Mental Illness and the Question of Genetics A recent book tells us the connection between big data, mental illness, and heredity is not new.

Genetics in the Madhouse: The Unknown History of Human Heredity

By Theodore M. Porter (2018, Princeton: Princeton University Press) 447 pp, with index, bibliography, endnotes, and illustrations

At the beginning of 2018, as part of the celebration of the American Psychiatric Association’s 175th anniversary, members of the Psychiatric Genomics Consortium (PGC) published an article in the American Journal of Psychiatry. The PGC authors explicitly drew a comparison between the 1946 publication of Franz Kallmann’s twin study on the genetics of schizophrenia and their current work. Though they acknowledged that Kallmann’s claim that schizophrenia was inherited in an autosomal recessive fashion had been discredited, they validated his argument that genetic knowledge would lead to prevention of mental illness. The modern writers asserted that history supported them in their current work–they pointed out that some kind of family history had long been noted for mental illness. And big data, they explained, would eventually reveal specific mechanisms for that family inheritance. ¹

The 2018 PGC assessment of the history of genetics in mental illness neatly stepped around the abundantly-sourced history of the quagmire that was psychiatric genetics in the first half of the twentieth century: the eugenics movement. The PGC authors presented Kallmann as a hero of psychiatric genetics while passing over his origins in Germany and his early advocacy for involuntary sterilization of family members of individuals with schizophrenia.² As historian Nathaniel Comfort has pointed out, this strategy of ignoring connections between eugenics and genetics has been a standard practice for genetic researchers in the last half-century who continue to argue for scientific achievements without acknowledging the troubling sludge attached to elements of their accounts of heroic progress. ³

Theodore Porter’s contribution to this discussion, Genetics in the Madhouse: The Unknown History of Human Heredity, takes a much broader perspective on the eugenics-genetics divide. Instead of seeing eugenics as either a founding contaminant in genetics or a temporary aberration in psychiatric science, Porter looks at the much longer history of data collection within the primary sites for psychiatry over several centuries: asylums or mental hospitals. Porter, who acknowledges that his earlier work on the history of statistics somehow missed asylums as sites of statistical data, brings his skills as a historian of the science of numbers and their manipulation to help us understand that the question of heredity has been at the heart of psychiatry well before–and long after–the eugenics movement.

Instead of seeing eugenics as either a founding contaminant in genetics or a temporary aberration in psychiatric science, Porter looks at the much longer history of data collection within the primary sites for psychiatry over several centuries: asylums or mental hospitals.

Porter travels all over the globe in his sweeping account of the use of record keeping and numbers in asylums from the eighteenth to the twentieth centuries. He divides his volume into three main sections based on the technologies of data science. In the first, which roughly covers from the eighteenth to the middle of the nineteenth centuries, he looks at the emergence of record-keeping systems within asylums. Local leaders wanted to know whether their investments in these large institutions were returning any benefits. How many people were being treated? Where did they come from? Were patients getting better? And in the beginning of speculation about why they were admitted to the asylum in the first place, heredity emerged as a legitimate cause.

The second section of the book covers the middle of the nineteenth century through the beginning of the twentieth. Porter examines the evolution of systematic tables that were intended to integrate information about individual patients and asylums into broader data sources, including national census. While some asylum leaders hoped for international collaboration, it proved impossible to overcome national differences to a degree possible to have uniform data standards. It was during this time period that psychiatrists began to attempt to correlate different factors to get a better sense for what might be causing mental disturbances. And it was also when psychiatrists pointed out that there was so much data for them to analyze that they could not make sense of it all.

The first two sections of the book provide information that is new for many of us. Porter shows us what was hidden in plain sight–that psychiatrists had been gathering what was in essence big data for centuries. Porter explains that asylum medicine involved science and investigation—through the accumulation of data. Eighteenth- and nineteenth-century psychiatrists were confident that certain scientific truths had emerged–including that heredity was a major factor in causing insanity. As Porter points out, “Heredity had the feel of a deep cause and yet seemed to be supported by ordinary experience. It was simultaneously scientific and popular, and it worked well with statistics.” (58) Well before the specific language of Mendelian inheritance–the concept that genes were responsible for transmission of traits–psychiatrists worked on the idea that heredity was key. They also began to conclude that the most effective method for preventing insanity was to control the reproduction of the insane.

In the third section, Porter acknowledges that he is covering a story more familiar to many readers, the emergence of pedigree tables and population surveys that were used to justify eugenics ideas and interventions. He does take a different perspective as he covers this material, though, and highlights continuities from the older story. He also offers a clearer explanation of the differences between biometrics (body measurements and accounting of unique physical characteristics) and Mendelism (search for gene-defined traits and patterns of inheritance), as well as the significance of the dispute among individuals in the field over those concepts. Readers who are less familiar with the particular background stories of individuals such as Karl Pearson, Francis Galton, Charles Davenport, and Ernst Rüdin might be at a disadvantage, as Porter presumes knowledge of the standard accounts in which these individuals appear.

For those of us who avoided math beyond the required courses in college or graduate/medical school, Porter provides a narrative that we can appreciate without getting too bogged down in technicalities. But he also offers enough glimpses of data tables and calculation explanations that readers who are looking for an informed history of statistics will get satisfying details. Porter makes the clear and important point that, “The history of data and recordkeeping is a very human history, involving decisions with welcome or distressing consequences for people at moments of particular vulnerability. The data may subsequently be converted to infrastructure, the basis for bureaucratic and scientific work, again with hopeful or terrible implications.” (198) Porter gives us a feel for those human processes. His writing is lively and the pace of the volume is brisk without being dizzy. He shows us that asylums were doing something other than just warehousing people–they were gathering data and speculating about causes of illness.

Porter shows that the population view of mental illness persisted throughout the history of the asylum and flowed logically into the era of eugenics. And he also illustrates that the history of madness helps expand the history of genetics beyond a narrow view of genes.

Porter makes valuable contributions to the history of psychiatry and the history of genetics with this book. Edward Shorter has explained that psychiatrists in the nineteenth and early twentieth centuries focused on somatic interventions with patients before abandoning these methods in favor of psychoanalysis in the beginning of the twentieth century. It was not until the resurgence of medications and the modern Diagnostic and Statistical Manual that psychiatrists returned to biology.⁴ But while Jonathan Sadowsky complicated that account of a pendulum swinging between biology and psychoanalysis by demonstrating how many psychiatrists used both interventions over the twentieth century, few historians have looked into the history of the statistical part of the diagnostic enterprise.⁵ As Porter explains, though, “Mental or psychological medicine was always only partly about cures. It was a statistical human science, increasingly focused on insanity as a social problem.” (6) Porter shows that the population view of mental illness persisted throughout the history of the asylum and flowed logically into the era of eugenics. And he also illustrates that the history of madness helps expand the history of genetics beyond a narrow view of genes.

But even more than his contribution to the historical literature, Porter’s perspective should help give us pause as we are confronted with evolving claims in psychiatric genetics. One of the new fashions in the field is something called epigenetics, the science of understanding on a molecular level that experiences from older generations can affect their children and grandchildren. As a recent New York Times article explained, this could mean that trauma experienced by individuals could somehow affect their offspring beyond the specific mechanism of the transmission of genes. ⁶ But while the science of this phenomenon sounds exciting and technical–possibly having to do with RNA particles in cells–Porter’s history reminds us that asylum physicians for centuries used this kind of hereditary mechanism (without the RNA) to explain how adverse family experiences were transmitted through the generations. We have heard this story before, and it did not end well the last time.

Porter’s careful history also reveals the long history behind modern claims that our ability to accumulate more data will lead to better science. As Porter points out, the idea of big data is not new. Current psychiatric geneticists have looked at brain architecture and family environments–and so did psychiatrists a century and a half ago. Current researchers are confident that their science is more advanced and that they are able to answer questions to which only speculation was possible in the past. And investigators from the nineteenth century were equally confident about the same things. Porter does not end with the simplistic formula about the need to remember the past to prevent the same things happening again. In fact, he articulates the role of history as a model for understanding complex human phenomena. But Porter’s reminder that we have been here before needs to be heeded. His history makes it impossible to continue the disconnect between the data of the past and the assertions of the present.

¹ Patrick F. Sullivan et al., “Psychiatric Genomics: An Update and an Agenda,” American Journal of Psychiatry 175 (2018): 15-27.

² Franz J. Kallmann, “Heredity, Reproduction and Eugenic Procedure in the Field of Schizophrenia,” Eugenical News 23 (1938): 105-113.

³ Nathaniel Comfort, The Science of Human Perfection: How Genes Became the Heart of American Medicine (New Haven: Yale University Press, 2012).

⁴ Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley & Sons, 1997).

⁵ Jonathan Sadowsky, “Beyond the Metaphor of the Pendulum: Electroconvulsive Therapy, Psychoanalysis, and the Styles of American Psychiatry,” Journal of the History of Medicine & Allied Sciences 61 (2006): 1-25.

⁶ Carey, Benedict, “Can We Really Inherit Trauma?,” The New York Times, December 10,  2018.