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.