In this section we must consider the competence for marriage of women
suffering from heart disease, of those suffering from hereditary
tendency to mental disorders and neurasthenic states, and, finally, of
those affected with tuberculosis.
Every doctor is confronted during the practice of his profession by the
problem whether a young woman known to suffer from heart disease is
justified in entering upon marriage and in exposing herself to the
dangers entailed on her diseased heart by copulation, pregnancy,
parturition, and the puerperium. The solution of this problem is as
important as it is difficult. On the one hand, it determines the whole
future course of a human life which is still ascending the upward path
of its vital career, and a negative decision often annuls in a moment
the young woman’s ideals and hopes; on the other hand, an affirmative
decision involves the responsibility for the consequences of marriage,
often grave in these cases.
The consequences are in fact apt to be very serious indeed. The normal
act of intercourse, in a young and sensitive woman, has already an
exciting influence on the nerve apparatus by which the movements of the
heart are controlled. The frequency of the heart’s action is greatly
increased, the cardiac impulse becomes much stronger, there is marked
pulsation of the peripheral arteries, the conjunctiva is injected, the
respiration more frequent. These manifestations, which normally are
quite transient, attain a greater intensity and exhibit a longer
duration in persons affected with heart disease. In some instances,
violent tachycardial paroxysms occur, with considerable dyspnœa, pains
in the cardiac region, headache, and even syncopal attacks.
Pregnancy, in consequence of the extensive changes undergone not only by
the reproductive apparatus but also by the general system, and further
in consequence of the vital needs of the developing embryo, involves
extensive claims upon the cardiac activity. It is easy to understand
that the diseased heart must be taxed more severely than the healthy
heart by the extension of existing vascular areas, the addition of new
vascular areas, and the increase in the quantity of the blood, during
pregnancy; and it is not surprising if the overtaxed organ threatens
sometimes to give way under the strain. Thus, during pregnancy in women
affected with morbus cordis, we observe numerous troubles in the way of
disturbances of cardiac activity and passive congestion of various
organs, culminating at times in abortion.
Parturition and the puerperium, moreover, bring several factors into
play which tend to affect unfavorably even a heart that is quite normal;
and in cases in which there is disease either of the heart or of the
great vessels, these factors may lead to the occurrence of most alarming
symptoms. In this connection we may refer to endocarditis, to fatty
degeneration of the myocardium, and to the rupture of atheromatous
arteries.
From the time of _Galen_ onwards all medical writers have agreed that
the heart is unfavorably influenced by pregnancy and its
consequences—but from this incontestable proposition to deduce the
general conclusion that young women affected with heart disease must be
forbidden to marry is in my opinion too great a jump, and altogether too
sweeping a statement. The apophthegm of _Peters_, an author to whom we
are certainly indebted for some of our knowledge of the _accidents
gravido-cardiaques_, that in the case of women suffering from morbus
cordis the rule must be enforced, _fille pas de mariage_, _femme pas de
grossesse_, _mère pas d’allaitement_, has a fine air of apodictic
brevity, but is entirely devoid of justification. No such rigid
prohibition is advanced by recent writers on heart disease, such as
_Huchard_, _von Leyden_, and _Rosenbach_; not, at least, without
qualifications.
The question as to the permissibility of marriage to girls and women
affected with heart disease cannot, in fact, be answered by any general
proposition; and each case demands separate inquiry and a careful
balancing of individual considerations. I have known cases in which the
marriage of young girls suffering from morbus cordis was equivalent to a
sentence of death, the execution of which was delayed for a few months
only. On the other hand, I have known many women belonging to the upper
classes and suffering from cardiac defects to pass through numerous
pregnancies and to give birth to a number of children with no more than
trifling disturbances of compensation. I am acquainted with a lady who
when a young girl was urgently advised against marriage, on account of
extensive aortic valvular incompetency, by two celebrated physicians.
The advice was disregarded, and this lady is now the mother of four
children, the eldest of whom is twenty-two years of age, and her general
condition is in no way worse than it was before her marriage. The
dangers of marriage in women suffering from morbus cordis are in my
opinion generally overrated.
The degree to which a woman affected with heart disease will be injured
by married life, will depend on the nature of the cardiac affection, on
the time it has already existed, on the adequacy of compensation or the
intensity of existing disturbances of compensation, on the general state
of nutrition of the patient, on the more or less favorable social
position, and on the manner in which sexual intercourse is regulated.
My own opinions in respect of this question may be summed up as follows:
A woman who has comparatively recently (within a few years) acquired a
valvular defect, and in whom the disease has run such a course that, in
consequence of dilatation of certain chambers of the heart and of
hypertrophy of those segments of the myocardium on which increased work
has been thrown, and thus in consequence of adaptation of the
cardio-vascular apparatus to the new conditions, the circulation and
distribution of the blood take place in a manner closely resembling that
in which these functions are effected in a normal, healthy individual—in
a word, a woman in whom the valvular disease appears to be adequately
compensated,—if, in addition, the patient is well nourished, if the
hæmatopoietic function has not undergone any notable disturbance, if the
muscular system is powerful and the nervous system possesses sufficient
power of resistance—then marriage may be permitted without hesitation.
In the case of such a girl or woman, we can confidently assume that the
adequate compensation of the valvular disease will enable the heart to
meet with success the claims made upon its reserve energies by sexual
intercourse, by pregnancy, and by parturition, and that these processes
will not involve any excessive danger to life.
A woman with valvular heart disease, even when that disease is well
compensated, will indeed during pregnancy and still more during
parturition and the early days of the puerperium, be liable to suffer
from various manifestations of cardiac disorder. The action of her heart
will be subject to paroxysmal increase in frequency and force, sometimes
also there may be transient attacks of cardiac asthenia; at the same
time the breathing will become more frequent and deeper, and
occasionally, even, there may be severe dyspnœa. Perhaps also symptoms
of venous congestion may manifest themselves, digestive disturbances,
sense of pressure in the head, swelling of the feet, œdema of the
abdominal wall, even slight albuminuria. Just after childbirth,
moreover, an abnormally intense depression of the circulation with
infrequency of the heart’s action will be liable to ensue. In the great
majority of cases, however, in which the conditions detailed above are
fulfilled, the disturbances of compensation occasioned by pregnancy and
the puerperal state will not seriously threaten life; and as soon as the
puerperal period has been safely passed through, the heart will again be
competent for its duties and will do its work as well as before.
These statements apply, not only to cases of well-compensated valvular
disease, especially mitral insufficiency, mitral stenosis, and aortic
insufficiency, but also to cases in which the heart has made a good
recovery after an attack of pericarditis, and to cases of moderately
extensive disease of the myocardium consequent on acute articular
rheumatism or the acute infections.
As indispensable conditions for such a favorable prognosis, we naturally
assume that the pregnant woman is in a position to command the extreme
bodily care that in her condition is doubly needful, that she is able to
avoid all severe physical exertion, and that she will be subjected to
continuous medical supervision in respect of the adoption of suitable
dietetic and hygienic measures.
Such a favorable prospect as regards marriage in cases of
well-compensated heart disease will, however, be clouded in the case of
women who are either very anæmic or predisposed to nervous disorders;
nor is the prognosis favorable as regards women in whom the heart
disease is either congenital, or acquired in early youth, or as regards
women contemplating marriage when already well up in years.
For in very anæmic women, even when the heart is quite sound, frequently
recurring attacks of tachycardia often occur during pregnancy, in the
absence of any obvious exciting cause; œdema of the lower extremities,
and the formation of extensive varices, are also common. Increased
nervous reflex irritability has also an unfavorable influence upon
cardiac innervation. In cases, again, in which the heart disease is of
long standing, the functional capacity of the heart is so notably
depressed that the organ is likely to prove incompetent to meet the
increased demands made upon it by the processes of pregnancy. Finally,
in elderly women, superadded to the valvular defects, we have the
dangers dependent upon the already beginning arteriosclerotic changes in
the bloodvessels. In all such cases, therefore, it will be the duty of
the physician to advise his patient not to marry; and in any case to
impress upon her mind the extreme probability, amounting almost to
certainty, of serious aggravation of the heart disease by marriage, with
permanent impairment of the general health.
In cases of valvular disease accompanied by serious disturbances of
compensation, and in cases of notable degeneration of the myocardium in
which pronounced symptoms of cardiac muscular insufficiency have made
their appearance, marriage must be absolutely forbidden, as directly
imperilling life. When even moderate bodily exertion suffices to cause
palpitation, increased frequency of the pulse, and shortness of breath,
when extensive œdema of the lower extremities is present and fails to
disappear even after the patient has been strictly confined to bed, when
the pulse very readily becomes irregular both in rhythm and force,
whilst the urine is often scanty and contains variable quantities of
albumin, when conditions of cardiac asthenia readily arise,
characterized by a small, irregular pulse, coldness of the extremities,
cyanotic tint, nausea, respiratory need,[42] and syncopal attacks—in all
such cases, whether the symptoms just described are dependent upon
valvular defects, upon pathological changes in the arteries, or upon
diseases of the myocardium, in all alike the occurrence of pregnancy is
a true disaster, which in the vast majority of cases causes a great and
enduring aggravation of the disease, and frequently enough costs the
patient her life.
Even in such cases as were previously described, in which, the heart
disease not being severe, the patient was told that marriage was
permissible, it is the duty of the physician to lay down certain rigid
rules regarding sexual activity.
Women suffering from heart disease should not have sexual intercourse
frequently, because, if the peripheral nervous stimulation of the
genital organs is excessive in consequence of too frequent acts of
coitus, cardiac activity is likely to be influenced powerfully in a
reflex manner, leading to the occurrence of attacks of cardiac asthenia.
Again, sexual intercourse must always be effected in such a manner that
the act attains its physiological conclusion, and that in the woman as
well as in the man the orgasm has its normal outcome, that is to say
that at the conclusion of the act the woman’s cervical glands are
evacuated with the accompaniment of the sense of ejaculation. The
_congressus interruptus_, which precisely in these cases in which the
wife suffers from heart disease is so frequently practiced by the
husband with a view to preventing conception, must be strictly
forbidden, since this mode of intercourse tends to give rise to various
forms of reflex cardiac disturbance, most commonly to paroxysms in which
the cardiac action becomes unduly frequent, in association with
diminution of vascular tone, vasomotor disturbances, and states of
mental depression; and where organic heart disease already exists, these
reflex functional disturbances involve various dangers.
The physician is further justified in advising that a woman with organic
heart disease should not give birth to more than one or two children.
This advice is the more needful for the reason that with each successive
pregnancy the functional capacity of the woman’s diseased heart
diminishes according to a geometrical ratio, and to a corresponding
degree the danger to life increases. These are cases in which in my
opinion it is the physician’s duty to concern himself with the
subject—in general so equivocal—of the use of preventive measures, and,
having regard for the preservation of a woman’s life, and uninfluenced
by any false delicacy, but with moral earnestness, to inform his patient
with respect to the needful prophylactic measures. The artificial
termination of pregnancy, which unquestionably is often justified in
women suffering from heart disease, but which unfortunately is apt to
have very unfavorable results, will rarely need to be discussed if by
the proper employment of preventive measures care is taken that
pregnancy does not recur too frequently.
To enable us to answer the question whether, in the case of neurasthenic
and hysterical young women, and in those hereditarily predisposed to the
occurrence of mental disorders, the physician shall advise for or
against marriage, attention must in the first instance be directed to
the established facts relating to the favorable or unfavorable
influence, as the case may be, of sexual intercourse and its
consequences (pregnancy and childbirth) upon existing nervous disorders
and upon the predisposition to their occurrence.
Without regarding as fully justified the opinion that in the female sex
sexual abstinence has in all circumstances an unfavorable influence upon
the nervous system or even that such abstinence is to be regarded as the
principal cause of nervous and hysterical troubles, we must consider it
fully proved that in a number of the commonest varieties of nervous
disease occurring in neurasthenically predisposed subjects, such as
neurasthenia, hysteria and neurosis of anxiety[43], the lack of sexual
satisfaction aggravates these troubles, whilst suitably regulated sexual
intercourse has an actively beneficial effect. Not, indeed, that it is
an infallible means, but none the less the effects are often striking,
as I have frequently had occasion to observe, both in young women so
affected entering upon marriage for the first time, and also in young
widows who have remarried. Especially is this true of women in whom the
sexual impulse is exceedingly powerful, and even pathologically
increased to the extent of marked sexual hyperæsthesia; likewise also in
women whose social circumstances and manner of life induce increased
sexual appetite. Be it understood, I refer here to regular and moderate
sexual intercourse, and not to sexual excesses, which latter, by
inducing nervous exhaustion, may have a distinctly deleterious effect.
In many cases, however, we observe in women suffering from sexual
neurasthenia, that sexual intercourse, even when practiced at long
intervals, gives rise to nervous prostration with deep emotional
depression and long-lasting aggravation of the existing nervous
disorder. This statement applies with especial force to very hysterical
epileptic girls with hereditary predisposition to mental disorder.
From the fact that among persons hereditarily predisposed to mental
disorder, the unmarried are on the average more often affected with
insanity than the married, the inference has been drawn that marriage
may be recommended to such persons as a measure likely to counteract
their hereditary tendency to insanity. The argument, however, lacks
validity, more especially as regards women; among whom, moreover, from
the age of sixteen to the age of thirty, insanity is proportionately
more prevalent among the married, though above the age of thirty it is
more prevalent among the unmarried.
In the great majority of neurasthenic women, normal sexual intercourse,
practiced in moderation, has, according to _Löwenfeld_, no deleterious
effect; often, indeed, as a consequence of unaccustomed abstinence, an
aggravation of existing nervous troubles may be observed. But, as this
author maintains, nervous exhaustion may result in the complete
disappearance of the orgasm during sexual intercourse, or in great
difficulty in its production; this circumstance suffices for the most
part to explain the fact that in women suffering from great depression
of the nervous functions, the fulfilment of their sexual duties has
sometimes an unfavorable influence on their general condition. As
regards hysteria, it cannot be denied, that in many hysterical women
marriage results in a favorable change in the general condition; we
must, however, be careful not to overrate the significance of such
observations. As a rule all that actually takes place is a diminution in
the intensity or even a disappearance of certain morbid manifestations
previously present, without, however, an eradication of the hysterical
temperament.
In epileptic young women, the first experience of sexual intercourse may
precipitate a fit. Cases are indeed on record in which, in hereditarily
predisposed girls, the first coitus was the exciting cause of the first
epileptic fit, the fits recurring every time sexual intercourse was
repeated.
It is a comparatively frequent occurrence in psychopathically
predisposed girls for severe mental disturbances to make their
appearance during the honeymoon, after the first experience of sexual
intercourse; when this occurs, it is doubtless to be accounted for by
the combined influence upon the mind of all the changes in the
circumstances of life which have resulted from the marriage. In the case
of two newly married women, one of whom had well-marked hereditary
predisposition, whilst in the other there was no known family history of
mental disorder, _Löwenfeld_ observed shortly after marriage the onset
of severe melancholia, with refusal of food. The delicate, nervous
temperament of these two women, on the one hand, and, on the other,
possibly, a somewhat too eager and passionate attitude on the part of
their respective husbands, led their first experience of sexual
intercourse to result in a nervous impression of the nature of shock,
which their nervous system was too weak to resist.
Frequently recurring pregnancy and childbirth may, according to
_Krönig_, act as the predisposing cause in the production of
neurasthenia. In regard to hysteria also we must admit that the onset of
some disease of the organs of generation frequently leads previously
latent hysteria to manifest itself openly, and further we have to
recognize that diseases of the reproductive system often give the
clinical picture of hysteria a quite distinctive coloration; the
physiological course of the functions of the generative organs is also
competent to produce both of these effects. _Krönig_, however, rejects
the view that the lack of sexual intercourse has an unfavorable
influence upon the nervous system in women, and gives rise to hysterical
and neurasthenic disorders. The favorable influence which marriage is
often observed to exercise upon the course of nervous disorders is
explicable with reference to psychical considerations of a very
different nature. Sexual abuses, masturbation, and the use of preventive
measures, give rise in women far less often than in men to neurasthenic
and hysterical conditions.
_Féré_ asserts that in certain neurasthenic patients sexual intercourse
induces a general blunting of the senses, and especially of hearing and
sight. Actual amaurosis of short duration may even be observed; also
cutaneous anæsthesias, paralytic conditions of the extremities taking
the form either of hemiplegia or paraplegia, convulsive attacks, and
somnolent paroxysms.
_Delasiauve_ observed that epileptic patients, who during residence in
an asylum had remained almost entirely free from fits, after returning
home and resuming sexual intercourse, even in strict moderation,
suffered from a recrudescence of the convulsive seizures; when
intercourse was excessive, the relapse was naturally even more severe.
In two instances, in women who in a single night had practiced
intercourse to very great excess, _Hammond_ observed paralysis of both
legs to ensue; he saw also in numerous cases spinal irritation and other
nervous disturbances as a consequence of sexual excesses.
_Von Krafft-Ebing_ points out, with reference to the prophylactic
influence of marriage in respect of mental disorder, that in men early
marriage diminishes the danger of the occurrence of such disorder,
whereas in women marriage is undesirable before the attainment of
complete physical maturity.
With regard to marriage in the case of persons suffering from nervous
diseases, _Ribbing_ lays down the rule that when such diseases have been
severe and have occurred in numerous members of a family, whilst a few
only in the family have remained healthy, when, moreover, the illness
has been accustomed to make its first appearance only after the
attainment of maturity, no indications of its onset being noticeable in
childhood or youth—one belonging to a family thus afflicted should be
advised not to marry. Where, however, the hereditary tendency is to a
disease likely to manifest itself in childhood or youth, a member of
such a family who has been fortunate enough to pass through the years of
development without exhibiting any pronounced disturbance of the nervous
system, may be permitted to marry if certain precautions are observed. A
woman with a tendency to alcoholism should in no circumstances be
allowed to marry. In the cases, fortunately rare, in which the
drink-craving exists in women, marriage is even more undesirable than it
is in the case of men similarly afflicted, for the female drunkard is in
a position in which she can mishandle and neglect her children
throughout the entire day; and, moreover, this affection appears to be
even more obstinately incurable in women than it is in men.
_Löwenfeld_ very rightly insists that in deciding on the advisability of
marriage in the case of neurasthenic and hysterical girls the
anticipated influence of sexual intercourse must not be the sole
determinant. “Regulated sexual intercourse, such as is rendered possible
by marriage, has often a favorable influence on previously existing
states of nervous weakness. But we should go too far if we were to
attribute the beneficial effect of married life on such conditions
solely to sexual intercourse. This latter is but one factor among
several, the others being no less important. These others are: The
pleasures of an orderly domestic activity; the withdrawal of the
patient’s attention from her own condition, partly by domestic duties
and difficulties, and partly by the novelty of marital companionship;
the gratification, especially strong in women, at having obtained a
support in life; and, finally, the joyful expectation of motherhood.
These factors, however, are not present in every marriage. When their
presence cannot reasonably be anticipated, when, in consequence of
insufficient means, the marriage is likely to entail increasing
troubles, or when, owing to the want of suitability of temperament,
annoyances and quarrels are likely to occur, we must throw the weight of
our advice into the scale against the proposed marriage, since the
advantages of regulated sexual intercourse are not likely to outweigh
the disadvantages just detailed. Even when means are ample and the
characters of the couple contemplating marriage are unquestionably
harmonious, we must nevertheless (temporarily, at any rate) advise
against marriage, we must, that is to say, advise the postponement of
marriage, if the bride is suffering from severe hysterical or
neurasthenic states. Where, further, such neurasthenic or hysterical
troubles occur in a woman with pronounced hereditary predisposition to
nervous disease, we must, both for the sake of the possible progeny and
on account of the uncertain influence of married life on the health of
the patient, absolutely and unconditionally prohibit marriage. In cases
also in which severe hereditary predisposition to mental disorder exists
(especially when derived from both parents), and in addition stigmata of
psychopathic degeneration are actually apparent in the patient, or she
has already suffered from the development of a psychosis, we must
decisively object to the patient’s marriage.”
As regards the marriage of young women suffering from tuberculosis, we
must take into consideration a fact that medical experience has
conclusively established, namely, that the processes of generation have
an unfavorable influence upon pulmonary phthisis. Girls with an
inherited predisposition to tubercular disease, sometimes first manifest
the symptoms of pulmonary tuberculosis at the time of the menarche. In
cases of developed tuberculosis, copulation and the excitement of the
vascular system associated therewith have a more or less unfavorable
influence—and all the more inasmuch as, in accordance with the saying
_omnis phthisicus salax_, women affected with tuberculosis often exhibit
a very lively sexual impulse, an almost insatiable sexual appetite.
Sexual excesses are, moreover, very likely to lead to the occurrence of
hæmoptysis.
In former days it was believed that conception and pregnancy, when
occurring in women suffering from tuberculosis, had a restraining
influence on the progress of the pulmonary disease, a view which found
expression in the assertion of _Baumes_ and _Rosières de la Chassagne_
that of two women affected with tuberculosis to the same degree of
severity, one who became pregnant would always outlive the other who
failed to become so. Careful and sufficient observations on the part of
physicians and gynecologists have, however, shown that this view was
fallacious, and, on the contrary, that during pregnancy tuberculosis
advances with more rapid strides, that pregnancy, and lying-in
accelerate the fatal event (_Grisolle_, _Lebert_), that tuberculosis
acquired shortly before pregnancy or in the course of that condition,
progresses with exceptional rapidity (_Larcher_), and that the lying-in
period is especially perilous to these patients (_A. Hanau_). In some
cases of consumption it is the first pregnancy that is the most
perilous, but in other cases a later pregnancy proves more destructive.
_Ribbing_ goes even further, insisting that neither man nor woman
affected with pulmonary consumption should marry. “If, indeed,” he
writes, “consumptives desire to enter upon marriage, merely with the aim
of being faithful to one another and assisting one another for the short
time that remains to them, I should offer no opposition. But there must
be a complete mutual understanding of the facts of the case, and an
unalterable determination on the part of both to carry out the
resolutions made prior to marriage, for failing this the consequences
will be most disastrous. In most cases, however, the course adopted by
_Bulwer’s Pilgrims of the Rhine_ is to be preferred, the lovers
contenting themselves with the condition of a betrothed pair, and in
that state awaiting the approach of death—or, if exceptionally
fortunate, proceeding to marriage only after restoration to health.”
It would certainly appear that in the case of girls suffering from
pronounced phthisis, we are justified in advising against marriage, on
account of the great danger which this state entails of a rapid advance
in the pulmonary disease.
Based upon the observations of _Schauta_ and _Fellner_, the latter
author advances the rule that in the case of a woman suffering from
disease, marriage should be forbidden only when the mortality from the
disease in question is not less than 10 per cent. In this category we
must include severe cases only of pulmonary tuberculosis; whilst cases
of laryngeal tuberculosis will, according to this rule, be absolutely
unfitted for marriage. Among heart-affections contra-indicating
marriage, he includes mitral stenosis, other valvular affections in
which there is serious disturbance of compensation, and myocarditis; he
considers marriage inadmissible also in cases of chronic nephritis, and,
among surgical affections, in cases of malignant tumour. In cases in
which during a previous pregnancy the patient has been affected by one
of the following diseases, viz., severe chorea, mental disorders, severe
epilepsy, pulmonary tuberculosis which progressed much during the
pregnancy, morbus cordis with considerable disturbance of compensation,
severe heart trouble due to Graves’ disease—in all such cases, a
repetition of pregnancy should be avoided.