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,[3] 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 _Spirochæta pallida_.[4] 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.
[3] See frontispiece.
[4] 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 Laënnec 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,[5] 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.
[5] 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 Spirochæta
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
Spirochæta 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,[6] 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.
[6] 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 reëxamine 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.