The germ of syphilis,[3] discovered by Schaudinn and Hoffmann in 1905, is an extremely minute spiral or corkscrew-shaped filament9, visible under only the highest powers of the microscope, which increase the area of the object looked at hundreds of thousands of times, and sometimes more than a million of times. Even under such intense magnifications, it can be seen only with great difficulty, since it is colorless in life, and it is hard to color or stain it with dyes. Its spiral form and faint staining have led to its being called the Spiroch?ta pallida.[4] It is best seen by the use of a special device, called a dark-field illuminator10, which shows the germ, like a floating particle in a sunbeam, as a brilliant white spiral against a black background, floating and moving in the secretions11 taken from the sore in which it is found. Some means of showing the germ should be in the hands of every physician, hospital, or dispensary which makes a claim to recognize and treat syphilis.
[3] See frontispiece.
[4] Pronounced spi-ro-kee'-ta.
Syphilis a Concealed12 Disease.—Syphilis is not a grossly conspicuous13 figure in our every-day life, as[Pg 23] leprosy was in the life of the Middle Ages, for example. To the casually14 minded, therefore, it is not at all unreasonable15 to ask why there should be so much agitation16 about it when so little of it is in evidence. It takes a good deal out of the graphic17 quality of the thing to say that most syphilis is concealed, that most syphilitics, during a long period of their disease, are socially presentable. Of course, when we hear that they may serve lunch to us, collect our carfare, manicure our nails, dance with us most enchantingly, or eat at our tables, it seems a little more real, but still a little too much to believe. Conviction seems to require that we see the damaged goods, the scars, the sores, the eaten bones, the hobbling cripples, the maimed, the halt, and the blind. There is no accurate estimate of its prevalence based on a census18, because, as will appear later, even an actual impulse to self-betrayal would not disclose 30 to 40 per cent of the victims of the disease. Approximately this percentage would either have forgotten the trivial beginnings of it, or with the germs of it still in their brains or the walls of their arteries19 or other out-of-the-way corners of their bodies, would think themselves free of the disease—long since "cured" and out of danger.
How Much Syphilis is There?—Our entire lack of a tangible20 idea of how much syphilis there really is among us is, of course, due to the absence of any form of registration21 or reporting of the disease to authorities such as health officers, whose duty it is to collect such statistics, and forms the principal argument in favor of dealing22 with syphilis legally as a contagious[Pg 24] disease. Such conceptions of its prevalence as we have are based on individual opinions and data collected by men of large experience.
Earlier Estimates of the Prevalence of Syphilis.—It is generally conceded that there is more syphilis among men than women, although it should not be forgotten that low figures in women may be due to some extent to the milder and less outspoken23 course of the disease in them. Five times more syphilis in men than women conservatively summarizes our present conceptions. The importance of distinguishing between syphilis among the sick and among the well is often overlooked. For example, Landouzy, in the La?nnec clinic in Paris, estimated recently that in the patients of this clinic, which deals with general medicine, 15 to 18 per cent of the women and 21 to 28 per cent of the men had syphilis. It is fair to presume, then, that such a percentage would be rather high for the general run of every-day people. This accords with the estimates, based on large experience, of such men as Lenoir and Fournier, that 13 to 15 per cent of all adult males in Paris have syphilis. Erb estimated 12 per cent for Berlin, and other estimates give 12 per cent for London. Collie's survey of British working men gives 9.2 per cent in those who, in spite of having passed a general health examination, showed the disease by a blood test. A large body of figures, covering thirty years, and dating back beyond the time when the most sensitive tests of the disease came into use, gives about 8 per cent of more than a million patients in the United States Public Health and Marine24 Hospital Service[Pg 25] as having syphilis. It should be recalled that this includes essentially25 active rather than quiescent26 cases, and is therefore probably too low.
Current Estimates of the Prevalence of Syphilis.—The constant upward tendency of recent estimates of the amount of syphilis in the general population, as a result of the application of tests which will detect even concealed or quiescent cases, is a matter for grave thought. The opinion of such an authority as Blaschko, while apparently27 extreme, cannot be too lightly dismissed, when he rates the percentage of syphilitics in clerks and merchants in Berlin between the ages of 18 and 28 as 45 per cent. Pinkus estimated that one man in five in Germany has had syphilis. Recently published data by Vedder, covering the condition of recruits drawn28 to the army from country and city populations, estimate 20 per cent syphilitics among young men who apply for enlistment29, and 5 per cent among the type of young men who enter West Point and our colleges. It can be pointed30 out also with justice that the percentage of syphilis in any class grouped by age increases with the age, since so few of the cases are cured, and the number is simply added to up to a certain point as time elapses. Even the army, which represents in many ways a filtered group of men, passing a rigorous examination, and protected by an elaborate system of preventions which probably keeps the infection rate below that of the civil population, is conceded by careful observers (Nichols and others) to show from 5 to 7 per cent syphilitics. Attention should be called to the difference between the percentage[Pg 26] of syphilis in a population and the percentage of venereal disease. The inclusion of gonorrhea with syphilis increases the percentages enormously, since it is not infrequently estimated that as high as 70 per cent of adult males have gonorrhea at least once in a lifetime.
On the whole, then, it is conservative to estimate that one man in ten has syphilis. Taking men and women together on the basis of one of the latter to five of the former, and excluding those under fifteen years of age from consideration, this country, with a population of 91,972,266,[5] should be able to muster31 a very considerable army of 3,842,526, whose influence can give a little appreciated but very undesirable32 degree of hyphenation to our American public health. In taking stock of ourselves for the future, and in all movements for national solidarity33, efficiency, and defense34, we must reckon this force of syphilo-Americans among our debits35.
[5] Figures based on 1910 census.
The Primary Stage of Syphilis
The So-called Stages of Syphilis.—The division of the course of syphilis into definite stages is an older and more arbitrary conception than the one now developing, and was based on outward signs of the disease rather than on a real understanding of what goes on in the body during these periods. The primary stage was supposed to extend from the appearance of the first sore or chancre to the time when an eruption36 appeared over the whole body. Since the discovery of the Spiroch?ta pallida, the germ of the disease, our knowledge of what the germ does in[Pg 27] the body, where it goes, and what influence it has upon the infected individual, has rapidly extended. We now appreciate much more fully37 than formerly38 that at the very beginning of the disease there is a time when it is almost purely39 local, confined to the first sore itself, and perhaps to the glands40 or kernels41 in its immediate42 neighborhood. Thorough and prompt treatment with the new and powerful aid of salvarsan ("606") at this stage of the disease can kill all the germs and prevent the disease from getting a foothold in the body which only years of treatment subsequently can break. This is the critical moment of syphilis for the individual and for society, and its importance and the value of treatment at this time cannot be too widely understood.
Peculiarities43 of the Germ.—Many interesting facts about the Spiroch?ta pallida explain peculiarities in the disease of which it is the cause. Many germs can be grown artificially, some in the presence of air, others only when air is removed. The germ of syphilis belongs in the latter class. The germ that causes tuberculosis44, a rod-like organism or bacillus, can stand drying without losing its power to produce the disease, and has a very appreciable45 ability to resist antiseptic agents. If the germ of syphilis were equally hard to kill, syphilis would be an almost universal disease. Fortunately it dies at once on drying, and is easily destroyed by the weaker antiseptics provided it has not gained a foothold on favorable ground. Its inability to live long in the presence of air confines the source of infection largely to those parts of the body which are moist and protected,[Pg 28] and especially to secretions and discharges which contain it. Its contagiousness46 is, therefore, more readily controlled than that of tuberculosis. It is impossible for a syphilitic to leave a room or a house infected for the next occupants, and it is not necessary to do more than disinfect objects that come in contact with open lesions or their secretions, to prevent its spread by indirect means. Such details will be considered more fully under the transmission and hygiene47 of the disease.
Mode of Entry of the Germ.—The germ of the disease probably gains entrance to the body through a break or abrasion48 in the skin or the moist red mucous49 surfaces of the body, such as those which line the mouth and the genital tract2. The break in the surface need not be visible as a chafe50 or scratch, but may be microscopic51 in size, so that the first sore seems to develop on what is, to all appearances, healthy surface. It should not be forgotten that this surface need not be confined to the genital organs, since syphilis may and often does begin at any part of the body where the germ finds favorable conditions for growth.
Incubation or Quiescent Period.—Almost all germ diseases have what is called a period of incubation, in which the germ, after it has gained entrance to the body, multiplies with varying rapidity until the conditions are such that the body begins to show signs of the injury which their presence is causing. The germ of syphilis is no exception to this rule. Its entry into the body is followed by a period in which there is no external sign of its presence to warn the[Pg 29] infected person of what is coming. This period of quiescence52 between the moment of infection with syphilis and the appearance of the first signs of the disease in the form of the chancre may vary from a week to six weeks or even two months or more, with an average of about two or three weeks.
In the length of the incubation period and the comparatively trifling53 character of the early signs, the germ of syphilis betrays one of its most dangerous characteristics. The germ of pneumonia54, 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 strenuous55 or wide-spread opposition56. 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[Pg 30] relatively57 insignificant58 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 flattens59 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 layman60 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 cleft61, and because it is apt to be painless, escape recognition entirely62. In women the opportunity for concealment63 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 deceptive64 and often misleads laymen65, 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 ulcers67 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 uncommon68 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 inoculation69 from[Pg 31] 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 inoculated70 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 fixed71 conception of a chancre into his head will argue insistently72 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 hearsay73 knowledge will maintain his opinion as if it were the product of lifelong experience, and will only too often pay for his folly74 and presumption75 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 judgment76 as a strictly77 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[Pg 32] 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 illicit78 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 tampering79 with sores, chafes80, 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 caustic81 or otherwise, which is the first impulse of the layman with a half-way knowledge and even of some doctors, promptly82 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 applied83 unwisely to even a harmless sore may make a mere66 chafe look like a hard chancre, and result in the patient's[Pg 33] 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 re?xamine and take blood tests at intervals84 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 eruptions85 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 situated86, 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 affected87. If it is on the lip, the neck glands become[Pg 34] swollen88. 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 swell89, 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 swelling90 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 jaw91 in the course of a few days or a couple of weeks, the question of syphilis should be thoroughly92 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 prospect93 of what we call abortive94 cure is past. Nothing can justify95 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 indifference96 many times over.
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contagious
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| adj.传染性的，有感染力的 | |
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tract
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| n.传单，小册子，大片(土地或森林) | |
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overestimated
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| 对（数量）估计过高，对…作过高的评价( overestimate的过去式和过去分词 ) | |
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pimple
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| n.丘疹，面泡，青春豆 | |
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ravages
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| 劫掠后的残迹，破坏的结果，毁坏后的残迹 | |
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culminated
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| v.达到极点( culminate的过去式和过去分词 ) | |
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paralysis
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| n.麻痹(症)；瘫痪(症) | |
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dispelled
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| v.驱散，赶跑( dispel的过去式和过去分词 ) | |
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filament
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| n.细丝；长丝；灯丝 | |
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illuminator
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| n.照明者 | |
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secretions
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| n.分泌（物）( secretion的名词复数 ) | |
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concealed
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| a.隐藏的，隐蔽的 | |
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conspicuous
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| adj.明眼的，惹人注目的；炫耀的，摆阔气的 | |
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casually
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| adv.漠不关心地，无动于衷地，不负责任地 | |
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unreasonable
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| adj.不讲道理的，不合情理的，过度的 | |
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agitation
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| n.搅动；搅拌；鼓动，煽动 | |
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graphic
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| adj.生动的，形象的，绘画的，文字的，图表的 | |
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census
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| n.(官方的)人口调查，人口普查 | |
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arteries
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| n.动脉( artery的名词复数 )；干线，要道 | |
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tangible
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| adj.有形的，可触摸的，确凿的，实际的 | |
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registration
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| n.登记，注册，挂号 | |
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dealing
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| n.经商方法，待人态度 | |
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outspoken
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| adj.直言无讳的，坦率的，坦白无隐的 | |
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marine
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| adj.海的；海生的；航海的；海事的；n.水兵 | |
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essentially
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| adv.本质上，实质上，基本上 | |
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quiescent
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| adj.静止的，不活动的，寂静的 | |
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apparently
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| adv.显然地；表面上，似乎 | |
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drawn
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| v.拖，拉，拔出；adj.憔悴的，紧张的 | |
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enlistment
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| n.应征入伍，获得，取得 | |
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pointed
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| adj.尖的，直截了当的 | |
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muster
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| v.集合，收集，鼓起，激起；n.集合，检阅，集合人员，点名册 | |
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undesirable
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| adj.不受欢迎的，不良的，不合意的，讨厌的；n.不受欢迎的人，不良分子 | |
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solidarity
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| n.团结；休戚相关 | |
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defense
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| n.防御，保卫；[pl.]防务工事；辩护，答辩 | |
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debits
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| n.（簿记中的）收方，借方( debit的名词复数 )；从账户中提取的款项v.记入（账户）的借方( debit的第三人称单数 ) | |
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eruption
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| n.火山爆发；（战争等）爆发；（疾病等）发作 | |
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fully
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| adv.完全地，全部地，彻底地；充分地 | |
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formerly
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| adv.从前，以前 | |
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purely
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| adv.纯粹地，完全地 | |
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glands
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| n.腺( gland的名词复数 ) | |
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kernels
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| 谷粒( kernel的名词复数 )； 仁； 核； 要点 | |
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immediate
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| adj.立即的；直接的，最接近的；紧靠的 | |
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peculiarities
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| n. 特质, 特性, 怪癖, 古怪 | |
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tuberculosis
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| n.结核病，肺结核 | |
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appreciable
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| adj.明显的，可见的，可估量的，可觉察的 | |
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contagiousness
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| [医] （接）触（传）染性 | |
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hygiene
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| n.健康法，卫生学 （a.hygienic） | |
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abrasion
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| n.磨（擦）破，表面磨损 | |
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mucous
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| adj. 黏液的，似黏液的 | |
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chafe
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| v.擦伤；冲洗；惹怒 | |
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microscopic
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| adj.微小的，细微的，极小的，显微的 | |
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quiescence
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| n.静止 | |
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trifling
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| adj.微不足道的；没什么价值的 | |
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pneumonia
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| n.肺炎 | |
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strenuous
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| adj.奋发的，使劲的；紧张的；热烈的，狂热的 | |
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opposition
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| n.反对，敌对 | |
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relatively
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| adv.比较...地，相对地 | |
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insignificant
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| adj.无关紧要的，可忽略的，无意义的 | |
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flattens
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| 变平，使（某物）变平( flatten的第三人称单数 )； 彻底打败某人，使丢脸； 停止增长（或上升）； （把身体或身体部位）紧贴… | |
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layman
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| n.俗人，门外汉，凡人 | |
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cleft
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| n.裂缝；adj.裂开的 | |
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entirely
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| ad.全部地，完整地；完全地，彻底地 | |
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concealment
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| n.隐藏, 掩盖，隐瞒 | |
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deceptive
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| adj.骗人的，造成假象的，靠不住的 | |
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laymen
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| 门外汉，外行人( layman的名词复数 )； 普通教徒（有别于神职人员） | |
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mere
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| adj.纯粹的；仅仅，只不过 | |
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ulcers
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| n.溃疡( ulcer的名词复数 )；腐烂物；道德败坏；腐败 | |
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uncommon
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| adj.罕见的，非凡的，不平常的 | |
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inoculation
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| n.接芽；预防接种 | |
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inoculated
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| v.给…做预防注射( inoculate的过去式和过去分词 ) | |
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fixed
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| adj.固定的，不变的，准备好的；(计算机)固定的 | |
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insistently
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| ad.坚持地 | |
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hearsay
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| n.谣传，风闻 | |
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folly
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| n.愚笨，愚蠢，蠢事，蠢行，傻话 | |
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presumption
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| n.推测，可能性，冒昧，放肆，[法律]推定 | |
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judgment
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| n.审判；判断力，识别力，看法，意见 | |
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strictly
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| adv.严厉地，严格地；严密地 | |
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illicit
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| adj.非法的，禁止的，不正当的 | |
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tampering
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| v.窜改( tamper的现在分词 )；篡改；（用不正当手段）影响；瞎摆弄 | |
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chafes
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| v.擦热（尤指皮肤）( chafe的第三人称单数 )；擦痛；发怒；惹怒 | |
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caustic
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| adj.刻薄的，腐蚀性的 | |
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promptly
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| adv.及时地，敏捷地 | |
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applied
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| adj.应用的；v.应用，适用 | |
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intervals
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| n.[军事]间隔( interval的名词复数 )；间隔时间；[数学]区间；（戏剧、电影或音乐会的）幕间休息 | |
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eruptions
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| n.喷发，爆发( eruption的名词复数 ) | |
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situated
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| adj.坐落在...的，处于某种境地的 | |
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affected
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| adj.不自然的，假装的 | |
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swollen
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| adj.肿大的，水涨的；v.使变大，肿胀 | |
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swell
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| vi.膨胀，肿胀；增长，增强 | |
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swelling
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| n.肿胀 | |
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jaw
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| n.颚，颌，说教，流言蜚语；v.喋喋不休，教训 | |
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thoroughly
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| adv.完全地，彻底地，十足地 | |
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prospect
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| n.前景，前途；景色，视野 | |
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abortive
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| adj.不成功的，发育不全的 | |
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justify
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| vt.证明…正当(或有理)，为…辩护 | |
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indifference
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| n.不感兴趣，不关心，冷淡，不在乎 | |
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