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.
[CHAPTER XX]
Gonorrhea in Marriage
Gonorrhea is caused by the gonococcus discovered by Neisser in 1879. The name was given to the disease in the second century by Galen, who supposed that the condition is a spermatorrhea. The infection begins as a surface inflammation and gradually penetrates more or less deeply into the underlying tissues. In the male, gonorrhea may affect any part of the body; and when the disease is chronic it is a source of infection for years. If a man who has had gonorrhea wishes to marry after careful treatment, most physicians will permit him to do so if he passes the customary tests which indicate cure, but he is always dangerous. The tests are: (1) the microscopic and cultural examinations of the centrifugalized morning urine—the washings from the urethra must be negative after repeated trials and over a space of months; (2) the microscopic and cultural examinations of urethral spontaneous and artificial discharges must be negative in the same manner; (3) the microscopic and cultural findings of the secretion expressed from the prostate and seminal vesicles must be negative in the same manner; (4) urethroscopic examinations of the anterior and posterior urethra must show no unhealed lesions; (5) the complement fixation test is to be repeatedly negative. The complement fixation test is like a Wassermann reaction, but the antigen should be polyvalent. This test does not give a positive reaction where no gonorrhea is present, but it is often negative where the gonococcus is present. Hence a positive result has value, but a negative result has little or no value. All these tests are to be tried repeatedly, and if negative for months, the physician may say the man is probably cured, but no physician can guarantee the cure so as to take the responsibility of the decision. Not one physician in five hundred can make these tests himself, because physicians in general lack the special training and the means to make them. As the effects of gonorrheic infection in a woman are so appalling, any woman who wittingly marries a man who has had gonorrhea is very rash, and the man who takes the risk of infecting such a woman is a rascal.
A physician is obliged to let a woman who innocently is about to marry a "cured" gonorrheic know of the man's condition, as in a case of supposedly cured syphilis. Taber Johnson, Noble, and other authorities, say no one can tell when a gonorrheic is absolutely cured.