The Transmission and Hygiene of Syphilis
The problem of the control of syphilis as a contagious disease is the
least appreciated and the most important one in the whole field. It
should be the key to our whole attitude toward the disease, and once
given its rightful place in our minds, will revolutionize our situation
with regard to it. For that reason, while some repetition of what has
gone before may be unavoidable, it will be worth while to gather in one
chapter the details relating to the question of how the disease is
spread about.
Two bed-rock facts stand out as the basis for the whole discussion.
First, for practical purposes syphilis is contagious only in the primary
and secondary stages. Second, syphilis is transmitted only by open sores
or lesions whose discharges contain the germs, or by objects which are
contaminated by those discharges. Infection with syphilis by such fluids
as the blood, milk, or spermatic fluid uncontaminated by contact with
active lesions is at least unusual.
+Contagiousness in the Primary Stage.+--The chancre is always
contagious. If it is covered with a dry crust, it is, of course, less
so, but as soon as the crust is rubbed off, the germ-infested surface is
exposed and the thin, watery discharge contains immense numbers of the
organisms, especially in the first two or three weeks. This is just as
true of a chancre on the lip or chin as on the genitals. Chancres which
are in moist places, as in the mouth, or on the neck of the womb, or
under the foreskin, are especially dangerous, because the moisture keeps
the germs on the surface.
+Contagiousness in the Secondary Stage.+--In the secondary period, when
the body is simply filled with germs, one would expect the risk to be
even greater than in the primary stage. As a matter of fact, however, no
matter how many germs there are in the body, the only ones that are
dangerous to others are those that are able to get to the surface. A
syphilitic nodule or hard pimple on the hand or face is not contagious
so long as the skin is dry and unbroken over it. The sores which occur
in the moist, warm, protected places, like the mouth, on the lips, about
the genitals, and in the folds of the body, such as the thighs, groins,
armpits, and under the breasts in women, are, like the chancre, the real
sources of danger in the spread of the disease.
+Relatively Non-contagious Character of Late Syphilis.+--The older a
syphilis is, the less dangerous it becomes. It is the fresh infection
and the early years which are a menace to others. It will be recalled
that the germs die out in the body in immense numbers after the active
secondary period is over, so that when the tertiary stage is reached,
there is only a handful left, so to speak. The germs in a tertiary sore
are so few in number that for practical purposes it is safe to say they
may be disregarded, and that for that reason late syphilis is
practically harmless for others. Just as every syphilitic runs a gradual
course to a tertiary period, so every syphilitic in time becomes
non-contagious, almost regardless of treatment.
+The Time Element in Contagiousness.+--It is the time that it takes an
untreated case to reach a non-infectious stage and the events or
conditions which can occur in the interval, that perpetuate syphilis
among us. The chancre is contagious for several weeks, and few
syphilitics escape having some contagious secondary lesions the first
year. These are often inconspicuous and misunderstood. They may be
mistaken for cold sores or the lesions about the opening of the rectum
may be mistaken for hemorrhoids, or piles. The recurrence of these same
kinds of sores may make the patient dangerous from time to time to those
about him, without his knowledge. It is an unfortunate thing that the
most contagious lesions of syphilis often give the patient least warning
of their presence in the form of pain or discomfort. While they can
often be recognized on sight by a physician, it is sometimes necessary
to examine them with a dark-field microscope to prove their character by
finding the germs. It is a safer rule to regard every open sore or
suspicious patch in a syphilitic as infectious until it is proved not to
be so.
+Contagious Recurrences or Relapses.+--The duration of the infectious
period in untreated cases and the proportion of infectious lesions in a
given case vary a good deal and both may be matters of the utmost
importance. Some persons with syphilis may have almost no recognizable
lesions after the chancre has disappeared. Others under the same
conditions may have crop after crop of them. There is a kind of case in
which recurrences are especially common on the mucous or moist surfaces
of the mouth and throat, and such patients may hardly be free from them
or from warty and moist growths about the genitals during the first five
years of the disease, unless they are continuously and thoroughly
treated. Irritation about the genitals and the use of tobacco in the
mouth encourage the appearance of contagious patches. Smokers, chewers,
persons with foul mouths and bad teeth, and prostitutes are especially
dangerous for these reasons.
+Average Contagious Period.+--It is a safe general rule, the product of
long experience, to consider a person with an untreated[10] syphilis as
decidedly infectious for the first three years of his disease, and
somewhat so the next two years. The duration of infectiousness may be
longer, although it is not the rule. It must be said, however, that more
exact study of this matter since the germ of syphilis was discovered has
tended to show that the contagious period is apt to be longer than was
at first supposed, and has taught us the importance of hidden sores in
such places as the throat and vagina.
[10] The control of infectiousness in syphilis through treatment is
considered in the next chapter.
[Illustration: FRITZ SCHAUDINN [1871-1906]
(From the "Galerie hervorragender Aerzte und Naturforscher."
Supplement to the Münchener med. Wochenschrift, 1906. J. F. Lehmann,
Munich.)]
+Individual Resistance to Infection.+--The contagiousness of untreated
syphilis is influenced by two other factors besides the mere lapse of
time. The first of these is the resistance or opposition offered to
the germ by the person to whom the infection is carried. The second is
the feebleness of the germ itself, and the ease with which it dies when
removed from the body. In regard to the first of these factors, while
natural resistance to the disease in uninfected persons is an uncertain
quantity, it is very probable that it exists. It is certain that the
absence of any break in the skin on which the germs are deposited makes
a decided difference if it does not entirely remove the risk of
infection. A favorable place for the germ to get a foothold is a matter
of the greatest importance. When, however, it is remembered that such a
break may exist and not be visible, it is evident that little reliance
should be placed on this factor in estimating the risk or possibility of
infection.
+Transmission by Infected Articles.+--The feebleness of the germ and the
ease with which it is destroyed are its redeeming qualities. This is of
special importance in considering transmission by contact with infected
articles. Nothing which is absolutely dry will transmit syphilis.
Moisture is necessary to infection with it, and only articles which have
been moistened, such as dressings containing the discharges, and
objects, such as cups, eating utensils, pipes, common towels, and
instruments which come in contact with open sores or their discharges,
are likely to be dangerous. Moreover, even though these objects remain
moist, the spirochetes are likely to die out within six or seven hours,
and may lose their infectiousness before this. Smooth, non-absorbent
surfaces, especially of metal, are unfavorable for the germ.
Wash-basins, dishes, silverware, and toilet articles are usually
satisfactorily disinfected by hot soapsuds, followed by drying. Barbers,
dentists, nurses, and physicians who take care at least to disinfect
instruments and other objects brought into contact with patients with
carbolic acid and alcohol will never transmit syphilitic infection to
others. Toilet-seats, bath-tubs, and door-knobs, although theoretically
dangerous, are practically never so, and syphilitic infection
transmitted by them can be dismissed as all but unknown. This is in
marked contrast to gonorrhea, which in the case of little girls can be
transmitted apparently by toilet-seats. Much depends, as has been said,
on placing the germ on a favorable ground for inoculation, and the bare
skin, unless the virus is massaged or rubbed in, is certainly not a
favorable situation. Many experts do not hesitate to handle infectious
lesions with the fingers provided the skin is not broken, relying simply
on the immediate use of soap and water, and perhaps alcohol, to remove
the germ. While this may be a risk, it should, none the less, reassure
those who are inclined to an unreasoning terror of infection whenever
they encounter the disease.
+Transmission Under the Conditions of Every-day Life.+--The question of
just how dangerous the worker with foodstuffs may be to others when he
has active contagious lesions is unsettled. Recent surveys of various
types of workers have tended to show that syphilis in transmissible form
is not especially prevalent among them. The same general principle
applies here as elsewhere. The risk of infection with syphilis
increases with dirty and unsanitary conditions, and becomes serious when
there is opportunity for moist materials to be transferred to sensitive
surfaces, like the mouth, sufficiently soon after they have left the
syphilitic person for the germs to be still alive. That the real extent
of the risk is not known does not make it any the less important that
persons who have opportunity to handle materials in which this may occur
should be subject to frequent sanitary inspection. Restaurants in which
the silverware is not properly cleaned, and is used over and over at
frequent intervals, and in which there is a careless and unsanitary type
of personal service, can hardly be regarded as safe. While there is no
need for hysterical alarm over such possibilities, it is just as well to
provide for them. Crowding, close quarters, and insufficient sanitary
conveniences in stores and offices, in restaurants or tenements, provide
just the conditions in which accidental infection may occur. A gang of
men with a common bucket and drinking cup may be at the mercy of
syphilis if one member is in a contagious condition. A syphilitic might
cough into the air with little risk, since the germs would die before
they could find a favorable place to infect. But a syphilitic who coughs
directly into one's face with a mouth full of spirochetes multiplies the
risk considerably. The public towel is certainly dangerous--almost as
much so as the common drinking cup. The possibility of syphilitic
infection by cutting the knuckle of the hand against the teeth of an
opponent in striking a blow upon his mouth should not be overlooked, and
the occurrence is common enough for this type of chancre to have
received the special name of brawl, or fist, chancre.
+Accidental Syphilis in Physicians and Nurses.+--Another type of
infection ought not to go unmentioned--that to which physicians and
nurses are exposed in operating on or handling patients with active
syphilis. Before the day of rubber gloves such things were much more
common perhaps than they are now, yet they are common enough at the
present time. Most of the risk occurs in exploring or working in
cavities of the body containing infected discharges. The blood may
become infected in passing over active sores. The risk from all these
sources is so considerable that it is justifiable as a measure of
protection to a hospital staff to take a blood test on every patient who
applies for treatment in a hospital, to say nothing of the advantage
which this would be to the patient.
+Transmission by Intimate Contacts--Kissing.+--As we pass from the less
to the more intimate means of contact between the syphilitic person and
others, the risk of transmitting syphilis may be said to increase
enormously. The fundamental conditions of moisture, a susceptible
surface, protection of the germ from drying and from air, and possibly
also massage or rubbing, are here better satisfied than in the risks
thus far considered. Kissing, caresses, and sexual relations make up the
origin of an overwhelming proportion of syphilitic infection. Infections
are, of course, traceable to the nursing of syphilitic infants. It is
through these sources of contact that syphilis invades the family
especially. Many a syphilitic who realizes that he should not have
sexual relations with his wife while he has the disease in active form
will thoughtlessly infect her or his children by kissing. Kissing games
are potentially dangerous, and a classical example of this danger is
that of a reported case[11] in which a young man in Philadelphia
infected seven young girls in one game, all of whom developed chancres
on the lips or cheeks. It is no great rarity to find a syphilis dating
from a sore on the lip that developed while a young couple were engaged.
Certainly the indiscriminate kissing of strangers is as dangerous an
indulgence as can be imagined. Syphilis does not by any means invariably
follow a syphilitic's kiss, but the risk, although not computable in
figures, is large enough to make even the impulsive pause. The
combination of a cold sore or a small crack on the lip of the one and a
mucous patch inside the lip of the other brings disaster very near.
Children are sometimes the unhappy victims of this sort of thing, and it
should be resented as an insult for a stranger to attempt to kiss
another's child, no matter on what part of the body. It would be easy to
multiply instances of the ways in which syphilis may be spread by the
careless or ignorant in the close associations of family life, but
little would be accomplished by such elaboration that would not occur to
one who took the trouble to acquaint himself with the principles already
discussed.
[11] Schamberg, J. F.: "An Epidemic of Chancres of the Lip from
Kissing," Jour. Amer. Med. Assoc., 1911, lvii, 783.
+The Sexual Transmission of Syphilis.+--The sexual transmission of
syphilis is beyond question the most important factor in the spread of
the disease. Here all the essential conditions for giving the germ a
foothold on the body are satisfied. The genitals are especially fitted
to keep the germs in an active condition because of the ease with which
air is excluded from the numerous folds about these parts. It is
remarkable what trifling lesions can harbor them by the million, and how
completely, especially in the case of women, syphilitic persons may be
ignorant of the danger for others. Sexual transmission of syphilis is
simply a physiologic fact, and in no sense to be confounded with
questions of innocence and guilt in relation to the acquiring of the
disease. A chancre acquired from a drinking cup or pipe may be
transmitted to husband or wife through a mucous patch on the genitals
and to children through an infected mother, without the question of
innocence or guilt ever having arisen. On the other hand, chancres on
parts other than the genitals may be _acquired in any but innocent
ways_. It is impossible to be fair or to think clearly so long as we
allow the question of innocence or guilt to color our thought about the
genital transmission of syphilis. That syphilis is so largely a sexually
transmitted disease is an incidental rather than the essential fact from
the broadly social point of view. We should recognize it only to the
extent that is necessary to give us control over it--not allow it to
hold us helplessly in its grip because we cannot separate it from the
idea of sexual indiscretion. There is a form of narrow-minded
self-righteousness about these things that sets the stamp of vice on
innocent and guilty alike simply on the strength of the sexual
transmission of syphilis. In the effort to avoid so mistaken and
heartless a view, we cannot remind ourselves too often that syphilis is
a disease and not a crime, and as such must be approached with the
impulse to heal and make whole, and not to heap further misfortune on
its victim or take vengeance on him.
+Extragenital and Marital Syphilis.+--Estimates of the ratio of genital
to non-genital or so-called extra-genital infection in syphilis vary a
good deal, and are largely the products of the clinical period in the
history of the disease before the days of more exact methods of
detecting its presence. The older statistics estimate from 5 to 10 per
cent of all syphilitic infections to be of non-genital origin, while the
remaining 90 per cent are genital. As we become better able to recognize
hidden syphilis, we shall probably find that the percentage of
non-genital infections will increase.
The physician's suspicions are easily aroused by a genital sore, less so
by one on the lip or the tonsil, for example. The same thing is true of
the layman. Syphilis which starts from a chancre elsewhere than on the
genitals runs the same course and may conceal itself quite as
effectively as syphilis from the usual sources, and for that reason may
even more easily escape notice because misinterpreted at the start. It
is my personal impression that careful study of patients with syphilis,
and of those who live with them, would bring to light many overlooked
extragenital infections, especially among those who are the victims of
crowding, poor living conditions, and ignorance. Estimates on the amount
of syphilis which is contracted in marriage are apt to be largely
guesswork in the absence of reliable vital statistics on the disease.
Fournier believed that 20 per cent of syphilis in women was contracted
in marriage. So much syphilis in married women is unsuspected, and so
little of what is recognized is traceable to outside sources, that 50
per cent seems a nearer estimate than twenty.