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

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.

Chapter IV

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.

Chapter V

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.

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.

Chapter VI

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 Spirochæta 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.