The Third Great Plague Part 5

+Transmission by Intimate Contacts--Kissing.+--As we pa.s.s 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 ma.s.sage or rubbing, are here better satisfied than in the risks thus far considered. Kissing, caresses, and s.e.xual 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 s.e.xual 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 cla.s.sical 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 a.s.sociations 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. a.s.soc., 1911, lvii, 783.

+The s.e.xual Transmission of Syphilis.+--The s.e.xual 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. s.e.xual 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 s.e.xually 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 s.e.xual 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 s.e.xual 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 cooperation, and demands also the cooperation 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 a.s.surance 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 s.e.xual 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 p.r.o.nouncing 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 s.e.xual 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 a.s.sumed 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 circ.u.mstances 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 Wa.s.sermann 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 pa.s.sed, his wife, though outwardly healthy, should have a Wa.s.sermann 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 s.e.xual 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 s.e.xual 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 fiancee 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 a.s.sume the character of an engagement. It is of little use to say that a Wa.s.sermann 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 Wa.s.sermann test. a.s.suredly 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 Wa.s.sermann 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 Wa.s.sermann 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 att.i.tude of the patient toward the examination and his willingness to cooperate. 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 a.s.surance 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 sanitary problem. It is by no means so serious, however, that it need lead clean young men and women to remain single for fear they will encounter it. The medical examination of both parties before marriage, efficiently carried out by disinterested experts, each perhaps of the other's appointing, is the best insurance a man and woman can secure at the present day against the risk that syphilis will mar their happiness.[12]

[12] The problem of gonorrhea is not considered in the framing of this statement.

Chapter XIII

The Transmission and Hygiene of Syphilis (Continued)

SYPHILIS AND PROSt.i.tUTION

In taking up the consideration of the relation of syphilis to illicit s.e.xual relations, we must again remind ourselves that we are approaching this subject, not as moralists, important though their point of view may be, but for the time being as sanitarians, considering it from the standpoint of a method of transmission of a contagious disease.

+Genital and Non-genital Syphilis in Lax Individuals.+--The prevalence of syphilis among women who receive promiscuous attentions is enormous.

It is practically an axiom that no woman who is lax in her relations with men is safe from the danger of the disease, or can long remain free from it. The type of man who is a Light o' Love does not go far before he meets the partner who has been infected by some one else. Becoming infected himself, he pa.s.ses on his infection to his next partner.

Syphilis is not so often transmitted in prost.i.tution, open or secret, as gonorrhea, but it is sufficiently so to make the odds overwhelmingly against even the knowing ones who hope to indulge and yet escape. The acquiring of syphilis from loose men or women is usually thought of as entirely an affair of genital contacts. Yet it is notable that extra-genital chancres are the not uncommon result of liberties taken with light women which do not go to the extent of s.e.xual relation. Women who accept intimacies of men who, while unwilling to commit an outright breach of decency, will take liberties with a woman who will accept them have only themselves to blame if it suddenly develops that the infection has been transmitted from one to the other by kisses or other supposedly mild offenses against the proprieties.

+Syphilis Among Prost.i.tutes.+--As to the prevalence of syphilis among both public and clandestine or secret prost.i.tutes, several notable surveys of more or less typical conditions have been made. With the aid of the Wa.s.sermann test much heretofore undiscovered syphilis has been revealed. Eighty to 85 per cent of prost.i.tutes at some time in their careers acquire the disease.[13] About half this number are likely to have active evidence of the disease. Thirty per cent of the prost.i.tutes investigated by Papee in Lemberg were in the most dangerous period--the first to the third year of the disease. Three-fourths of these dangerous cases were in women under twenty-five years of age--in the most attractive period of their lives. Averaging a number of large European cities, it was found that not more than 40 per cent of prost.i.tutes were even free of the outward signs of syphilis, to say nothing of what laboratory tests might have revealed. It is more than evident that prost.i.tution is admirably fitted to play the leading role in the dissemination of this disease. The young and attractive prost.i.tute, whether in a house of ill-fame, on the street, or in the more secret and private highways and by-ways of illicit s.e.xual life, is the one who attracts the largest number with the most certain prospect of infecting them.

[13] The figures here given are based on those of Papee, Wwednesky, Raff, Sederholm, and others. The recently published investigations of the Baltimore Vice Commission showed that 63.7 per cent of 289 prost.i.tutes examined by the Wa.s.sermann test had syphilis. Of 266 examined for gonorrhea, 92.1 per cent showed its presence. Nearly half the girls examined had both diseases and only 3.39 per cent had neither. (Survey, March 25, 1916, Vol. 35, p. 749.)

+Concealed Syphilis and Medical Examinations of Prost.i.tutes.+--A number of delusions center around the relation of open and secret prost.i.tution to disease. From the description of syphilis given in the foregoing pages, it must be apparent how little reliance can be placed, for example, on the ordinary medical examination of prost.i.tutes as practised in segregated districts. The difficulties of efficient examination are enormous, especially in women. Even with the best facilities and a high degree of personal skill, with plenty of time and laboratory help in addition, extremely contagious syphilis can escape observation entirely, and even the negative result of one day's examination may be reversed by the appearance of a contagious sore on the next. Women can transmit syphilis pa.s.sively by the presence of infected secretions in the genital ca.n.a.l even when they themselves are not in a contagious state. In the same way a woman may find herself infected by a man without any idea that he was in an infectious state. She may in turn develop active syphilis without ever realizing the fact. Medical examination of prost.i.tutes as ordinarily carried out does actual harm by deluding both the women and their partners into a false sense of security. The life which such women lead, with the combination of local irritation, disease, and fast living, makes them especially likely to develop the contagious mucous patches, warts, and other recurrences, and to relapse so often that there can be little a.s.surance that they are not contagious all the time.

Under such circ.u.mstances one might almost expect every contact with a prost.i.tute on the part of a non-syphilitic individual to result in a new infection. The factors which interfere to prevent such wholesale disaster are the same which govern infectiousness throughout the disease. Local conditions may be unfavorable, even though the germs are present, or there may be no break in the skin for the germs to enter. If the syphilitic individual is beyond the infectious period, there may be no dangerous lesions. Here, as all through the history of infections with syphilis, there is an element of the unexpected, a favoring combination of circ.u.mstances. Sometimes when infection is most to be expected it is escaped, and conversely it seems at times that in the "sure thing," the "safe chance," and the place where infection seems most improbable, it is most certain to occur.

PERSONAL HYGIENE IN SYPHILIS

Syphilis is a const.i.tutional disease, affecting in one way or another the whole body. For that reason, measures directed to improving the general health and maintaining the resistance of the patient at the highest point have an important place in the management of the disease.

By his habits and mode of life a person with syphilis does much to help or hinder his cure, and to protect or endanger those around him. For that reason a statement of general principles may well be drawn up to indicate what is desirable in these regards.

+A Well-balanced Life.+--First, for his own sake, a syphilitic should live a well-balanced and simple life so far as possible. In this disease the organs and structures of the body which are subject to greatest strain are the ones most likely to suffer the serious effects of the disease. Worry and anxiety, excessive mental work, long hours without proper rest, strain the nervous system and predispose it to attack.

Excessive physical work, fatigue, exhaustion, poor food, bad air, exposure, injure the bodily resistance. Excesses of any kind are as injurious as deprivation. In fact, it is the dissipated, the high livers, who go to the ground with the disease even quicker than those who have to pinch.

+Alcohol.+--Alcohol in any form, in particular, has been shown by extensive experience, especially since the study of the nervous system in syphilis has been carried to a fine point, to have an especially dangerous effect on the syphilitic. Alcohol damages not only the nervous system, but also the blood vessels, and makes an unrivaled combination in favor of early syphilitic apoplexy, general paresis, and locomotor ataxia. A syphilitic who drinks at all is a bad risk, busily engaged in throwing away his chances of cure. Even mild alcoholic beverages are undesirable and the patient should lose no time in dropping them entirely.

+Tobacco.+--Tobacco has a special place reserved for it as an unfavorable influence on the course of syphilis. It is dangerous to others for a syphilitic to smoke or chew because, more than any other one thing, it causes the recurrence of contagious patches in the mouth.

It is remarkable how selfish many syphilitic men are on this point. In spite of the most positive representations, they will keep on smoking.

Not a few of them pay for their selfishness with their lives. These mucous patches in the mouth, often called "smoker's patches," predispose the person who develops them to one of the most dangerous forms of cancer, which is especially likely to develop on tissues, like those of the mouth and tongue, which have been the seat of these sores.

+s.e.xual Relations, Kissing, Etc.--Contagious Sores.+--s.e.xual indulgence, kissing, and other intimate contacts during the active stage of syphilis, as has been indicated, directly expose others to the risk of getting the disease. For that reason they should not be indulged in during the first two years of the average well-treated case receiving salvarsan and mercury by the most modern methods. Exceptions to this rule should be granted only by the physician, and should be preceded by careful and repeated examination in connection with the treatment. Under no circ.u.mstances should a patient kiss or have intercourse if there is even the slightest sore or chafe on the parts, regardless of whether or not it is thought to be syphilitic.