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 par with that in men, and give the physician's insistence on a complete cure for the woman a reasonable prospect of being needed. Where his advice is disregarded and a pregnancy 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 applied 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 intimacies 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 distressingly 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 testimony 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 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 prevailing 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 incorporation 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 decided by an expert. A thorough general or physical examination is desirable, and if this reveals suspicious signs, such as scars, enlarged glands, etc., it is then possible to investigate the Wassermann report more thoroughly by repeating the test, sending it to another expert for confirmation. In some cases it may even be necessary to insist that the patient submit to a special test, called the provocative 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 coöperate. A resourceful physician can usually settle the question of a person's fitness for marriage, and 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 laymen 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 violation 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 awakening. For example, Ohio has recently amended 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 distinguished from the old policy of locking the stable door after the horse was stolen by laws punishing one who infects another with a venereal disease after marriage has been contracted. Recent Supreme 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 annulment of the marriage, provided the uninfected party ceases to have marital 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 sanitary 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 disinterested 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 mar their happiness.[12]
[12] The problem of gonorrhea is not considered in the framing of this statement.