Hereditary Disease
THE JOURNAL PSYCHOLOGICAL MEDICINE AND ft MENTAL PATHOLOGY. J Art. I.?. :Author: J. M. WINN, M.D., M.R.C.P., &c.
Formerly Resident Physician of Sussex House Lunatic Asylum. The inheritance of disease is one of the most mysterious and deplorable conditions of humanity. Any suggestions that may tend to throw light on the laws which regulate the development of hereditary diseases, with a view to their prevention or alle- viation, cannot fail to interest not only the physician or philo- sopher, but all mankind; for how few of us can boast of an ancestry entirely free from some form of hereditary taint. How often does it become the painful lot of the physician to see some member of a family, who had given every promise of health and a brilliant career, struck down by an attack of insanity, which his friends would fain attribute wholly to some accidental cause, mental or physical, but which the experienced medical man discovers, on close enquiry, to be the development of constitu- tional disease, transmitted from some member of the family more or less remote. If he does not find evidence of decided insanity (for friends and relations will often take infinite pains to conceal this fact), he will probably discover that some have manifested the existence of hereditary disease in the form of phthisis, scrofula, epilepsy, &c. Having made the connection between these diseases and insanity the object of close observa- tion and study during many years, the conviction of their having a common origin became so strong to my mind that, in 186^, I published a treatise on the subject.* Since that time extended observations have confirmed my belief in the truth of the theory which I then advanced?that all hereditary diseases were mutually convertible?and convinced me that it was founded on sound principles, and supported by undeniable facts. It may be as well to premise the remarks I am about to make, with a recapitulation of the principal arguments which I brought forward in that essay:?
1. I showed, by a series of examples, that hereditary disease frequently appears in different forms in members of the same family, and often even in one and the same individual?the disease passing from one form to another. From these facts I inferred a correlation of morbific forces.
2. The examples which I brought forward to prove a corre- lation of force had reference to mania, epilepsy, phthisis, scrofula, and cutaneous affections. I suggested that gout and cancer might also probably belong to the same group, but could not at that time speak confidently on the point. I have now no hesitation in including these diseases, as well as hereditary rheumatism, in the same generalisation.
3. I stated that the dissimilarity of the symptoms between some of the hereditary diseases?such, for example, as phthisis and insanity?does not prove that they are owing to different causes. Similar phenomena are traceable in the purely mate- rial world. Grove observes, ” The attraction and repulsion of amber is very unlike the decomposition of water, and yet they are the same force.” I also instanced zymotic diseases as ex- amples, presenting marked special differences, and yet subject to the same general law. The frequent occurrence of carbuncle in gouty subjects may be cited as another example of a rela- tion between diseases that exhibit dissimilar symptoms. This is a fact to which I was, I believe, the first to draw the at- tention of the profession. What can prima facie be more unlike than carbuncle and an ordinary attack of the gout? One an affection of the skin and cellular membrane, terminating in the death of the cellular tissue; the other, an acute inflam- mation of a joint, ending for the most part in resolution. The worst case of carbuncles I ever met with was that of an indi- vidual who had suffered from repeated attacks of the gout. The usual symptoms of gout had, however, been for some time in abeyance before the commencement of his fatal illness; and the carbuncular disease, of which he died, was evidently the vicarious action of the same subtle morbific force as that which had previously caused his sufferings from gout.
4. From various facts which I adduced, I drew the inference that if there be but one cause for the existence of a large class of hereditary diseases, there must necessarily be one general plan of treatment more or less applicable to the whole. In applying the theory of a correlation of force to disease, it is necessary, in the first place, to assume what scarcely admits of a doubt, that a force of some kind is incessantly at work in disease as well as in health. Force is in operation everywhere, in the organic as well as in the inorganic world. Carlyle has quaintly expressed its universality by saying, ” there is force in a rotting apple.” I have provisionally termed the disease- producing force which obtains in hereditary disease, morbific. Exception has been taken to the existence of such a force: one writer considers it an improbable assumption, but surely a mere deficiency of vital force is insufficient to explain why we have tetanic symptoms from a vegetable poison (strychnine), tetanic symptoms from an animal poison, and tetanic symptoms fol- lowing an injury. In these cases, as well as in epilepsy and acute maniacal excitement, the existence of a morbific force can scarcely be considered an improbable assumption.
The phenomena of recurrent insanity afford convincing proofs of the existence of a force which may remain latent in the nervous system for many months between the intervals of its manifestation. I published a case which exemplifies this fact. The patient, a highly educated gentleman, about forty years of age, and of unexceptionable moral character, was sub- ject to attacks of recurrent acute mania of the most violent character. During the intervals his mental and bodily condition were those of a person entirely free from disease, and formed a striking contrast to his maniacal state. The paroxysms were marked by outbursts of uncontrolled passion, violent gestures, and the use of obscene and blasphemous language. After the lapse of a few weeks this terrible commotion would subside, leaving the patient calm and rational. It was like the clearing of the atmosphere by a thunder-storm, and supports the theory that there were latent morbific forces in the system, which became developed by some exciting cause, leading to a” disturbance of the nervous centres, somewhat analogous to electrical phenomena. The same argument applies with equal force to epilepsy. The two diseases are so often associated in the same individual, that it is impossible not to infer a similarity of origin. An attack of epileptic convulsions bears a strong analogy to one of acute recurrent mania. After an interval of apparently perfect health, the patient is seized with a paroxysm of what may be termed intense nervous excitement. In one the paroxysm lasts for weeks, in the other generally for a few minutes only. In both we witness the accumulation of a force, which expends itself in the one instance in maniacal violence, and in the other in convulsive movements.
In the course of my practice I have constantly found insanity supervene on the subsidence of disease of the lungs, and, in the same manner, phthisis has followed the recovery from various forms of mental disease. The way in which I have seen skin disease alternate with attacks of insanity is still more striking. These and similar facts strongly suggested to me a correlation of force in hereditary disease. Before this can be established, it is necessary to prove this mutual con- vertibility. It is not sufficient to give instances of one disease passing into another, we must demonstrate a see-saw sort of action. In my essay to which I referred, I gave several exam- ples of the remarkable manner in which the various phases of hereditary disease passed backwards and forwards, either in the same individual, or in various members of different genera- tions of the same family. Subsequently to the publication of these cases, I forwarded, on May 21, 1870, a letter to the Medical Times and Gazette, containing cases illustrative of my theory, which I will briefly repeat:
Mrs. , aged forty, had been troubled with psoriasis for many years. The rash disappeared, and she became acutely insane. On the subsidence of the maniacal attack the psoriasis reappeared.
Three children in one family were afflicted with hereditary disease; one was the victim of epilepsy, another of phthisis, and a third of insanity. Their aunt and two cousins died of phthisis. Mr. , aged 24, was sent to a warm climate on account of decided symptoms of phthisis. Whilst abroad the disease was arrested, but was followed by an attack of acute mania. Miss , aged 19. This was a case of religious mania, succeeded by phthisis.
Miss , aged 25. Scrofula, followed by suicidal mania. Miss , aged 27. Chronic monomania of suspicion. Her uncle died of phthisis.
Count became insane late in life and died in an asylum. His daughter suffered severely from scrofula, and subsequently died of phthisis.
Mr. , aged 25. Profound melancholia. This gentleman was one of a very morbific family. One of his sisters died of phthisis. Two brothers died of phthisis. Two sisters died insane, and another was exceedingly eccentric. The mother died of pulmonary consumption.
Mrs. , aged 33. A decided epileptic. Her father and mother are dipsomaniacs.
Miss , aged 14. Epileptic. Her uncle died of phthisis. Mr. , aged 18. Psoriasis of head and face. Father died of phthisis.
Miss , aged 12. Severe eczema of the scalp and neck. Mother died of cancer.
Master , aged 7. Dr eczema of the face &c., of two years’ duration. His mother has been subject to melancholia for upwards of four years, and his grandfather was a martyr to gout. Miss , aged 18. Melancholia, of many weeks’ duration. Several of her family have suffered from scrofula. Miss , aged 20. Beligious melancholia. Father is a very gouty subject.
JNXiss ?, aged 24. In this case maniacal excitement and rheumatic fever occurred alternately. Mr. , aged 40. Incoherent mania of more than ten years’ duration. His sister died of cancer of the oesophagus. Cases like these can be multiplied to almost any extent, and all medical men connected with asylums have met with them, the most frequent being the relation of insanity to phthisis. The cases I have enumerated are sufficient to prove the truth of the doctrine that there is a correlation of force in disease. With respect to the nature of this mysterious force, it can no more be explained than that of any other force?we can only know it by its effects. All that medical science can do is to determine the laws by which it is governed. The present state of our knowledge will not admit of its being considered identical with physical force. As it is destructive of life, and therefore opposed to vital force, I have called it morbific. It is conceivable that infinitesimally minute particles of matter endowed with morbific energy, transmitted to the ovum at the time of conception, might lie dormant in the system until developed by some exciting cause. We can thus form some notion how disease may be conveyed from grandparents to grandchildren, without any manifestation of its existence in the intermediate generation.
That a terrible force may be dormant in the system for an indefinite time, is shown in the effects produced by the bite of a rabid dog.
Since the appearance of my treatise the tendency of thought amongst medical men has been in the direction of my theory. Nine months after its publication in October 1869, Mr. Jonathan Hutchinson read a paper at a meeting of the Hunterian Society on ” Some of the principal diatheses, and their mutual relation,” in which he argued that gout, syphilis, scrofula, cancer, bron- chocele, dartrous affections, &c., have common properties. This group (although syphilis is mentioned, which I do not include in my category, and insanity is omitted) bears a very close resemblance to mine. Mr. Hutchinson classifies these diseases under the head of diathesis, which he considers different from dyscrasia or temperament; but all these words are vague, and do not convey to the mind the same clear idea that is expressed in the term, correlation of force.
In Drs. C. J. B. and C. T. Williams’s work on pulmonary consumption, published in 1871, I find it stated that gouty and asthmatical patients often produce phthisical offspring. In the number of the Medico-Chirurgical Review for July 1875, the writer of an article on Heredity says : ” The practice of endeavouring to establish a law of heredity, by pointing out the liability of certain families or communities to certain classes, though not to the same class of diseases, is prevalent in the present day, and we have elaborate treatises and tables to prove that scrofula, phthisis, gout, rheumatism, convulsive affections, and insanity frequently affect members of the same family or their collateral connections, with the implied or appended inference that they are congeneric affections, and though separated so widely by the tissues involved, and the nature and event of the maladies themselves, they may be traced to a common factor in hereditary tendency.” I am not aware that ” the practice of endeavouring to establish a law” that ” scrofula, phthisis, gout, rheumatism, convulsive affections, and insanity ” are ” congeneric affections ” was prevalent before the appearance of my essay; and, although the writer has not mentioned my name, I can scarcely help concluding that it is my theory to which he refers. He denounces the theory as improbable; nevertheless he cannot deny the truth of the induction, or ignore the facts on which it is based. With respect to the origin of hereditary disease, which seems to be involved in impenetrable obscurity, the oldest historical works give us scarcely any information. The earliest records refer to insanity and epilepsy. All we can say is, that they must have had a beginning. The variety of races, however, shows how peculiarities in the physical conformation of the parents, induced by peculiar habits, have been transmitted to their offspring; and in the same manner we may infer that disease engendered by vicious courses in our progenitors may be entailed on their descendants.
I will now proceed to re-consider some points in connection with the treatment of hereditary disease, to which I referred in my treatise, and which involve the two deeply important ques- tions of hygiene and marriage.
Where there is reason to suspect a tendency to hereditary disease, hygienic treatment cannot begin too soon. It should commence with the earliest period of infancy, for it often happens that the symptoms of constitutional disease are exhibited soon after birth, and often they are manifested before the period of dentition, in the form of convulsions, or some other affection of tlie nervous system. The brain and nerves of infants being proportionally larger than those of adults, will, to a certain extent, account for their proclivity to nervous disease. If my conjecture be correct, that it is in the nervous system that the morbific force is located, it is to be expected that infants, from this preponderance of nervous tissue, should be especially liable to convulsive disease.
The first consideration that demands our attention is the nourishment of the infant. It is of the greatest moment that it should have the food which nature has provided for it in the mother’s breast.* Even if the mother is supposed to belong to a family in which some form of hereditary disease has been manifested, I do not think it an objection to nursing, provided she be strong and has plenty of milk; for there is no ground for believing that the class of hereditary diseases to which I have referred can be communicated, like syphilis, through the secretions of the mother. If the mother should not have the power of suckling her child, a healthy nurse should be provided. The three other great requisites for an infant’s health are air, warmth, and bathing. It must be warmly clad, and taken out into the open air whenever the weather permits. Education should begin with the first dawn of intelligence. The child must be managed with firmness, combined with tenderness. Nothing is more prejudicial to its future health, both bodily and mental, than the capricious behaviour of those parents or guardians who are over-indulgent at one time and needlessly severe at another.
It would be out of place here to enter at any length into the subject of education, but it is desirable that a few words should be said on the danger to mental and bodily health arising from the too prevalent practice of over-exciting the brain by a variety of useless studies. It is an established fact that precocious children are often scrofulous; parents are delighted with an early exhibition of talent, and take a fond, foolish pride in displaying the accomplishments of their child, not knowing that they are thereby stimulating a brain already morbidly active, and are disposed to keep him at his books and studies when he ought to be romping with his companions in the playground. The same attention to hygienic rules is * It is a deplorable fact, in which I am borne out by a medical man engaged in an extensiyo obstetric practice in the West End, that it is quite the exception for fashionable mothers to suckle their infants. The Saturday Review for July 24,1875, contains a satirical and well-timed article, entitled “The Modern Mother,” in which the writer says, “From the first the mother in the well-to-do classes acts much the part of the ostrich with her eggs. She trusts to the kindly influence of external circumstances, rather than to her own care, to make the hatching success- ful. Nurses, governesses, schools, in turn relieve her of the irksome duties of maternity.”required as the child advances in years, and especially during the period of puberty. The modern institution of competitive examinations has been the means of seriously injuring the health of many an ardent youth who had not stamina enough to bear the intense application necessary for such an ordeal. I have been consulted in many cases where constitutional disease has been developed by this forcing system.
The most critical period of life for those who are liable to hereditary diseases, especially epilepsy or phthisis, is the interval between the ages of fifteen and twenty-five. This fact shows the importance of controlling the sexual passions at this important epoch; but long after this period it will be necessary to follow the general precautions I have recommended. From long observation, I have come to the conclusion that there is a numerous class of persons disposed to hereditary maladies who would have escaped disease, had they been careful to choose the profession or vocation best suited to their con- stitutional powers. No one can command the circumstances of his position, and no care on our part can secure us from the various accidents, and moral shocks, which are inseparable from the condition of humanity; but as it is generally an apparently accidental cause that determines the particular form that disease assumes, it should be borne in mind that if a person disposed to hereditary complaints is exposed to the debilitating effects of impure air, and in-door employment, it will probably be the lungs that will suffer; if, to the wear and tear of an anxious profession, or if impelled by an eager desire for literary fame, he over-exerts his intellectual faculties, he is more likely to become the victim of some brain affection. It is therefore most desirable that he should cultivate a taste for all such pursuits and employments as should keep him constantly in free exercise in the open air, and give occupation for the mind, without excessive fatigue. The benefit of change of climate cannot be too strongly insisted on. Many years ago I was called to attend a gentleman, apparently sinking fast from the effects of phthisis. As a last resource, I sent him to a warm and dry climate in the south of Europe. He perfectly re- covered, and lived abroad for about twelve years in the enjoy- ment of good health. He then returned to England, when he soon after became insane, and it was found necessary to place him in an asylum. This case not only displays the advantages of change of climate, but also gives a striking example of a mutual relation of morbific forces.
In selecting a climate, it is necessary to fix on a dry as well as warm atmosphere. Dr Crisp read a valuable paper at a meeting of the St. Andrew’s Graduates’ Association, ” On the influence of a moist atmosphere in the production of pul- monary consumption,” giving an analysis of 623 cases in various parts of England and Wales, to show that phthisis prevails mostly in places where not only the atmosphere, but the air is moist, and most especially ” where there is a want of the free circulation of air, from the presence of woods, houses, bad drainage, &c.” One of the greatest advantages of a warm climate is, that it enables an invalid to be almost con- stantly in the open air without risk of cold.
Begular daily exercise in the open air?either walking,, riding, or driving, according to the strength of the patient? is perhaps the most powerful therapeutical agent in the class of diseases under our notice. In insanity, phthisis, scrofula, and epilepsy, it is generally admitted to be of immense value. Many years ago, an empiric gained great celebrity for his cure of epilepsy. His plan was simply to order his patients to walk a considerable number of miles every day. Now, making allowance for the benefit which his patients derived from faith in their adviser, we may conclude that the success lay, in a great degree, in the far larger amount of outdoor exercise which they were induced to take, than most people can be prevailed on to try.
Whilst on the subject of prophylactic treatment, I must add a few words respecting the great value of cod liver oil, which seems to stand somewhat in the same relation to hereditary, that quinine does to zymotic disease. Its utility in scrofula, phthisis, and cutaneous diseases is universally admitted. Although we cannot explain its modus operandi by any che- mical theory,* its beneficial effects as an alterative are un- mistakable.
It is a great mistake to administer this remedy in large and nauseating doses, and I have never found it necessary to give more than one teaspoonful at a time.
It is also an error to think that glycerine, cream, or any other kind of oil can be used as a substitute for cod liver oil. The prevalent notion that it acts chiefly as a nourishing article of food has often led to the neglect of its use, when the disease is not attended with loss of fat and muscle. I have found it act as a cure in skin disease, where the robust and plethoric * The following singular fact I found recorded in the second volume of Saint jPaul’s Annual for 1872, relating to the birds of the Hebrides, by Mr. Robert Buchanan, on the authority of Mr. Graham. Ho states that he reared somo young stormy petrels solely on ” cod liver oil, “which they sucked from a feather dipped into it, clattering their beaks and shaking their heads -with evident satis- faction.” This fact shows that, apart from its medical virtues, cod liver oil possesses a wonderful power of sustaining life, which cannot be reconciled with the commonly accepted chemical theory of nutrition. t condition of the patient would have contra-indicated its use, were it a dietetic remedy.
As an auxiliary for arresting hereditary disease, I think that issues and small open blisters, once so much in vogue, should not be overlooked; combined with cod liver oil, they are often of the greatest use.
The subject of marriage is one in which the health and .happiness of mankind is so much involved, that it demands the earnest attention not only of medical men, but of all man- kind. Nothing can be more difficult to determine than the degree of moral and social responsibility which is incurred in the marriage of those who are conscious that they are themselves the victims of hereditary taint, or at least are members of a family whose ancestors or relatives are known to have been .so. There cannot be a doubt as to the danger of two indi- viduals marrying, where there is hereditary taint on both sides. It is not necessary, if the view that I have introduced be cor- rect, that the form of disease exhibited should be precisely the same; it is sufficient that it belongs to the same class. The ordinary rule of hereditary transmission is from the parents uninterruptedly to the children, and from them to the grandchildren, frequently with an interruption from the grand- parents to the grandchildren. Sometimes the taint is commu- nicated indirectly to the collateral branches.
When I have been consulted as to the advisability of an individual’s marrying into a family of which one or more mem- bers have suffered from constitutional disease, I have thought it best to lay before him, for his guidance, the following rules, which I drew up and published, with a view to estimate the different degrees of risk which would be incurred as to the transmission of disease, with reference to the various degrees of relationship.
1. If there be a constitutional taint of any kind in either father or mother on both sides of the contracting parties, the risk is so great as almost to amount to a certainty, that their offspring would inherit some form of disease belonging to the class to which these investigations refer.
2. If the constitutional disease is only on one side, either directly, or collaterally through uncles or aunts, and the con- tracting parties are both in good bodily health, the risk is diminished one-half, and healthy offspring may be the issue of the marriage.
3. If there have been no signs of constitutional disease for a whole generation, we can scarcely consider the risk materially lessened, as it so frequently reappears, after being in abeyance for a whole generation.
4. If two whole generations have escaped any symptoms of hereditary disease, we may fairly hope that the danger hag passed, and that the morbific force has expended itself. It must be borne in mind that I do not include in these rules any cases of phthisis, insanity, &c., which may have been produced by accidental causes.
And here I come to the consideration of a vexed question, which bears strongly on the subject before us. It is one that has been regarded as a fruitful cause of disease: I mean the intermarriage of blood relations. Perhaps the true reason why near consanguinity is deemed an objection to marriage, and why it is so often followed by ill effects, is, that if there should’ be any latent morbific force in the constitution of either of the parties (both of whom are derived from a common ancestor) which may have been lying dormant for one or two generations,, there would be, I believe, in the event of such a union, a double amount of probability that the old hereditary disease would reappear in some form in the offspring. If this solution of the matter be the true one, we may infer that where there is no’ hereditary tendency to disease, and both individuals are in perfectly sound health, there can be no fair or reasonable- ground for objecting to the marriage of cousins. On this subject, however, opinions are conflicting. A friend of mine,, a gentleman who has devoted much attention to social questions,- has obligingly given me the result of his observations on- consanguineous marriages. He resides in a locality whichy from its insular position and the fact of the inhabitants having intermarried for many generations, affords especial facilities for studying this point. He writes:?” In many cases more than in ordinary marriages, first cousins have no children. 4 Le sang” ne se marie pas,’ is a common saying. Where children are born they are generally females, and for the most part die- young?fortunately so, for they are usually weak in mind as- * Feuchtersleben, in his work on The Principles of Medical Psychology, trans- lated by the Sydenham Society, gives it as his opinion that one-half of the cases’ of insanity that are met with owe their origin to hereditary causes. With regard to the frequency of hereditary phthisis, the late Dr Theophilus Thompson, in his Clinical Lectures on Pulmonary Consumption, after referring to his statistical tables, says: ” You will learn that amongst a thousand patients; questioned on the subject, above one-third mentioned have lost one parent by it.” I am inclined to believe that hereditary disease is much more frequent than is generally supposed, and that a vast number of cases of insanity that have been attributed to some moral or physical shock, which has apparently produced them, aro really only the manifestations of latent disease brought into existence by external accident. This applies to puerperal mania. In 1854 I read a paper before the Medical Society, afterwards published in the Psychological Journal of Medicine, in which I observed that the term puerperal mania, used in a specific sense, had led to serious errors. As an expression of a mere variety of insanity, it was sufficiently distinctive; but puerperal mania was not a special form of insanity requiring a treatment entirely different from that of mania in general, &c. well as body. Where sons are born they have generally a strong tendency to take stimulating drinks.”
On the other hand, a note appeared in the Lancet for February 26, 1870, in answer to an enquiry respecting the advisability of the marriage of cousins, in which the writer observes:?(i The matter as we understand it may be stated thus: the marriage of cousins, provided both are healthy, has no tendency to produce disease in offspring. If, however, the cousins inherit the disease or the proclivity to disease of their common ancestor, their children would have a strong tendency to this disease, which might be fostered or suppressed by ?circumstances.” This agrees with the opinion I have given above, which appeared in my treatise published in 1869. After all, it may be argued that it is of little avail to give prudential rules respecting marriage where the affections are strongly engaged, and that the stamping out of hereditary disease is a Utopian notion; but medical science should aim at a high ideal, and it is the province of the physician to point out the best means of preventing physical evils, as it is that of the moral philosopher to exhibit the disastrous consequences of a violation of moral laws.
Whether the rules I have suggested concerning marriage be adopted or not, there can be no doubt that hygienic means have done much to arrest and alleviate hereditary disease. A medical man is often rewarded for his care and attention by seeing delicate children grow up strong and healthy men and women, the morbific force either expending itself or continuing latent. Sometimes, if disease cannot be eradicated, a favourable change of type occurs; a grave malady being transmuted into one of a less fatal character. One case of this kind especially recurs to me?that of a professional man, who was very delicate in his youth, and subject to haemoptysis. In after years he became subject to attacks of gout. He is now in his ninetieth year, and able to ride on horseback and attend to business, although still occasionally laid up with gout.
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