The Nature and Course of Syphilis (Continued)
LATE SYPHILIS (TERTIARY STAGE)
+The Seriousness of Late Syphilis.+--While we recognize a group of
symptoms in syphilis which we call late or tertiary, there is no
definite or sharp boundary of time separating secondary from tertiary
periods. The man who calculates that he will have had his fling in the
ten or twenty years before tertiary troubles appear may be astonished to
find that he can develop tertiary complications in his brain almost
before he is well rid of his chancre. "Late accidents," as we call them,
are the serious complications of syphilis. They are, as has been said,
brought about by relatively few germs, the left-overs from the flooding
of the body during the secondary period. There is still a good deal of
uncertainty as to just what the distribution of the germs which takes
place in the secondary period foreshadows in the way of prospects for
trouble when we come to the tertiary period. It may well be that the man
who had many germs in his skin and a blazing eruption when he was in the
second stage, may have all his trouble in the skin when he comes to the
late stage. It is the verdict of experience, however, that people who
have never noticed their secondary eruption because it was so mild are
more likely to be affected in the nervous system later on. But this may
be merely because the condition, being unrecognized, escapes treatment.
It is at least safe to say that those whose skins are the most affected
early in the disease are the fortunate ones, because their recognition
and treatment in the secondary stage help them to escape locomotor
ataxia and softening of the brain. Conversely the victim who judges the
extent and severity of his syphilis by the presence or absence of a
"breaking out" is just the one to think himself well for ten or twenty
years because his skin is clean, and then to wake up some fine morning
to find that he cannot keep his feet because his concealed syphilis is
beginning to affect his nervous system.
+Nature of the Tissue Change in Late Syphilis--Gummatous
Infiltration.+--The essential happening in late syphilis is that body
tissue in which the germs are present is replaced by an abnormal tissue,
not unlike a tumor growth. The process is usually painless. This
material is shoddy, so to speak, and goes to pieces soon after it grows.
The shoddy tissue is called "gummatous infiltration," and the tumor, if
one is formed, is called a "gumma." The syphilitic process at the edge
of the gumma shuts off the blood supply and the tissue dies, as a finger
would if a tight band were wound around it, cutting off the blood
supply. Gumma can develop almost anywhere, and where it does, there is a
loss of tissue that can be replaced only by a scar. In this way gummas
can eat holes in bone, or leave ulcerating sores in the skin where the
gumma formed and died, or take the roof out of a mouth, or weaken the
wall of a blood-vessel so that it bulges and bursts. The sunken noses
and roofless mouths are usually syphilitic--yet if they are recognized
in time and put under treatment, all these horrible things yield as by
magic. There are few greater satisfactions open to the physician than to
see a tertiary sore which has refused to heal for months or years
disappear under the influence of mercury and iodids within a few weeks.
Still better, if treatment had been begun early in the disease, and
efficiently and completely carried out, none of these conditions need
ever have been.
+Destructive Effects of Late Syphilis.+--Late syphilis is, therefore,
destructive, and the harm that it does cannot, except within narrow
limits, be repaired. It is responsible for the kind of damaged goods
which gives the disease its reality for the every-day person. It is a
matter of desperate importance where the damage is done. Late syphilis
in the skin and bones, while horrible enough to look at, and disfiguring
for life, is not the most serious syphilis, because we can put up with
considerable loss of tissue and scarring in these quarters and still
keep on living. But when late syphilis gets at the base of the aorta,
the great vessel by which the blood leaves the heart, and damages the
valves there, the numbering of the syphilitic's days begins. Few can
afford to replace much brain substance by tertiary growths and expect to
maintain their front against the world. Few are so young that they can
meet the handicap that old age and hardening of the arteries, brought on
prematurely by late syphilis, put upon them. When late syphilis affects
the vital structures and gains headway, the victim goes to the wall.
This is the really dangerous syphilis--the kind of syphilis that
shortens and cripples life.
There are few good estimates of the extent of late accidents, as we
often call the serious later complications in syphilis, or of the part
that they play in medicine as a whole. Too many of them are
inconspicuous, or confused with other internal troubles that result from
them. Deaths from syphilis are all the time being hidden under the
general terms "Bright's disease," or "heart disease," or "paralysis," or
"apoplexy." It is a hopeful fact that, even under unfavorable
conditions, only a comparatively small percentage, from 10 to 20 per
cent, seem to develop obvious late accidents. On the other hand, it must
not be forgotten that the obscure costs of syphilis are becoming more
apparent all the time, and the influence of the disease in shortening
the life of our arteries and of other vital structures is more and more
evident. There is still good reason for avoiding the effects of syphilis
by every means at our disposal--by avoiding syphilis itself in the first
place, and by early recognition of the disease and efficient treatment,
in the second.
+Late Syphilis of the Nervous System--Locomotor Ataxia.+--The ways in
which late syphilis can attack the nervous system form the real terrors
of the disease to most people. Locomotor ataxia and general paralysis of
the insane (or softening of the brain) are the best known to the laity,
_though only two of many ways in which syphilis can attack the nervous
system_. Though their relation to the disease was long suspected, the
final touch of proof came only as recently as 1913, when Noguchi and
Moore, of the Rockefeller Institute, found the germs of the disease in
the spinal cords of patients who had died of locomotor ataxia, and in
the brains of those who had died of paresis. The way in which the damage
is done can scarcely be explained in ordinary terms, but, as in all late
syphilis, a certain amount of the damage once done is beyond repair.
Locomotor ataxia begins to affect the lower part of the spinal cord
first, so that the earliest symptoms often come from the legs and from
the bladder and rectum, whose nerves are injured. Other parts higher up
may be affected, and changes resulting in total blindness and deafness
not infrequently occur. Through the nervous system, various organs,
especially the stomach, may be seriously affected, and excruciating
attacks of pain with unmanageable attacks of vomiting (gastric crises)
are apt to follow. This does not, of course, mean that all pain in the
stomach with vomiting means locomotor ataxia. All sorts of obscure
symptoms may develop in this disease, but the signs in the eyes and
elsewhere are such that a decision as to what is the matter can usually
be made without considering how the patient feels, and by evidence which
is beyond his control.
+Late Syphilis of the Nervous System--General Paralysis.+--General
paralysis, or paresis, is a progressive mental degeneration, with
relapses and periods of improvement which reduce the patient by
successive stages to a jibbering idiocy ending invariably in death. Such
patients may, in the course of their decline, have delusions which lead
them to acts of violence. The only place for a paretic is in an asylum,
since the changes in judgment, will-power, and moral control which occur
early in the disease are such that, before the patient gets
unmanageable, he may have pretty effectually wrecked his business and
the happiness of his family and associates. When the condition is
recognized, the family must at least be forewarned, so that they can
take action when it seems necessary. Both locomotor ataxia and paresis
may develop in the same person, producing a combined form known as
taboparesis.
The importance of locomotor ataxia and paresis in persons who carry
heavy responsibilities is very great. In railroad men, for example, the
harm that can be done in the early stages of paresis is as great as or
even greater than the harm that an epileptic can do. A surgeon with
beginning taboparesis may commit the gravest errors of judgment before
his condition is discovered. Men of high ability, on whom great
responsibilities are placed, may bring down with them, in their
collapse, great industrial and financial structures dependent on the
integrity of their judgment. The extent of such damage to the welfare of
society by syphilis is unknown, though here and there some investigation
scratches the surface of it. It will remain for the future to show us
more clearly the cost of syphilis in this direction.
+Syphilis and Mental Disease.+--Williams,[7] before the American Public
Health Association, has recently carefully summarized the rôle of
syphilis in the production of insanity, and the cost of the disease to
the State from the standpoint of mental disease alone. He estimates
that 10 per cent of the patients who enter the Massachusetts State
hospitals for the insane are suffering from syphilitic insanity. Fifteen
per cent of those at the Boston Psychopathic Hospital have syphilis. In
New York State hospitals, 12.7 per cent of those admitted have
syphilitic mental diseases. In Ohio, 12 per cent were admitted to
hospitals for the same reason. An economic study undertaken by Williams
of 100 men who died at the Boston State Hospital of syphilitic mental
disease, the cases being taken at random, showed that the shortening of
life in the individual cases ranged from eight to thirty-eight years,
and the total life loss was 2259 years. Of ten of these men the earning
capacity was definitely known, and through their premature death there
was an estimated financial loss of $212,248. It cost the State of
Massachusetts $39,312 to care for the 100 men until their death.
Seventy-eight were married and left dependent wives at the time of their
commission to the hospital. In addition to the 100 men who became public
charges, 109 children were thrown upon society without the protection of
a wage-earner. Williams estimates, on the basis of published admission
figures to Massachusetts hospitals, that there are now in active life,
in that state alone, 1500 persons who will, within the next five years,
be taken to state hospitals with syphilitic insanity.
[7] Williams, F. E.: "Preaching Health," Amer. Jour. Pub. Health,
1917, vi, 1273.
+Frequency of Locomotor Ataxia and General Paralysis.+--The percentage
of all syphilitic patients who develop either locomotor ataxia or
paresis varies in different estimates from 1 to 6 per cent of the total
number who acquire syphilis. The susceptibility to any syphilitic
disease of the nervous system is hastened by the use of alcohol and by
overwork or dissipation, so that the prevalence of them depends on the
class of patients considered. It is evident, though, that only a
relatively small proportion of the total number of syphilitics are
doomed to either of these fates. Taking the population as a whole, the
percentage of syphilitics who develop this form of late involvement
probably does not greatly exceed 1 per cent.
+Treatment and Prevention of Late Syphilis of the Nervous
System.+--Locomotor ataxia and paresis, even more than other syphilitic
diseases of the nervous system, are extremely hard to affect by
medicines circulating in the blood, and for that reason do not respond
to treatment with the ease that syphilis does in many other parts of the
body. Early locomotor ataxia can often be benefited or kept from getting
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.
SUMMARY
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.