Syphilis of the innocent; a study of the social effects of syphilis on the family and the community, with 152 illustrative cases, made under a grant from the United States Interdepartmental social hygiene board

Front matter

REFERENCE ROOM.

LOCKT CASF

Book -.S^gg.

Preface

For some years we have been interested in the family of the syphilitic. This interest has extended beyond the purely medical problems to the social effects of syphilis. There has come the realization that in many instances syphilis is a c; disease which invades the family. The family being but a i unit of the community, it follows that the communal structure

is also involved. The United States Interdepartmental Social Hygiene Board has granted us funds for the study and investigation of problems related to the familial and social aspects of syphilis. The results of several studies have been published in current journals, but as our investigations increased it seemed to be more satisfactory to publish them as a unit rather than as separate entities. We have attempted to present the subject of syphilis in its social aspects, portraying the practical problems as they actually arise in the handling of syphilitic cases, and illustrating the text with cases from the clinic. It is our hope that we have been able to show that the problems of syphilis are many more than those of purely medical interest.

Acknowledgment must be made first of all to the United States Interdepartmental Social Hygiene Board whose grant of funds made it possible to carry on many of the investigations and to collect and publish the material here presented. Our revered former chief, Dr. E. E. Southard, suggested the idea of presenting our work in the form of a monograph. While his untimely death prevented him from giving the oversight and advice that he otherwise would have done, we hope that we have profited to some extent by what he did give us.

While the major portion of the material comes from our clinic at the Boston Psychopathic Hospital, we have fortunately been able to collect material from several other sources. We would especially acknowledge our indebtedness to the following persons and institutions :

Dr. C. Morton Smith, physician in chief of the South Medical Department of the Massachusetts General Hospital, Boston,

IV PREFACE and Miss Ora M. Lewis, chief social worker of the Department; the Children's Hospital, Boston, for the privilege of using cases from their clinics ; Dr. W. A. Hinton of the Wassermami Laboratory of the Massachusetts Department of Public Health who, through his cooperation over a period of years, has enabled us to examine and follow our cases serologically in a manner that is rarely possible, and who gave us access to original statistics concerning the "Wassermann reaction on various groups of patients ; our present chief, Dr. C. Macfie Campbell, who has been most helpful in reading the manuscript and offering valuable suggestions, in addition to having done everything possible to facilitate our work from the material side; Dr. H. A. Bunker, who has been kind enough to give a very careful reading of the proof.

The work has been greatly lightened by the conscientious and intelligent secretarial assistance of Miss Louise C. Francis and Miss Theresa Vesce. Finally, we acknowledge our indebtedness for editorial assistance and care of publication details to the American Social Hygiene Association and especially to Mr. Kenneth M. Gould.

H. C. S.

M. H. S.

Boston Psychopathic Hospital.

Chapter I The Individual

Syphilis as a Disease. — Syphilis is a chronic, infectious, contagious disease, caused by a specific organism known as the Treponema pallidum, or the Spirochaeta pallida. It is a disease, which, unless cured, runs a course as long as the life of the person infected. It is characterized by exacerbations of symptoms and by long periods in which there is no evidence of disease so far as the subjective feelings of the patient are concerned. It has a tendency, nevertheless, to cause various types of physical and mental deterioration, and may lead to incapacity or death.

Syphilis has a very much broader significance than attaches to mere consideration of the individual who originally acquired the disease. Every syphilitic person must be considered as a focus of infection, as a potential danger to the community, in the same category with the ' ' typhoid carrier. " He is thus liable to certain rules and regulations for the benefit of the public health. In addition, as the disease may lead to disintegration of the person's mental and physical abilities, the infected individual must be viewed as a possible social liability. He is likely to become incapable of caring for his family, to be the progenitor of defective children, or to become an inmate of a public institution.

Methods of Infection; Incubation and Primary Periods. —

It will probably be most satisfactory to sketch the life history of syphilis by considering it in relation to an individual. Infection with syphilis means that the Treponema pallidum, the organism of the disease, has in some manner made its way through the skin or mucous membrane of the body, and thus gained access to the underlying tissues. As a rule this occurs through contact between person and person. It is possible, although less usual, for this contact to occur through the mediation of an object which has been contaminated by treponemata from the body of an infected individual. These

A SYPHILIS OF THE INNOCENT

treponemata may then be carried over to the body of a second person. Sexual intercourse is the most frequent method by which the disease is spread, but there are many instances of extragenital infection. For some little time there is no indication that anything has happened. Then at the end of from three to six weeks there occurs what is known as a chancre, or primary sore. The period from the moment that the treponemata enter the body until the appearance of this sore is known as the incubation period. During the incubation period the treponemata which have entered the body begin to multiply. They make their way through the lymphatic vessels which drain the locus at which they entered and reach the blood stream by which they are carried throughout the body. Thus, during this incubation period, although the patient knows of nothing untoward, his body is being invaded by numerous organisms. Finally, after several weeks, the local reaction appears, and with its development the so-called primary period of the disease begins. This local reaction characteristically takes the form of a painless papule, which slowly increases in size, reaching, ordinarily, the dimensions of a small pea. It is prone to assume a crater-like shape, and with the suiTOunding tissue to become indurated. Unless it is then secondarily infected by some pus-producing organism, there is no purulent exudate, but only a thin serous excretion. The glands which drain this region shortly become enlarged and fairly hard. It is rare, indeed, that they become secondarily infected. Thus, if the sore is on the genitals, the glands in the groin will become easily palpable and have a shot-like hardness. If the chancre is on the lip, the glands under the chin will become swollen.

Diagnosis of Primary Stage by Inspection. — The primary sore is rarely painful or in itself a serious symptom. Occasionally it becomes infected and leads to grave and unpleasant consequences. Such infected chancres are spoken of as phagedenic, and a considerable amount of local damage may be done. Ordinarily the chancre will begin to disappear, with or without treatment, after the third or fourth week. It slowly recedes in size, and soon becomes only a scar. If the lesion takes on its most characteristic appearance and is located on the genital organs it will readily be recognized by a physician. When, however, it is located on the finger, lip, or tonsil, it is much less likely to be recognized by its physical characteristics. When it occurs inside of the vagina, on the uterus, or in the urinary meatus it may be entirely overlooked. Many times the chancre does not present characteristic features, but may be merely a small excoriation. It not infrequently occurs at the same time with gonorrhea or with what is known as a soft chancre, non-syphilitic in nature. Under these circumstances, diagnosis is not easy by mere observation.

Laboratory Aids to Diagnosis; Demonstration of Organism. — Fortunately, however, there is a more exact method of making the diagnosis than by depending merely upon the physical picture. The most satisfactory method of diagnosis at the early period of the primary stage is by the demonstration of the organism of the disease. This organism is quite characteristic in its appearance. It can best be demonstrated by the dark-field microscope. A drop of the secretion examined in this way by a person expert in the procedure, will practically always demonstrate the treponema in the first weeks of the disease. Every modern clinic dealing with syphilis has facilities for such an examination, and both private and public laboratories are available to the physician who is without the proper equipment.

Wassermann Reaction and Diagnosis. — During the first week or two after the appearance of the primary sore, the Wassermann reaction is negative and thus, at this period, is of no help in making a diagnosis. After the second or third week, and certainly by the fourth or fifth week, the Wassermann reaction becomes positive, and affords another very satisfactory and reliable method of diagnosing the disease. It is very important, however, to make a diagnosis before the Wassermann reaction becomes positive, because the earlier the diagnosis is made and treatment instituted, the more satisfactory will be the results of treatment.

History and Diagnosis. — Later in the primary stage the diagnosis of syphilis is made not only from the Wassermann reaction but from the history, which includes the evidence of exposure and an incubation period of several weeks, followed by the chancre and the enlargement of the regional lymph glands.

Apparent Innocuousness of Primary Period. — Since the discovery of the treponema in 1906 and the Wassermann reaction in 1909, syphilology has entered into a new era. Many more cases are being correctly diagnosed in the primary stage, owing to the possibility of establishing the diagnosis practically as soon as the first objective evidence of a lesion appears, as well as during the first weeks of the disease. Previously to 1906 it was often necessary to withhold diagnosis and delay treatment for some time, in order to watch the course of the disease and see whether the manifestations of the secondary stage would confirm the suspicions of a syphilitic diagnosis. This was really necessary, for one can readily understand what a terrible injustice to the patient it would be to make an erroneous diagnosis of syphilis with its concomitant implications and mental suffering. By our ability to make an early diagnosis one battle has been won against the vagaries of the syphilitic manifestations. One of the ways the disease is still able to get the better of us is due to its apparent innocuousness in this early stage. The chancre may be quite painless and the general condition of the patient seem in no way affected. However, even before the appearance of the chancre the disease has become systemic and the entire body invaded by the treponema. For this reason, localized treatment has relatively little value in curing the general infection. Indeed it has a great disadvantage if applied before the diagnosis is thoroughly confirmed, as the action of mercury on the lesion tends to kill the superficial treponemata, making the demonstration of the organisms very difficult.

Contagiousness of Primary Period; Importance of Early Treatment.— During the first stage the patient is extremely contagious to others. This contagiousness certainly occurs with the first appearance of the primary sore, and there is a chance that it may be present even earlier. As a rule, several days elapse before the patient seeks advice. During this period he may infect others. As every syphilitic in the primary stage is a most dangerous focus of infection, unless treatment is instituted at once to sterilize the individual, he will continue to be "a carrier' ' for a long time. Treatment at this early period is of the utmost importance for the reasons, first, that it protects others in the community against the infection; second, because the most good can be done to the individual; and third, because with proper care at this time, the patient may avoid becoming a social liability years later. Thus, for its own protection, society has a vital interest in seeing that the patient receives an early diagnosis and adequate treatment. The care and treatment of syphilis is at least as important to the public as the proper control of smallpox, typhoid fever, or other infections, and it is more prevalent than most of the other infections.

Amount of Treatment for Sterilization of Contagiousness; Hospitalization. — Arsphenamin (salvarsan) has the utmost value in the sterilization of the disease, that is, in producing a noncontagious condition. In the majority of cases, three to five injections of this drug will go a long way toward making the patient noncontagious; at any rate, it will cut down the infectivity to such a degree that he is no longer a danger to anyone except those in the very closest contact. The patient must still use great care, of course, to prevent the spread of his disease, and this can best be accomplished by keeping himself and the implements with which he comes in contact away from others. The most satisfactory method of handling the early syphilitic in order to protect others is to hospitalize him at once. Ideally, he should be placed in a hospital as soon as the diagnosis is made. Here he is taught cleanliness and care. In addition, he is immediately placed under vigorous anti syphilitic treatment, consisting of arsphenamin and mercury. At the end of ten days or two weeks, in which period he has received three or more injec-

6 SYPHILIS OF THE IXNOCENT

tions of arsphenamin and a certain amount of mercury, he is relatively sterile as far as the spread of the disease is concerned. At any rate, he is no longer the dangerous individual that he was. By remaining in the hospital he avoids chance contact. He is given more vigorous treatment than would be possible if he were about his ordinary business, and he is taught the principles of personal hygiene. He can then go out into the community with relative safety to others, and continue his treatment.

Early Treatment and a "Cure." — The cure of syphilis is never a rapid process. There are many who maintain that syphilis is incurable. However, there is much evidence indicating the probability that cures can be accomplished, or that, at least, the patient can remain free from symptoms and not endanger others. The earlier treatment is instituted, the better the outlook. In cases that receive adequate treatment beginning at a time before the Wassermann is positive, it is frequently possible to prevent this reaction from ever becoming positive. While this does not prove that the disease has been aborted, it does suggest that a long step has been taken in this direction. Some of the German authorities have stated that if treatment is started during the early primary period, a cure can be obtained by some six months of treatment. Most American authorities would insist upon a longer period of treatment, irrespective of signs or symptoms. However, the outlook is relatively very favorable if treatment is begun in the early stage and pushed with vigor. Hence, there is every reason from the point of view of the patient, his progeny, and society to further early diagnosis and treatment.

Treatment has a tendency to shorten the period of the chancre, that is, the chancre will disappear fairly rapidly under arsphenamin and mercury, and where the treatment has been pushed during the early period the symptoms of the so-called secondary period may be prevented. In the untreated case, the primary period lasts, on the average, from three to six weeks.

Secondary Period — Characteristics. — It must be borne in mind that there is no sharp line demarcating primary,

THE INDIVIDUAL I

secondary, or tertiary periods, but that these divisions are made on a symptomatic basis as an aid in the discussion of the disease. The secondary period may be said to begin with the disappearance of the chancre or the appearance of certain other symptoms which are spoken of as characteristic of the secondary period. In the typical case, about the time that the chancre retrogresses, a rash presents itself on the trunk. This rash may be of the most varied type, from a slight blushing of the skin to severe skin lesions. One of the most frequent forms is the so-called roseola, beginning as a faint reddening and then appearing as small red blotches, which fade upon pressure of the finger. Occurring at the same time are many manifestations of the general invasion. The patient will frequently feel below par, have aching joints and muscles. Slight fever may occur. Headaches of considerable severity, frequently much worse at night, are common. Sore throats frequently lead the patient to seek medical advice. Falling out of the hair and eyebrows (alopecia) are characteristic symptoms.

The symptoms of the secondary stage may be of many different varieties, in some cases quite severe, in other cases so insignificant as to be unnoticed by the patient. The noteworthy feature of this period is the appearance for the first time of symptoms due to a generalized infection throughout the body. The virus, having circulated throughout the body during the primary period, now begins to cause a reaction, giving rise to symptoms, these symptoms being merely the indicators of a bodily reaction to the disease. They have a very real value to the patient in that they lead to treatment. Those cases in which the secondary symptoms are not at all marked or pass unnoticed, are likely to go untreated. Among the severe symptoms which may arise during the secondary period are marked skin and mucous membrane lesions. These rarely lead to any real damage except a certain scarring which may be unpleasant esthetically or cosmetically. However, the central nervous system itself may be definitely involved, and an occasional thrombus (plugging of a blood vessel) in the cerebral vessels may produce paralysis. Meningitis may also occur, leading to severe symptoms or even death. The blood vessels are very frequently involved, and although the involvement may not be of sufficient degree to produce symptoms, it is the forerunner of future trouble. The secondary period of the disease may be looked upon as a period in which the foundation of later serious bodily disease is laid. Involvement of the eyes and ears is another not infrequent occurrence. Iritis, hemorrhagic retinitis, and opacity of the vitreus may lead to blindness. Involvement of the auditory nerve may lead to deafness.

Clinical and Laboratory Diagnosis in Secondary Period. —

There are many features of the secondary period, particularly in its early stage, which point to the diagnosis of the disease from the clinical appearance. The rash, when at all typical, as it is in a large number of cases, offers a very satisfactory opportunity for diagnosis. The combination of the roseola with headache, malaise, falling of the hair and eyebrows, patches on the mucous membranes of the mouth, sore throat, and condylomata, or skin lesions around the anus or vagina, following a few weeks after the appearance of a primary lesion, are very definite proof of a syphilitic infection. When these symptoms occur, there can be little doubt about the correctness of the diagnosis without laboratory assistance. The laboratory findings are naturally of very great importance in conclusively checking up the evidence. During the secondary period of the disease, the Wassermann reaction is positive in about 100 per cent of the cases. Treponemata may be demonstrated from the mucous patches of the mouth and from the condylomata. The latter are particularly rich in treponemata. A caution may be given in regard to the demonstration of treponemata in the mouth : in normal health the mouth is frequently the abode of certain varieties of treponemata which are not associated with syphilis. It is the Treponema pallidum that is the organism of syphilis, and it takes a certain amount of knowledge to be able to distinguish this treponema from other organisms of related groups.

Contagiousness of Secondary Period; Importance of Treatment. — The secondary period, like the primary, is a period

THE INDIVIDUAL V

of great contagiousness. Every patient in the secondary period of the disease may be considered a focus of infection and a definite carrier of a contagious disease. It becomes obvious that, if treponemata are readily demonstrable in the lesions of the mouth, considerable care must be taken in order that these organisms may not be spread to other persons. Kissing is likely to lead to infection in those cases in which there are active mucous membrane lesions, and it is from this source that many lip chancres are produced. Care of utensils which come in contact with syphilitic patients in the secondary period is essential. A comparatively small amount of treatment in this period will make the patient relatively harmless, certainly as far as ordinary social contact is concerned. This is not so true where intimate relations obtain. It should be strongly emphasized that there is a vast difference between sterilization in the sense of the ordinary relations of business and social contact and that required for the intimacies of family life. It should also be borne in mind that there is a similar difference between sterilization as far as the likelihood of infecting the casual contact is concerned, and a cure of the disease. It is likewise true that while a small amount of treatment gives this relative sterility it will not last over a long period of time if treatment is discontinued. It is essential that the treatment be continued faithfully for months or years, in order to produce a complete noncontagiousness. Treatment in the secondary period is very important from the standpoint of the patient's prognosis, as well as of his contagiousness to others. The ideal time to begin treatment, of course, is the very earliest period after the organism has reached the body. If this is not accomplished during the primary stage, then the earlier in the secondary stage treatment is begun, the better the prognosis of the patient.

One frequently sees the patient for the first time in the secondary period of the disease, when the rash or sore throat, mucous patches, malaise, and the like, lead him to consult a physician. This is especially true in the case of women, in whom the chancre may be intravaginal or uterine, and hence not detectable. The same is true of the majority of oases of extragenital infections.

Tertiary Period; Possibility of Involvement of Many Organs of Body. — There is no definite demarcation between the secondary and tertiary periods of syphilis, and, as has already been mentioned, these terms are chiefly applicable for purposes of description. The differentiation of secondary and tertiary periods has been based largely upon the time of the appearance of skin lesions rather than upon any other characteristic of the disease. As one comes to regard syphilis more and more as a generalized infection and less as a skin disease, the arbitrary distinction between secondary and tertiary periods breaks down, and it is more logical to consider the early and late manifestations of the disease. However, it may be stated in a general way that the symptoms which have been described as occurring frequently in the secondary period tend to change their form or to disappear, somewhere around one to two years after the primary infection. The roseola and alopecia are likely to improve spontaneously, even if untreated, at the end of six months or thereabouts. Sometime during the second year of the disease lesions of a somewhat different type begin to make their appearance and hence about this time the disease is considered as having passed into the tertiary period.

As has been stated, the disease is always a generalized one, involving the various parts of the body. The treponemata, circulating as they do throughout the blood stream, may reach any portion of the body. During the early period the blood contains a great number of circulating organisms. As a result of the defense reactions of the patient a large proportion of them are killed. A residual number, however, remain implanted in the various organs of the body and it is from the activity of these organisms that the later manifestations are likely to result. One rather definite characteristic of the treponema is a tendency to involve the blood vessels, and it is chiefly through disease of the blood vessels that the later troubles become manifest. It is also true that the organisms may make a habitat in any organ, where they remain apparently dormant for years, only to come later into definite activity. It may, therefore, be said that any organ or portion of the body may show late signs of syphilitic disease. The skin, the bones, the internal organs, — lungs, liver, kidneys, — the vascular system, blood vessels and heart, — the central nervous system — all may become affected by the treponemal toxins. As a result, syphilis may simulate almost any form of disease. Its late manifestations lie in the province of all specialists of medicine, the internist, the neurologist, the psychiatrist, the dermatologist, the aurist, the ophthalmologist; in fact, there is no specialty which is not concerned with its problems.

Apparent Latency of Disease. — One of the important characteristics of syphilis is the apparent latency or inactivity for years or decades. It is frequently the case that the patient, after his primary or secondary symptoms, or even when these have not been noted, has remained in what he considers the best of health, without any manifestation of illness related to syphilis, for a period of many years, ten, fifteen, twenty, thirty, or even forty years, and then has become the victim of a severe disorder caused entirely by syphilis. This period of so-called latency may, therefore, be considered apparent rather than real. Probably for a time the treponemata are relatively inactive, and then gradually becoming more and more active, lead to a destruction of tissue. This destruction of tissue may be very slow and be unaccompanied by symptoms until the damage is marked and severe. As an illustration, damage to the blood vessels may progress slowly for a period of years without the patient's being aware of the fact. The process continues progressively until some day the patient finds himself less capable of activity, short of breath, possibly with pain in the chest, and examination may then disclose a large aneurysm. This condition, a destruction of the aorta, is one which can hardly be improved by medical treatment, or at least, only very slightly. During all this period the patient is likely to consider himself cured or the disease inactive, whereas, on the contrary, it has been most active and wrought the utmost damage.

A similar story holds for the central nervous system, where the organism may be actively destroying the tissue for years before the symptoms arise which lead to its recognition. By the time such symptoms are noticed a great deal of destruction, irreparable in type, may have occurred. Such is the history of many cases of tabes dorsalis (locomotor ataxia) and general paresis of the insane. From the point of view of frequency and the severity of the damage done, syphilitic involvement of the cardiovascular system and that of the nervous system are the most important. All the other systems, as already stated, are liable to involvement and are frequently affected. In some instances, such as bone and skin lesions, the damage may be relatively less important because it does not affect life and usefulness to the same extent, and the lesions are much more satisfactorily treated.

Clinical Diagnosis of Tertiary Period; Therapeutic Test. —

The diagnosis of late syphilis is often very difficult and obscure. Certain syndromes are recognized as usually, if not always syphilitic, and thus from the clinical picture a diagnosis may be made. Thus arteriosclerosis and angina pectoris, occurring in young people, are most often due to syphilis. In the majority of instances aortic aneurysms are considered as syphilitic. Tabes dorsalis and general paresis are always syphilitic diseases. Skin lesions are likely to be fairly characteristic, so that the diagnosis can be made upon their appearance. Often the conclusion that the patient has had syphilis is arrived at on the basis of his past history or of the finding of certain characteristic skin and mucous membrane lesions. Considerable clinical acumen is essential. In certain conditions such as ulcers, enlarged liver, etc., diagnosis is completed by the so-called therapeutic test. If antisyphilitic treatment leads to rapid improvement, it may be assumed that the condition was of syphilitic origin. The therapeutic test is valuable in certain cases. But it has the disadvantage of often wasting time before one can be sure. This is particularly unfortunate in cases which are not syphilitic. It also is of little value in those cases in which antisyphilitic remedies will not produce very rapid or satisfactory results.

Laboratory Aids to Diagnosis in Tertiary Period; Wassermann Test. 1 — The Wassermann test is of great value, though by no means a final criterion. Although a great number of late syphilitics have a positive Wassermann reaction, there are late syphilitics with active lesions who do not give a positive reaction. On the other hand, it does not follow that because the patient has syphilis the symptoms from which he is suffering are of syphilitic origin. A positive Wassermann may show the presence of a latent syphilitic process in a patient with symptoms of another disease.

Spinal Fluid Examination; Luetin Test.— In cases of syphilis of the central nervous system the spinal fluid examination is of great importance. In the overwhelming majority of these cases positive findings leading to the diagnosis will be present. There are several tests in addition to the Wassermann reaction which are positive in the spinal fluid in the cases of central nervous system disease. Noguchi's luetin test is another satisfactory test for syphilis. Unfortunately, few people are in a position to read correctly this skin reaction for syphilis.