The first manifestations of syphilis make their appearance about three or four weeks after infection, at the place at which infection has occurred, and this is not in every case the genital organs. It is true that syphilis is most commonly transmitted by means of sexual intercourse, but frequently also by contacts of other kinds—for example, by kissing; by gynecological or surgical examinations and operations; by drinking from a glass which has previously been used by some one suffering from syphilis; by the use of uncleansed pocket-handkerchiefs, towels, and bedding, which have been used by a syphilitic patient; by the use of tobacco-pipes, wind-instruments, tooth-brushes, tooth-picks, a glass-blower’s mouthpiece, etc., belonging to strangers; by an uncleansed razor; by the nasty habit of licking the point of a pencil; by moistening postage-stamps with the tongue; by sucking the wound in circumcision; by the suckling of the infant at the breast of a syphilitic wet-nurse, etc.[319] In England the custom, when taking a judicial oath, of kissing the Bible has repeatedly sufficed to transmit syphilitic infection.
In certain districts in which the level of civilization is a low one—as, for example, in some parts of Russia and of Turkey—as many as 50 to 60 % of all infections occur independently of sexual intercourse.
All the discharges from syphilitic lesions in all three stages of the disease are infective. The infective character of the tertiary stage of syphilis was formerly doubted, but has recently been proved beyond dispute. Blood also, although more rarely, can prove infective. On the other hand, the pure secretions—that is, the physiological secretions, not contaminated by morbid products—such as the saliva, tears, and milk, are not infective. Syphilis is, however, very frequently transmitted by means of the semen.
Infection occurs in places in which there is a solution of continuity of the skin or mucous membrane, such as a scratch or a superficial wound, through which the virus can enter. In this way an apparently healthy syphilitic patient—when, for example, he gets a small abrasion on the penis (or, in the case of a woman, in the vagina)—can transmit syphilis if the other individual also has a similar abrasion through which infection can occur.
As we have said, it is not till the lapse of two to four weeks after infection has occurred that the first manifestations of syphilis appear, in the form of a small vesicle or nodule in the infected area; less often merely an abraded area of a peculiar red colour. Gradually this nodule or area enlarges, and becomes continually harder at the base, whilst the surface often undergoes ulceration, and secretes extremely infective pus (the so-called “hard chancre” or “primary lesion”[320]).
This induration is in most cases a certain sign that the syphilitic virus has already entered the body; at least, it has only been possible in a few very rare cases, by excision or cauterization of the hard chancre, to prevent syphilis from entering the blood. Almost always, notwithstanding such endeavours, the manifestations of general infection of the body soon appear.
From the place of infection—that is, from the place at which the hard chancre forms—the syphilitic virus next passes by way of the lymph-stream into the inguinal glands, so that these, in the third or fourth week after the appearance of the hard chancre, begin to swell and to become hard. This swelling of the inguinal glands is painless (the so-called “indolent bubo”), in contrast to the painful swelling which accompanies the soft chancre. From this region the poison now proceeds by way of the bloodvessels and lymph paths on its wanderings all over the body, the individual stages of which can be detected by swellings of the lymph-glands of the axilla, the elbow, the neck, etc. Sometimes other symptoms of general infection are noticeable; above all, the appearance of fever (never earlier than forty days after infection), pains in the muscles, joints, nerves, also severe headaches, a general feeling of lassitude, pallor, and a falling-off in the nutritive condition.
These are the forerunners of the so-called secondary stage of syphilis, which now manifests itself by the appearance of a multiform skin eruption, rendering the diagnosis of syphilis absolutely certain. For this reason, in doubtful cases of ulceration of the genital organs the patient should inspect his skin very carefully every day for several weeks or months, and keep watch for the appearance of red spots or nodules. This syphilitic eruption on the skin is also in the later periods one of the most certain and most characteristic insignia of the disease.
The eruption commonly appears first on the trunk, in the form of rose-coloured spots (the so-called “roseola syphilitica”), spreads thence over the whole body, and in many cases, simultaneously with or shortly after the spotted eruption, nodules appear on the skin, and marked thickenings form on the mucous membranes, especially at the anus, in the mouth, and on the tongue (the so-called “plaques muqueuses,” or “condylomata”). The patient’s attention is spontaneously directed to these lesions by painful sensations in the mouth or by itching of the anus. Often it is these painful sensations, associated with a violent inflammation of the tonsils and pharynx (the so-called “angina syphilitica”), which first lead the patient to consult a doctor, after all the earlier symptoms have passed by unnoticed! As characteristic forms of the secondary syphilitic changes in the skin must, therefore, be mentioned the so-called “corona Veneris,” by which distinguished name is denoted an eruption on the forehead, especially along the margin of the hair, which by members of the laity is easily confused with other affections of the skin common in this locality; the so-called “collier de Venus,” or leukoderma syphiliticum, a peculiar pigmentation of the skin on the throat and the back of the neck in the form of brown patches with white intervening areas. This symptom, which occurs almost exclusively in women, is an absolutely certain sign of syphilis. Equally characteristic is the so-called “syphilitic psoriasis,” the appearance of peculiar patches and thickenings on the palms of the hands and the soles of the feet; characteristic also is the syphilitic loss of hair, by its sudden onset and by the patchy way in which it occurs. Not rarely do we see purulent eruptions on the skin in this secondary stage of syphilis.
The syphilitic eruption of the skin is only an external manifestation of a disease affecting the entire body, for the internal organs also suffer. The affection of the liver manifests itself by jaundice; that of the brain and the meninges by headaches and by weakness of memory, which is often well marked at this stage; that of the spleen by swelling; that of the kidneys by the appearance of albumin in the urine; that of the bones by very painful inflammatory swellings; that of the eyes specially by the well-known syphilitic iritis (60 % of all inflammations of the iris are syphilitic in nature!).