infection in which alcohol was the direct, primary factor. How many
such cases there are altogether in the period of a year nobody can
say, but that they constitute a considerable percentage of the total
venereal morbidity every investigating sexologist will testify. Forel
claims that 76 per cent. of all venereal infection takes place under
the influence of alcohol; Notthaft is more moderate, more
discriminating in his statistics and his claims are--30 per cent. An
analysis of 1,000 cases of venereal infection, just published by Dr.
Hugo Hecht (_Venerische Infektion und Alkohol, Z.B.G._, Vol. XVI, No.
11) gives over 40 per cent. And the saddest part of it is that among
the infected were 75 married men (the author thinks there were more,
but only 75 confessed to being married), and of these, 45, equivalent
to 60 per cent., were under the influence of alcohol when they
contracted their venereal disease (extra-matrimonially, of course).
Alcoholic indulgence contributes to the spread of venereal disease
directly and indirectly. First and foremost it increases enormously
the amount of intercourse indulged in. I certainly do not belong to
those who believe that the sex instinct is merely a vicious appetite,
like the appetite for alcohol or drugs, which can easily and
completely be suppressed by the exertion of will-power. I believe that
the sex instinct can be suppressed only within reasonable limits; if
an attempt is made to exceed these limits dire results are apt to
follow. But I also believe that the sex instinct can be stimulated
artificially beyond the natural needs, and among the artificial
stimulants of the sex instinct alcohol occupies first place. And bear
in mind that alcohol produces even a stronger effect on women, in
exciting the sexual passion, than it does on men. Women are more
easily upset by stimulants and narcotics, and that is the reason why
it is more dangerous for women to drink than it is for men.
So this, then, is count number one: The man and the woman who in a
sober condition would easily abstain, with their libido stimulated and
their will-power paralyzed by alcohol, indulge unnecessarily, with the
risk of venereal infection to the man and the double risk of venereal
infection and pregnancy to the woman. Count two: The man who in the
sober condition would use care and discrimination, under the influence
of alcohol soon loses all his judgment and sees an angel and a Helen
of Troy in the worst and most impudent harlot; with the result that
the chances of venereal infection are greatly increased. Count three:
Where under ordinary circumstances the man would stay a few minutes to
half an hour, under the influence of alcohol he stays several hours,
or all night, thus increasing his chances of infection a hundredfold.
Count four: Alcohol increases the congestion in the genital organs of
both man and woman and renders them much more _susceptible_ to
infection. All other factors being equal, a connection which will
under strict sobriety remain without bad results, may when one or
both partners are under the influence of alcohol be followed by
infection. Count five: The man who is in the habit of using venereal
prophylactics under the influence of alcohol becomes both careless and
reckless; he looks with contempt at preventive measures and the result
is--venereal disease.
It is impossible to give statistics and exact or even approximate
figures. But there is no question in my mind, in the mind of any
careful investigator, that if alcoholic beverages could be eliminated,
the number of cases of venereal infection would be diminished by about
one-half. And what is true of venereal disease is also true of
seduction of young girls. Alcohol is the most efficient weapon that
either the refined Don Juan or the vulgar pimp has in his possession.
You cannot hope for complete success in eliminating venereal disease
and seduction unless you also eliminate alcoholism. For Bacchus is the
ally not only of Venus Aphrodite but also of Venus vulgivaga.
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.