The problem of the syphilitic differs from the problem of the exgonorrheal patient. When a gonorrheal patient is cured, so far as infectivity is concerned, and is not sterile, there is no apprehension as to the offspring. Gonorrhea is not hereditary, and the child of a gonorrheal patient does not differ from the child of a nongonorrheal person. In the case of syphilis, it is different. The patient may be safe so far as infecting the partner is concerned, but yet there may be danger for the offspring.
The rules for permitting a man or a woman who once had syphilis to marry, therefore, are different from those applied to the gonorrheal patient. Here are the rules:
1. I would make it an invariable rule that no syphilitic patient should marry or should be permitted to marry before five years have elapsed from the day of infection. But the period of time alone is not sufficient; other conditions must be met before we may give a syphilitic patient permission to marry.
2. The man or the woman must have received thorough systematic treatment for at least three years, either constantly or off and on, according to the physician's judgment.
3. For at least one year before the intended marriage, the person must have been absolutely free from any manifestations of syphilis; that is, from any eruptions on the skin, from any mucous patches, swelling in the bones, ulcerations, and so on.
4. Four Wassermann tests, taken at intervals of three months and at a time when the patient was receiving no specific treatment, must be absolutely negative.
If these four conditions are fully met, then the patient may be permitted to marry.
It is important, however, to state that, in permitting or refusing syphilitic persons to marry, we are guided to a great extent by the fact as to whether they expect to have children soon or not.
In the case of a couple who are anxious to have children soon after their marriage, the conditions for our permission must be more severe than when the couple are willing or anxious to use contraceptive measures for the first years of their married life.
For, if a man is free from any skin lesions and from any mucous patches, his wife is safe from infection as long as she does not become pregnant. But, if she does get pregnant, she may become infected through the fetus; and, of course, the child also is liable to be syphilitic. Hence, much stricter requirements for syphilitics who expect to become parents are necessary than for those who do not.
In case both the man and the woman are or have been syphilitic, permission to marry may be granted without hesitation, as the danger of infection is absent, but permission to have children must be refused absolutely and unequivocally. Regardless of the time that may have elapsed from the period of infection, regardless of treatment, regardless of Wassermann tests, the danger to the child is too great if both parents have the syphilitic taint in them. A healthy child may be born from two syphilitic parents who have undergone energetic treatment, but we have no right to take the chance. I, at least, never wanted to, nor ever will want to, take such a responsibility.
The Danger of Locomotor Ataxia or Paresis. There is still one more point to consider in dealing with a syphilitic patient. In patients who did not receive energetic treatment from the very beginning of the disease as also in patients whose treatment was only desultory and irregular, we never can guarantee, in spite of lack of external symptoms, in spite of a negative Wassermann reaction, that some trouble may not develop later in life.
What shall we do in such cases and what particularly shall we do if, from a general examination of the patient, we carry away the impression that, while free from the danger of infection, the man is not a good risk? Under these circumstances, we must refuse all personal responsibility, leaving the assumption of the responsibility to the prospective wife.
Here is a case in point. About five years ago a man came to me for examination; he came with his fiancée. He had contracted syphilis ten years previously, received irregular treatment by mouth, off and on. For five years, he had had no symptoms of any kind. He considered himself cured, but wanted to know, and his fiancée wanted to know, whether he really was cured. There were no symptoms of any kind and the Wassermann test was negative. Nevertheless, I could not give him a clean bill of health. I noticed what seemed to me a slowness in thinking and just the least bit of hesitation in his speech.
I told the girl (the man was thirty-five, she was thirty-two) that I could not render a definite decision in the matter, that everything might be all right, and then again it might not; but, that the question about children she would have to decide definitely, once for all, namely, that she was not to have any children. She was fully satisfied so far as that part was concerned; she said she herself objected to children and did not intend to have any and knew how to take care of herself. All she wanted to know was, whether she was in danger of being infected. I told her no, but that in my opinion there was some danger of her husband developing general paresis or locomotor ataxia.
The girl had been a teacher for about twelve years, and she was so sick at heart of the work, was so anxious for a home of her own, that she decided to take the risk. And they got married. The marriage remained childless. The man developed general paresis (softening of the brain) three years later and died about a year afterward. The woman, now a widow, I understand, is not sorry for the step she had taken. This shows what things our social-economic conditions and our moral code are responsible for.
The rules for permitting a man or a woman who once had syphilis to marry, therefore, are different from those applied to the gonorrheal patient. Here are the rules:
1. I would make it an invariable rule that no syphilitic patient should marry or should be permitted to marry before five years have elapsed from the day of infection. But the period of time alone is not sufficient; other conditions must be met before we may give a syphilitic patient permission to marry.
2. The man or the woman must have received thorough systematic treatment for at least three years, either constantly or off and on, according to the physician's judgment.
3. For at least one year before the intended marriage, the person must have been absolutely free from any manifestations of syphilis; that is, from any eruptions on the skin, from any mucous patches, swelling in the bones, ulcerations, and so on.
4. Four Wassermann tests, taken at intervals of three months and at a time when the patient was receiving no specific treatment, must be absolutely negative.
If these four conditions are fully met, then the patient may be permitted to marry.
It is important, however, to state that, in permitting or refusing syphilitic persons to marry, we are guided to a great extent by the fact as to whether they expect to have children soon or not.
In the case of a couple who are anxious to have children soon after their marriage, the conditions for our permission must be more severe than when the couple are willing or anxious to use contraceptive measures for the first years of their married life.
For, if a man is free from any skin lesions and from any mucous patches, his wife is safe from infection as long as she does not become pregnant. But, if she does get pregnant, she may become infected through the fetus; and, of course, the child also is liable to be syphilitic. Hence, much stricter requirements for syphilitics who expect to become parents are necessary than for those who do not.
In case both the man and the woman are or have been syphilitic, permission to marry may be granted without hesitation, as the danger of infection is absent, but permission to have children must be refused absolutely and unequivocally. Regardless of the time that may have elapsed from the period of infection, regardless of treatment, regardless of Wassermann tests, the danger to the child is too great if both parents have the syphilitic taint in them. A healthy child may be born from two syphilitic parents who have undergone energetic treatment, but we have no right to take the chance. I, at least, never wanted to, nor ever will want to, take such a responsibility.
The Danger of Locomotor Ataxia or Paresis. There is still one more point to consider in dealing with a syphilitic patient. In patients who did not receive energetic treatment from the very beginning of the disease as also in patients whose treatment was only desultory and irregular, we never can guarantee, in spite of lack of external symptoms, in spite of a negative Wassermann reaction, that some trouble may not develop later in life.
What shall we do in such cases and what particularly shall we do if, from a general examination of the patient, we carry away the impression that, while free from the danger of infection, the man is not a good risk? Under these circumstances, we must refuse all personal responsibility, leaving the assumption of the responsibility to the prospective wife.
Here is a case in point. About five years ago a man came to me for examination; he came with his fiancée. He had contracted syphilis ten years previously, received irregular treatment by mouth, off and on. For five years, he had had no symptoms of any kind. He considered himself cured, but wanted to know, and his fiancée wanted to know, whether he really was cured. There were no symptoms of any kind and the Wassermann test was negative. Nevertheless, I could not give him a clean bill of health. I noticed what seemed to me a slowness in thinking and just the least bit of hesitation in his speech.
I told the girl (the man was thirty-five, she was thirty-two) that I could not render a definite decision in the matter, that everything might be all right, and then again it might not; but, that the question about children she would have to decide definitely, once for all, namely, that she was not to have any children. She was fully satisfied so far as that part was concerned; she said she herself objected to children and did not intend to have any and knew how to take care of herself. All she wanted to know was, whether she was in danger of being infected. I told her no, but that in my opinion there was some danger of her husband developing general paresis or locomotor ataxia.
The girl had been a teacher for about twelve years, and she was so sick at heart of the work, was so anxious for a home of her own, that she decided to take the risk. And they got married. The marriage remained childless. The man developed general paresis (softening of the brain) three years later and died about a year afterward. The woman, now a widow, I understand, is not sorry for the step she had taken. This shows what things our social-economic conditions and our moral code are responsible for.
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