certain strains of Spirochæta pallida tend to thrive in the nervous
system, others perhaps in the skin. On the other hand, in certain
persons, for example, heavy drinkers, the nervous system is most open
to attack, in others the bones may be most affected, in still others,
the skin.

+Variations in the Course of Syphilis in Different Persons.+ - So it
comes about that in the secondary stage there may be wide differences in
the amount and the location of the damage done by syphilis. One patient
may have a violent eruption, and very little else. Another will scarcely
show an outward sign of the disease and yet will be riddled by one
destructive internal change after another. In such a case the secondary
stage of the disease may pass with half a dozen red spots on the body
and no constitutional symptoms, and the patient go to pieces a few years
later with locomotor ataxia or general paralysis of the insane. On the
other hand, a patient may have a stormy time in the secondary period and
have abundant reason to realize he has syphilis, and under only moderate
treatment recover entirely. Still another will have a bad infection from
the start, and run a severe course in spite of good treatment, to end in
an early wreck. The last type is fortunately not common, but the first
type is entirely too abundant. It cannot be said too forcibly that in
the secondary as in the primary stage, syphilis may entirely escape the
notice of the infected person, and he may not realize what ails him
until years after it is too late to do anything for him. Here, as in the
primary stage, the lucky person is the one who shows his condition so
plainly that he cannot overlook it, and who has an opportunity to
realize the seriousness of his disease. It used to be an old rule not
to treat people who seemed careless and indifferent until their
secondary eruption appeared, in the hope that this flare-up would bring
them to their senses. The necessity for such a rule shows plainly how
serious a matter a mild early syphilis may be.

+The Dangerous Contagious Relapses.+ - Secondary syphilis does not begin
like a race, at the drop of a hat, or end with the breaking of a tape.
When the first outburst has subsided, a series of lesser outbreaks,
often covering a series of years, may follow. These minor relapses or
recurrences are mainly what make the syphilitic a danger to his fellows.
They are to a large extent preventable by thorough modern treatment. Few
people are so reckless as wholly to disregard precautions when the
severe outburst is on. But the lesser outbreaks, if they occur on the
skin, attract little or no attention or are entirely misunderstood by
the patient. Only too often they occur as the flat, grayish patches in
the mouth and genital tract, such as are seen in the secondary stage,
where, because they are out of sight and not painful, they pass
unnoticed. The tonsils, the under side and edges of the tongue, and the
angles of the mouth just inside the lips are favorite places for these
recurrent mucous patches. They are thus ideally placed to spread
infection, for, as in the secondary stage, each of these grayish patches
swarms with the germs of syphilis. Similar recurrences about the
genitals often grow, because of the moisture, into buttons and flat,
cauliflower-like warts from which millions of the germs can be squeezed.
Sometimes they are mistaken for hemorrhoids or "piles." With all the
opportunities that these sores offer for infection, it is surprising
that the disease is not universal. Irritation from friction, dirt, and
discharges, and in the mouth the use of tobacco, are the principal
influences acting to encourage these recurrences.

+Relapses in the Nervous System and Elsewhere.+ - Mucous patches are, of
course, not the only recurrences, though they are very common. At any
time a little patch of secondary eruption may appear and disappear in
the course of a short time. Recurrences are not confined to the skin,
and those which take place in the nervous system may result in temporary
or permanent paralysis of important nerves, including those of the eyes
and ears. Again, recurrences may show themselves in the form of a
general running down of the patient from time to time, with loss of
weight and general symptoms like those of the active secondary period.

The secondary period as a whole is not in itself the serious stage of
syphilis. Most of the symptoms are easily controlled by treatment if
they are recognized. Now and then instances of serious damage to sight,
hearing, or important organs elsewhere occur, but these are relatively
few in spite of the enormous numbers and wide distribution of the germs.
Accordingly, the problems that the secondary stage offers the physician
and society at large must center around the recognition of mild and
obscure cases and adequate treatment for all cases. The identification
of the former is vital because of the recurrence of extremely infectious
periods throughout this stage of the disease, and the latter is
essential because vigorous treatment, carried out for a long enough
time, prevents not only the late complications which destroy the
syphilitic himself, but does away with the menace to society that arises
through his infecting others, whether in marriage and sexual contact or
in the less intimate relations of life.




Chapter V

The Nature and Course of Syphilis (Continued)


LATE SYPHILIS (TERTIARY STAGE)

+The Seriousness of Late Syphilis.+ - While we recognize a group of
symptoms in syphilis which we call late or tertiary, there is no
definite or sharp boundary of time separating secondary from tertiary
periods. The man who calculates that he will have had his fling in the
ten or twenty years before tertiary troubles appear may be astonished to
find that he can develop tertiary complications in his brain almost
before he is well rid of his chancre. "Late accidents," as we call them,
are the serious complications of syphilis. They are, as has been said,
brought about by relatively few germs, the left-overs from the flooding
of the body during the secondary period. There is still a good deal of
uncertainty as to just what the distribution of the germs which takes
place in the secondary period foreshadows in the way of prospects for
trouble when we come to the tertiary period. It may well be that the man
who had many germs in his skin and a blazing eruption when he was in the
second stage, may have all his trouble in the skin when he comes to the
late stage. It is the verdict of experience, however, that people who
have never noticed their secondary eruption because it was so mild are
more likely to be affected in the nervous system later on. But this may
be merely because the condition, being unrecognized, escapes treatment.
It is at least safe to say that those whose skins are the most affected
early in the disease are the fortunate ones, because their recognition
and treatment in the secondary stage help them to escape locomotor
ataxia and softening of the brain. Conversely the victim who judges the
extent and severity of his syphilis by the presence or absence of a
"breaking out" is just the one to think himself well for ten or twenty
years because his skin is clean, and then to wake up some fine morning
to find that he cannot keep his feet because his concealed syphilis is
beginning to affect his nervous system.

+Nature of the Tissue Change in Late Syphilis - Gummatous
Infiltration.+ - The essential happening in late syphilis is that body
tissue in which the germs are present is replaced by an abnormal tissue,
not unlike a tumor growth. The process is usually painless. This
material is shoddy, so to speak, and goes to pieces soon after it grows.
The shoddy tissue is called "gummatous infiltration," and the tumor, if
one is formed, is called a "gumma." The syphilitic process at the edge
of the gumma shuts off the blood supply and the tissue dies, as a finger
would if a tight band were wound around it, cutting off the blood
supply. Gumma can develop almost anywhere, and where it does, there is a
loss of tissue that can be replaced only by a scar. In this way gummas
can eat holes in bone, or leave ulcerating sores in the skin where the
gumma formed and died, or take the roof out of a mouth, or weaken the
wall of a blood-vessel so that it bulges and bursts. The sunken noses
and roofless mouths are usually syphilitic - yet if they are recognized
in time and put under treatment, all these horrible things yield as by
magic. There are few greater satisfactions open to the physician than to
see a tertiary sore which has refused to heal for months or years
disappear under the influence of mercury and iodids within a few weeks.
Still better, if treatment had been begun early in the disease, and
efficiently and completely carried out, none of these conditions need
ever have been.

+Destructive Effects of Late Syphilis.+ - Late syphilis is, therefore,
destructive, and the harm that it does cannot, except within narrow
limits, be repaired. It is responsible for the kind of damaged goods
which gives the disease its reality for the every-day person. It is a
matter of desperate importance where the damage is done. Late syphilis
in the skin and bones, while horrible enough to look at, and disfiguring
for life, is not the most serious syphilis, because we can put up with
considerable loss of tissue and scarring in these quarters and still
keep on living. But when late syphilis gets at the base of the aorta,
the great vessel by which the blood leaves the heart, and damages the
valves there, the numbering of the syphilitic's days begins. Few can
afford to replace much brain substance by tertiary growths and expect to
maintain their front against the world. Few are so young that they can
meet the handicap that old age and hardening of the arteries, brought on
prematurely by late syphilis, put upon them. When late syphilis affects
the vital structures and gains headway, the victim goes to the wall.
This is the really dangerous syphilis - the kind of syphilis that
shortens and cripples life.

There are few good estimates of the extent of late accidents, as we
often call the serious later complications in syphilis, or of the part
that they play in medicine as a whole. Too many of them are
inconspicuous, or confused with other internal troubles that result from
them. Deaths from syphilis are all the time being hidden under the
general terms "Bright's disease," or "heart disease," or "paralysis," or
"apoplexy." It is a hopeful fact that, even under unfavorable
conditions, only a comparatively small percentage, from 10 to 20 per
cent, seem to develop obvious late accidents. On the other hand, it must
not be forgotten that the obscure costs of syphilis are becoming more
apparent all the time, and the influence of the disease in shortening
the life of our arteries and of other vital structures is more and more
evident. There is still good reason for avoiding the effects of syphilis
by every means at our disposal - by avoiding syphilis itself in the first
place, and by early recognition of the disease and efficient treatment,
in the second.

+Late Syphilis of the Nervous System - Locomotor Ataxia.+ - The ways in
which late syphilis can attack the nervous system form the real terrors
of the disease to most people. Locomotor ataxia and general paralysis of
the insane (or softening of the brain) are the best known to the laity,
_though only two of many ways in which syphilis can attack the nervous
system_. Though their relation to the disease was long suspected, the
final touch of proof came only as recently as 1913, when Noguchi and
Moore, of the Rockefeller Institute, found the germs of the disease in
the spinal cords of patients who had died of locomotor ataxia, and in
the brains of those who had died of paresis. The way in which the damage
is done can scarcely be explained in ordinary terms, but, as in all late
syphilis, a certain amount of the damage once done is beyond repair.
Locomotor ataxia begins to affect the lower part of the spinal cord
first, so that the earliest symptoms often come from the legs and from
the bladder and rectum, whose nerves are injured. Other parts higher up
may be affected, and changes resulting in total blindness and deafness
not infrequently occur. Through the nervous system, various organs,
especially the stomach, may be seriously affected, and excruciating
attacks of pain with unmanageable attacks of vomiting (gastric crises)
are apt to follow. This does not, of course, mean that all pain in the
stomach with vomiting means locomotor ataxia. All sorts of obscure
symptoms may develop in this disease, but the signs in the eyes and
elsewhere are such that a decision as to what is the matter can usually
be made without considering how the patient feels, and by evidence which
is beyond his control.

+Late Syphilis of the Nervous System - General Paralysis.+ - General
paralysis, or paresis, is a progressive mental degeneration, with
relapses and periods of improvement which reduce the patient by
successive stages to a jibbering idiocy ending invariably in death. Such
patients may, in the course of their decline, have delusions which lead
them to acts of violence. The only place for a paretic is in an asylum,
since the changes in judgment, will-power, and moral control which occur
early in the disease are such that, before the patient gets
unmanageable, he may have pretty effectually wrecked his business and
the happiness of his family and associates. When the condition is
recognized, the family must at least be forewarned, so that they can
take action when it seems necessary. Both locomotor ataxia and paresis
may develop in the same person, producing a combined form known as
taboparesis.

The importance of locomotor ataxia and paresis in persons who carry
heavy responsibilities is very great. In railroad men, for example, the
harm that can be done in the early stages of paresis is as great as or
even greater than the harm that an epileptic can do. A surgeon with
beginning taboparesis may commit the gravest errors of judgment before
his condition is discovered. Men of high ability, on whom great
responsibilities are placed, may bring down with them, in their
collapse, great industrial and financial structures dependent on the
integrity of their judgment. The extent of such damage to the welfare of
society by syphilis is unknown, though here and there some investigation
scratches the surface of it. It will remain for the future to show us
more clearly the cost of syphilis in this direction.

+Syphilis and Mental Disease.+ - Williams,[7] before the American Public
Health Association, has recently carefully summarized the rôle of
syphilis in the production of insanity, and the cost of the disease to
the State from the standpoint of mental disease alone. He estimates
that 10 per cent of the patients who enter the Massachusetts State
hospitals for the insane are suffering from syphilitic insanity. Fifteen
per cent of those at the Boston Psychopathic Hospital have syphilis. In
New York State hospitals, 12.7 per cent of those admitted have
syphilitic mental diseases. In Ohio, 12 per cent were admitted to
hospitals for the same reason. An economic study undertaken by Williams
of 100 men who died at the Boston State Hospital of syphilitic mental
disease, the cases being taken at random, showed that the shortening of
life in the individual cases ranged from eight to thirty-eight years,
and the total life loss was 2259 years. Of ten of these men the earning
capacity was definitely known, and through their premature death there
was an estimated financial loss of $212,248. It cost the State of
Massachusetts $39,312 to care for the 100 men until their death.
Seventy-eight were married and left dependent wives at the time of their
commission to the hospital. In addition to the 100 men who became public
charges, 109 children were thrown upon society without the protection of
a wage-earner. Williams estimates, on the basis of published admission
figures to Massachusetts hospitals, that there are now in active life,
in that state alone, 1500 persons who will, within the next five years,
be taken to state hospitals with syphilitic insanity.

[7] Williams, F. E.: "Preaching Health," Amer. Jour. Pub. Health,
1917, vi, 1273.

+Frequency of Locomotor Ataxia and General Paralysis.+ - The percentage
of all syphilitic patients who develop either locomotor ataxia or
paresis varies in different estimates from 1 to 6 per cent of the total
number who acquire syphilis. The susceptibility to any syphilitic
disease of the nervous system is hastened by the use of alcohol and by
overwork or dissipation, so that the prevalence of them depends on the
class of patients considered. It is evident, though, that only a
relatively small proportion of the total number of syphilitics are
doomed to either of these fates. Taking the population as a whole, the
percentage of syphilitics who develop this form of late involvement
probably does not greatly exceed 1 per cent.

+Treatment and Prevention of Late Syphilis of the Nervous
System.+ - Locomotor ataxia and paresis, even more than other syphilitic
diseases of the nervous system, are extremely hard to affect by
medicines circulating in the blood, and for that reason do not respond
to treatment with the ease that syphilis does in many other parts of the
body. Early locomotor ataxia can often be benefited or kept from getting