Syphilis in Pregnancy and Marriage
Syphilis in pregnancy at times assumes peculiar malignancy. The virulence depends on the patient's power of resistance, and whether or not there are septic microörganisms mixed with the syphilitic spirochetes. There are, moreover, varying strains of spirochetes which differ in virulence, or there are familial idiosyncrasies. Tropical syphilis is worse than northern infections, and syphilis of the nervous system is often incurable. Fournier was of the opinion that a syphilitic woman who becomes pregnant is more likely to abort than a pregnant woman who becomes syphilitic. The percentage of fetal deaths is also greater in the first class than in the second. The longer a woman has been syphilitic, provided she has not been treated for the disease, the worse the prognosis for the duration of the pregnancy and the life of the fetus. The earlier in pregnancy the syphilis appears, the worse the prognosis for gestation. General fetal mortality in syphilis under the best circumstances is 75 per cent. Syphilis should be looked for in every case where the cause of an abortion is not evident. Ruge holds that in 83 per cent. of repeated abortions syphilis is at fault; late abortions are characteristic of this disease.
Inoculation with syphilis before conception almost always results in abortion. In 130 women studied by Le Pileur there were 3.8 per cent. still-births before infection by syphilis, but 78 per cent. after infection. In premature labor the child is, as a rule, born dead; less frequently it is born syphilitic; still less frequently it is born apparently sound, but the syphilis appears later; in a few cases, when the maternal syphilis is old, the child may be born normal. Interruption of gestation is the commonest symptom in syphilis complicating pregnancy. The labor itself is affected: the pains are weak and tardy. Abnormal presentations occur frequently when the fetus is dead. Chancres on the cervix may cause obstruction, and there may be indurations so dense as to necessitate cesarean delivery. The perineum may become so friable as to tear, as De Lee says, "like wet paper."
When the mother is infected at the time of conception the child is always syphilitic. If the mother is infected early in pregnancy the child is almost always infected. If she is infected late in pregnancy the child may escape infection. Men with tertiary syphilis have begotten children without, to all clinical appearance, inoculating the wife. In such a case the mother may nurse the child with safety to herself, but the child will infect a wet nurse other than its own mother, and in very rare instances mothers in this condition have been floridly infected. The condition here described is called Colles's Law.[152] The doctrine of Colles's Law has fallen into disuse because we can now demonstrate by the Wassermann reaction that almost all apparently healthy mothers of this class are in reality infected. The term now used is "Syphilis by Conception."[153] The virus passes through the fetal placenta to the mother, although immunizing substances are held back by the placenta. A fetus cannot make immunizing bodies before its eighth month, and on that account the earlier the fetus is infected, the more likely it is to die. Recently, however, some scanty testimony has been collected which sustains Colles's Law in a few cases. Ledermann reported three cases, and Nonne others, in which the wives of men with tabes or paralysis bore syphilitic children and yet never responded positively themselves to the Wassermann test, or showed any symptoms suggesting syphilis. To this list Kroon[154] adds a case corresponding fully to the requirements of Colles's Law. A woman of twenty-eight years who had had eight abortions was delivered of a child with undoubted congenital syphilis. The child's father had been infected with syphilis twelve years before. The woman showed no signs of syphilis, two Wassermann tests were negative, and she nursed the child without injury to herself.
Should the husband have florid primary or secondary syphilis, and infect his wife at impregnation, abortion is the rule. The commonest cases are those where the husband has been treated for syphilis more or less thoroughly before marriage. Even if at the time of impregnation the husband has no apparent infective lesion, the child is usually syphilitic, or it may show signs of the disease later in life. Ibsen's Ghosts is founded on a case like this. If the syphilis is recent, or uncured, the child dies, macerates, and is expelled. These conditions recur in pregnancy after pregnancy, until the virus is removed by time or drugs. As the nucleus of the spermatozoön is too small to carry the spirochete of syphilis, the infection is through the semen in a manner not yet clear to us.
Wolff[155] studied a group of nine syphilitic women and their children. There were sixty-six pregnancies, but only thirty-three viable children were born. Of these last fourteen died in childhood, three committed suicide at twelve, twenty, and twenty-eight years of age; and of the thirteen still living only two were normal. The others are all feeble-minded, epileptic, hysteric, or otherwise neurotic. Post[156] tabulated the mortality in thirty syphilitic families in which there were 168 pregnancies. Of these fifty-three ended in still-birth or miscarriage and there were forty-four early deaths—a total loss of 57 per cent. Of the children that were born alive 38 per cent. are now dead, and of the seventy-one that are alive only thirty-nine are apparently healthy. There are very many cases of diseased children and adults with serious lesions of obscure etiology, and in a great number of instances of anemia, malnutrition, extreme nervousness, aortitis, bone diseases, vague pain, and similar conditions, the origin is congenital syphilis. Stoll,[157] in sixty-eight such cases, found a positive luetin syphilitic reaction, and a positive Wassermann in 17 per cent.
Gottheil,[158] professor of dermatology and syphilography in Fordham University, holds that if a man has gone through a modern treatment for syphilis, given by a competent physician and extended over three years, and if during the fourth year, without treatment, he repeatedly shows a negative Wassermann reaction, he may marry. That is the common opinion of physicians, but it is decidedly erroneous.
In one series of 562 cases of hereditary syphilis observed by the great syphilographer Fournier, sixty children, or over 10 per cent., were infected more than six years after the primary parental inoculation. He tells of one woman who had nineteen consecutive still-births from syphilis. Gowers[159] says: "There is no evidence that the disease ever is or ever has been cured, the word 'disease' being here used to designate that which causes the various manifestations of the malady." This statement is too sweeping, but it is very near the truth.
Bruhns recently reported the outcome of the Wassermann test repeated about yearly from 1908 to 1915 in one hundred private cases infected with syphilis ten or more years before the time of the report. In forty-two the test was constantly negative; in thirty-two, positive at first but negative later; in seven, constantly positive notwithstanding repeated courses of treatment; in three, positive at first, then long negative, but finally changing to positive again; in eight, negative at first, then positive, and finally negative; and in eight, negative at first but finally positive. The last three groups are particularly significant. In some the long negative reaction, for five or six years, indicated cure, and physicians would pronounce such cases positively cured; but suddenly they changed to a positive reaction without any clinical manifestations showing at the time. After renewed courses of treatment in the following two years the reaction became negative. Among the cases with constant negative reaction there were some who developed brain syphilis, or tabes, proving that they were not cured despite the absence of clinical manifestations of the disease and the negative Wassermann reactions. Professor Blaschko of Berlin, at the seventeenth International Medical Congress in 1913, in the presence of Ehrlich, Wassermann and Hata, said no one could even talk of a cure of syphilis until an interval of ten years without symptoms had occurred. Where a blood Wassermann is negative a spinal fluid reaction may be positive.
In from 60 to 75 per cent. of all cases of tabes or paresis members of the family other than the patient have shown infection. The proportion of infections in the families of tabetics and paretics is far larger than that found in families in which the syphilis does not go on to these extremes. Tabes is also called locomotor ataxia. It is a degeneration of a part of the spinal cord, with unsteadiness and incoördination of motion, lightning pains, disorders of vision, and other symptoms. Paresis is softening of the brain, with insanity and death.
These and other facts strongly indicate that the form of syphilis which ends in tabes or paresis remains infectious over a much longer time than ordinary syphilis does. No one has cured either tabes or paresis. Raven reported in 1914 an investigation of ninety families in each of which a case of metalues had developed. The interval between the date of infection and the marriage was known in about half of these, and it was four years in two families, five years in one, and from six to twenty-one years in ten! Fournier, in 4400 cases of syphilis, saw three cases where the tertiary symptoms appeared fifty years after infection, and in one case fifty-five years after infection. Bonnet[160] reported such a case which came to him for treatment fifty-four years after infection. The man had no children.
Syphilis that affects the nervous system as in tabes and paresis is an incurable syphilis, and there is no means whereby any physician, no matter how skilful he may be, can tell whether or not a given patient has such an infection. The physician, then, who tells a syphilitic that he or she is cured and lets such a person marry is responsible for all the evils that result from his rashness. Once a syphilitic, not necessarily always a syphilitic; but once a syphilitic, possibly and probably always a syphilitic, and that no matter what the treatment or the lack of clinical symptoms. Damaged goods of this kind are to be looked upon as damaged goods forever.
Any man or woman, then, who has ever had a clear case of syphilis (and the diagnosis is easy, as a rule) is likely to be for the remainder of life a source of syphilitic infection. There is even question of late of spirochete-carriers, as there are typhoid-carriers and diphtheria-carriers, who may infect others while not suffering themselves. If one who has been a syphilitic marries without informing the other party to the contract of the condition, the injustice is, without doubt, very grave. I should call such concealment a mortal sin, and a condition exposing the sacrament to sacrilege.
Suppose the second party is informed of the old infection and is then foolish enough to risk the marriage. No one but an experienced physician has any notion of the indescribable horror that may come of taking this risk, and no one has the right to expose his own body to infection by syphilis for the advantage of marriage. There is no approach to a juridic equilibrium between these two conditions. If in such a marriage children are begotten and infected, (1) embryos will die without baptism; (2) later possible children will be born who will die of congenital syphilis; (3) possible children who will escape syphilis; (4) children who may have to pass through tabes or paresis to death, after begetting other degenerates.
A syphilitic embryo which dies without baptism is better than no child at all. It will live in a state of natural happiness after abortion. A baptized child which has congenital syphilis is immeasurably better off than a sound child that lacks baptism. Eugenics as a prudent investigation of conditions before marriage is a good thing; eugenics as the drivel of agitators, who cannot tell the difference between a gentleman and a corn-fed hog, is quite another thing. The marriage, therefore, of a person who has been syphilitic to one who knows or does not know of this condition gets its mortality chiefly from the damage to one of the contracting parties which is imminent. It is difficult to estimate the morality of the act as it refers to the children infected congenitally, and to society.
The natural order, charity, justice, and related principles give every child the right to be born with bodily health, if such an event is possible. If it is not possible in particular circumstances, then melius esse quam non esse, and the decision in each case depends on its own qualities.
If a physician knows that a person who has been infected with syphilis is about to marry, should the physician warn the innocent party?
There are several conditions: (1) the infected person about to marry may be actively infectious; (2) the person may be probably infective, as any one is who has once had syphilis; (3) the physician may know the fact of the infection officially or unofficially; (4) the infective person may have gone to the physician for treatment for a condition not connected with the syphilis—say, for a bronchitis or a broken bone—and the physician in the examination discovers syphilis.
Again, there are various kinds of secrets. St. Alphonsus Liguori[161] classifies secrets in three groups: (1) natural; (2) promised; (3) entrusted secrets. A natural secret is one which obliges us in justice to observe it if divulging it will gravely injure any one in reputation or possessions. We are not obliged to observe a secret of this kind at the risk of our lives unless the damage from the divulging would affect the community gravely. A promised secret obliges to silence either gravely or lightly, according to the intention of the promiser. Where reasonable doubt exists as to grave obligation, such obligation does not exist. A promise to secrecy made even under oath is not binding if one is obliged in justice to reveal the secret; therefore we must testify to the crime of another when a judge legitimately demands our testimony, even if we have promised not to tell anything. If a secret is entrusted to one, and divulging would cause grave damage, but justice, or similar circumstances, do not oblige us to reveal it, we are bound to observe it even when questioned by legitimate authority. Then we may answer we know nothing about it, at least for revelation. St. Alphonsus's text is: "Potes respondere te nihil scire, scilicet ad revelandum." His meaning seems to be: "You may say you know nothing about the matter inquired into." Any other signification would be futile. To say literally, "I do not know anything I may tell," would only expose one to punishment for contempt. He seems to make the answer a conventional denial, like the "not guilty" of a criminal. A judge may not abrogate the natural right by which an entrusted secret is protected, unless the secret is already known in some other way, or there is a just cause for revealing it.[162]
When an entrusted secret, however, which is also called a strict or absolutely natural secret, is imparted expressly or tacitly, say, to physicians, lawyers, or priests, and becomes a professional secret, it obliges more strictly than any other. There are four conditions under which such an entrusted secret may be revealed, at least without mortal sin (except by a confessor): (1) If we have the presumed consent of the principal. (2) If the material of the secret is trivial, or if it is known from another source, or is already public. Is it a mortal sin to divulge a grave entrusted secret to a responsible person who is under the same bond? St. Alphonsus, De Lugo, and others say probably it is not, provided the secret is not divulged to the particular person from whom the principal wished it to be concealed. The term probably here is technical and refers more to the absolute truth of an assertion than to its practical application. (3) One might reveal such a secret without mortal sin, through inadvertence or thoughtlessness, or under the supposition that it is not a grave secret. Some moralists hold, however, that to excuse from mortal sin, the revealer must be certain that the matter of the secret is not grave. (4) Such a secret may be revealed if keeping it would cause public injury, or injury to an innocent person, or injury to the person to whom the secret has been entrusted; then the law of charity demands that it be revealed. Therefore, even if one has bound himself under oath, he may reveal the secret—always excepting a priest or confessor. This is the common doctrine of moral theologians. It is for the common good of human society that entrusted secrets be absolutely kept unless so grave a damage befalls another from such observance that it becomes more conducive to the public good to reveal than to conceal. To let an infective syphilitic, for example, spread his contagion merely because an entrusted secret should be kept is a much greater damage to the public than a good.
Barrett[163] says a physician may not divulge the diseases of a family to an insurance company unless the family assents; he may not tell the man before marriage that the woman had been operated upon, say, for ovariotomy, unless the woman gives permission; nor may he let the woman know, before marriage, of those diseases of the man which are not contagious. Ho says further that if a man has had syphilis and is now completely cured, the physician may not reveal this previous condition to the woman.
That doctrine about ovariotomy, if it includes double ovariotomy, is disputed by physicians because, they say, such a woman is sterile and she knowingly is going to deprive the man of his chances of having children; secondly, a woman upon whom double ovariotomy has been performed is almost always a neurasthenic invalid with a marked tendency to insanity, and it is a grave injustice to any man to saddle such a degenerate upon him for life by treachery. The prospective injury to the man is so great that the physician should first try to induce the woman to divulge her condition, and if she does not, the physician at least may divulge it.
Secondly, I deny most emphatically that any physician can tell that a man who once has had syphilis is completely cured and is not a source of infection. The facts I have cited in this chapter prove conclusively that once a syphilitic always probably a syphilitic, and the risk is always so great that the physician is obliged first to insist that the man does not marry, and if the man persists the physician may let the woman know. If preparations for the marriage have been made publicly, the physician will, as a rule, for his pains from the woman and her family get only a rebuff and the woman will later get her syphilis more or less certainly. If the man is actively infective the physician is bound to let the woman know, through her confessor if no other way presents, provided the man cannot be frightened out of his scoundrelism. If nothing else avails, the physician would be justified in reporting such a man to the Board of Health or the sanitary police. Barrett says the physician may be excused from divulging that the man has infective syphilis if such a revelation would cause the physician to lose the confidence of his patients. It never does have such an effect, although physicians constantly expose such cases in the interests of humanity. Because a man who is apparently cured of syphilis may or may not infect the woman, this doubt probably excuses the physician from the strict obligation of divulging the condition, although he may tell her if he wishes to do so, salvo meliore consilio, as far as the release from strict obligation to divulge is concerned.
If a patient with syphilis goes to a physician for the treatment of some other physical disability, and the physician discovers the syphilis in the course of the examination, this knowledge of the syphilis would be a tacitly entrusted secret. Whether, however, a secret that a man is actively infective or very probably infective is entrusted either tacitly or directly, it is not a privileged secret owing to the danger or certainty of extraordinary calamity to the innocent second party.
The fact that in these cases of active or latent syphilis the disease has been acquired criminally does not in itself affect the state of the question one way or another—a criminal syphilitic has a right to his reputation and goods despite his moral condition; but even where the disease has been acquired without moral guilt the syphilitic is always a formally or materially unjust aggressor in a prospective marriage to an innocent and uninfected woman, and is to be treated accordingly. If a woman may kill an unjust aggressor in defence of her chastity, and if quod liceat per se licet per alium, her natural protectors, kin, physician, and so on, may at least divulge the secret of the man's condition in defence of her from a fate which in many respects is worse than rape.
In keeping with this matter of entrusted secrets it is worth noting that physicians should remember that the case histories they leave after them at death, or which they leave unguarded in their offices, are likely to be read by some third party who has no right to the secrets they contain. Case histories which the patients would not have divulged should be kept in cipher so far as proper names and addresses are concerned.