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John H. Stokes.

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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.




Chapter XII

The Transmission and Hygiene of Syphilis (Continued)


THE CONTROL OF INFECTIOUSNESS IN SYPHILIS. - SYPHILIS AND MARRIAGE

+Means for Controlling Infectiousness.+ - The usual method of controlling
a very contagious disease, such as scarlet fever or measles, is to put
the patient off by himself with those who have to care for him and to
keep others away - that is, to quarantine them. This works very well for
diseases which run a reasonably short course, and in which contagious
periods are not apt to recur after the patient has been released. But in
diseases such as tuberculosis and syphilis, in which contagiousness may
extend over months and years, such a procedure is evidently out of the
question. We cannot deprive a patient of his power to earn a living, to
say nothing of his liberty, without providing for his support and for
that of those who are dependent on him. To do this in so common a
disease as syphilis would involve an expenditure of money and an amount
of machinery that is unthinkable. Accordingly, as a practical scheme for
preventing its spread, the quarantine of syphilis throughout the
infectious period is out of the question. We must, therefore, consider
the other two means available for diminishing the risk to others. The
first of these, and the most important, is to treat the disease
efficiently right from the start, so that contagious sores and patches
will be as few in number as possible, and will recur as little as
possible in the course of the disease. This will be in effect a
shortening of the contagious period, and should be recognized as one of
the great aims of treatment. The second means will be to teach the
syphilitic and the general public those things which one who has the
disease can do to make himself as harmless as possible to others. This
demands the education of the patient if we hope for his coöperation, and
demands also the coöperation of those around him in order that the
pressure of public sentiment may oblige him to do his part in case he
does not do it of his own free will.

+Control of Infectiousness by Treatment - Importance of Salvarsan.+ - In a
disease which yields so exceptionally well to treatment as syphilis, a
great deal can be done to shorten the contagious period. Especially is
this so when we are able to employ an agent such as salvarsan, which
kills off the germs on the surface within twenty-four hours after its
injection. When a patient is discovered to be in a contagious state, in
a large majority of cases the risk to the community which he represents
can be quickly eliminated, at least for the time being. Combining the
use of mercury and salvarsan in accordance with the best modern
standards, the actively contagious period as a whole can be reduced in
average cases from a matter of years to one of a few weeks or months.
Certainly, so far as recognizable dangerous sores are concerned,
periodic examination, with salvarsan whenever necessary, would seem to
dispose of much of the difficulty.

+Obstacles to Control by Treatment.+ - There are, however, obstacles in
the way of complete control of infectiousness by treatment. For example,
one might ask whether a single negative blood test would not be
sufficient assurance that the patient was free from contagious sores. It
is, however, a well-recognized fact that a person with syphilis may
develop infectious sores about the mouth and the genitals even while the
blood test is negative. An examination, moreover, is not invariably
sufficient to determine if a patient is in a contagious state. The value
of an examination depends, of course, entirely on its thoroughness and
on the experience of the physician who makes it. It is only too easy to
overlook one of the faint grayish patches in the mouth or a trifling
pimple on the genitals. The time and special apparatus for a microscopic
examination are not always available. Moreover, contagious lesions come
and go. One may appear on the genitals one day and a few days later be
gone, without the patient's ever realizing that it was there - yet in
this interval a married man might infect his wife by sexual contact. The
patient with a concealed syphilis often lacks even the incentive to seek
examination by a doctor. It is important also to realize that when
mercury has to be the only reliance, the risk of infection cannot be
entirely controlled by treatment. Contagious sores may develop even
during a course of mercurial injections, especially in early cases. It
requires the combination of mercury and salvarsan to secure the highest
percentage of good results.

+The Five-year Rule.+ - The truth of the matter is that, as Hoffmann
says, no treatment can _guarantee_ the non-infectiousness of a
syphilitic in the first five years of his disease. Time is thus an
essential element in pronouncing a person non-infectious and hence in
deciding his fitness for marriage, for example. The person with active
syphilis who has intimate relations with uninfected persons, who will
not abandon smoking or take special precautions about articles of
personal use which are likely to transmit the disease, is unsafe no
matter what is done for him. In spite of this qualifying statement it
may be reiterated, however, that good treatment with salvarsan and
mercury reduces the risk of infecting others in the ordinary relations
of life practically to the vanishing point, and of course reduces, but
not entirely eliminates, the dangers of the intimate contacts.

+Personal Responsibility of the Patient.+ - If we are compelled then to
fall back to some extent upon the personal sense of responsibility of
the patient himself to fill in the gap where treatment does not entirely
control the situation, it becomes increasingly important that in the
irresponsible and ignorant, when the patient fails to meet his
obligation, we should push treatment to the uttermost in our effort to
prevent the spread of the disease. To supply this necessary treatment to
every syphilitic who cannot afford it for himself, and make it
obligatory, if need be, will be a long step forward in the control of
the disease. The educational campaign for it is well under way all over
the world, and the money and the practical machinery will inevitably
follow. We have the precedents of the control of tuberculosis, smallpox,
malaria, and yellow fever to guide us, to say nothing of a practical
system against sexual disease already in operation in Norway, Sweden,
Denmark, and Italy.

+Syphilis and Marriage.+ - The problem of the relation of syphilis to
marriage is simply an aspect of the transmission of an infectious
disease. The infection of one party to the marriage by the other and the
transmission of that infection to children summarizes the social
problem. Through the intimate contacts of family life, syphilis attacks
the future of the human race.

+Estimated Risk of Infecting the Wife.+ - How serious is the risk of
infecting the wife if a man should marry during the contagious period of
syphilis? This will depend a good deal on the frequency of relapses
after the active secondary stage. On this point Sperk estimated that in
1518 patients, only ten escaped relapses entirely. These were, however,
not patients that had been specially well treated. Keyes, quoted by
Pusey, estimated, on the basis of his private records, that the chances
taken by a syphilitic husband who used no special precautions to prevent
infecting his wife were twelve to one the first year in favor of
infection, five to two the second year, and one to four the third year,
being negligible after the fourth year.

+Syphilis in the Father.+ - Even while we recognize the infection of
women and children as the greatest risk in marriage we should not lose
sight of the cost to society which syphilis in the father of the family
himself may entail. For such a man to be stricken by some of the serious
accidents of late syphilis throws his family as well as himself upon
society. A syphilitic infection which has not been cured not only makes
a man a poor risk to an insurance company, but a poor risk to the family
which has to look to him for support and for his share and influence in
the bringing up of the children. A sufficient number of men and women in
the thirties and forties are crippled, made dependent, or lost to the
world entirely, to make the responsibilities of the family when assumed
by persons with untreated or poorly treated syphilis a matter of some
concern, whether or not they are still able to transmit the disease to
others.

+The Time-treatment Principle and the Five-year Rule.+ - In setting a
modern standard for the fitness of syphilitics for marriage it may be
said at the outset that there is little justification for making the
mere fact of a previous syphilitic infection a permanent bar in the
majority of cases. The risk of economic disaster to the parent and
wage-earner, and the risk of transmission of the disease to the partner
and the children, are both controllable by a combination of efficient
treatment and time. The man who has conformed to the best practice in
both particulars may usually marry and have healthy children. The woman
under the same circumstances need not fear that the risk of having
offspring injured by her disease is any greater than the risk that they
will be injured by any other of the unforeseen risks that surround the
bringing of a child into the world. A vast experience underlies what
might be called the time-treatment principle on which permission to
marry after syphilis should be based. It has recently been ably
summarized again, and with commendable conservatism, by Hoffmann in the
rule that a syphilitic who has been efficiently treated by modern
standards, with mercury and salvarsan, over a period of two to three
years, and who has remained free from all symptoms and signs of the
disease for two years after all treatment was stopped, including
negative blood and spinal fluid tests, may marry in from four to five
years from the beginning of his infection. Variations of this rule must
be allowed only with great conservatism, since salvarsan, on whose
efficiency many pleas for a shortening of probation have been based, is
still too recent an addition to our implements of warfare to justify a
rash dependence upon it. The abortive cure in relation to marriage is a
problem in itself, and the shortening of time allowed in such cases must
be individually determined by an expert who has had the case in charge
from the beginning, and not, at least as yet, by the average doctor.
Such a standard as this for the marriage of persons who have had
syphilis steers essentially a middle course between those who condemn
syphilitics to an unreasonable and needless deprivation of all the joys
of family life, and those who are too ready to take our conquest of
syphilis for granted and to cast to the winds centuries of experience
with the treachery of the disease.

Even while we concede the value of generations of experience with
syphilis in determining the probable risk of infection, it is a duty to
investigate thoroughly by the modern methods, such as the Wassermann
blood test, the condition of all members of a family in which syphilis
has appeared. This means, for example, that even though the husband with
syphilis may have married years after the usual period of infectiousness
has passed, his wife, though outwardly healthy, should have a Wassermann
test, and his children would be none the worse for an examination, even
though they seem normal. Syphilis is an insidious disease, a consummate
master of deceit, able to strike from what seems a clear sky. The latest
means for its recognition have already revolutionized some of our
conceptions of its dangers and its transmission. It is only common
prudence to take advantage of them in every case, to forestall even the
remotest possibility of mistake or oversight.

Where both husband and wife have had syphilis, even though both are past
the infectious stage, both should be treated, and a complete cure for
the wife is advisable before they undertake to have children. This must
mean an added burden of responsibility on both physician and patient,
and one extremely difficult to meet under existing conditions. A
reliable means of birth control used in such cases would place the
problem in women on a par with that in men, and give the physician's
insistence on a complete cure for the woman a reasonable prospect of
being needed. Where his advice is disregarded and a pregnancy results,
the woman should be efficiently treated while she is carrying the child.

+Syphilis and Engagements to Marry.+ - If a five-year rule is to be
applied to marriage, a similar rule should cover the engagement of a
syphilitic to marry, and it should cover the sexual relations of married
people who acquire syphilis. It is not too much to expect that an
engaged person who contracts syphilis shall break his engagement, and
not renew it or contract another until by the five-year rule he would be
able to marry with safety.

Engagements nowadays may well be thought of as equivalent to marriage
when the question of syphilis is considered. They not infrequently offer
innumerable opportunities for intimacies which may or may not fall short
of actual sexual relations. Attention has been called to this situation
by social workers among wage-earning girls. It has been a distressingly
frequent experience in my special practice to find that the young man,
overwrought by the excitement of wooing, has exposed himself elsewhere
to infection and unwittingly punished the trustfulness of his fiancée by
infecting her with syphilis through a subsequent kiss. The publication
of banns before marriage is worth while, and unmistakable testimony as
to the character and health of the parties concerned might well be
exchanged before a wooing is permitted to assume the character of an
engagement. It is of little use to say that a Wassermann and a medical
examination should be made before marriage, when the damage may be done
long before that point is reached.

+Medical Examination for Syphilis before Marriage.+ - How shall we
recognize syphilis in a candidate for marriage? The prevailing idea is
to demand a negative Wassermann test. Assuredly this is good as far as
it goes, but it is not so reliable as to deserve incorporation into law
as sole sufficient evidence of the absence of syphilis, as has been done
in one state. From what has been said, it is plain that a single
negative Wassermann is no proof of the absence of syphilis. The subject
must be approached from other angles, and when syphilis may be
suspected, the question should be decided _by an expert_. A thorough
general or physical examination is desirable, and if this reveals
suspicious signs, such as scars, enlarged glands, etc., it is then
possible to investigate the Wassermann report more thoroughly by
repeating the test, sending it to another expert for confirmation. In
some cases it may even be necessary to insist that the patient submit to
a special test, called the provocative test, in which a small injection
of salvarsan is used to bring out a positive blood test if there is a
concealed syphilis. These are, of course, measures which are seldom
necessary except in patients who have had the disease. Much depends on
the attitude of the patient toward the examination and his willingness
to coöperate. A resourceful physician can usually settle the question of
a person's fitness for marriage, and the result of a reliable
examination offers a reasonable assurance of safety.

+Laws Crippling Physicians in Such Matters.+ - What shall the physician
do when confronted with positive evidence that a patient who is about to
marry has an active syphilis? It is important for laymen to understand
that the law relating to professional confidence between physician and
patient ties the hands of the physician in such a situation. For the
doctor to tell the relatives of the healthy party to such an intended
marriage that the other has active syphilis would make him subject to
severe penalties in many states for a violation of professional
confidence, or to suit for libel. Of course, if the patient has agreed
to submit to examination to determine his fitness for marriage, the
physician's path is clear, but if the condition is discovered in
ordinary professional relations, there is nothing to be done except to
try to persuade the patient not to marry - advice he usually rejects. To
this blind policy of protecting the guilty at the expense of the
innocent an immeasurable amount of human efficiency and happiness has
been sacrificed. Fortunately there are signs of an awakening. For
example, Ohio has recently amended the law so as to permit a physician
to disclose to the parties concerned that a person about to be married
has a venereal disease (Amendment to Section 1275, General Code, page
177). This is preventive legislation, as distinguished from the old
policy of locking the stable door after the horse was stolen by laws
punishing one who infects another with a venereal disease after
marriage has been contracted. Recent Supreme Court decisions (Wisconsin)
have also taken the ground that a venereal disease existing at the time
of marriage and concealed from the other party is ground for annulment
of the marriage, provided the uninfected party ceases to have marital
relations as soon as the fact is discovered.

The problem of syphilis in its relation to marriage is, of course, a
serious one. It is safe to say that it will never be completely met
except by a vigorous general public program against syphilis as a


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