THE LEUTIC’S FITNESS FOR MARRIAGE
By Major M. P. Vora, M.B.B.S., D.V.D, I.M.S. (Rtd) Bombay
Indian Medical Record
A monthly journal of Public Health, Tropical Medicine and Surgery etc .
VolumeNo - LXXXVII, Number. 6 of June 1967
This article was solely contributed to Indian Medical Record
How serious and difficult it is to tell casually any unmarried syphilitic person that he or she is ‘cured and fit to marry’ is not frequently realised. To appreciate its gravity and dimensions one has only to recollect the vast and varied damage syphilis is capable of doing to the family in the most economically critical period. Syphilis causes unhappiness and family dissentions or marital insecurity; the infected person is not only dangerous to self but to all others with whom he or she may come in contact. It may cause impotence or impose an involuntary barren marriage on the partner. It is an enemy of good breeding. It induces certain unescapable risks of neurosyphilis, cardiovascular syphilis and heredosyphilis, thus causing disablement, premature death and huge economic loss. In short, no one can say what the end may be, once the disease is contracted.
It should be understood at the outset that there is no landmark which when once passed, can indicate fitness for marriage. There is no single test, in fact, which is free from fallacy. The negative serological test for syphilis (STS), too often relied on by both the patient and the medical practitioner, is absolutely untrustworthy. It has no deciding value in determining one’s fitness either for marriage or pregnancy. Under no circumstances should the mere negative STS be made an excuse for withholding the usual precautions. The duration of infection and the amount of treatment, though substantially lesson the virulence of transmission cannot completely eliminate the possibility of passing on the infection either to the marriage-partner or to its offspring. All married person with syphilis must regard life totally or completely spoiled so far as the possibility of subsequent marriage is concerned. In most cases, the person may sooner or later marry with every assurance of the safety for the spouse and children.
The risks which are involved in this problem are:
The factors which govern fitness for marriage are:
With the passage of time, syphilis whether treated or not, loses its infectiousness so that by the end of five or six years, the risk to others is small even by such intimate contacts as conjugal relations. This observation is of course not cent percent true. There are however, occasional instances in which a syphilitic woman transmits infection to her offspring, even up to twenty years from the time of primary infection.
Transmission of syphilis in marriage is primarily dependent on the duration of infection and adequacy of regular treatment. While this duration can not be defined precisely, experience shows that the main danger lies in the first five years. Apart from the uncertain problem of infectivity of semen itself in some cases, an average male patient should reach non-infectious condition reasonably by five years from the date of infection; but a woman is some what an exception to this rule. She may violate all time rules especially with regard to transmission of infection to her children. The maternal infection, therefore, has more profound effect on the health of the child than the paternal one. Hence a woman is always more uncertainly eligible than man.
Similarly, the difficulty in determining the exact amount of treatment and its adequacy will be easily apparent. Speaking generally, a person in sero-negative primary state should receive a minimum of 4.8m.u. of procain penicillin-G in 8 days, in sero-positive primary stage 6.0m.u. in ten days, and in the late secondary stage 9.0m.u. in 15 days. Thereafter he or she should have two years’ symptom-free observation period. If the patient has received either under or irregular treatment specially in the early stages of syphilis, it is likely to make the vital organs of the body more vulnerable to infection, leading to crippling disabilities at a future date. If the infection is older than five years, whatever little danger there is of infecting the spouse is eliminated by 6 to 9m.u. in 10 to 15 days. Initial or interim serologic negativity has no significance and should be disregarded; while any tendency to serological fastness or relapse shown by steady rise in titre is significant and must be viewed with caution. In late syphilitics, sero-resistance or fastness is a recognised phenomenon and need not be considered as absolute contraindication for marriage. In some patients where a vital organ of the body is involved or where the disease is of a par excellence relapsing nature, the question of marriage has to be judged on individual merits and many times, the marriage may have to be deferred.
Transmissibility of syphilis to the marital partner, though most important, is not the only issue in judging the fitness for marriage. The danger of birth of syphilitic children is another issue of importance which cannot be waived lightly. In general, the maternal syphilis is undoubtedly the most common method of transmission in large majority of instances and the mother of child with congenital syphilis is always herself syphilitic. Hence the birth of syphilitic children may be said to vary with the sex of the infected partner. In case of a man, the birth of syphilitic child depends on his infectiousness for his wife. If she remains uninfected, her children will probably be free from syphilis. In case of a woman, on the contrary it is rather difficult to dismiss totally the possibility of her child being infected. Duration of infection and adequacy of treatment, though often help to protect the would be husband, do not always help to rule out completely this contingency of maternal transmission of infection. Treatment has certainly greater effect than the time factor in lessening the virulence of infection in her. Absolute safety for the child may be secured if the infected mother is adequately treated early during her pregnancy. She should receive a minimum of 6m.u. of procain penicillin-G in ten days well in advance of the date of delivery. It is advisable to give the mother the benefit of observation and treatment as a prophylactic measure during the next pregnancy. It enables her to eliminate the small chance of transmission of syphilis to the child and to reassure the parents that their child will be free from syphilis. In the case of congenital syphilitics, even when treated properly it is difficult to state with confidence that their offspring will always be normal and healthy. Third generation syphilis is a recognised fact. Effects on the genes or genesis are often permanent.
The danger for invalidism and premature death from syphilis is a real one. Syphilis especially in the male induces certain unavoidable risks of future break-down even under average conditions of modern treatment. Syphilis of the nervous system to the extent of 5 to 10 per cent, optic nerve, and that of the cardiovascular system to the extent of 10 to 15 per cent of the syphilitic husbands are often impossible to avoid. If the life is shortened or if he becomes invalid and bedridden, especially after having a few children to be looked after, a tragedy of great magnitude is bound to occur. The mishaps are sure to add to the economic difficulties of the early married life; the families of these people become a liability to the community. The marriage of a young and recently infected person with the prospect of children and unknown economic future involves an issue of major importance. The younger the patient with syphilis who seeks marriage and the less prepared economically to meet the situation, the more careful and strict should the doctor be in advising the marriage and the establishment of the family. The marriage of an elderly non- infectious person in easy circumstances is not a matter of concern and some relaxations may be considered without minimisation of the risks. However, measures for the prevention of transmission of infection to the partner and children should not be neglected especially during the reproductive life of the partners. Sexual relations should be permitted only when the infected person is made non-infectious i.e. after he or she has received 6m.u. of procaine penicillin-G in ten days. If conception is contemplated, the treatment of the mother is considered essential during the gestation even though she is serologically negative and does not show any outward signs of syphilis. The mother must be watched during the whole course of pregnancy and treated at once if found necessary. Similarly children born to her need to be observed till they reach adolescence.
It is difficult to outline the full requirement of the marriage-fitness; still more difficult it is to induce their acceptance in the actual practice. In general it may be stated that a regular and adequate treatment and two year’s symptom-free observation before marriage is considered reasonably sound proposal. The symptom-free observation must include repeated negative physical examination, blood serology and cerebrospinal fluid studies. The careful examination of the nervous and cardiovascular systems eyeground etc. ought to be made to rule out any possibility of late complications or sequelae. This is true for an average syphilitic case.
It will be therefore, clear that unqualified assurance regarding the fitness for marriage of a syphilitic person can not be had and that neither unqualified pessimism nor optimism can be justified in estimating the risks of marital transmission of syphilis.
One million units of penicillin = 1m.u.