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[pg 46] 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[pg 47] 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[pg 48] 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[pg 49] 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[pg 50] 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 r?le of syphilis in the production of insanity, and the cost of the disease to the state from the standpoint of mental disease alone.[pg 51] 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[pg 52] 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,[pg 53] 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.