MARRIAGEABILITY OF A SYPHILITIC
M. P. Vora , M.B.B.S., St. George’s Hospital, Bombay .
The Medical Bulletin
Vol. X, No. 22 of 21 st November 1942; Pages: 507-510
How serious and difficult it is to give any assurance to an unmarried syphilitic person that he or she is “cured and fit to marry” does not become easily apparent. To appreciate its seriousness one has only to recollect the vast and varied damage syphilis is capable of doing to the family in its most economically critical period. Syphilis brings unhappiness, family dissentions or marital insecurity; sometimes, it causes impotence or imposes an involuntary barren marriage on the partner. It is an enemy of good bearing. It induces certain inescapable risk of neurosyphilis, cardiovascular syphilis, and heredosyphilis, thus causing disablement, premature death and a huge economic loss. The infected person is not only dangerous to self but to all others whom he or she may come in contact. In short, no one can say what the end may be once the disease is contracted.
It should be remembered at the outset that there is no landmark which, when once passed, can indicate fitness for marriage. There is no test, in fact, which is free from fallacy. The negative blood Wassermann reaction too often relied on by both the patient and the doctor is absolutely untrustworthy. It has no deciding value in determining one’s fitness either for marriage or pregnancy. Under no circumstances should the mere negativity of blood Wassermann be made an excuse for withholding the usual precautions. The duration of infection and the amount of treatment though substantially lessen the virulence of transmission, cannot completely eliminate the probability of passing on the infection either to the marriage-partner or to its offsprings. All this does not mean, of course, that an unmarried person with syphilis must regard life as spoiled so far as the possibility of subsequent marriage is concerned. In most instances 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 may be considered under the following heads:
The factors which govern fitness for marriage are as follows:-
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 contact as conjugal relationship. This observation is, of course, not hundred percent true. There are, however, occasional instances in which a syphilitic man infects his wife or a woman transmits infection to her offspring, even up to twenty years from the time of primary infection.
Transmission of syphilis in marriage is primarily dependant on the duration of infection and the adequacy of treatment. While this duration cannot be defined experience shows that the chief 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 by five years from the date of infection; but women are somewhat an exception to this rule. They may violate all time rules especially with regard to transmission of infection to children. The maternal infection, therefore, has more profound effect on the health of the child than the paternal one. Hence women are always more uncertainly eligible than men.
Similarly the difficulty in determining definitely the amount of treatment and its adequacy will become easily apparent. Speaking generally, a person is seronegative primary stage should receive three full courses in continuity and have two years’ symptom-free observation period; a person infected within 4 to 5 years should be subjected to 2 to 3 years’ observation after the treatment; if the infection is older than five years, the danger of infecting the spouse is probably eliminated by six months’ active treatment. Initial or interim negativity of the blood has no significance and should be disregarded, while any tendency to serologic fastness or relapse is significant and must be viewed with caution. In some cases where a vital organ of the body is involved or where the disease is of a relapsing nature, the question of marriage may have 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 weighing the fitness to marry. The danger of the birth of syphilitic children is another issue of importance which cannot be waived. Leaving aside the debatable point, whether paternal or maternal syphilis is the chief etiological factor in heredosyphilis, it may be presumed that the maternal syphilis is undoubtedly the most common method of transmission, the infection being by way of the placental route. Proofs that a syphilitic father can infect the child ‘in utero’ without infecting the mother are wanting. The paternal transmission though rare, may be theoretically possible with the first pregnancy, while the large majority of cases follow on maternal transmission and the mother of a child with congenital syphilis is almost always herself syphilitic. Hence the birth of syphilitic children may be said to vary with the sex of the infected partner. In the case of the man, the birth of syphilitic child depends on his infectiousness for his wife. If she remains uninfected, children will very probably be free from infection. The risk is, indeed, very slight. If she acquires infection from him, children may have syphilis. In the case of women, on the contrary, it is very difficult to dismiss completely the possibility of her child being infected. Duration of infection and adequacy of treatment though often help to rule out completely this contingency of maternal transmission of infection. Treatment has decidedly greater effect than the time factor in lessening the virulence of transmission, in them. Absolute safety for the child may be secured if the infected mother is adequately treated not only before the pregnancy but also during the pregnancy, regardless of her own state at that time. The advisability to give the infected mother the benefit of observation and treatment as a prophylactic measure cannot be overestimated. It enables one to eliminate the possibility of transmission of syphilis to the child and to reassure the parents that their child will not suffer from inherited syphilis. In the case of congenital syphilitics, even when treated satisfactorily, it is difficult to sate with confidence that their offsprings will be normal.
The danger of invalidism and premature death from syphilis is a real one. Syphilitic infection especially of the male induces certain unavoidable risk of future breakdown even under the average conditions of modern treatment. Syphilis of the nervous system to the extent of 5 to 10% and that of the cardiovascular system to the extent of 15% of the syphilitic husbands (Stokes) are often impossible to avoid. If life is shortened or if he becomes invalid and bedridden especially after leaving a number of children to be looked after, a tragedy of great magnitude is bound to occur. These mishaps are sure to add to the economic difficulties of early married life; and the families of these people become a liability on 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. Younger the patient with syphilis who seeks marriage and the less prepared economically to meet the situation, the more careful and stringent should the medical man therefore be in advising the marriage and the establishment of a family. The marriage of an elderly non infectious person in easy circumstances is not a matter of great concern; some relaxation, therefore, may be considered conveniently without minimization of the risks.
When relaxation is contemplated the following points should be kept in mind:-
It is difficult to outline the full requirements for marriage-fitness; still more difficult it is to induce their acceptance in actual practice. Fournier considered necessary a decade of celibacy on the part of a syphilitic person to qualify for marriage. Hoffmann’s conservative estimate opines for three years treatment and two years’ symptom-free observation before marriage could be sanctioned. In the light of the recent knowledge, the treatment should consist of combined use of arsenic and bismuth, given as far as possible continuously; and the symptom-free observation must include repeated negative examination not only of blood but of the cerebrospinal fluid also. The study of the spinal fluid and cardiovascular system should have been negative long enough to overrule the possibility of neurosyphilis or cardiovascular syphilis. This is true for an average case.
It will be, therefore, perfectly clear that “unqualified assurance regarding the fitness for marriage of a syphilitic person cannot be had and that neither unqualified pessimism nor careless optimism can be justified in estimating the risk of marital transmission of syphilis”.
I am indebted to Dr. V. V. Gupte for his suggestions.