The Third Great Plague
A Discussion of Syphilis for Everyday People
John H. Stokes, A.B., M.D.
Chief of the Section of Dermatology and Syphilology The Mayo Clinic, Rochester, Minnesota
Assistant Professor of Medicine The Mayo Foundation Graduate School of the University of Minnesota
Philadelphia and London W. B. Saunders Company 1920
Published, November, 1917
Copyright, 1917, by W. B. Saunders Company
Reprinted July, 1918
Reprinted February, 1920
PRINTED IN AMERICA
The struggle of man against his unseen and silent enemies, the lower or bacterial forms of life, once one becomes alive to it, has an irresistible fascination. More dramatic than any novel, more sombre and terrifying than a battle fought in the dark, would be the intimate picture of the battle of our bodies against the hosts of disease. If we could see with the eye of the microscope and feel and hear with the delicacy of chemical and physical interactions between atoms, the heat and intensity and the savage relentlessness of that battle would blot out all perception of anything but itself. Just as there are sounds we cannot hear, and light we cannot see, so there is a world of small things, living in us and around us, which sways our destiny and carries astray the best laid schemes of our wills and personalities. The gradual development of an awareness, a realization of the power of this world of minute things, has been the index of progress in the bodily well-being of the human race through the centuries marking the rebirth of medicine after the sleep of the Dark Ages.
In these days of sanitary measures and successful public health activity, it is becoming more and more difficult for us to realize the terrors of the Black Plagues, the devastation, greater and more frightful than war, which centuries ago swept over Europe and Asia time and again, scarcely leaving enough of the living to bury the dead. Cholera, smallpox, bubonic plague, with terrifying suddenness fell upon a world of ignorance, and each in turn humbled humanity to the dust before its invisible enemies. Even within our own recollection, the germ of influenza, gaining a foothold inside our defenses, took the world by storm, and beginning probably at Hongkong, within the years 1889-90, swept the entire habitable earth, affecting hundreds of thousands of human beings, and leaving a long train of debilitating and even crippling complications.
Here and there through the various silent battles between human beings and bacteria there stand out heroic figures, men whose powers of mind and gifts of insight and observation have made them the generals in our fight against the armies of disease. But their gifts would have been wasted had they lacked the one essential aid without which leadership is futile. This is the force of enlightened public opinion, the backing of the every-day man. It is the cooeperation of every-day men, acting on the organized knowledge of leaders, which has made possible the virtual extinction of the ancient scourges of smallpox, cholera, and bubonic plague.
Just as certain diseases are gradually passing into history through human effort, and the time is already in sight when malaria and yellow fever, the latest objects of attack, will disappear before the campaign of preventive medicine, so there are diseases, some of them ancient, others of more recent recognition, which are gradually being brought into the light of public understanding. Conspicuous among them is a group of three, which, in contrast to the spectacular course of great epidemics, pursue their work of destruction quietly, slowly undermining, in their long-drawn course, the very foundations of human life. Tuberculosis, or consumption, now the best known of the three, may perhaps be called the first of these great plagues, not because it is the oldest or the most wide-spread necessarily, but because it has been the longest known and most widely understood by the world at large. Cancer, still of unknown cause, is the second great modern plague. The third great plague is syphilis, a disease which, in these times of public enlightenment, is still shrouded in obscurity, entrenched behind a barrier of silence, and armed, by our own ignorance and false shame, with a thousand times its actual power to destroy. Against all of these three great plagues medicine has pitted the choicest personalities, the highest attainments, and the uttermost resources of human knowledge. Against all of them it has made headway. It is one of the ironies, the paradoxes, of fate that the disease against which the most tremendous advances have been made, the most brilliant victories won, is the third great plague, syphilis—the disease that still destroys us through our ignorance or our refusal to know the truth.
We have crippled the power of tuberculosis through knowledge,—wide-spread, universal knowledge,—rather than through any miraculous discoveries other than that of the cause and the possibility of cure. We shall in time obliterate cancer by the same means. Make a disease a household word, and its power is gone. We are still far from that day with syphilis. The third great plague is just dawning upon us—a disease which in four centuries has already cost a whole inferno of human misery and a heaven of human happiness. When we awake, we shall in our turn destroy the destroyer—and the more swiftly because of the power now in the hands of medicine to blot out the disease. To the day of that awakening books like this are dedicated. The facts here presented are the common property of the medical profession, and it is impossible to claim originality for their substance. Almost every sentence is written under the shadow of some advance in knowledge which cost a life-time of some man's labor and self-sacrifice. The story of the conquest of syphilis is a fabric of great names, great thoughts, dazzling visions, epochal achievements. It is romance triumphant, not the tissue of loathsomeness that common misconception makes it.
The purpose of this book is accordingly to put the accepted facts in such a form that they will the more readily become matters of common knowledge. By an appeal to those who can read the newspapers intelligently and remember a little of their high-school physiology, an immense body of interested citizens can be added to the forces of a modern campaign against the third great plague. For such an awakening of public opinion and such a movement for wider cooeperation, the times are ready.
JOHN H. STOKES.
PAGE CHAPTER I THE HISTORY OF SYPHILIS 11
CHAPTER II SYPHILIS AS A SOCIAL PROBLEM 15
CHAPTER III THE NATURE AND COURSE OF SYPHILIS 21 The Prevalence of Syphilis 24 The Primary Stage 26
CHAPTER IV THE NATURE AND COURSE OF SYPHILIS (Continued) 35 The Secondary Stage 35
CHAPTER V THE NATURE AND COURSE OF SYPHILIS (Continued) 45 Late Syphilis (Tertiary Stage) 45
CHAPTER VI THE BLOOD TEST FOR SYPHILIS 54
CHAPTER VII THE TREATMENT OF SYPHILIS 60 General Considerations 60 Mercury 62
CHAPTER VIII THE TREATMENT OF SYPHILIS (Continued) 70 Salvarsan 70
CHAPTER IX THE CURE OF SYPHILIS 80
CHAPTER X HEREDITARY SYPHILIS 92
CHAPTER XI THE TRANSMISSION AND HYGIENE OF SYPHILIS 109
CHAPTER XII THE TRANSMISSION AND HYGIENE OF SYPHILIS (Continued) 121 The Control of Infectiousness in Syphilis 121 Syphilis and Marriage 125
CHAPTER XIII THE TRANSMISSION AND HYGIENE OF SYPHILIS (Continued) 133 Syphilis and Prostitution 133 Personal Hygiene of Syphilis 136
CHAPTER XIV MENTAL ATTITUDES IN THEIR RELATION TO SYPHILIS 141
CHAPTER XV MORAL AND PERSONAL PROPHYLAXIS 156
CHAPTER XVI PUBLIC EFFORT AGAINST SYPHILIS 164
LIST OF ILLUSTRATIONS
PAGE PAUL EHRLICH [1854-1915] 69
FRITZ SCHAUDINN [1871-1906] 112
E. ROUX 161
ELIE METCHNIKOFF [1845-1916] 161
The Third Great Plague
The History of Syphilis
Syphilis has a remarkable history, about which it is worth while to say a few words. Many people think of the disease as at least as old as the Bible, and as having been one of the conditions included under the old idea of leprosy. Our growing knowledge of medical history, however, and the finding of new records of the disease, have shown this view to be in all probability a mistake. Syphilis was unknown in Europe until the return of Columbus and his sailors from America, and its progress over the civilized world can be traced step by step, or better, in leaps and bounds, from that date. It came from the island of Haiti, in which it was prevalent at the time the discoverers of America landed there, and the return of Columbus's infected sailors to Europe was the signal for a blasting epidemic, which in the sixteenth and seventeenth centuries devastated Spain, Italy, France, and England, and spread into India, Asia, China, and Japan.
 For a detailed account in English, see Pusey, W. A.: "Syphilis as a Modern Problem," Amer. Med. Assoc., 1915.
It is a well-recognized fact that a disease which has never appeared among a people before, when it does attack them, spreads with terrifying rapidity and pursues a violent and destructive course on the new soil which they offer. This was the course of syphilis in Europe in the years immediately following the return of Columbus in 1493. Invading armies, always a fruitful means of spreading disease, carried syphilis with them everywhere and left it to rage unchecked among the natives when the armies themselves went down to destruction or defeat. Explorers and voyagers carried it with them into every corner of the earth, so that it is safe to say that in this year of grace 1917 there probably does not exist a single race or people upon whom syphilis has not set its mark. The disease, in four centuries, coming seemingly out of nowhere, has become inseparably woven into the problems of civilization, and is part and parcel of the concerns of every human being. The helpless fear caused by the violence of the disease in its earlier days, when the suddenness of its attack on an unprepared people paralyzed comprehension, has given place to knowledge such as we can scarcely duplicate for any of the other scourges of humanity. The disease has in its turn become more subtle and deceiving, its course is seldom marked by the bold and glaring destructiveness, the melting away of resistance, so familiar in its early history. The masses of sores, the literal falling to pieces of skeletons, are replaced by the inconspicuous but no less real deaths from heart and brain and other internal diseases, the losses to sight and hearing, the crippling and death of children, and all the insidious, quiet deterioration and degeneration of our fiber which syphilis brings about. From devouring a man alive on the street, syphilis has taken to knifing him quietly in his bed.
Although syphilis sprang upon the world from ambush, so to speak, it did the world one great service—it aroused Medicine from the sleep of the Middle Ages. Many of the greatest names in the history of the art are inseparably associated with the progress of our knowledge of this disease. As Pusey points out, it required the force of something wholly unprecedented to take men away from tradition and the old stock in trade of ideas and formulas, and to make them grasp new things. Syphilis was the new thing of the time in the sixteenth century and the study which it received went far toward putting us today in a position to control it. Before the beginning of the twentieth century almost all that ordinary observation of the diseased person could teach us was known of syphilis. It needed only laboratory study, such as has been given it during the past fifteen years, to put us where we could appeal to every intelligent man and woman to enlist in a brilliantly promising campaign. For a time syphilis was confused with gonorrhea, and there could be no better proof of the need for separating the two in our minds today than to study the way in which this confusion set back progress in our knowledge of syphilis. John Hunter, who fathered the idea of the identity of the two diseases, sacrificed his life to his idea indirectly. Ricord, a Frenchman, whose name deserves to be immortal, set Hunter's error right, and as the father of modern knowledge of syphilis, prepared us for the revolutionary advances of the last ten years.
There is something awe-inspiring in the quiet way in which one great victory has succeeded another in the battle against syphilis in the last decade. If we are out of the current of these things, in the office or the store, or in the field of industry and business, announcements from the great laboratories of the world seldom reach us, and when they do, they have an impractical sound, an unreality for us. So one hears, as if in a speaking-tube from a long distance, the words that Schaudinn and Hoffmann, on April 19, 1905, discovered the germ that causes syphilis, not realizing that the fact contained in those few brief words can alter the undercurrent of human history, and may, within the lives of our children and our children's children, remake the destiny of man on the earth. A great spirit lives in the work of men like Metchnikoff and Roux and Maisonneuve, who made possible the prophylaxis of syphilis, in that of Bordet and Wassermann, who devised the remarkable blood test for the disease, and in that of Ehrlich and Hata, who built up by a combination of chemical and biological reasoning, salvarsan, one of the most powerful weapons in existence against it. Ehrlich conceived the whole make-up and properties of salvarsan when most of us find it a hardship to pronounce its name. Schaudinn saw with the ordinary lenses of the microscope in the living, moving germ, what dozens can scarcely see today with the germ glued to the spot and with all the aid of stains and dark-field apparatus. After all, it is brain-power focused to a point that moves events, and to the immensity of that power the history of our growing knowledge of syphilis bears the richest testimony.
Syphilis as a Social Problem
The simple device of talking plain, matter-of-fact English about a thing has a value that we are growing to appreciate more and more every day. It is only too easy for an undercurrent of ill to make headway under cover of a false name, a false silence, or misleading speech. The fact that syphilis is a disease spread to a considerable extent by sexual relations too often forces us into an attitude of veiled insinuation about it, a mistaken delicacy which easily becomes prudish and insincere. It is a direct move in favor of vulgar thinking to misname anything which involves the intimacies of life, or to do other than look it squarely in the eye, when necessity demands, without shuffling or equivocation. On this principle it is worth while to meet the problem of a disease like syphilis with an open countenance and straightforward honesty of expression. It puts firm ground under our feet to talk about it in the impersonal way in which we talk about colds and pneumonia and bunions and rheumatism, as unfortunate, but not necessarily indecent, facts in human experience. Nothing in the past has done so much for the campaign against consumption as the unloosing of tongues. There is only one way to understand syphilis, and that is to give it impartial, discriminating discussion as an issue which concerns the general health. To color it up and hang it in a gallery of horrors, or to befog it with verbal turnings and twistings, are equally serious mistakes. The simple facts of syphilis can appeal to intelligent men and women as worthy of their most serious attention, without either stunning or disgusting them. It is in the unpretentious spirit of talking about a spade as a spade, and not as "an agricultural implement for the trituration of the soil," that we should take stock of the situation and of the resources we can muster to meet it.
The Confusion of the Problem of Syphilis with Other Issues.—Two points in our approach to the problem of syphilis are important at the outset. The first of these is to separate our thought about syphilis from that of the other two diseases, gonorrhea, or "clap," and chancroids, or "soft sores," which are conventionally linked with it under the label of "venereal diseases." The second is to separate the question of syphilis at least temporarily from our thought about morals, from the problem of prostitution, from the question as to whether continence is possible or desirable, whether a man should be true to one woman, whether women should be the victims of a double standard, and all the other complicated issues which we must in time confront. Such a picking to pieces of the tangle is simply the method of scientific thought, and in this case, at least, has the advantage of making it possible to begin to do something, rather than saw the air with vain discussion.
 The three so-called venereal diseases are syphilis, gonorrhea, and chancroid or soft ulcer. Gonorrhea is the commonest of the three, and is an exceedingly prevalent disease. In man its first symptom is a discharge of pus from the canal through which the urine passes. Its later stages may involve the bladder, the testicles, and other important glands. It may also produce crippling forms of rheumatism, and affect the heart. Gonorrhea may recur, become latent, and persist for years, doing slow, insidious damage. It is transmitted largely by sexual intercourse. Gonorrhea in women is frequently a serious and even fatal disease. It usually renders women incapable of having children, and its treatment necessitates often the most serious operations. Gonorrhea of the eyes, affecting especially newborn children, is one of the principal causes of blindness. Gonorrhea may be transmitted to little girls innocently from infected toilet seats, and is all but incurable. Gonorrhea, wherever it occurs, is an obstinate, treacherous, and resistant disease, one of the most serious of modern medical problems, and fully deserves a place as the fourth great plague.
Chancroid is an infectious ulcer of the genitals, local in character, not affecting the body as a whole, but sometimes destroying considerable portions of the parts involved.
Let us think of syphilis, then, as a serious but by no means hopeless constitutional disease. Dismiss chancroid as a relatively insignificant local affair, seldom a serious problem under a physician's care. Separate syphilis from gonorrhea for the reason that gonorrhea is a problem in itself. Against its train of misfortune to innocence and guilt alike, we are as yet not nearly so well equipped to secure results. Against syphilis, the astonishing progress of our knowledge in the past ten years has armed us for triumph. When the fight against tuberculosis was brought to public attention, we were not half so well equipped to down the disease as we are today to down syphilis. For syphilis we now have reliable and practical methods of prevention, which have already proved their worth. The most powerful and efficient of drugs is available for the cure of the disease in its earlier stages, and early recognition is made possible by methods whose reliability is among the remarkable achievements of medicine. It is the sound opinion of conservative men that if the knowledge now in the hands of the medical profession could be put to wide-spread use, syphilis would dwindle in two generations from the unenviable position of the third great plague to the insignificance of malaria and yellow fever on the Isthmus of Panama. The influences that stand between humanity and this achievement are the lack of general public enlightenment on the disease itself, and public confusion of the problem with other sex issues for which no such clean-cut, satisfactory solution has been found. Think of syphilis as the wages of sin, as well-earned disgrace, as filth, as the badge of immorality, as a necessary defense against the loathesomeness of promiscuity, as a fearful warning against prostitution, and our advantage slips from us. The disease continues to spread wholesale disaster and degeneration while we wrangle over issues that were old when history began and are progressing with desperate slowness to a solution probably many centuries distant. Think of syphilis as a medical and a sanitary problem, and its last line of defense crumbles before our attack. It can and should be blotted out.
Syphilis, a Problem of Public Health Rather than of Morals.—Nothing that can be said about syphilis need make us forget the importance of moral issues. The fact which so persistently distorts our point of view, that it is so largely associated with our sexual life, is probably a mere incident, biologically speaking, due in no small part to the almost absurdly simple circumstance that the germ of the disease cannot grow in the presence of air, and must therefore find refuge, in most cases, in the cavities and inlets from the surface of the body. History affords little support to the lingering belief that if syphilis is done away with, licentiousness will overrun the world. Long before syphilis appeared in Europe there was sexual immorality. In the five centuries in which it has had free play over the civilized world, the most optimistic cannot successfully maintain that it has materially bettered conditions or acted as a check on loose morals, though its relation to sexual intercourse has been known. As a morals policeman, syphilis can be obliterated without material loss to the cause of sexual self-restraint, and with nothing but gain to the human race.
It is easier to accept this point of view, that the stamping out of syphilis will not affect our ability to grapple with moral problems, and that there is nothing to be gained by refusing to do what can so easily be done, when we appreciate the immense amount of innocent suffering for which the disease is responsible. It must appeal to many as a bigoted and narrow virtue, little better than vice itself, which can derive any consolation in the thought that the sins of the fathers are being visited upon the children, as it watches a half-blind, groping child feel its way along a wall with one hand while it shields its face from the sunlight with the other. There are better ways of paying the wages of sin than this. Best of all, we can attack a sin at its source instead of at its fulfilment. How much better to have kept the mother free from syphilis by giving the father the benefit of our knowledge. The child who reaped his sowing gained nothing morally, and lost its physical heritage. Its mother lost her health and perhaps her self-respect. Neither one contributes anything through syphilis to the uplifting of the race. They are so much dead loss. To teach us to avoid such losses is the legitimate field of preventive medicine.
On this simplified and practical basis, then, the remainder of this discussion will proceed. Syphilis is a preventable disease, usually curable when handled in time, and its successful management will depend in large part upon the cooeperation, not only of those who are victims of it, but of those who are not. It is much more controllable than tuberculosis, against which we are waging a war of increasing effectiveness, and its stamping out will rid humanity of an even greater curse. To know about syphilis is in no sense incompatible with clean living or thinking, and insofar as its removal from the world will rid us of a revolting scourge, it may even actually favor the solution of the moral problems which it now obscures.
The Nature and Course of Syphilis
The simplest and most direct definition of syphilis is that it is a contagious constitutional disease, due to a germ, running a prolonged course, and at one time or another in that course is capable of affecting nearly every part of the body. One of the most important parts of this rather abstract statement is that which relates to the germ. To be able to put one's finger so definitely on the cause of syphilis is an advantage which cannot be overestimated. More than in almost any other disease the identification of syphilis at its very outset depends upon the seeing of the germ that causes it in the discharge from the sore or pimple which is the first evidence of syphilis on the body. On our ability to recognize the disease as syphilis in the first few days of its course depends the greatest hope of cure. On the recognition of the germ in the tissues and fluids of the body has depended our knowledge of the real extent and ravages of the disease. With the knowledge that the germ was related to certain other more familiar forms, Ehrlich set the trap for it that culminated in salvarsan, or "606," the powerful drug used in the modern treatment. By the finding of this same germ in the nervous system in locomotor ataxia and general paralysis of the insane, the last lingering doubt of their syphilitic character was dispelled. Every day and hour the man who deals with syphilis in accordance with the best modern practice brings to bear knowledge that arises from our knowledge of the germ cause of syphilis. No single fact except perhaps the knowledge that certain animals (monkeys and rabbits especially) could be infected with it has been of such immense practical utility in developing our power to deal with it.
The germ of syphilis, discovered by Schaudinn and Hoffmann in 1905, is an extremely minute spiral or corkscrew-shaped filament, visible under only the highest powers of the microscope, which increase the area of the object looked at hundreds of thousands of times, and sometimes more than a million of times. Even under such intense magnifications, it can be seen only with great difficulty, since it is colorless in life, and it is hard to color or stain it with dyes. Its spiral form and faint staining have led to its being called the Spirochaeta pallida. It is best seen by the use of a special device, called a dark-field illuminator, which shows the germ, like a floating particle in a sunbeam, as a brilliant white spiral against a black background, floating and moving in the secretions taken from the sore in which it is found. Some means of showing the germ should be in the hands of every physician, hospital, or dispensary which makes a claim to recognize and treat syphilis.
 See frontispiece.
 Pronounced spi-ro-kee'-ta.
Syphilis a Concealed Disease.—Syphilis is not a grossly conspicuous figure in our every-day life, as leprosy was in the life of the Middle Ages, for example. To the casually minded, therefore, it is not at all unreasonable to ask why there should be so much agitation about it when so little of it is in evidence. It takes a good deal out of the graphic quality of the thing to say that most syphilis is concealed, that most syphilitics, during a long period of their disease, are socially presentable. Of course, when we hear that they may serve lunch to us, collect our carfare, manicure our nails, dance with us most enchantingly, or eat at our tables, it seems a little more real, but still a little too much to believe. Conviction seems to require that we see the damaged goods, the scars, the sores, the eaten bones, the hobbling cripples, the maimed, the halt, and the blind. There is no accurate estimate of its prevalence based on a census, because, as will appear later, even an actual impulse to self-betrayal would not disclose 30 to 40 per cent of the victims of the disease. Approximately this percentage would either have forgotten the trivial beginnings of it, or with the germs of it still in their brains or the walls of their arteries or other out-of-the-way corners of their bodies, would think themselves free of the disease—long since "cured" and out of danger.
How Much Syphilis is There?—Our entire lack of a tangible idea of how much syphilis there really is among us is, of course, due to the absence of any form of registration or reporting of the disease to authorities such as health officers, whose duty it is to collect such statistics, and forms the principal argument in favor of dealing with syphilis legally as a contagious disease. Such conceptions of its prevalence as we have are based on individual opinions and data collected by men of large experience.
Earlier Estimates of the Prevalence of Syphilis.—It is generally conceded that there is more syphilis among men than women, although it should not be forgotten that low figures in women may be due to some extent to the milder and less outspoken course of the disease in them. Five times more syphilis in men than women conservatively summarizes our present conceptions. The importance of distinguishing between syphilis among the sick and among the well is often overlooked. For example, Landouzy, in the Laennec clinic in Paris, estimated recently that in the patients of this clinic, which deals with general medicine, 15 to 18 per cent of the women and 21 to 28 per cent of the men had syphilis. It is fair to presume, then, that such a percentage would be rather high for the general run of every-day people. This accords with the estimates, based on large experience, of such men as Lenoir and Fournier, that 13 to 15 per cent of all adult males in Paris have syphilis. Erb estimated 12 per cent for Berlin, and other estimates give 12 per cent for London. Collie's survey of British working men gives 9.2 per cent in those who, in spite of having passed a general health examination, showed the disease by a blood test. A large body of figures, covering thirty years, and dating back beyond the time when the most sensitive tests of the disease came into use, gives about 8 per cent of more than a million patients in the United States Public Health and Marine Hospital Service as having syphilis. It should be recalled that this includes essentially active rather than quiescent cases, and is therefore probably too low.
Current Estimates of the Prevalence of Syphilis.—The constant upward tendency of recent estimates of the amount of syphilis in the general population, as a result of the application of tests which will detect even concealed or quiescent cases, is a matter for grave thought. The opinion of such an authority as Blaschko, while apparently extreme, cannot be too lightly dismissed, when he rates the percentage of syphilitics in clerks and merchants in Berlin between the ages of 18 and 28 as 45 per cent. Pinkus estimated that one man in five in Germany has had syphilis. Recently published data by Vedder, covering the condition of recruits drawn to the army from country and city populations, estimate 20 per cent syphilitics among young men who apply for enlistment, and 5 per cent among the type of young men who enter West Point and our colleges. It can be pointed out also with justice that the percentage of syphilis in any class grouped by age increases with the age, since so few of the cases are cured, and the number is simply added to up to a certain point as time elapses. Even the army, which represents in many ways a filtered group of men, passing a rigorous examination, and protected by an elaborate system of preventions which probably keeps the infection rate below that of the civil population, is conceded by careful observers (Nichols and others) to show from 5 to 7 per cent syphilitics. Attention should be called to the difference between the percentage of syphilis in a population and the percentage of venereal disease. The inclusion of gonorrhea with syphilis increases the percentages enormously, since it is not infrequently estimated that as high as 70 per cent of adult males have gonorrhea at least once in a lifetime.
On the whole, then, it is conservative to estimate that one man in ten has syphilis. Taking men and women together on the basis of one of the latter to five of the former, and excluding those under fifteen years of age from consideration, this country, with a population of 91,972,266, should be able to muster a very considerable army of 3,842,526, whose influence can give a little appreciated but very undesirable degree of hyphenation to our American public health. In taking stock of ourselves for the future, and in all movements for national solidarity, efficiency, and defense, we must reckon this force of syphilo-Americans among our debits.
 Figures based on 1910 census.
THE PRIMARY STAGE OF SYPHILIS
The So-called Stages of Syphilis.—The division of the course of syphilis into definite stages is an older and more arbitrary conception than the one now developing, and was based on outward signs of the disease rather than on a real understanding of what goes on in the body during these periods. The primary stage was supposed to extend from the appearance of the first sore or chancre to the time when an eruption appeared over the whole body. Since the discovery of the Spirochaeta pallida, the germ of the disease, our knowledge of what the germ does in the body, where it goes, and what influence it has upon the infected individual, has rapidly extended. We now appreciate much more fully than formerly that at the very beginning of the disease there is a time when it is almost purely local, confined to the first sore itself, and perhaps to the glands or kernels in its immediate neighborhood. Thorough and prompt treatment with the new and powerful aid of salvarsan ("606") at this stage of the disease can kill all the germs and prevent the disease from getting a foothold in the body which only years of treatment subsequently can break. This is the critical moment of syphilis for the individual and for society, and its importance and the value of treatment at this time cannot be too widely understood.
Peculiarities of the Germ.—Many interesting facts about the Spirochaeta pallida explain peculiarities in the disease of which it is the cause. Many germs can be grown artificially, some in the presence of air, others only when air is removed. The germ of syphilis belongs in the latter class. The germ that causes tuberculosis, a rod-like organism or bacillus, can stand drying without losing its power to produce the disease, and has a very appreciable ability to resist antiseptic agents. If the germ of syphilis were equally hard to kill, syphilis would be an almost universal disease. Fortunately it dies at once on drying, and is easily destroyed by the weaker antiseptics provided it has not gained a foothold on favorable ground. Its inability to live long in the presence of air confines the source of infection largely to those parts of the body which are moist and protected, and especially to secretions and discharges which contain it. Its contagiousness is, therefore, more readily controlled than that of tuberculosis. It is impossible for a syphilitic to leave a room or a house infected for the next occupants, and it is not necessary to do more than disinfect objects that come in contact with open lesions or their secretions, to prevent its spread by indirect means. Such details will be considered more fully under the transmission and hygiene of the disease.
Mode of Entry of the Germ.—The germ of the disease probably gains entrance to the body through a break or abrasion in the skin or the moist red mucous surfaces of the body, such as those which line the mouth and the genital tract. The break in the surface need not be visible as a chafe or scratch, but may be microscopic in size, so that the first sore seems to develop on what is, to all appearances, healthy surface. It should not be forgotten that this surface need not be confined to the genital organs, since syphilis may and often does begin at any part of the body where the germ finds favorable conditions for growth.
Incubation or Quiescent Period.—Almost all germ diseases have what is called a period of incubation, in which the germ, after it has gained entrance to the body, multiplies with varying rapidity until the conditions are such that the body begins to show signs of the injury which their presence is causing. The germ of syphilis is no exception to this rule. Its entry into the body is followed by a period in which there is no external sign of its presence to warn the infected person of what is coming. This period of quiescence between the moment of infection with syphilis and the appearance of the first signs of the disease in the form of the chancre may vary from a week to six weeks or even two months or more, with an average of about two or three weeks.
In the length of the incubation period and the comparatively trifling character of the early signs, the germ of syphilis betrays one of its most dangerous characteristics. The germ of pneumonia, for example, may be present on the surface of the body, in the mouth or elsewhere, for a long time, but the moment it gets a real foothold, there is an immediate and severe reaction, the body puts up a fight, and in ten days or so has either lost or won. The germ of syphilis, on the other hand, secures its place in the body without exciting very strenuous or wide-spread opposition. The body does not come to its own defense so well as with a more active enemy. The fitness of the germ of syphilis for long-continued life in the body, and the difficulty of marshaling a sufficient defense against it, is what makes it impossible to cure the disease by any short and easy method.
The First Sore or Chancre.—The primary lesion, first sore or chancre, is the earliest sign of reaction which the body makes to the presence of the growing germs of syphilis. This always develops at the point where the germs entered the body. The incubation period ends with the appearance of a small hard knot or lump under the skin, which may remain relatively insignificant in some cases and in others grow to a considerable size. Primary lesions show the greatest variety in their appearance and degree of development. If the base of the knot widens and flattens so that it feels and looks like a button under the skin, and the top rubs off, leaving an exposed raw surface, we may have the typical hard chancre, easily recognized by the experienced physician, and perhaps even by the layman as well. On the other hand, no such typical lesion may develop. The chancre may be small and hidden in some out-of-the-way fold or cleft, and because it is apt to be painless, escape recognition entirely. In women the opportunity for concealment of a primary sore itself is especially good, since it may occur inside the vagina or on the neck of the womb. In men it may even occur inside the canal through which the urine passes (urethra). The name "sore" is deceptive and often misleads laymen, since there may be no actual sore—merely a pinhead-sized pimple, a hard place, or a slight chafe. The development of a syphilitic infection can also be completely concealed by the occurrence of some other infection in the same place at the same time, as in the case of a mixed infection with syphilis and soft ulcers or chancroids. Even a cold-sore on the mouth or genitals may become the seat of a syphilitic infection which will be misunderstood or escape notice.
 Pronounced shan'-ker.
Syphilis and Gonorrhea may Coexist.—It is a not uncommon thing for gonorrhea in men to hide the development of a chancre at the same time or later. In fact, it was in an experimental inoculation from such a case that the great John Hunter acquired the syphilis which cost him his life, and which led him to declare that because he had inoculated himself with pus from a gonorrhea and developed syphilis, the two diseases were identical. Just how common such cases are is not known, but the newer tests for syphilis are showing increasing numbers of men who never to their knowledge had anything but gonorrhea, yet who have syphilis, too.
Serious Misconceptions About the Chancre.—Misconceptions about the primary lesion or chancre of syphilis are numerous and serious, and are not infrequently the cause for ignoring or misunderstanding later signs of the disease. A patient who has gotten a fixed conception of a chancre into his head will argue insistently that he never had a hard sore, that his was soft, or painful instead of painless, or that it was only a pimple or a chafe. All these forms are easily within the ordinary limits of variation of the chancre from the typical form described in books, and an expert has them all in mind as possibilities. But the layman who has gathered a little hearsay knowledge will maintain his opinion as if it were the product of lifelong experience, and will only too often pay for his folly and presumption accordingly.
Importance of Prompt and Expert Medical Advice.—The recognition of syphilis in the primary stage does not follow any rule of thumb, and is as much an affair for expert judgment as a strictly engineering or legal problem. In the great majority of cases a correct decision of the matter can be reached in the primary stage by careful study and examination, but not by any slipshod or guesswork means. To secure the benefit of modern methods for the early recognition of syphilis those who expose themselves, or are exposed knowingly, to the risk of getting the disease by any of the commoner sources of infection, should seek expert medical advice at once on the appearance of anything out of the ordinary, no matter how trivial, on the parts exposed. The commoner sources of infection may be taken to be the kissing of strangers, the careless use of common personal and toilet articles which come in contact with the mouth especially,—all of which are explained later,—and illicit sexual relations. While this by no means includes all the means for the transmission of the disease, those who do these things are in direct danger, and should be warned accordingly.
Modern Methods of Identifying an Early Syphilitic Infection.—The practice of tampering with sores, chafes, etc., which are open to suspicion, whether done by the patient himself or by the doctor before reaching a decision as to the nature of the trouble, is unwise. An attempt to "burn it out" with caustic or otherwise, which is the first impulse of the layman with a half-way knowledge and even of some doctors, promptly makes impossible a real decision as to whether or not syphilis is present. Even a salve, a wash, or a powder may spoil the best efforts to find out what the matter is. A patient seeking advice should go to his doctor at once, and absolutely untreated. Then, again, irritating treatment applied unwisely to even a harmless sore may make a mere chafe look like a hard chancre, and result in the patient's being treated for months or longer for syphilis. Nowadays our first effort after studying the appearance of the suspected lesion is to try to find the germs, with the dark-field microscope or a stain. Having found them, the question is largely settled, although we also take a blood test. If we fail to find the germs, it is no proof that syphilis is absent, and we reexamine and take blood tests at intervals for some months to come, to be sure that the infection has not escaped our vigilance, as it sometimes does if we relax our precautions. In recognizing syphilis, the wise layman is the one who knows he does not know. The clever one who is familiar with everything "they say" about the disease, and has read about the matter in medical books into the bargain, is the best sort of target for trouble. Such men are about as well armed as the man who attacks a lion with a toothpick. He may stop him with his eye, but it is a safer bet he will be eaten.
Enlargement of Neighboring Glands.—Nearly every one is familiar with the kernels or knots that can be felt in the neck, often after tonsillitis, or with eruptions in the scalp. These are lymph-glands, which are numerous in different parts of the body, and their duty is, among other things, to help fight off any infection which tries to get beyond the point at which it started. The lymph-glands in the neighborhood of the chancre, on whatever part of the body it is situated, take an early part in the fight against syphilis. If, for example, the chancre is on the genitals, the glands in the groin will be the first ones affected. If it is on the lip, the neck glands become swollen. The affected glands actually contain the germs which have made their way to them through lymph channels under the skin. When the glands begin to swell, the critical period of limitation of the disease to the starting-point will soon be over and the last chances for a quick cure will soon be gone. At any moment they may gain entrance to the blood stream in large numbers. While the swelling of these glands occurs in other conditions, there are peculiarities about their enlargement which the physician looking for signs of the disease may recognize. Especially in case of a doubtful lesion about the neck or face, when a bunch of large swollen glands develops under the jaw in the course of a few days or a couple of weeks, the question of syphilis should be thoroughly investigated.
Vital Significance of Early Recognition.—The critical period of localization of an early infection will be brought up again in subsequent pages. As Pusey says, it is the "golden opportunity" of syphilis. It seldom lasts more than two weeks from the first appearance of the primary sore or chancre, and its duration is more often only a matter of four or five days before the disease is in the blood, the blood test becomes positive, and the prospect of what we call abortive cure is past. Nothing can justify or make up for delay in identifying the trouble in this early period, and the person who does not take the matter seriously often pays the price of his indifference many times over.
The Nature and Course of Syphilis (Continued)
THE SECONDARY STAGE
The Spread of the Germs Over the Body.—The secondary stage of syphilis, like the primary stage, is an arbitrary division whose beginning and ending can scarcely be sharply defined. Broadly speaking, the secondary stage of syphilis is the one in which the infection ceases to be confined to the neighborhood of the chancre and affects the entire body. The spread of the germs of the disease to the lymph-glands in the neighborhood of the primary sore is followed by their invasion of the blood itself. While this may begin some time before the body shows signs of it, the serious outburst usually occurs suddenly in the course of a few days, and fills the circulating blood with the little corkscrew filaments, sending showers of them to every corner of the body and involving every organ and tissue to a greater or less extent. This explosion marks the beginning of the active secondary stage of syphilis. The germs are now everywhere, and the effect on the patient begins to suggest such infectious diseases as measles, chickenpox, etc., which are associated with eruptions on the skin. But there can be no more serious mistake than to suppose that the eruptions which usually break out on the skin at this time represent the whole, or even a very important part, of the story. They may be the most conspicuous sign to the patient and to others, but the changes which are to affect the future of the syphilitic are going on just at this time, not in his skin, but in his internal organs, and especially in his heart and blood-vessels and in his nervous system.
Constitutional Symptoms.—It is surprising how mild a thing secondary syphilis is in many persons. A considerable proportion experience little or nothing at this time in the way of disturbances of the general health to suggest that they have a serious illness. A fair percentage of them 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 Spirochaeta 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.
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, before the American Public Health Association, has recently carefully summarized the role 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.
 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 any worse by the proper treatment. For paresis, in our present state of knowledge, nothing can be done once the disease passes its earliest stages. In both these diseases only too often the physician is called upon to lock the stable door after the horse is stolen. The problem of what to do for the victims of these two conditions is the same as the problem in other serious complications of syphilis—keep the disease from ever reaching such a stage by recognizing every case early, and treating it thoroughly from the very beginning.
Summing up briefly the main points to bear in mind about the course of syphilis—there is a time, at the very beginning of the disease, even after the first sore appears, when the condition is still at or near the place where it entered the body. At this time it can be permanently cured by quick recognition and thorough treatment. There are no fixed characteristics of the early stages of the disease, and it often escapes attention entirely or is regarded as a trifle. The symptoms that follow the spread of the disease over the body may be severe or mild, but they seldom endanger life, and again often escape notice, leaving the victim for some years a danger to other people from relapses about which he may know nothing whatever. Serious syphilis is the late syphilis which overtakes those whose earlier symptoms passed unrecognized or were insufficiently treated. Late syphilis of the skin and bones, disfiguring and horrible to look at, is less dangerous than the hidden syphilis of the blood-vessels, the nerves, and the internal organs, which, under cover of a whole skin and apparent health, maims and destroys its victims. Locomotor ataxia and softening of the brain, early apoplexy, blindness and deafness, paralysis, chronic fatal kidney and liver disease, heart failure, hardening of the blood-vessels early in life, with sudden or lingering death from any of these causes, are among the ways in which syphilis destroys innocent and guilty alike. And yet, for all its destructive power, it is one of the easiest of diseases to hold in check, and if intelligently treated at almost any but the last stages, can, in the great majority of cases, be kept from endangering life.
The Blood Test for Syphilis
It seems desirable at this point, while we are trying to fix in mind the great value of recognizing syphilis in a person in order to treat it and thus prevent dangerous complications, to say something about the blood test for syphilis, the second great advance in our means of recognizing doubtful or hidden forms of the disease. The first, it will be recalled, is the identification of the germ in the secretions from the early sores.
Antibodies in the Blood in Disease.—It is part of the new understanding we have of many diseases that we are able to recognize them by finding in the blood of the sick person substances which the body makes to neutralize or destroy the poisons made by the invading germs, even when we cannot find the germs themselves. These substances are called antibodies, and the search for antibodies in different diseases has been an enthusiastic one. If we can by any scheme teach the body to make antibodies for a germ, we can teach it to cure for itself the disease caused by that germ. So, for example, by injecting dead germs as a vaccine in typhoid fever and certain other diseases, we are able to teach the body to form protective substances which will kill any of the living germs of that particular kind which gain entrance to the body. Conversely, if the body is invaded by a particular kind of germ, and we are in doubt as to just which one it is, we can identify it by finding in the blood of the sick person the antibody which we know by certain tests will kill or injure a certain germ. This sort of medical detective work was first applied to syphilis successfully by Wassermann, Neisser, and Bruck in 1904, and for that reason the test for these antibodies in the blood in syphilis is called the Wassermann reaction. To be sure, it is now known that in syphilis it is not a true antibody for the poisons of the Spirochaeta pallida for which we are testing, but rather a physical-chemical change in the serum of patients with syphilis, which can be produced by other things besides this one disease. But this fact has not impaired the practical value of the test, since the other conditions which give it are not likely to be confused with syphilis in this part of the world. The fact that no true antibody is formed simply makes it unlikely that we shall ever have a vaccine for syphilis.
Difficulties of the Test.—The Wassermann blood test for syphilis is one of the most complex tests in medicine. The theory of it is beyond the average man's comprehension. A large number of factors enter into the production of a correct result, and the attaining of that result involves a high degree of technical skill and a large experience. It is no affair for the amateur. The test should be made by a specialist of recognized standing, and this term does not include many of the commercial laboratories which spring up like mushrooms in these days of laboratory methods.
The Recognition of Syphilis by the Blood Test.—When the Wassermann test shows the presence of syphilis, we speak of it as "positive." Granted that the test is properly done, a strong positive reaction means syphilis, unless it is covered by the limited list of exceptions. After the first few weeks of the disease, and through the early secondary period, the blood test is positive in practically all cases. Its reliability is, therefore, greatest at this time. Before the infection has spread beyond the first sore, however, the Wassermann test is negative, and this fact makes it of little value in recognizing early primary lesions. In about 20 to 30 per cent of syphilitic individuals the test returns to negative after the active secondary stage is passed. This does not necessarily mean that the person is recovering. It is even possible to have the roof fall out of the mouth from gummatous changes and the Wassermann test yet be negative. It is equally possible, though unusual, for a negative Wassermann test to be coincident with contagious sores in the mouth or on the genitals. So it is apparent that as an infallible test for syphilis it is not an unqualified success. But infallibility is a rare thing in medicine, and must be replaced in most cases by skilful interpretation of a test based on a knowledge of the sources of error. We understand pretty clearly now that the Wassermann test is only one of the signs of syphilis and that it has quite well-understood limitations. It has revealed an immense amount of hidden syphilis, and in its proper field has had a value past all counting. Experience has shown, however, that it should be checked up by a medical examination to give it its greatest value. Just as all syphilis does not show a positive blood test, so a single negative test is not sufficient to establish the absence of syphilis without a medical examination. In a syphilitic, least of all, is a single negative Wassermann test proof that his syphilis has left him. In spite of these rather important exceptions, the Wassermann test, skilfully done and well interpreted, is one of the most valuable of modern medical discoveries.
The Blood Test in the Treatment and Cure of Syphilis.—In addition to its value in recognizing the disease, the Wassermann test has a second field of usefulness in determining when a person is cured of syphilis, and is an excellent guide to the effect of treatment. Good treatment early in a case of syphilis usually makes the Wassermann test negative in a comparatively short time, and even a little treatment will do it in some cases. But will it stay negative if treatment is then stopped? In the high percentage of cases it will not. It will become positive again after a variable interval, showing that the disease has been suppressed but not destroyed. For that reason, if we wish to be sure of cure, we must continue treatment until the blood test has become negative and stays negative. This usually means repeated tests, over a period of several years, in connection with such a course of treatment as will be described later. During a large part of this time the blood test will be the only means of finding out how the disease is being affected by the treatment. To all outward appearance the patient will be well. He may even have been negative in repeated tests, and yet we know by experience that if treatment is stopped too soon, he will become positive again. There is no set rule for the number of negative tests necessary to indicate a cure. The whole thing is a matter of judgment on the part of an experienced physician, and to that judgment the patient should commit himself unhesitatingly. If a patient could once have displayed before him in visible form the immense amount of knowledge, experience, and labor which has gone into the devising and goes into the performing of this test, he would be more content to leave the decision of such questions to his physician than he sometimes is, and would be more alive to its reality and importance. The average man thinks it a rather shadowy and indefinite affair on which to insist that he shall keep on doctoring, especially after the test has been negative once or twice.
Just as a negative test may occur while syphilis is still actively present and doing damage in the body, so a positive Wassermann test may persist long after all outward and even inward signs of the disease have disappeared. These fixed positives are still a puzzle to physicians. But many patients with fixed positives, if well treated regardless of their blood test, do not seem to develop the late accidents of the disease. If their nervous systems, on careful examination, are found not to be affected, they are reasonably safe as far as our present knowledge goes. People with fixed positives should accept the judgment of their physicians and follow their recommendations for treatment without worrying themselves gray over complications which may never develop.
Practical Points About the Test.—Certain practical details about this test are of interest to every one. Blood for it is usually drawn from a small vein in the arm. The discomfort is insignificant—no more than that of a sharp pin-prick. Blood is drawn in the same way for other kinds of blood tests, so that a needle-prick in the arm is not necessarily for a Wassermann test. There is no cutting and no scar remains. The amount of blood drawn is small and does not weaken one in the least. The test is done on the serum or fluid part of the blood, after the corpuscles are removed. It can also be done on the clear fluid taken from around the spinal cord, and this is necessary in certain syphilitic nervous diseases. There is nothing about the test that need make anybody hesitate in taking it, and it is safe to say that, when properly done, the information that it gives is more than worth the trouble, especially to those who have at any time been exposed, even remotely, to the risk of infection. But the test must be well done, by a large hospital or through a competent physician or specialist, and the results interpreted to the patient by the physician and not by the laboratory that does the test, or in the light of the patient's own half-knowledge of the matter.
The Treatment of Syphilis
Scientific Methods of Treating Disease.—In trying to treat diseases caused by germs, the physician finds himself confronted by several different problems. Certain of these diseases run their course and the patient gets well or dies, pretty much regardless of anything that can be done for him. In certain others, because of our knowledge of the way in which the body makes its fight against the germ, we are able either to prepare it against attack, as in the case of protective vaccination, or we are able to help it to come to its own defense after the disease has developed. This can be done either by supplying it with antitoxin from an outside source, or helping it to make its own antitoxin by giving it dead germs to practise on. In the third group, the smallest of the three, we are fortunate enough to know of some substance which will kill the germ in the body without killing the patient. For such diseases we are said to have a "specific" method of treatment. Syphilis is one of these diseases. It is not to be understood that there is a sharp line of division between these three groups, since in every disease we try as far as possible to use all the methods we can bring to bear. In pneumonia we have to let the body largely make its own fight, and simply help it to clear out the poisons formed by the germ, and keep the heart going until the crisis is past. In diphtheria, nowadays, we help the body out promptly by supplying it with antitoxin from an outside source, before it has time to make any for itself. We do the same thing for lockjaw if we are early enough. We practise the body on dead typhoid germs by vaccination until it is able to fight the living ones and destroy them before they get a foothold. The diseases for which we have specific methods of treatment are few in number, and each has associated with it the name of a particular drug. Quinin kills the germ of malaria, sodium salicylate cures inflammatory rheumatism, and mercury cures syphilis. To mercury in the case of syphilis must now be added salvarsan or arsenobenzol ("606"), the substance devised by Ehrlich in 1910, which will be considered in the next chapter.
The action of a specific is, of course, not infallible, but the failures are exceptional, so that one feels in attacking one of these diseases with its specific remedy as a man called upon to resist a savage beast would feel if he were armed with a powerful rifle instead of a stick. The situation in syphilis, for which there is a specific, as compared with tuberculosis, for which there is no specific, is incomparably in favor of the former. If we had as powerful weapons against tuberculosis as we have against syphilis, the disease would now be a rarity instead of the disastrous plague it is. Comparing the situation in two diseases for which we have specifics, such as syphilis and malaria, malaria has lost most of its seriousness as a problem in any part of the world, while syphilis is rampant everywhere. Malaria has, of course, been extinguished not only through the efficiency of quinin, but also through preventive measures directed at mosquitos, which are the carriers of the disease from person to person. But allowing for this, if it becomes possible to apply mercury and salvarsan as thoroughly to the prevention and treatment of syphilis as quinin can be applied to malaria, syphilis will soon be a rarity over the larger part of the civilized world. To bring the specific remedies for syphilis and the patient together constitutes, then, one of the greatest problems which confronts us in the control of the disease at the present day.
Mercury in the Treatment of Syphilis.—Mercury is, of course, familiar to every one, and there is nothing peculiar about the mercury used in the treatment of syphilis. The fluid metallic mercury itself may be used in the form of salves, in which the mercury is mixed with fatty substances and rubbed into the skin. Mercury can be vaporized and the vapor inhaled, and probably the efficiency of mercury when rubbed into the skin depends to no small extent on the inhalation of the vapor which is driven off by the warmth of the body. Mercury in the form of chemical salts or compounds with other substances can be given as pills or as liquid medicine. Similarly, the metal itself or some of its compounds can be injected in oil with a hypodermic needle into the muscles, and the drug absorbed in this way.
Misconceptions Concerning Mercury.—The use of mercury in syphilis is nearly as old, in Europe at least, as the disease itself. The drug was in common use in the fifteenth century for other conditions, and was promptly tried in the new and terrible disease as it spread over Europe, with remarkable results. But doses in the old days were anything but homeopathic, and overdoses of mercury did so much damage that for a time the drug fell into undeserved disfavor. Many of the superstitions and popular notions about mercury originated at this period in its history. It was supposed to make the bones "rot" and the teeth fall out, an idea which one patient in every ten still entertains and offers as an objection when told he must take mercury. Insufficiently treated syphilis is, of course, what makes the bones "rot," and not the mercury used in treating the disease. Mercury apparently has no effect on the bones whatever. The influence of the drug on the teeth is more direct and refers to the symptoms caused by overdoses. No physician who knows his business ever gives mercury at the present time to the point where the teeth are in any danger of falling out.
The Action of Mercury.—The action of mercury on syphilis is not entirely clear. The probabilities are that the drug, carried to all parts of the body by the blood, helps to build up the body's resistance and stimulates it to produce substances which kill the germs. In addition, of course, it kills the germs by its own poisonous qualities. Its action is somewhat slow, and it is even possible for syphilitic sores containing the germs to appear, especially in the mouth and throat and about the genitals, while the person is taking mercury. Just as quinin must be used in malaria for some time after all signs of chill and fever have disappeared, to kill off all germs lurking in out-of-the-way corners of the body, or especially resistant to the drug, so it is necessary to continue the use of mercury long after it has disposed of all the obvious signs of the disease, like the eruption, headaches, and other symptoms, in order to prevent a relapse. No matter in what form it is used, the action of mercury on syphilis is one of the marvels of medicine. It can clear up the most terrific eruption with scarcely a scar, and transform a bed-ridden patient into a seemingly healthy man or woman, able to work, in the course of a few weeks or months. Symptoms often vanish before it like snow in a thaw. This naturally makes a decided impression, and often an unfavorable one, on the patient. It is only too easy to think that a disease which vanishes under the magic influence of a few pills is a trifle, and that outwardly cured means the same thing as inwardly cured. Mercury therefore carries its disadvantages with its advantages, and by its marvelous but transient effect only too often gives the patient a false idea of his progress toward cure.
Methods of Administering Mercury.—As has been said, mercury is given principally in three ways at the present time. It can be given by the mouth, in the form of pills and liquids, and in this form is not infrequently incorporated into patent medicine blood purifiers. Mercury in pills and liquid medicine has the advantage for the patient of being an easy and inconspicuous way of taking the drug, and for that reason patients usually take it willingly or even insist on it if they know no better. Even small doses taken in this way will hide the evidences of syphilis so completely that only a blood test will show that it exists. If it were true that large doses taken by mouth could always be relied on to cure the disease, there would be little need for other ways of giving it. But there is a considerable proportion of persons with syphilis treated with pills who do not get rid of the disease even though the dose is as large as the stomach can stand. Such patients often have all the serious late complications which befall untreated patients. It seems almost impossible to give enough mercury by mouth to effect a cure. Thus pill treatment has come to be a second-best method, and suitable only in those instances in which we simply expect to control the outward signs rather than effect a cure.
The mercury rub or inunction, under ideal conditions, all things considered, is the best method of administering mercury to a patient with the hope of securing a permanent result. In this form of treatment the mercury made up with a salve is rubbed into the skin. The effectiveness of the mercurial rub is reduced considerably by its obvious disadvantages. It requires time to do the rubbing, and the ointment used seems uncleanly because of its color and because it is necessary to leave what is not rubbed in on the skin so that it discolors the underwear. The mercurial rub is at its best when it is given by some one else, since few patients have the needed combination of conscientiousness, energy, and determination to carry through a long course. The advantages of the method properly carried out cannot be overestimated. It is entirely possible in a given case of syphilis to accomplish by a sufficient number of inunctions everything that mercury can accomplish, and with the least possible damage to the body. Treatment by mouth cannot compare with inunctions and cannot be made to replace them, when the only objection to the rubs is the patient's unwillingness to be bothered by them. The patient who is determined, therefore, to do the best thing by himself will take rubs conscientiously as long as his physician wishes him to do so, even though it means, as it usually does, not a dozen or two, but several hundreds of them, extending over a period of two or three years, and given at the rate of four to six rubs a week.
The giving of mercury by injections is a very powerful method of using the drug for the cure of syphilis. It reduces the inconvenience of effective treatment to a minimum and has all the other advantages of secrecy and convenience. It keeps the patient, moreover, in close touch with his physician and under careful observation. Injections by some methods are given daily, by others once or twice a week. The main disadvantage is the discomfort which follows each injection for a few hours. For any one who has one of the serious complications of syphilis, injections may be a life and death necessity. Mercurial injections are a difficult form of treatment and should be given only by experts and physicians who are thoroughly familiar with their use.
Like every important drug in medicine, mercury is a poison if it is abused. Its earliest effect is on the mouth and teeth, and for that reason the physician, in treating syphilis by vigorous methods, has his patients give special attention to the care of their mouths and teeth and of their digestions as well. Mercury also affects the kidneys and the blood, if not properly given, and for that reason the person who is taking it must be under the care and observation of a physician from time to time. Only the ignorant undertake to treat themselves for syphilis, though how many of these there are can be inferred from the amount of patent medicine and quack treatment there is in these fields. Properly given, mercury has no harmful effects, and there is no ground whatever for the notion some people have, that mercury will do them more harm than a syphilitic infection. Improperly used, either as too much or too little, it is capable of doing great harm, not only directly, but indirectly, by making it impossible later for the patient to take enough to cure the disease. The extent to which some overconfident persons fail in their efforts to treat and cure themselves explains the necessity for such a warning.