Competence for Marriage of Women Suffering from Disease.
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.