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.
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.