=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 p.r.o.ne 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 s.e.m.e.n 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 s.e.m.e.n 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 fiances 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 fiancees 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 Wa.s.sermann 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 Wa.s.sermann 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 Wa.s.sermann 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 circ.u.mstances, we must refuse all personal responsibility, leaving the a.s.sumption 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 fiancee. 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 fiancee wanted to know, whether he really was cured. There were no symptoms of any kind and the Wa.s.sermann 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_--s.e.xual Appet.i.te of Tubercular Patients--Effect of Pregnancy Contraceptive Knowledge for Tubercular Wife-- _Heart Disease_--Serious Bar to Marriage--Influence of s.e.xual 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 s.e.xual Act--_Gout_--Real Causes of Gout--_Mumps_--Parotid Glands and s.e.x Organs--Mumps and Sterility--Oophoritis 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--s.e.xual Impotence and Genius--_Drug Addiction_--External Causes--_Consanguineous Marriages_--When Consanguineous Marriages are Advisable--Offspring of Consanguineous Marriages--h.o.m.os.e.xuality--h.o.m.os.e.xuals Often Ignorant of Their Condition--s.e.xual Repression and h.o.m.os.e.xuality--Sadism and Divorce--Masochism--s.e.xual 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, n.o.body 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, n.o.body 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 a.s.sumed 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 const.i.tution_, 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 const.i.tution 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 s.e.xual intercourse has, as a rule, a strong influence on the development of the disease. Unfortunately the s.e.xual appet.i.te of tuberculous patients is not diminished, but, rather, very frequently heightened; and frequent s.e.xual 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 succ.u.mb. 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 s.e.xual 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, s.e.xual 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 circ.u.mstance, 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.