Chapter Twenty-nine
MARRIAGE AND GONORRHEA
Decision of Physician Regarding Marriage of Patients Infected with Gonorrhea or Syphilis—Advisability of Certificate of Freedom from Transmissible Disease—Premarital Examination as a Universal Custom—When a Man Who Had Gonorrhea May Be Allowed to Marry—When a Woman Who Had Gonorrhea May be Allowed to Marry—Antisepsis Before Coitus—Question of Sterility in the Man Who Has Had Gonorrhea Easily Answered—Impossibility of Determining Whether the Woman is Fertile or Not.
For a man or a woman who has once suffered from gonorrhea or syphilis to enter matrimony without having secured a competent physician's opinion is a great responsibility. And a great responsibility rests upon the shoulders of the physician who is called upon to give such an opinion. For, a wrong decision—a wrong decision either way—that is, permission to marry when permission should not have been granted or refusal to give permission when permission should have been granted—may be responsible for much future unhappiness and much disease: disease of the mother and of the offspring. It may even be responsible for death.
There is no easy, short road to a positive opinion. It requires a thorough, painstaking examination at the hands of an experienced physician, one thoroughly familiar with all the modern tests, to tell whether it is safe for a man who once suffered from venereal disease to enter the bonds of matrimony. Sometimes one examination is not sufficient, and several examinations may be necessary; but, the opinion of a conscientious, experienced physician may be relied upon, and, if all men and women who once suffered from venereal disease would seek for, and be guided by, such an opinion, there would be no cases of marital infection, there would be no children afflicted with gonorrheal ophthalmia, there would be no cases of hereditary syphilis.
I firmly believe that a time will come when all venereal disease will have disappeared from the face of the earth. But, until that time comes, it would be for the benefit of the race and of posterity if people had to present a certificate of freedom from transmissible venereal disease as a prerequisite to a marriage license. Custom is often more efficient than law, and, if a premarital examination should become a universal custom (and there are indications in this direction), no law would be needed.
When May a Man Who Had Gonorrhea Get Married? For a man who once suffered from gonorrhea to be pronounced cured and a safe candidate for marriage, the following conditions must be present:
1. There must be no discharge.
2. The urine must be perfectly clear and free from shreds.
3. The secretion from the prostate gland, as obtained by prostatic massage, and from the seminal vesicles, as obtained by "milking," or "stripping," the vesicles, must be free from pus and gonococci. To make sure, it is best to repeat such examination at three different times.
4. There must be neither stricture nor patches in the urethra.
5. What we call the complement-fixation test, which is a blood test for gonorrhea similar to the Wassermann blood-test for syphilis, must be negative.
Referring to conditions 1 and 2, it sometimes happens that the patient has a minute amount of discharge or a few shreds in the urine, and I still permit him to marry; but this is done only after the discharge and shreds have been repeatedly examined and have been found to be catarrhal in character and absolutely free from any gonococci or other germs.
It sometimes happens that a patient comes to me for an examination a few days before the date set for the wedding. I examine him and find that he is not in a safe condition to marry, and so advise him to delay the wedding. Sometimes he follows the advice, but in some cases he is unable to do so. He claims the wedding has been arranged, the invitation-cards have been sent out, and to delay the wedding would lead to endless trouble and perhaps scandal. In such cases I, of course, assume no responsibility; however, I do advise the man to use an antiseptic suppository or some other method that will protect the bride from infection for the time being, while he, the husband, has an opportunity to take treatment until cured. Of the many cases in which I advised this method, I do not know of one in which infection has taken place.
When May a Woman Who Once Had Gonorrhea Be Permitted to Marry? In the case of a woman, the decision may be harder to reach than in that of a man. Of course, the urine must be clear and the urethra must be normal; however, we cannot insist that there must be no discharge. This, because practically every woman has some slight discharge; even, if not all the time, then at least immediately prior and subsequent to menstruation. Of course, the discharge must be free from gonococci and pus. Also the complement-fixation tests must be negative. But, even so, we cannot be absolutely sure, because gonococci may be hidden in the uterus or in the Fallopian tubes.
Here, we have to go a good deal by the history given us. If the woman, during the course of the gonorrhea, had salpingitis, that is, an inflammation of the Fallopian tubes, then we can never say positively that she is cured; all we can say, at best, is: presumably cured. And, further, if she has no pains in the uterine appendages, either spontaneous or on examination, and, if several examinations made within a day or two following menstruation are negative, then we may assume that she is cured. It is important, though, that this examination be made on the last day of menstruation or on the first or second day following; for there are many cases in which no pus and no gonococci will show in the inter-menstrual period, but will appear on those particular days, because, if the gonococci are hidden high up, they are likely to come down with the menstrual blood and portions of mucous membrane that are shed during menstruation.
At best, it is a delicate problem, so that whenever there has been the least suspicion that the woman may harbor gonococci I have always advised (as is my custom, to be on the safe side) and directed the woman to use either an antiseptic suppository or an antiseptic douche before coitus. With these precautions adopted, I have never had an accident happen.
The Question of Probable Sterility. Thus far I have considered the problem of marriage from the standpoint of infectivity. But, we know that, besides the effect on the individual, gonorrhea has also a far-reaching influence on the race; in other words, that it is prone to make the subjects—both men and women—sterile. And a candidate for marriage may, and often does, want to know whether, besides being noninfective, he or she is capable of begetting or having children.
In the case of man, the problem is, fortunately, a very simple one. We can easily obtain a specimen of the man's semen and determine, by means of the microscope, whether it contains spermatozoa or not. If it does contain a normal number of lively, rapidly moving spermatozoa, the man is fertile, regardless of whether he ever had epididymitis or not. If the semen contains no spermatozoa, or only a few deformed or lazily moving ones, then he is sterile.
In the case of woman, it is absolutely impossible to determine whether the gonorrhea has made her sterile or not; because there is no way of expressing an ovum from the ovary. The woman may not have had any pain or inflammation in the Fallopian tubes, and yet there may have been sufficient inflammation to close up the orifices of the tubes. On the other hand, she may have had a severe salpingitis on both sides and still be fertile. Nor is there any way of telling whether the ovaries were so involved in the process as to become incapable of generating healthy ova, or any ova at all. In short, there is absolutely no way of telling whether a woman is sterile or fertile—we can only surmise. And our surmise in this respect is liable to be wrong just as often as right. The only way the question can be decided is by experience. If the prospective husband is willing to take a chance, well and good.
While just as many girls marry as do young men, still, in practice, we always shall have to examine an incomparably larger number of male than of female candidates. This is due, not only to the fact that an incomparably larger number of men suffer from venereal disease, but also because very few women will confess to their fiancés that they ever entertained antematrimonial relations and—what is still worse—were infected with venereal disease. This, of course, is owing to our double standard of morality, which looks upon as a trivial or no offense in the man what it condemns as a heinous crime in the woman. I have known hundreds of men who confessed freely to their fiancées that they had had gonorrhea, but I have known only two girls who made a confession of the fact to their future husbands. They got married, however, and lived happily with their husbands ever after.
Chapter Thirty
MARRIAGE AND SYPHILIS
Rules for Permitting a Syphilitic Patient to Marry—Rules More Severe in Cases Where Children Are Desired—Where Both Partners Are Syphilitic—Danger of Paresis in Some Syphilitic Patients—A Case in the Author's Practice.
The problem of the syphilitic differs from the problem of the exgonorrheal patient. When a gonorrheal patient is cured, so far as infectivity is concerned, and is not sterile, there is no apprehension as to the offspring. Gonorrhea is not hereditary, and the child of a gonorrheal patient does not differ from the child of a nongonorrheal person. In the case of syphilis, it is different. The patient may be safe so far as infecting the partner is concerned, but yet there may be danger for the offspring.
The rules for permitting a man or a woman who once had syphilis to marry, therefore, are different from those applied to the gonorrheal patient. Here are the rules:
1. I would make it an invariable rule that no syphilitic patient should marry or should be permitted to marry before five years have elapsed from the day of infection. But the period of time alone is not sufficient; other conditions must be met before we may give a syphilitic patient permission to marry.
2. The man or the woman must have received thorough systematic treatment for at least three years, either constantly or off and on, according to the physician's judgment.
3. For at least one year before the intended marriage, the person must have been absolutely free from any manifestations of syphilis; that is, from any eruptions on the skin, from any mucous patches, swelling in the bones, ulcerations, and so on.
4. Four Wassermann tests, taken at intervals of three months and at a time when the patient was receiving no specific treatment, must be absolutely negative.
If these four conditions are fully met, then the patient may be permitted to marry.
It is important, however, to state that, in permitting or refusing syphilitic persons to marry, we are guided to a great extent by the fact as to whether they expect to have children soon or not.
In the case of a couple who are anxious to have children soon after their marriage, the conditions for our permission must be more severe than when the couple are willing or anxious to use contraceptive measures for the first years of their married life. For, if a man is free from any skin lesions and from any mucous patches, his wife is safe from infection as long as she does not become pregnant. But, if she does get pregnant, she may become infected through the fetus; and, of course, the child also is liable to be syphilitic. Hence, much stricter requirements for syphilitics who expect to become parents are necessary than for those who do not.
In case both the man and the woman are or have been syphilitic, permission to marry may be granted without hesitation, as the danger of infection is absent, but permission to have children must be refused absolutely and unequivocally. Regardless of the time that may have elapsed from the period of infection, regardless of treatment, regardless of Wassermann tests, the danger to the child is too great if both parents have the syphilitic taint in them. A healthy child may be born from two syphilitic parents who have undergone energetic treatment, but we have no right to take the chance. I, at least, never wanted to, nor ever will want to, take such a responsibility.
The Danger of Locomotor Ataxia or Paresis. There is still one more point to consider in dealing with a syphilitic patient. In patients who did not receive energetic treatment from the very beginning of the disease as also in patients whose treatment was only desultory and irregular, we never can guarantee, in spite of lack of external symptoms, in spite of a negative Wassermann reaction, that some trouble may not develop later in life.
What shall we do in such cases and what particularly shall we do if, from a general examination of the patient, we carry away the impression that, while free from the danger of infection, the man is not a good risk? Under these circumstances, we must refuse all personal responsibility, leaving the assumption of the responsibility to the prospective wife.
Here is a case in point. About five years ago a man came to me for examination; he came with his fiancée. He had contracted syphilis ten years previously, received irregular treatment by mouth, off and on. For five years, he had had no symptoms of any kind. He considered himself cured, but wanted to know, and his fiancée wanted to know, whether he really was cured. There were no symptoms of any kind and the Wassermann test was negative. Nevertheless, I could not give him a clean bill of health. I noticed what seemed to me a slowness in thinking and just the least bit of hesitation in his speech.
I told the girl (the man was thirty-five, she was thirty-two) that I could not render a definite decision in the matter, that everything might be all right, and then again it might not; but, that the question about children she would have to decide definitely, once for all, namely, that she was not to have any children. She was fully satisfied so far as that part was concerned; she said she herself objected to children and did not intend to have any and knew how to take care of herself. All she wanted to know was, whether she was in danger of being infected. I told her no, but that in my opinion there was some danger of her husband developing general paresis or locomotor ataxia.
The girl had been a teacher for about twelve years, and she was so sick at heart of the work, was so anxious for a home of her own, that she decided to take the risk. And they got married. The marriage remained childless. The man developed general paresis (softening of the brain) three years later and died about a year afterward. The woman, now a widow, I understand, is not sorry for the step she had taken. This shows what things our social-economic conditions and our moral code are responsible for.
Chapter Thirty-one
WHO MAY AND WHO MAY NOT MARRY
The Physician Often Consulted as to Advisability of Marriage—Venereal Disease the Most Common Question—Tuberculosis—Sexual Appetite of Tubercular Patients—Effect of Pregnancy Contraceptive Knowledge for Tubercular Wife—Heart Disease—Serious Bar to Marriage—Influence of Sexual Intercourse—Cancer—Fear of Hereditary Transmission—Exophthalmic Goiter—Most Frequent in Women—Simple Goiter—Exceptions to Rule—Obesity—Family History—Obesity and Stoutness Not Synonymous—Arteriosclerosis—Danger in Sexual Act—Gout—Real Causes of Gout—Mumps—Parotid Glands and Sex Organs—Mumps and Sterility—Oöphoritis Due to Mumps—Hemophilia—Hemophilic Sons May Marry—Hemophilic Daughters May Not Marry—Anemia—Chlorosis—Epilepsy—Hysteria—Symptoms of Hysteria—Marriage of Hysterical Women—Alcoholism—Effect on Offspring—Alcoholics and Impotence—Feeblemindedness—Evil Effects on Offspring—Sterilization of Feebleminded Only Preventive—Insanity—Functional Insanity—Organic Insanity—Hereditary Transmissibility of Insanity—Fear Resulting in Insanity—Environment versus Heredity in Insanity—Neurosis—Neurasthenia—Psychasthenia—Neuropathy—Psychopathy—Nervous Conditions and Genius—Sexual Impotence and Genius—Drug Addiction—External Causes—Consanguineous Marriages—When Consanguineous Marriages are Advisable—Offspring of Consanguineous Marriages—Homosexuality—Homosexuals Often Ignorant of Their Condition—Sexual Repression and Homosexuality—Sadism and Divorce—Masochism—Sexual Impotence and Marriage—Effect Upon the Wife—Frigidity—Marital Relations and Frigid Woman—Excessive Libido and Marriage—Excessive Demands Upon Wife—Satyriasis—The Excessively Libidinous Wife—Nymphomania—Treatment—Harelip—Myopia—Astigmatism—Premature Baldness—Criminality—Crime as Result of Environment—Legal and Moral Crime—Ancestral Criminality and Marriage—Rules of Heredity—Pauperism—Difference Between Pauperism and Poverty.
In former years, nobody thought of asking a physician for permission to get married. He was not consulted in the matter at all. The parents would investigate the young man's social standing, his ability to make a living, his habits perhaps, whether he was a drinking man or not, but to ask the physician's expert advice—why, as said, nobody thought of it. And how much sorrow and unhappiness, how many tragedies the doctor could have averted, if he had been asked in time! Fortunately, in the last few years, a great change has taken place in this respect. It is now a very common occurrence for the intelligent layman and laywoman, imbued with a sense of responsibility for the welfare of their presumptive future offspring and actuated, perhaps, also by some fear of infection, to consult a physician as to the advisability of the marriage, leaving it to him to make the decision and they abiding by that decision.
As a matter of fact, as often is the case, the pendulum now is in danger of swinging to the other extreme; for, a little knowledge is a dangerous thing, and the tendency of the layman is to exaggerate matters and to take things in an absolute instead of in a relative manner. As a result, many laymen and laywomen nowadays insist upon a thorough examination of their own person and the person of their future partner, when there is nothing the matter with either. Still, this is a minor evil, and it is better to be too careful than not careful enough.
I am frequently consulted as to the advisability or nonadvisability of a certain marriage taking place. I, therefore, thought it desirable to discuss in a separate chapter the various factors, physical and mental, personal and ancestral, likely to exert an influence upon the marital partner and on the expected offspring, and to state as briefly as possible and so far as our present state of knowledge permits which factors may be considered eugenic, or favorable to the offspring, and dysgenic, or unfavorable to the offspring.
The questions concerning the advisability of marriage which the layman as well as the physician have most often to deal with are questions concerning venereal disease. On account of the importance of the subject, these have been discussed rather in detail under the headings "Gonorrhea and Marriage" and "Syphilis and Marriage." Other factors affecting marriage, either in the eugenic or dysgenic sense, will be discussed more briefly in the present chapter, and more or less in the order of their importance.
Tuberculosis
Tuberculosis, which carries off such a large part of humanity every year, is caused by the well-known bacillus tuberculosis, discovered by Koch. The germ is generally inhaled through the respiratory tract, and most frequently settles in the lungs, giving rise to what is known as pulmonary consumption. However, many other organs and tissues may be affected by tuberculosis.
Tuberculosis used to be considered the hereditary disease par excellence. Entire families were carried off by it, and, seeing a tuberculous father or mother and then tuberculous children, it was assumed that the infection had been transmitted to the children by heredity. As a matter of fact, the disease was spread by infection. In former years, little care was exercised about destroying the sputum; the patients would spit indiscriminately on the floor, and the sputum, drying up, would be mixed with the dust and inhaled. Often the children crawling on the floor would introduce the infective material directly, by putting their little fingers in their mouths.
It is now known that tuberculosis is not a hereditary disease, that is, that the germs are not transmitted by heredity. The weak constitution, however, which favors the development of tuberculosis, is inherited. And children of tuberculous parents, therefore, must not only be guarded against infection, but must be brought up with special care, so as to strengthen their resistance and overcome the weakened constitution which they inherited.
That a person with an active tuberculous lesion should not get married goes without saying. But, it is a good rule to follow for a tuberculous person not to marry for two or three years, until all tuberculous lesions have been declared healed by a competent physician. As a rule, a tuberculous patient is a poor provider, and that also counts in the advice against marriage. Then sexual intercourse has, as a rule, a strong influence on the development of the disease. Unfortunately the sexual appetite of tuberculous patients is not diminished, but, rather, very frequently heightened; and frequent sexual relations weaken them and hasten the progress of the disease.
As to pregnancy, that has an extremely pernicious effect on the course of tuberculosis, and no tuberculous woman should ever marry. If such a one does marry or if the disease develops after her getting married, means should be given her to prevent her from having children. During the pregnancy, the disease may not seem to be making any progress—occasionally the patient may even seem to improve—but after childbirth the disease makes very rapid strides and the patient may quickly succumb. In the early days of my practice I saw a number of such cases. If precautions are taken against pregnancy, then permission to indulge in sexual relations may be given, provided it is done rarely and moderately.
If a patient who has tuberculosis conceals the fact from the future partner, a fraud is committed, and the marriage is morally annullable. It has been declared legally annullable by a recent decision of a New York judge.
Heart Disease
Heart disease also is no longer considered hereditary. Nevertheless, heart disease, if at all serious, is a contraindication to marriage. First, because the patient's life may be cut off at any time. Second, sexual intercourse is injurious for people having heart disease; it may aggravate the disease or even cause sudden death. It is more injurious even than it is in tuberculosis. Third—and this concerns the woman only—pregnancy has a very detrimental effect upon a diseased heart. A heart that, with proper care, might be able to do its work for years, often is suddenly snapped by the extra work put upon it by pregnancy and childbirth. Sometimes a woman with a diseased heart will keep up to the last minute of the delivery of the child and then suddenly will gasp and expire. In the first year of my practice I saw such a case, and I never have wanted to see another. Women suffering from heart disease of any serious character should not, under any circumstance, be permitted to become pregnant.
Cancer
No man will knowingly marry a woman, and no woman will marry a man, afflicted with cancer. However, this question often comes up in cases where the matrimonial candidates are free from cancer, but where there has been cancer in the family.
Cancer is not a hereditary disease, contrary to the opinions that have prevailed, and, if the matrimonial candidate otherwise is healthy, no hesitation need be felt on the score of heredity. The fear of hereditary transmission of the disease has caused a great deal of mischief and unnecessary anxiety to people. Scientifically conducted investigations and carefully prepared statistics have shown that many diseases formerly considered hereditary are not hereditary in the least degree.
Should it, however, be shown that in one family there were many members who died of cancer, it would indicate that there is some disease or dyscrasia in that family, and the contracting of a marriage with any member of that family would be inadvisable.
Exophthalmic Goiter (Basedow's Disease)
Exophthalmic goiter is a disease characterised by enlargement of the thyroid gland, protrusion of the eyeballs, and rapid beating of the heart. The disease is confined almost entirely, though not exclusively, to women, and I should not advise any exophthalmic woman to marry; neither should I advise a man to marry an exophthalmic goiter woman. It is a very annoying disease, while sexual intercourse aggravates all the symptoms, particularly the palpitation of the heart. The children, if not affected by exophthalmic goiter, are liable to be very neurotic.
Simple goiter, that is, enlargement of the thyroid gland (chiefly occurring in certain high mountainous localities, such as Switzerland), is not so strongly dysgenic as is exophthalmic goiter. Still, goiter patients are not good matrimonial risks.
Of course, there are always exceptions. I know an exophthalmic goiter woman who brought up four children, and very good, healthy children they are. But in writing we can only speak of the average and not of exceptions.
Obesity
Obesity, or excessive stoutness, is an undue development of fat throughout the body. That it is hereditary, that it runs in families, there is no question whatsoever. And, while with great care as to the diet and by proper exercise, obesity may, as a rule, be avoided in those predisposed, it none the less often will develop in spite of all measures taken against it. Some very obese people eat only one-half or less of what many thin people do; but in the former, everything seems to run to fat.
Obesity must be considered a dysgenic factor. The obese are subject to heart disease, asthma, apoplexy, gallstones, gout, diabetes, constipation; they withstand pneumonia and acute infectious diseases poorly, and they are bad risks when they have to undergo major surgical operations. They also, as a rule, are readily fatigued by physical and mental work. (As to the latter, there are remarkable exceptions. Some very obese people can turn out a great amount of work, and are almost indefatigable in their constant activity.) Each case should be considered individually, and with reference to the respective family history. If the obese person comes from a healthy, long lived family and shows no circulatory disturbances, no strong objections can be raised to him or to her. But, as a general proposition, it must be laid down that obesity is a dysgenic factor.
But bear in mind that obesity and stoutness are not synonymous terms.
Arteriosclerosis
Arteriosclerosis means hardening of the arteries. All men over fifty are beginning to develop some degree of arteriosclerosis; but, if the process is very gradual, it may be considered normal and is not a danger to life; when, however, it develops rapidly and the blood pressure is of a high degree, there is danger of apoplexy. Consequently, arteriosclerosis and high blood pressure must be considered decided bars to marriage.
It must be borne in mind that the sexual act is, in itself, a danger to arteriosclerotics and people with high blood pressure, because it may bring about rupture of a blood-vessel. There are many cases of sudden death from this cause of which the public naturally never learns. Married persons who find that they have arteriosclerosis or high blood pressure should abstain from sexual relations altogether or indulge only at rare intervals and moderately.
Gout
A consideration of gout in connection with the question of heredity will show how near-sighted people can be, how they can go on believing a certain thing for centuries without analyzing, until somebody suddenly shows them the absurdity of the thing. Gout was always considered a typical hereditary disease; for it was seen in the grandfathers, fathers, children, grandchildren, and so on. So, certainly, it must be hereditary! It did not come to our doctors' minds to think that perhaps, after all, it was not heredity that was to blame, but simply that the same conditions that produced gout in the ancestors likewise produced it in their descendants.
We know now that gout is caused by excessive eating, excessive drinking, lack of exercise, and faulty elimination. And, since, as a general thing, children lead the same lives that their fathers did, they are likely to develop the same diseases as their fathers did. A poor man who leads an abstemious life doesn't develop gout, and if his children lead the same abstemious lives they do not develop gout. (There are some cases of gout among the poor, but they are very rare.) But if they should begin to gorge and live an improper life they would be prone to develop the disease.
The disease, therefore, cannot in any way be considered hereditary. In matrimony, gout in either of the couple is not a desirable quality, but it is not a bar to marriage; and, if the candidate individually is healthy and free from gout, the fact that there was gout in the ancestry should play no rôle.
Mumps
Mumps is the common name for what is technically called parotitis (or parotiditis). Parotitis is an inflammation of the parotid glands. The parotid glands are situated, one on each side, immediately in front and below the external ear, and they are between one-half and one ounce in weight. They belong to the salivary glands; that is, they manufacture saliva, and each parotid gland has a duct through which it pours the saliva into the mouth. These ducts open opposite the second upper molar teeth.