On Medical Advice Regard- ing the Marriage of Sub- jects, with a Personal or Family History of Insan- ity. BY HENRY R. STEDMAN, M.D., OF BOSTON. Reprinted from the January number of the Journal of Nervous and Mental Disease, 1889. M. J. Rooney & Co., Printers, Corner Broadway and 35th Street. NEW YORK. ON MEDICAL ADVICE REGARDING THE MAR- RIAGE OF SUBJECTS WITH A PERSONAL OR FAMILY HISTORY OF INSANITY.1 By HENRY R. STEDMAN, M.D., BOSTON. IN considering this subject many questions arise which concern the generat practitioner quite as closely as the alienist, as the family physician is almost invari- ably the first to be consulted in such matters, and his is often the only medical opinion asked. It should be stated at the outset, that this paper is in no degree an effort to cope with the vast subject of the relations between insanity and marriage in general, but merely an attempt to state systematically what seem to me to be the salient considerations regarding medical advice as to the liability after marriage to insanity in the person or progeny of those who are heriditarily so predisposed or have experienced the disease in person. It concerns the solution of some of the most difficult problems in the prac- tice of medicine. That medical opinion on this subject is given compara- tively little thought by people at large and by those who seek our advice in individual cases is evident from the great frequency of marriages in families of strong neuropathic 1 Read before the Boston Society for Medical Improvement, Oct. 22d, 1888, and (by title) at the meeting of the Am. Neurological Assoc., Sept., 1888. 2 HENRYK. STEDMAN. taint and the not uncommon union in wedlock of those who have been actually insane or possibly are so at the time. In the former class the physician's advice is rarely sought, and in the latter far too seldom. In both it is rarely heeded when given. When, in a given case,we believe our opinion to be sincerely sought and conscientiously followed, it is often more than likely that family, social or pecuniary influences have brought about the fortunate result. If, then, our counsel on this point is seldom asked, and when accepted rarely followed from disinterested motives, we can well understand why the subject receives such scant notice from physicians, and, with such a forbidding prospect, why it is looked upon as questionable whether the medical pro- fession can be of much practical help in regulating such unions. We can also, in a measure, explain the hastily consid- ered advice often given in such cases, by the confidence that is felt that no matter what may be the physician's advice it will have little to do with the result. We are by no means alone in the belief that the instances are comparatively few in which the man or woman who consults us is actuated by high motives and honestly re- gardless of personal disappointment will implicitly follow our advice in view of further and irreparable disaster to either contracting parties or their possible descendants. But when this is the case no physician can fail to be im- pressed by the enormous responsibility thrown upon him. And, by the way, can we invariably say that this or that case does not come under this head ? If we cannot, there is another reason to be added to those now to be presented for the exercise of great caution in such consultations. The causes just mentioned-the necessary lack of special knowledge of insanity in the profession at large-- taken with the tendency to under-estimate dangers of the far future have been the prime factors in the present dispo- sition to generalize rather than to definitely investigate individual cases as to their causes, nature and hereditary history. It is not a far-fetched criticism then that at least a little of the public indifference to medical opinion in such REGARDING MARRIAGE AND INSANITY. 3 matters may properly be laid at our door, so widely diver- gent and so inconsistent are the views of physicians in many cases which, by their very nature, could possibly result in but one, and that a disastrous way. Again, al- though the advice of the individual physician may have been a very small factor in promoting a marriage or in breaking an engagement, he is nevertheless frequently ex- posed to lasting blame or ridicule by the family according as the result proves to be disastrous or otherwise. If these observations are accurate, we must conclude that careful examination of each case in all its bearings, based on the best knowledge to be obtained from the con- tracting parties, our own experience and that of others in the prognosis of mental disease, will lead to much practical help in these directions to physicians. If thereby special research in this comparatively neglected field of medical inquiry is developed, we may reasonably hope for some slight mitigation at least of this scourge to the individual, the family and society, through improved public sentiment born of a greater respect for medical opinion in such matters. Landmarks are therefore needed, especially for the guid- ance of the general practitioner, for to him alone in his double role of family physician and confidant such ques- tions are, as we have said, often committed for decision. A preliminary step in this direction is a knowledge of the obstacles which arise in the way of dealing with these problems. First come those of a social character, which sometimes present greater difficulties than the second class which relates to the purely medical aspect of the question. It sometimes transpires in the course of our inquiries that on one side a family anxiously desires a marriage to take place for the sake of improving their relative's position socially or financially, or both,while in anther case a union is opposed for the opposite reasons. Therefore, either im- portant facts regarding the mental status of the party in question or his or her family history may be kept carefully out of sight, or trivial incidents may be greatly exaggerated, as the case may be. Thus the physician who feels called upon to give an opinion may, in a highly important case, 4 HENRY R. STEDMAN. be obliged to obtain his own evidence unaided against a prearranged and formidable array of statements, and to pass judgment himself. It is well, then, in view of possibly calamitous consequences to be on our guard against such attempts to improperly influence our opinion. It is, there- fore, permissible we think, without meddlesome or ex- tended investigation to endeavor to ascertain the probabili- ties of interested evidence on both sides in order to clear the way for forming our judgment on purely medical grounds. If in cases involving commitment to an asylum it be necessary preparatory to the examination of the patient himself for the physician, before certifying, to learn from the family the truth regarding facts bearing upon the question of a person's insanity and to properly balance them to prevent his unjust commitment or any danger to himself or his family, how much more important is it to gain in the same way a little evidence regarding a prospec- tive union which may prevent the transmission of insanity to generations. Other facts of the non-medical variety which should influence our decision are those relating to the surroundings of the future husband or wife. Is he or she likely to have a life of comfort and prosperity, or one of care, sacrifice and anxiety, or too great responsibility ? Is there a great disparity in years ? Will the neurotic com- panion be separated from congenial friends and surround- ings ? These points need only to be mentioned lor us to recognize their importance in the question of the mental health of those in question. We now take up the second class of difficulties, viz.: the medical problems to be solved in order to form as accurate an opinion as possible. These pertain to the etiology, forms and clinical history of mental disease, and concern both those persons who are predisposed to insanity by inheritance simply, and those who have in person experi- enced the disease. Afterwards are to be considered the dangers, viz.: those threatening the prospective mother, father or family, and their property, perhaps, through the appearance of insanity in either parent or both, or its trans- mission through inheritance to their offspring; and on the REGARDING MARRIAGE AND INSANITY. 5 other hand, those affecting the man or woman deprived of marriage through wrong advice. The amount of hereditary taint through mental defect which should preclude marriage cannot be gauged with any approach to accuracy, as at present, in spite of diligent research, but a few general and elementary laws regarding the transmission of even the normal physical and mental condition in man have been ascertained so as to admit of accurate application to individuals. As every one knows, however, a certain class of physical diseases are more liable than others to reappear in descendants. So, in the domain of insanity, there are certain disorders that bear the hereditary stamp and are, therefore, more productive than others of harm to the offspring. In estimating the prob- abilities after ascertaining the number of ancestors who have been mentally deranged, the nature of their maladies is, therefore, of importance. Where the reappearance of insanity has long been a feature of the family history, the chances are evidently more unfavorable than if one or two immediate ancestors have had sporadic attacks of that dis- order. Periodical insanity, dipsomania, epilepsy, imbecility, etc., are some of the prominent hereditary forms that are especially dangerous under these circumstances. Family peculiarities, defects, and diseases of the body have also a certain influence, such as poor physique, actual deformity, and especially frequent cases of phthisis in the ancestry. The size of families may furnish a little corroborative evi- dence as well as the temperaments of individual members. Another point to be considered is whether a parent's insan- ity has occurred before or after the birth of the person who is the object of consultation. Cases occur also where the insane ancestor is a woman, her insanity solely of puerperal origin, and the inquirer a man. Here, the chances are largely in favor of marriage. If general paralysis of the insane alone figures in the ancestry, immediate or remote, it is usually quite safe to disregard it, except in the case of a child born during the disease. This disorder does not spring from the soil of insanity proper, nor does it give rise to it, but is a cerebral malady and engenders cerebral dis- 6 HEMIYR. STEDMAN. orders. Prof. Ball and Regis, after a most thorough and instructive analysis based on extensive statistics collected by them, go so far as to affirm that the physician may say with perfect confidence that a child of a general paralytic by the fact ofits being an offspring of a general paralytic, is in no way likely to become insane ; that it has only to fear cerebral disorders by predisposition, and that, consequently, the two critical periods of its life are childhood, by reason of the danger of brain troubles at this period, and mature life the season of cerebral paralyses and general paralysis itself. Apart from the liability to such accidents, the descendance is absolutely normal. It might be added that the liability of a repetition of general paralysis itself in the offspring, except where it is begotten during the disease, is lessened by the fact that it could be propagated only through a predisposition, a tendency to cerebral excitement and not by the inherited effects of the disorder itself, which, contrary to the progress of ordinary insanity, is invariably fatal. It is well to keep in mind also that insanity is much more likely to be transmitted through the mother than the father, as it has been found that there is a much larger pro- portion of mothers than fathers among the insane, not to speak of the fact that, as Spitzka puts it, the relative pre- ponderance of maternal influence in hereditary transmission is almost a dogma of natural history. The same author quotes Richarz as establishing the following order of liabil- ity to insane inheritance. Mother insane, I, the daughter resembling mother. " " 2, " son " " " " 3, " daughter " father. " " 4, " son " " Father, " 5, " " " " " " 6, " daughter " " " " 7, " " " mother. " " 8, " son " " Above all is to be considered the great importance of the mental and physical organization of the person himself. Has he the insane or neurotic diathesis ; whether it be hereditary or acquired ? If so, he should be dissuaded REGARDING MARRIAGE AND INSANITY. 7 from marrying if possible. The signs of such a constitution relate both to physical and mental anomalies (not to be enumerated here), both of birth and development, expressed it may be, in the cranial conformation on the one side, or an excitable, nervous, melancholic temperament, perhaps an exaggerated egotism on the other, or both together. A tendency to recurrent headaches and other similar signs of the neurotic diathesis call for consideration as corroborative evidence. Our examination, moreover, should not be con- fined to the person consulting us, as not unfrequently a personal or family history of disease is thus discovered in the other partner which is sufficiently marked to change a heretofore lenient view regarding the marriage or to con- firm an unfavorable one.2 If the parties are near of kin to each other, a very slight mental taint is sufficient ground for cautioning them against marriage. But the thoughtful persons of this class who are suffi- ciently concerned by the possibility of the transmission of insanity to their children to ask our advice before marrying, are very few compared with those who have themselves ex- perienced that disease. To such cases, all that has been said regarding the dangers from marriage in those who are simply predisposed to mental disease through inheritance naturally applies with much greater force. Where each party is known to have had an attack of insanity, the fami- lies of such persons should be immediately warned of the alarming consequences of such a marriage. When but one of the contracting parties has had several attacks, no matter what the form of insanity, recurrence has become a feature, and marriage is also to be strongly discouraged. Yet we have known, in more than one case, physicians of high rank in the profession and unquestioned ability to give qualified assent to the union of patients, men with histories of period- ical mania, in one of whom the attacks were of the most extreme homicidal and destructive nature. The apparently 2 Perhaps the case alluded to by Drs. Bucknill and Tuke (Psychological Medicine, p. 65), might have had a different ending had this precaution been taken. It was that of an individual, not who had once been insane, but the one who had risked having an insane partner for life who was the one to become the subject of mental disease. 8 HENRY R. STEDMAN. sane interval in many of these cases is often marked by a certain amount of mental deterioration. In others, how- ever, especially when the attacks are of very short duration, the return to mental health is quite complete, reawakening in the patient's friends the strongest hopes, and blinding their belief in further insanity or the probability of its trans- mission. Unfortunately, this turn of affairs may also lead to the hasty medical verdict. When there has been but a single attack on either side, there is still cause for much hesitancy in sanctioning mar- riage. Many elements will enter into the decision besides those already mentioned. Nevertheless, there are not a few such cases in which marriage is justifiable and celibacy, with destroyed hopes and affections, a positive harm. Every specialist in mental disease meets with such instances, and however strongly impressed he may be, in the mass of cases, with the dangers that are so often unseen and disregarded, he has also to keep in mind that the minority who may safely marry, on the other hand, can only obtain their rights at his hands. The policy of the protection of the family and society through the individual is a wise one only when it leaves room for intelligent scientific discrimination. The chances of the reappearance of insanity in the person, and its transmission to the offspring, are greater if the mother has been insane than if the father has been mentally affected. The cases where the marriages of women so situated is allowable are, consequently, more exceptional than are those of men. It is important, moreover, to inquire whether the woman has passed the menopause, as there are not a few instances in which marriage would be permissible, and possibly beneficial, where there is no danger of the trans- mission of the insanity of the parents, and in a restricted number, even although there be a prospect of its recur- rence. The outcome as to recurrence and transmission depends upon the causation of the person's insanity and its course, and it is much less difficult in this class of cases to ascertain the nature of the antecedent mental disease than where it is a question of family history. If the insanity oc- curring long before, has been fully recovered from, was of REGARDING MARRIAGE AND INSANITY, 9 short duration, in a man without the hereditary taint or the insane diathesis, especially if the attack was mild in its na- ture, unattended with pronounced impulses or propensities, and due to accidental causes, or such as were temporary and have entirely disappeared without a probability of re- turn, he presents the most suitable conditions for favorably influencing our decision, especially if his future external sur- roundings indicate increased comfort in life and he is to marry into a sound, fat, non-nervous stock. On the other hand, when the insanity has been one of those forms which are the expression of a continuous neurotic condition, e.g., dipsomania, hysterical insanity, epileptic insanity, or para- noia, all of which may present remissions simulating re- covery, there is no question as to the nature of our advice. Another point we have also to consider is the best time for giving our advice. Only those who have had to deal with such questions can realize the temptation to give an early opinion, when the patient is rapidly convalescing, and one is being pressed on all sides for a decision. We have, nevertheless, to defer it in all cases, except in hope- lessly chronic ones of long standing. Should a patient un- expectedly make a full recovery and remain well long afterwards, we may be obliged to confess that we have exaggerated the dangers, and to allow the union to take place, provided, of course, the favorable conditions above indicated be also present. Again, if a patient must be told that marriage is out of the question, by those whose decision will be actually final with that of the betrothed acting on our advice, he will be only able to bear the shock of a separation without a relapse after a considerable time has elapsed and recovery has been fully established. The interval that should elapse between an attack and marriage is exceedingly important, as, if a child be begot while a trace of insanity lingers in either parent, the result is almost certain to be offspring who are idiotic, imbecile, or weakminded. In this connection, much might be said were it germane to our subject on the duty of the asylum physician as to the scrutiny of visits of husbands and wives to patients. 10 HENRY R. STEDMAN. The possible dangers from unwise marriages of the neurotic and insane can hardly be exaggerated. By an attack de- veloping in the father or mother as feared, more than one fellow-being is now involved and new and dearer ties will have been made only to be broken. The wife in many cases becomes worn by care, ill-health, and anxiety on account of her husband's illness, and their circumstances, perhaps, become reduced through the increased expense for his care and his inability to longer support the family. Added to this is the dread as to the possible outcome for the children through the re-enacting by them and their children of this domestic drama. This is especially to be feared if the patient recover, and it is a very melancholy aspect of this question that, as Tuke points out, in propor- tion to the number of recoveries obtained, so there is the probability of a greater number of cases of insanity through hereditary transmission.3 Any further enumeration of the probable ills to health, life and property would be super- fluous here. They are well known, and yet we are often tempted to withhold the facts or to understate them out of mistaken consideration for the feelings of an anxious lover or relative instead of distinctly and boldly explaining the situation. On the other hand, if from the tendency to gen- eralize, which we have, perhaps, already too often alluded to, we refuse in favorable cases to consider the advisability of marriage on the ground that no risks of the sort should ever be taken, as much misery may be caused through the disappointment of those who had made up their minds to marry, as would be likely to occur from the development of disease in the progeny. By giving such sweeping advice we go no farther than many of the general public who, recognizing the fact, now scientifically established, that most insane never permanently recover, and that many have relapses, some with,fewer without mental deterioration in the intervals, lose sight of the exceptional cases where marriage is really advisable. We believe, on the contrary, 3 If the attach occur early in life, the dangers are by so many years greater, through the longer period of life thus given for recurrence of attack or continu- ance of the disease and the greater length of the child-bearing period. REGARDING MARRIAGE AND INSANITY. 11 that we should use the same careful discrimination and consideration of all the extenuating circumstances that every physician exercises in advising patients with physical disorders as to their future. The subject should not be left without reference to the possible cases where the physician will fail to find the necessary elements upon which to found his opinion. In this event he will refrain, as Fournier cau- tions us to do in similar situations in questions of syphilis and marriage, from announcing a verdict, as the physician is not bound to have an opinion. Often, as we have shown, we have to advise delay until further developments, either in the line of the previous history or personal mental im- provement or failure makes our course plainer. Finally, in spite of a seemingly accurate weighing of probabilities, we have to acknowledge that in the present obscurity of the pathology of insanity our most painstaking investigations may meet with disappointment. Attacks of insanity unexpectedly recur, and recoveries, to our surprise, become permanent. Our point is simply that mistakes should be reduced to the least minimum possible along lines such as have been here indicated.