Means for Controlling Infectiousness.—The usual method of controlling a very contagious2 disease, such as scarlet3 fever or measles4, 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 recur5 after the patient has been released. But in diseases such as tuberculosis6 and syphilis, in which contagiousness7 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 expenditure8 of money and an amount of machinery9 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 efficiently10 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 actively13 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, entirely14 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 trifling15 pimple16 on the genitals. The time and special apparatus17 for a microscopic18 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 interval19 a married man might infect his wife by sexual contact. The patient with a concealed20 syphilis often lacks even the incentive21 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 mercurial22 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 reiterated23, 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 obligatory24, 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 inevitably25 follow. We have the precedents26 of the control of tuberculosis, smallpox27, malaria28, 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 specially12 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 entail29. 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 justification30 for making the mere31 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 underlies32 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 commendable33 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 spinal34 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 probation35 have been based, is still too recent an addition to our implements36 of warfare37 to justify38 a rash dependence39 upon it. The abortive40 cure in relation to marriage is a problem in itself, and the shortening of time allowed in such cases must be individually determined41 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 steers42 essentially43 a middle course between those who condemn44 syphilitics to an unreasonable45 and needless[Pg 128] deprivation46 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 thoroughly47 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 insidious48 disease, a consummate49 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 prudence50 to take advantage of them in every case, to forestall51 even the remotest possibility of mistake or oversight52.
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 par11 with that in[Pg 129] men, and give the physician's insistence53 on a complete cure for the woman a reasonable prospect54 of being needed. Where his advice is disregarded and a pregnancy55 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 applied56 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 intimacies57 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 distressingly58 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 testimony59 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 prevailing60 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 incorporation61 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 decided62 by an expert. A thorough general or physical examination is desirable, and if this reveals suspicious signs, such as scars, enlarged glands63, etc., it is then possible to investigate the Wassermann report more thoroughly by repeating the test, sending it to another expert for confirmation64. In some cases it may even be necessary to insist that the patient submit to a special test, called the provocative65 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 laymen66 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 violation67 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 awakening68. For example, Ohio has recently amended69 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 distinguished70 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 Supreme71 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 annulment72 of the marriage, provided the uninfected party ceases to have marital73 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 sanitary74 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 disinterested75 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 mar1 their happiness.[12]
[12] The problem of gonorrhea is not considered in the framing of this statement.
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1
mar
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| vt.破坏，毁坏，弄糟 | |
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contagious
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| adj.传染性的，有感染力的 | |
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scarlet
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| n.深红色，绯红色，红衣；adj.绯红色的 | |
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measles
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| n.麻疹，风疹，包虫病，痧子 | |
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recur
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| vi.复发，重现，再发生 | |
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tuberculosis
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| n.结核病，肺结核 | |
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contagiousness
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| [医] （接）触（传）染性 | |
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expenditure
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| n.(时间、劳力、金钱等)支出；使用，消耗 | |
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machinery
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| n.(总称)机械，机器；机构 | |
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efficiently
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| adv.高效率地，有能力地 | |
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par
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| n.标准，票面价值，平均数量；adj.票面的，平常的，标准的 | |
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specially
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| adv.特定地；特殊地；明确地 | |
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actively
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| adv.积极地，勤奋地 | |
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entirely
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| ad.全部地，完整地；完全地，彻底地 | |
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trifling
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| adj.微不足道的；没什么价值的 | |
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pimple
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| n.丘疹，面泡，青春豆 | |
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apparatus
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| n.装置，器械；器具，设备 | |
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microscopic
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| adj.微小的，细微的，极小的，显微的 | |
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interval
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| n.间隔，间距；幕间休息，中场休息 | |
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concealed
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| a.隐藏的，隐蔽的 | |
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incentive
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| n.刺激；动力；鼓励；诱因；动机 | |
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mercurial
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| adj.善变的，活泼的 | |
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reiterated
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| 反复地说，重申( reiterate的过去式和过去分词 ) | |
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obligatory
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| adj.强制性的，义务的，必须的 | |
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inevitably
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| adv.不可避免地；必然发生地 | |
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precedents
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| 引用单元； 范例( precedent的名词复数 )； 先前出现的事例； 前例； 先例 | |
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smallpox
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| n.天花 | |
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malaria
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| n.疟疾 | |
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entail
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| vt.使承担，使成为必要，需要 | |
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justification
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| n.正当的理由；辩解的理由 | |
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mere
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| adj.纯粹的；仅仅，只不过 | |
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underlies
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| v.位于或存在于（某物）之下( underlie的第三人称单数 )；构成…的基础（或起因），引起 | |
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commendable
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| adj.值得称赞的 | |
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spinal
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| adj.针的，尖刺的，尖刺状突起的；adj.脊骨的，脊髓的 | |
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probation
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| n.缓刑(期)，(以观后效的)察看；试用(期) | |
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implements
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| n.工具( implement的名词复数 )；家具；手段；[法律]履行（契约等）v.实现( implement的第三人称单数 )；执行；贯彻；使生效 | |
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warfare
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| n.战争(状态)；斗争；冲突 | |
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justify
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| vt.证明…正当(或有理)，为…辩护 | |
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dependence
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| n.依靠，依赖；信任，信赖；隶属 | |
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abortive
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| adj.不成功的，发育不全的 | |
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determined
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| adj.坚定的；有决心的 | |
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steers
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| n.阉公牛，肉用公牛( steer的名词复数 )v.驾驶( steer的第三人称单数 )；操纵；控制；引导 | |
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essentially
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| adv.本质上，实质上，基本上 | |
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condemn
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| vt.谴责，指责；宣判(罪犯)，判刑 | |
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unreasonable
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| adj.不讲道理的，不合情理的，过度的 | |
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deprivation
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| n.匮乏；丧失；夺去，贫困 | |
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thoroughly
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| adv.完全地，彻底地，十足地 | |
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insidious
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| adj.阴险的，隐匿的，暗中为害的，（疾病）不知不觉之间加剧 | |
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consummate
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| adj.完美的；v.成婚；使完美 [反]baffle | |
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prudence
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| n.谨慎，精明，节俭 | |
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forestall
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| vt.抢在…之前采取行动；预先阻止 | |
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oversight
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| n.勘漏，失察，疏忽 | |
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insistence
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| n.坚持；强调；坚决主张 | |
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prospect
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| n.前景，前途；景色，视野 | |
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pregnancy
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| n.怀孕，怀孕期 | |
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applied
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| adj.应用的；v.应用，适用 | |
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intimacies
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| 亲密( intimacy的名词复数 )； 密切； 亲昵的言行； 性行为 | |
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distressingly
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| adv. 令人苦恼地；悲惨地 | |
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testimony
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| n.证词；见证，证明 | |
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prevailing
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| adj.盛行的；占优势的；主要的 | |
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incorporation
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| n.设立，合并，法人组织 | |
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decided
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| adj.决定了的，坚决的；明显的，明确的 | |
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glands
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| n.腺( gland的名词复数 ) | |
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confirmation
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| n.证实，确认，批准 | |
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provocative
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| adj.挑衅的，煽动的，刺激的，挑逗的 | |
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laymen
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| 门外汉，外行人( layman的名词复数 )； 普通教徒（有别于神职人员） | |
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violation
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| n.违反(行为)，违背(行为)，侵犯 | |
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awakening
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| n.觉醒，醒悟 adj.觉醒中的；唤醒的 | |
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Amended
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| adj. 修正的 动词amend的过去式和过去分词 | |
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distinguished
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| adj.卓越的，杰出的，著名的 | |
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supreme
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| adj.极度的，最重要的；至高的，最高的 | |
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72
annulment
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| n.废除，取消，（法院对婚姻等）判决无效 | |
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73
marital
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| adj.婚姻的，夫妻的 | |
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74
sanitary
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| adj.卫生方面的，卫生的，清洁的，卫生的 | |
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75
disinterested
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| adj.不关心的，不感兴趣的 | |
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