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[............