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[Pg 110] 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[Pg 111] 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[Pg 112] 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.
Fritz Schaudinn [1871-1906] 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[Pg 113] 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[Pg 114] 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............