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Fertility and Mental Illness
356
5000 to 60,000 marriages of the insane were more fertile than others, of leukaemia a year. But if a threshold is put at The idea of Nature’s beneficent hand extinguishing its 400 rem it is unlikely that there will be any additional less useful members was now replaced by a fear of leukaemia. If there is no threshold and tests stop soon, unrestricted proliferation among the mentally diseased, 400-2000 leukaemias a year may temporarily result; if Despite the exposure of fallacies in method and reason400 rem is the key level, nothing. Even though these ing, the belief persisted, and it was not until the 1930s estimates are admittedly very uncertain, they must be that the matter was really put to the test. DAHLBERG6 respected for the long and careful judgment that backs in Sweden and DAYTON in the U.S.A. showed inde. them. They are a warning of what may happen if the pendently that the pre-admission fertility of insane release of radioactive poisons is allowed to continue. married women was significantly lower than among a As an agreed international statement of opinion comparable group of women in the general population. based on as wide a survey as possible, the U.N. document It remained for Professor EssEN-M6LLER8 in Sweden is a notable achievement. Its confirmation of so many of to compare the two main diagnostic categories-manicthe findings of the M.R.C. committee, pronounced depressives and schizophrenics. From a group of nearly 5000 married patients he deduced that manic-depresmore than two years ago, is a striking tribute to that sives were about as fertile as the general population. committee. The schizophrenics, on the other hand, were as a whole Illness and Mental about a quarter as fertile as the general population; but Fertility THE extent to which people liable to mental affliction more detailed analysis showed that schizophrenic men procreate has long concerned those administering before their illness had average fertility, whereas women mental-health policy. Between the wars large families were about half as fertile as normals. Over the years among the lower social classes led to fears (now largely both sexes followed the national decline in birthdissipated) about declining national intelligence and to rate more slowly than was expected, until the prethe closely related fear that unrestricted breeding among schizophrenic women were about as fertile as normals. stock of poor mental background was creating an After the onset of the illness the birth-rates, as expected, increasing problem of mental disorder. Beliefs have fell greatly. Patients who married after the illness (presusprung up with the most far-reaching effects: sterilisa- mably mild) had developed were normally fertile. Paration schemes-voluntary, pseudo-voluntary, and com- doxically the birth-rate was higher than expected in pulsory-have been advocated. Prof. GLANVILLE the year before admission. On close examination this WILLIAMS1 has given us the most up-to-date and com- seemed to be a sociopsychological phenomenon due to prehensive survey of the approaches to sterilisation here postponement of admission until after the birth. More and in America and argues persuasively for legalisation recently BooK,9 surveying a shut-off community in and wider use, although some of his grounds must North Sweden, found that the fertility of marriages remain open to question. The importance of these contracted by schizophrenics was very slightly greater issues and the power with which views on them are than normal; but fertility of the unmarried schizoexpressed make it appropriate that Prof. AUBREY LEWIS phrenics was lower than among others, and as 75% of should have examined in detail some of the evidence. the men were single the over-all fertility was well below His critical survey of work on the fertility of the mentally that of the normal population. It appeared, therefore, ill (but not of the mentally defective) in a Galton that lowered fertility among schizophrenics might be an lecture2 shows how few and contradictory are the facts index of the lower chances of marriage rather than an effect of the disease itself. The preponderance of single so far obtained. He pointed out that a hundred years ago the concept persons over married among schizophrenics has often of " degeneracy " was put forward by MoREL,3 and been noted; NORRIS,10 for example, found in English until the turn of the century it was thought that inferior male patients about six times as many unmarried as stock underwent decay generation by generation, psycho- married on first admissions. The most probable reason " " pathy breeding neuroses, then at a younger age schizo- seemed to be that the premorbid schizoid personphrenia (the origin of the term " dementia praecox "), ality makes marriage less likely, although the protective the line being extinguished when idiocy in childhood effect of an affectionate home life and enhanced likeliprecluded further procreation. Such a tidy scheme hood of being sent to hospital may play a part. A man fitted in well with current religious beliefs on reproba- who is shy and indrawn is at a special disadvantage in tion and the sins of the forefathers being visited on the our culture; whereas a woman of this type is more likely. children, and with LOMBROSO’S views on atavism and perhaps, to contract matrimony. It is evident, though criminal types. HENRY MAUDSLEY4 in 1862 subscribed from BööK’s figures that the probabilities vary in different environments : his schizophrenic women had a much. to it, and even ADOLF MEYER agreed. But in the early 1900s the pendulum swung to the other extreme, and better chance of marriage than those of other comDAVID HERON5 in 1907 expressed the belief that munities studied.
equilibrium fallout may eventually mean cases
1. The Sanctity of Life and the Criminal Law. London, 1958. 2. Eugen. Rev. 1958, 50, 91. 3. Morel, B. A. Traité des dégénérescences physiques, intellectuelles, et morales de l’espèce humaine. Paris, 1857. 4. J. ment. Sci. 1862, 8, 61. 5. A First Study of the Statistics of Insanity and the Inheritance of the insane Diathesis. London, 1907.
Dahlberg, G. Z. ges. Neurol. Psychiat. 1933, 144, 427. Dayton, N. A. Stud. quant. cult. Sociol. 1930, 24, 123. New Facts Mental Disorders. Springfield, Ill., 1940. 8. Essen-Moller, E. Acta psychiat., Kbh. 1935, suppl. 8. Arch. R GesBiol. 1936, 30, 367. 9. Böök, J. A. Acta genet. 1953, 4, 133. 10. Norris, V. A. J. ment. sci. 1956, 102, 467. 6. 7.
357
of schizophrenics the possible LEWIS considered was low, Professor factors maintaining the disease at its present level: he subscribed to the view that spontaneous gene mutation occurs at a high rate, and he called attention to the Medical Research Council report on the possible effects of radiation." Mental illness, it said, is the most important single category of disease determined largely by heredity, and he believed that increased radiation may be raising the mutation-rates for these diseases. The fertility of neurotic persons is almost completely unknown. One study 12 suggested a vague link between small families and feelings of inadequacy in the parents, but unpublished work at the Maudsley Hospital on a limited sample has shown no differences in fertility or in the number of single women. The psychological mechanisms believed to play a part in sterility, and the sexual disturbances which so often plague the neurotic, may be expected to affect birth-rate, but so far nothing has been proved. Professor LEWIS speculated on the possible consequences of present mental-hygiene campaigns, which, very laudably, seek to instil into the public a more sympathetic and informed understanding of mental illness. To play down the differences between mental and physical illness, and to ignore the genetic implications, might, he suggested, lead to higher marriage-rates among those liable to manic-depressive illness or with a schizoid personality : a contributory factor might be the increasing use of treatment in the community and shorter periods in hospital. With increased birth-rates among these groups there would be more children destined to become mentally ill, and such children would be in the care of parents liable to spend periods in mental hospitals-a thing which he felt no humanitarian person could regard with equanimity. On this most important subject we agree with Professor LEWIS that hereditary factors should be squarely faced both by ourselves and by the public, and that the risks of marriage and procreation should be made known as fairly as possible in the light of present knowledge: this is already the standard practice in the case of epilepsy, where commonly the normal marriage partner undergoes electroencephalographic examination in order .that the chances of epilepsy in the children may be assessed. While no-one would wish to ignore the effects of environment in the formative years of life, the psychodynamic view of causation must not be allowed to obscure the work of KALLMANN 13 and others on heredity. No person must be deprived, against his will, I of the fundamental right to procreate (especially at our i primitive level of knowledge); but we as doctors would B be doing less than our duty if we did not place the facts, as far as they are known, before our patients and the public. Further work is badly needed, and no-one is better placed than Professor LEWIS to see that it is properly carried out.
The Anatomy of the Cardia
Having concluded that the fertility
,
,
Hazards
to Man of Nuclear and Allied Radiations. H.M. Stationery Office, 1956. Westoff, C. F., Kiser, C. V. Millbank Mem. Fund Quart. 1952, 30, 239. Kallmann, F. J. Heredity in Health and Disease. New York, 1953.
of the lower oesophagus was out of phase, for diseases in this region were well documented while anatomical study lagged behind. In hypotheses about the mechanism of closure at the cardia, extrinsic pinchcocks replaced intrinsic valves, while deviationists concerned themselves with the acuteness of the angle between oesophagus and stomach. Recently, however, intrinsic valvular mechanisms have returned to favour. By marking the anterior edge of the diaphragmatic hiatus at operation with a clip, BOTHA showed that the manner in which the crura embrace the oesophagus at the hiatus can have little effect on the closure mechanism; for when the diaphragm contracts the gastric fundus is pushed downwards in relation to the hiatus,l thus opening the gastro-oesophageal angle and vitiating any sling effect the crura might have at that point. Radiographically controlled studies undertaken by him with ASTLEY and CARRÉ2 pointed to the lower aesophagus as an area which, in the majority of the 18 persons investigated, provided a pressure " barrier " between stomach and upper oesophagus; this lay above the level of the hiatus. ATKINSON et al.3 confirmed this finding; they showed that the pressure differentials were removed by swallowing, and that in cases of reflux the pressure barrier was absent. That the barrier in no way relies on the diaphragm for its existence they proved conclusively by demonstrating its presence in a case of hiatus hernia without reflux when the barrier was quite definitely above hiatal level. In a converse fashion they found that the barrier was eliminated in a case subjected to Heller’s operation when particular care had been taken not to damage the hiatus. From their radiographic studies they were likewise unable to demonstrate any correlation between reflux and angle of entry of the oesophagus into the gastric hernia in cases of hiatus defect. The recent findings thus suggest that a sphincter exists, if not in the palpable anatomical sense, certainly in the allimportant functional sense; and in this respect JoHNSTONE’S4 report of a woman who suffered oesophageal reflux only when tired is of interest. The understanding of reflux has now a firmer basis; and treatment of FOR
some
time
investigation
oesophagitis, particularly as regards surgical technique, can be designed more rationally. BOTHA5 has now added to knowledge of the gastrocesophageal junction by showing that many people have mucosal folds which, when drawn together, act as a cork close the top of the stomach. These folds are not valvular and mechanical but are thrown up longitudin-
to
ally by contraction of
muscularis mucosae. The presence of such folds has been in doubt since MAGENDIE first described them; indeed BoTHA’s work left him in doubt until he began to study the living organism instead of specimens. (The pathological condition of lower oesophageal ring appears to be due to hypertrophy of the 1. 2. 3. 4. 5.
Botha, G. S. M. Lancet, 1957, i, 662. Botha, G. S. M., Astley, R., Carré, I. J. ibid. p. 659. Atkinson, M., Edwards, D. A. W., Honour A. J., Rowlands, E. N. ibid. 1957, ii, 1138. Johnstone, A. S. Brit. J. Radiol. 1955, 28, 2. Botha, G. S. M. Brit. J. Surg. 1958, 45, 569.
5000 to 60,000 marriages of the insane were more fertile than others, of leukaemia a year. But if a threshold is put at The idea of Nature’s beneficent hand extinguishing its 400 rem it is unlikely that there will be any additional less useful members was now replaced by a fear of leukaemia. If there is no threshold and tests stop soon, unrestricted proliferation among the mentally diseased, 400-2000 leukaemias a year may temporarily result; if Despite the exposure of fallacies in method and reason400 rem is the key level, nothing. Even though these ing, the belief persisted, and it was not until the 1930s estimates are admittedly very uncertain, they must be that the matter was really put to the test. DAHLBERG6 respected for the long and careful judgment that backs in Sweden and DAYTON in the U.S.A. showed inde. them. They are a warning of what may happen if the pendently that the pre-admission fertility of insane release of radioactive poisons is allowed to continue. married women was significantly lower than among a As an agreed international statement of opinion comparable group of women in the general population. based on as wide a survey as possible, the U.N. document It remained for Professor EssEN-M6LLER8 in Sweden is a notable achievement. Its confirmation of so many of to compare the two main diagnostic categories-manicthe findings of the M.R.C. committee, pronounced depressives and schizophrenics. From a group of nearly 5000 married patients he deduced that manic-depresmore than two years ago, is a striking tribute to that sives were about as fertile as the general population. committee. The schizophrenics, on the other hand, were as a whole Illness and Mental about a quarter as fertile as the general population; but Fertility THE extent to which people liable to mental affliction more detailed analysis showed that schizophrenic men procreate has long concerned those administering before their illness had average fertility, whereas women mental-health policy. Between the wars large families were about half as fertile as normals. Over the years among the lower social classes led to fears (now largely both sexes followed the national decline in birthdissipated) about declining national intelligence and to rate more slowly than was expected, until the prethe closely related fear that unrestricted breeding among schizophrenic women were about as fertile as normals. stock of poor mental background was creating an After the onset of the illness the birth-rates, as expected, increasing problem of mental disorder. Beliefs have fell greatly. Patients who married after the illness (presusprung up with the most far-reaching effects: sterilisa- mably mild) had developed were normally fertile. Paration schemes-voluntary, pseudo-voluntary, and com- doxically the birth-rate was higher than expected in pulsory-have been advocated. Prof. GLANVILLE the year before admission. On close examination this WILLIAMS1 has given us the most up-to-date and com- seemed to be a sociopsychological phenomenon due to prehensive survey of the approaches to sterilisation here postponement of admission until after the birth. More and in America and argues persuasively for legalisation recently BooK,9 surveying a shut-off community in and wider use, although some of his grounds must North Sweden, found that the fertility of marriages remain open to question. The importance of these contracted by schizophrenics was very slightly greater issues and the power with which views on them are than normal; but fertility of the unmarried schizoexpressed make it appropriate that Prof. AUBREY LEWIS phrenics was lower than among others, and as 75% of should have examined in detail some of the evidence. the men were single the over-all fertility was well below His critical survey of work on the fertility of the mentally that of the normal population. It appeared, therefore, ill (but not of the mentally defective) in a Galton that lowered fertility among schizophrenics might be an lecture2 shows how few and contradictory are the facts index of the lower chances of marriage rather than an effect of the disease itself. The preponderance of single so far obtained. He pointed out that a hundred years ago the concept persons over married among schizophrenics has often of " degeneracy " was put forward by MoREL,3 and been noted; NORRIS,10 for example, found in English until the turn of the century it was thought that inferior male patients about six times as many unmarried as stock underwent decay generation by generation, psycho- married on first admissions. The most probable reason " " pathy breeding neuroses, then at a younger age schizo- seemed to be that the premorbid schizoid personphrenia (the origin of the term " dementia praecox "), ality makes marriage less likely, although the protective the line being extinguished when idiocy in childhood effect of an affectionate home life and enhanced likeliprecluded further procreation. Such a tidy scheme hood of being sent to hospital may play a part. A man fitted in well with current religious beliefs on reproba- who is shy and indrawn is at a special disadvantage in tion and the sins of the forefathers being visited on the our culture; whereas a woman of this type is more likely. children, and with LOMBROSO’S views on atavism and perhaps, to contract matrimony. It is evident, though criminal types. HENRY MAUDSLEY4 in 1862 subscribed from BööK’s figures that the probabilities vary in different environments : his schizophrenic women had a much. to it, and even ADOLF MEYER agreed. But in the early 1900s the pendulum swung to the other extreme, and better chance of marriage than those of other comDAVID HERON5 in 1907 expressed the belief that munities studied.
equilibrium fallout may eventually mean cases
1. The Sanctity of Life and the Criminal Law. London, 1958. 2. Eugen. Rev. 1958, 50, 91. 3. Morel, B. A. Traité des dégénérescences physiques, intellectuelles, et morales de l’espèce humaine. Paris, 1857. 4. J. ment. Sci. 1862, 8, 61. 5. A First Study of the Statistics of Insanity and the Inheritance of the insane Diathesis. London, 1907.
Dahlberg, G. Z. ges. Neurol. Psychiat. 1933, 144, 427. Dayton, N. A. Stud. quant. cult. Sociol. 1930, 24, 123. New Facts Mental Disorders. Springfield, Ill., 1940. 8. Essen-Moller, E. Acta psychiat., Kbh. 1935, suppl. 8. Arch. R GesBiol. 1936, 30, 367. 9. Böök, J. A. Acta genet. 1953, 4, 133. 10. Norris, V. A. J. ment. sci. 1956, 102, 467. 6. 7.
357
of schizophrenics the possible LEWIS considered was low, Professor factors maintaining the disease at its present level: he subscribed to the view that spontaneous gene mutation occurs at a high rate, and he called attention to the Medical Research Council report on the possible effects of radiation." Mental illness, it said, is the most important single category of disease determined largely by heredity, and he believed that increased radiation may be raising the mutation-rates for these diseases. The fertility of neurotic persons is almost completely unknown. One study 12 suggested a vague link between small families and feelings of inadequacy in the parents, but unpublished work at the Maudsley Hospital on a limited sample has shown no differences in fertility or in the number of single women. The psychological mechanisms believed to play a part in sterility, and the sexual disturbances which so often plague the neurotic, may be expected to affect birth-rate, but so far nothing has been proved. Professor LEWIS speculated on the possible consequences of present mental-hygiene campaigns, which, very laudably, seek to instil into the public a more sympathetic and informed understanding of mental illness. To play down the differences between mental and physical illness, and to ignore the genetic implications, might, he suggested, lead to higher marriage-rates among those liable to manic-depressive illness or with a schizoid personality : a contributory factor might be the increasing use of treatment in the community and shorter periods in hospital. With increased birth-rates among these groups there would be more children destined to become mentally ill, and such children would be in the care of parents liable to spend periods in mental hospitals-a thing which he felt no humanitarian person could regard with equanimity. On this most important subject we agree with Professor LEWIS that hereditary factors should be squarely faced both by ourselves and by the public, and that the risks of marriage and procreation should be made known as fairly as possible in the light of present knowledge: this is already the standard practice in the case of epilepsy, where commonly the normal marriage partner undergoes electroencephalographic examination in order .that the chances of epilepsy in the children may be assessed. While no-one would wish to ignore the effects of environment in the formative years of life, the psychodynamic view of causation must not be allowed to obscure the work of KALLMANN 13 and others on heredity. No person must be deprived, against his will, I of the fundamental right to procreate (especially at our i primitive level of knowledge); but we as doctors would B be doing less than our duty if we did not place the facts, as far as they are known, before our patients and the public. Further work is badly needed, and no-one is better placed than Professor LEWIS to see that it is properly carried out.
The Anatomy of the Cardia
Having concluded that the fertility
,
,
Hazards
to Man of Nuclear and Allied Radiations. H.M. Stationery Office, 1956. Westoff, C. F., Kiser, C. V. Millbank Mem. Fund Quart. 1952, 30, 239. Kallmann, F. J. Heredity in Health and Disease. New York, 1953.
of the lower oesophagus was out of phase, for diseases in this region were well documented while anatomical study lagged behind. In hypotheses about the mechanism of closure at the cardia, extrinsic pinchcocks replaced intrinsic valves, while deviationists concerned themselves with the acuteness of the angle between oesophagus and stomach. Recently, however, intrinsic valvular mechanisms have returned to favour. By marking the anterior edge of the diaphragmatic hiatus at operation with a clip, BOTHA showed that the manner in which the crura embrace the oesophagus at the hiatus can have little effect on the closure mechanism; for when the diaphragm contracts the gastric fundus is pushed downwards in relation to the hiatus,l thus opening the gastro-oesophageal angle and vitiating any sling effect the crura might have at that point. Radiographically controlled studies undertaken by him with ASTLEY and CARRÉ2 pointed to the lower aesophagus as an area which, in the majority of the 18 persons investigated, provided a pressure " barrier " between stomach and upper oesophagus; this lay above the level of the hiatus. ATKINSON et al.3 confirmed this finding; they showed that the pressure differentials were removed by swallowing, and that in cases of reflux the pressure barrier was absent. That the barrier in no way relies on the diaphragm for its existence they proved conclusively by demonstrating its presence in a case of hiatus hernia without reflux when the barrier was quite definitely above hiatal level. In a converse fashion they found that the barrier was eliminated in a case subjected to Heller’s operation when particular care had been taken not to damage the hiatus. From their radiographic studies they were likewise unable to demonstrate any correlation between reflux and angle of entry of the oesophagus into the gastric hernia in cases of hiatus defect. The recent findings thus suggest that a sphincter exists, if not in the palpable anatomical sense, certainly in the allimportant functional sense; and in this respect JoHNSTONE’S4 report of a woman who suffered oesophageal reflux only when tired is of interest. The understanding of reflux has now a firmer basis; and treatment of FOR
some
time
investigation
oesophagitis, particularly as regards surgical technique, can be designed more rationally. BOTHA5 has now added to knowledge of the gastrocesophageal junction by showing that many people have mucosal folds which, when drawn together, act as a cork close the top of the stomach. These folds are not valvular and mechanical but are thrown up longitudin-
to
ally by contraction of
muscularis mucosae. The presence of such folds has been in doubt since MAGENDIE first described them; indeed BoTHA’s work left him in doubt until he began to study the living organism instead of specimens. (The pathological condition of lower oesophageal ring appears to be due to hypertrophy of the 1. 2. 3. 4. 5.
Botha, G. S. M. Lancet, 1957, i, 662. Botha, G. S. M., Astley, R., Carré, I. J. ibid. p. 659. Atkinson, M., Edwards, D. A. W., Honour A. J., Rowlands, E. N. ibid. 1957, ii, 1138. Johnstone, A. S. Brit. J. Radiol. 1955, 28, 2. Botha, G. S. M. Brit. J. Surg. 1958, 45, 569.