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[pg 122] 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 co?peration, and demands also the co?peration 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[pg 123] 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[pg 124] 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[pg 125] 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[pg 126] 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[pg 127] 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[pg 128] 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[pg 129] 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[pg 130] 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 co?perate. a resourceful physician can usually settle the question of a person's fitness for marriage, and[pg 131] 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[pg 132] 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.