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.
[152] From Abraham Colles, Dublin, 1837.
[153] Wolff, 1879.
[154] _Nederlandisch Tijdschrift voor Geneeskunde_, i, 9.
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.
[155] _Zeitschr. f. klinisch. Med._, vol. lxxvi. Berlin.
[156] _Boston Med. and Surg. Jour._, vol. clvii, n. 4.
[157] _Jour. Amer. Med. Assoc._, October 31, 1914.
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.
[158] _Forchheimer's Therapeusis of Internal Diseases_, vol. ii,
p. 421. New York, 1913.
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.
[159] _Syphilis and the Nervous System_, 1892.
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.
[160] _Lyon Med._, November 7, 1907.
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]
[161] _Theologia Moralis_, iv, n. 970 et seq.
[162] Cf. De Lugo, _De Justitia et Jure_, disp. 14, n. 141.
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.
[163] Sabetti-Barrett, _Compend. Theol. Moral._, n. 565. New
York, 1915.
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.