In the length of the incubation period and the comparatively trifling character of the early signs, the germ of syphilis betrays one of its most dangerous characteristics. The germ of pneumonia, for example, may be present on the surface of the body, in the mouth or elsewhere, for a long time, but the moment it gets a real foothold, there is an immediate and severe reaction, the body puts up a fight, and in ten days or so has either lost or won. The germ of syphilis, on the other hand, secures its place in the body without exciting very strenuous or wide-spread opposition. The body does not come to its own defense so well as with a more active enemy. The fitness of the germ of syphilis for long-continued life in the body, and the difficulty of marshaling a sufficient defense against it, is what makes it impossible to cure the disease by any short and easy method.
The First Sore or Chancre.—The primary lesion, first sore or chancre,[6] is the earliest sign of reaction which the body makes to the presence of the growing germs of syphilis. This always develops at the point where the germs entered the body. The incubation period ends with the appearance of a small hard knot or lump under the skin, which may remain relatively insignificant in some cases and in others grow to a considerable size. Primary lesions show the greatest variety in their appearance and degree of development. If the base of the knot widens and flattens so that it feels and looks like a button under the skin, and the top rubs off, leaving an exposed raw surface, we may have the typical hard chancre, easily recognized by the experienced physician, and perhaps even by the layman as well. On the other hand, no such typical lesion may develop. The chancre may be small and hidden in some out-of-the-way fold or cleft, and because it is apt to be painless, escape recognition entirely. In women the opportunity for concealment of a primary sore itself is especially good, since it may occur inside the vagina or on the neck of the womb. In men it may even occur inside the canal through which the urine passes (urethra). The name "sore" is deceptive and often misleads laymen, since there may be no actual sore—merely a pinhead-sized pimple, a hard place, or a slight chafe. The development of a syphilitic infection can also be completely concealed by the occurrence of some other infection in the same place at the same time, as in the case of a mixed infection with syphilis and soft ulcers or chancroids. Even a cold-sore on the mouth or genitals may become the seat of a syphilitic infection which will be misunderstood or escape notice.
[6] Pronounced shan'-ker.
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.