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 Spirochæta pallida tend to thrive in the nervous
system, others perhaps in the skin. On the other hand, in certain
persons, for example, heavy drinkers, the nervous system is most open
to attack, in others the bones may be most affected, in still others,
the skin.
+Variations in the Course of Syphilis in Different Persons.+--So it
comes about that in the secondary stage there may be wide differences in
the amount and the location of the damage done by syphilis. One patient
may have a violent eruption, and very little else. Another will scarcely
show an outward sign of the disease and yet will be riddled by one
destructive internal change after another. In such a case the secondary
stage of the disease may pass with half a dozen red spots on the body
and no constitutional symptoms, and the patient go to pieces a few years
later with locomotor ataxia or general paralysis of the insane. On the
other hand, a patient may have a stormy time in the secondary period and
have abundant reason to realize he has syphilis, and under only moderate
treatment recover entirely. Still another will have a bad infection from
the start, and run a severe course in spite of good treatment, to end in
an early wreck. The last type is fortunately not common, but the first
type is entirely too abundant. It cannot be said too forcibly that in
the secondary as in the primary stage, syphilis may entirely escape the
notice of the infected person, and he may not realize what ails him
until years after it is too late to do anything for him. Here, as in the
primary stage, the lucky person is the one who shows his condition so
plainly that he cannot overlook it, and who has an opportunity to
realize the seriousness of his disease. It used to be an old rule not
to treat people who seemed careless and indifferent until their
secondary eruption appeared, in the hope that this flare-up would bring
them to their senses. The necessity for such a rule shows plainly how
serious a matter a mild early syphilis may be.
+The Dangerous Contagious Relapses.+--Secondary syphilis does not begin
like a race, at the drop of a hat, or end with the breaking of a tape.
When the first outburst has subsided, a series of lesser outbreaks,
often covering a series of years, may follow. These minor relapses or
recurrences are mainly what make the syphilitic a danger to his fellows.
They are to a large extent preventable by thorough modern treatment. Few
people are so reckless as wholly to disregard precautions when the
severe outburst is on. But the lesser outbreaks, if they occur on the
skin, attract little or no attention or are entirely misunderstood by
the patient. Only too often they occur as the flat, grayish patches in
the mouth and genital tract, such as are seen in the secondary stage,
where, because they are out of sight and not painful, they pass
unnoticed. The tonsils, the under side and edges of the tongue, and the
angles of the mouth just inside the lips are favorite places for these
recurrent mucous patches. They are thus ideally placed to spread
infection, for, as in the secondary stage, each of these grayish patches
swarms with the germs of syphilis. Similar recurrences about the
genitals often grow, because of the moisture, into buttons and flat,
cauliflower-like warts from which millions of the germs can be squeezed.
Sometimes they are mistaken for hemorrhoids or "piles." With all the
opportunities that these sores offer for infection, it is surprising
that the disease is not universal. Irritation from friction, dirt, and
discharges, and in the mouth the use of tobacco, are the principal
influences acting to encourage these recurrences.
+Relapses in the Nervous System and Elsewhere.+--Mucous patches are, of
course, not the only recurrences, though they are very common. At any
time a little patch of secondary eruption may appear and disappear in
the course of a short time. Recurrences are not confined to the skin,
and those which take place in the nervous system may result in temporary
or permanent paralysis of important nerves, including those of the eyes
and ears. Again, recurrences may show themselves in the form of a
general running down of the patient from time to time, with loss of
weight and general symptoms like those of the active secondary period.
The secondary period as a whole is not in itself the serious stage of
syphilis. Most of the symptoms are easily controlled by treatment if
they are recognized. Now and then instances of serious damage to sight,
hearing, or important organs elsewhere occur, but these are relatively
few in spite of the enormous numbers and wide distribution of the germs.
Accordingly, the problems that the secondary stage offers the physician
and society at large must center around the recognition of mild and
obscure cases and adequate treatment for all cases. The identification
of the former is vital because of the recurrence of extremely infectious
periods throughout this stage of the disease, and the latter is
essential because vigorous treatment, carried out for a long enough
time, prevents not only the late complications which destroy the
syphilitic himself, but does away with the menace to society that arises
through his infecting others, whether in marriage and sexual contact or
in the less intimate relations of life.