EDITORIAL E6bitortal HEREDITY IN PSYCHIATRY r NHE recent controversy started on eugenic grounds regarding the inheritance of mental deficiency has A-served at least one useful purpose. It has drawn atten- tion to the almost complete absence of data of a scientifically acceptable kind from any source in this country on the heredity of mental defect. Such statistics as were available in the text- books and journals covered an insignificant total of cases, and have not been collected in a way that would bring satis- faction to a geneticist. The same is true of work abroad in this particular field but not to the same extent. It does not very well become us to criticize some of the foreign work because it seems extravagant. Only in the past three years or so has any sound attempt been made in this country to fill the gap with regard to the inheritance of mental deficiency on well-considered genetic principles. With mental disease as with mental deficiency, the position in this country is also unsatisfactory. In the technical journals, which presumably reflect in their contents the leading interests of those engaged in research, it is a rare event to find a paper on the inheritance of mental disease. Yet the opportunities are very great. Clouston, many years ago, set an example of what might be done. ' . . . An inquiry I made into the history of 83 families, taken at random, in a country parish in Scotland, all the members of which were personally known to me for three generations. I took every family I really knew and no others. I made no selection. They were all country people, decent folks, hard-working, thrifty, few very poor, indeed mostly money-loving, with scarcely any drunkards. ' I took advantage of my intimate knowledge of the people as a doctor to count in the lesser attacks of melancholia, the milder delusional states and the milder degrees of imbecility, that would not have gone into any public statistics of lunacy or census schedules. Still, they were all mental diseases or defects just as truly, from the scientific point of view, as our acutest case in Morningside. The result was this, that of those 83 139 P ro te cte d b y co p yrig h t. o n A p ril 5 , 2 0 2 1 b y g u e st. h ttp ://jn n p .b m j.co m / J N e u ro l P sych o p a th o l: first p u b lish e d a s 1 0 .1 1 3 6 /jn n p .s1 -1 4 .5 4 .1 3 9 o n 1 O cto b e r 1 9 3 3 . D o w n lo a d e d fro m http://jnnp.bmj.com/ families, I knew that in 41 of them one or other of those four diseases had occurred.' The great majority of our mental hospitals draw on a local non-migratory population resembling that available to Clouston on a much larger scale. A high proportion of the families on which they draw have been settled in the same district for several generations, presenting opportunities that can seldom be surpassed; yet for our more thorough informa- tion at present we have to go abroad. While we are surprised and disturbed by some of the conclusions reached by our foreign colleagues, we have little of our own except clinical impressionism to fall back upon. This lack of interest in heredity, judging from the pub- lished material, justifies pointing out what should be obvious, that hereditary data are most valuable and sometimes essential in daily medical practice. Medical students do not have it emphasized enough to them how important the information about a patient's heredity can be for diagnosis, especially in difficult cases. The old type of doctor was credited with a knowledge of the constitution of his patient. How much of this must have been compounded of a knowledge of the disease- tendencies of their families whom they looked after often through two or even three generations ? Mental constitution, apart from mental disease, is a more or less important factor in almost any morbid condition. It has familial and hereditary .aspects which are more readily grasped through the study of those exaggerated traits which are transmitted through succes- sive generations, appearing in various combinations in indi- vidual members, of families tainted with mental disease. Studies of the inheritance of characterological and temperamental traits of this type, that is, the type usually credited with close association with or predisposition to actual mental disorder, is one of the most interesting by-products of the recent work on constitution with which Kretschmer's name is so much associated. It throws light conversely on what constitutes a unitary trait of character and temperament and thereby illumines a very difficult field of psychopathology. What has been partly done for the psychoses in this way badly needs extending to the psychoneuroses. Even those psychopathologists who claim to reduce any psychoneurosis to ultimate immediately postnatal terms are forced to postulate a constitutional factor for anxiety, to take an example. A study of the inheritance of such a supposed constitutional factor can show how much it matters. There can be little 140 EDITORIAL P ro te cte d b y co p yrig h t. o n A p ril 5 , 2 0 2 1 b y g u e st. h ttp ://jn n p .b m j.co m / J N e u ro l P sych o p a th o l: first p u b lish e d a s 1 0 .1 1 3 6 /jn n p .s1 -1 4 .5 4 .1 3 9 o n 1 O cto b e r 1 9 3 3 . D o w n lo a d e d fro m http://jnnp.bmj.com/ doubt that psychopathologists in general sometimes set them- selves too hard a task which a better knowledge of the con- stitutional element and of the weight to be assigned to it would teach them to undertake not so optimistically. Thereby they offer themselves too willing victims to that excessive demand made by the public of medicine in general, namely, to make bricks without straw and to give mental or physical 'stuff ' and a resistance to disease that the patient has never been given the opportunity by his ancestors to possess. And thus psycho- logical medicine, especially, sometimes comes into unnecessary disrepute. There are certain offshoots of any investigation into the inheritance of mental disease which are of interest and might prove fruitful topics for research. The hereditary aspects of allergy have always been appreciated, as, for example, with the eczema-asthma-prurigo complex, but there is an analogous field for investigation in hereditary idiosyncrasies to certain drugs. That individual idiosyncrasy exists with regard to the barbiturates is well known, and that they can have something like a specific action on anxiety is also well known. It would be very interesting to know whether such drug idiosyncrasies are heritable. It seems possible from fragmentary clinical observation that something of interest might emerge; for example, it has even been occasionally observed that a family hypersensitivity to bromide exists. Knowledge of the heredi- tary aspects of nervous temperaments and constitutions might be increased in this way. The true neuroses-that is, functional disturbances which are not apparently psychogenic-form another domain which overlaps that of the hereditary psychopathies. It seems that the vegetative functions, in spite of Langley's brilliant pioneer work, have received less attention clinically here than abroad, and probably much less attention than they deserve. Everyone knows how obscure disturbances seemingly subjective, but not easily explained on purely psychological grounds, are sometimes found, for instance, in association with an epileptic ' anlage.' It seems that in many of these obscure disturbances where there is no physical disease which is relevant, a study of the hereditary relationships, as Alvarez has recently pointed out, especially in the mental field, often gives a clue to what would otherwise remain a mysterious disorder, or might readily be mistaken for something else and given erroneous and un- fortunate treatment. Work undertaken along these or similar lines would not only add to our fund of knowledge, but would EDITORIAL 141 P ro te cte d b y co p yrig h t. o n A p ril 5 , 2 0 2 1 b y g u e st. h ttp ://jn n p .b m j.co m / J N e u ro l P sych o p a th o l: first p u b lish e d a s 1 0 .1 1 3 6 /jn n p .s1 -1 4 .5 4 .1 3 9 o n 1 O cto b e r 1 9 3 3 . D o w n lo a d e d fro m http://jnnp.bmj.com/ 142 EDITORIAL tend gradually to produce an influence on the teaching of medicine, so that the present trend of seeing the patient as a whole, which is gaining momentum, would be reinforced by a sane philosophical viewpoint of the patient as a whole against the background of his ancestry. P ro te cte d b y co p yrig h t. o n A p ril 5 , 2 0 2 1 b y g u e st. h ttp ://jn n p .b m j.co m / J N e u ro l P sych o p a th o l: first p u b lish e d a s 1 0 .1 1 3 6 /jn n p .s1 -1 4 .5 4 .1 3 9 o n 1 O cto b e r 1 9 3 3 . D o w n lo a d e d fro m http://jnnp.bmj.com/