Foreword to 'Man, Mind, and Heredity'

by Sir Denis Hill

When Eliot Slater went to Germany in 1934 on a Rockefeller Travelling Fellowship to study psychiatric genetics at Rüdin's clinic in Munich, he left behin him at the Maudsley a staff largely influenced by the teaching of Adolf Meyer. This orientation could not have been much to his liking, for the psychological study ci personality based on the relationship which the psychiatrist could develop with his patient was not one which his temperament and his particular scientific cast of mimi could readily adapt to. It was, however, already being displaced, for Eric Guttmann, Willi Mayer‑Gross, Alfred Meyer, and other distinguished refugees from Hitler's Germany had arrived and, by the time of Slater's return a year later, an orientation based on German constitutional psychiatry was already established.

By this time neuropathology and genetics seemed the most exciting areas for psychiatric research, with biochemistry and neurophysiology appearing as potential candidates. On his return Slater felt the need to study in greater depth the then comparatively new subject of statistical methods applied to clinical problems, and to this end went to the School of Hygiene where he obtained what he needed under the tutelage of Bradford Hill. Within a very short time he began to collect and study psychiatric twins in the London mental hospitals ‑ the occupation which was to exercise his mind so fully in the years ahead.

    When I first met him at the Maudsley in 1938, he seemed a rather aloof man, but kind and hospitable to us juniors, who took pleasure in contentious argument which excited him, and was given to sudden, mercurial bursts of extremely loud laughter. He was already imbued with the aura of the clinical scientist ‑ having knowledge and techniques in a field which was unfamiliar to most of us. His work on the inheri­tance of manic‑depressive disorder was already well known. In a sense, he was a prototype of what was to become the necessary requirement of the academic psychiatrist in Britain in the postwar years ‑ a man of intellectual distinction, a man of scholarly habit, a sound and experienced clinician, but above all a man who had made himself expert in some branch of applied science which he could use in psychiatric research. To be a good clinician, a pleasant colleague, even a good teacher was not enough. The psychiatrist as clinical scientist was nevertheless a new phenomenon in the academic scene, and there can be no doubt that Eliot Slater was one of the first of the new breed. Within a few years he had established the reputa­tion of being the leading clinician in psychiatric genetics in Britain.

    When war came and when the Maudsley Hospital was evacuated, the staff were divided into two groups, half going to Sutton, half to Mill Hill. It seemed natural that Slater should lead the team who went to Sutton in South London. The emer­gency hospital established there was to meet the enormous numbers of expected air‑raid casualties which of course did not occur, and it soon became for practical purposes a military one. During the war years twenty thousand psychiatric casual­ties, mainly from the army, were admitted to it. While the administration was the responsibility of Louis Minski, Slater was appointed Clinical Director. He had a team of men (among whom were William Sargant, Alexander Kennedy, Geoffrey Tooth, Joe Shorvon, Gilbert Debenham, and myself) of varying orientations, decided opinions, and different interests. It was a very busy, noisy war; the hospital was evacuated twice ‑ once after it had been bombed, another time to meet the emer­gency of the Normandy invasion in 1944; throughout, the Clinical Director managed to pursue his genetical research with a ruthless determination while doing his full share of the clinical work ‑ and to persuade and help others to do theirs. Slater's direction was unobtrusive, but his scientific enthusiasm and his great willingness to help, particularly on methodological and statistical problems which were beyond the ken of many of his staff, are remembered by many who still owe him a debt of gratitude. It was during this time that Slater's own stable temperament and courage as well as his scientific distinction became apparent. There are of course many stories told about him. There are those who recall the Clinical Director playing chess against himself on his pocket‑set during the worst of the bombing while those of different genetical constitution got under the heavy table at which he sat. There are probably more soldiers than one who, having arrived in the night at Sutton for admission after a long journey across England, can remember being met by a tall donnish figure who asked him only one question, "Are you a twin?"; and, on replying that he was not, being told to go to bed and that he would be interviewed in the morning.

    While I believe all his colleagues in the war years regarded Slater with personal affection and esteem and deferred to him for help with their clinical and research problems, there were many who could not share his orientation to the subject. At least one of the first papers (not reproduced in this book) on the subject of war neurosis was the product of an uneasy compromise by authors of different orienta­tion who could not share Slater's essentially biological approach to psychiatry ‑ his preoccupation with the interaction of genetical constitution and environmental stress, the latter viewed by him in what they regarded as over‑simplified terms. There seemed to be no place for a psychology of personality; all the important and identi­fiable differences between men must, it seemed, be due to endogenous or genetical differences. It was the nature of the vulnerability to "stress" and his belief in its genetical basis which occupied Slater's mind. The mass phenomenon of "war neuro­sis" provided him with problems which he believed could be tackled by the tech­niques of psychiatric genetics; the issues were essentially biological ones. The accumulated research of those years led to the two important papers, on the neu­rotic constitution and on the heuristic theory of neurosis, published during the war.

    These papers excited little interest at the time, but the second paper, written with his brother Patrick, remains an intellectual achievement of high order. It presents a logical analysis of the available data relevant to biological thinking and examines the evidence for each theory, its practicality and probability. It concludes that a poly­genie theory fits best the facts‑each of many genetic components has a small effect and each reduces resistance to some form of environmental stress; these effects are additive and "so facilitate the appearance of neurosis." The evidence that the various components were genetic in origin still seemed an act of faith, although the normal distribution of some of them in the population was known. Slater's conclusion that the neurotically predisposed has a more than average susceptibility to environmental stresses put the neurotic at one end of normal curves of human variation. Neurosis was therefore not a disease, but a product of multifactorial deviance. In this respect it was therefore quite unlike manic‑depression and schizophrenia. Because of Slater's insistence that the degree of vulnerability must be due to genetical variation little attention was aroused by his work at the time. It also seemed barely relevant to the psychiatrists who had espoused a psycho‑dynamic theory of neurosis, and being a general biological theory based on massed statistical data, it had no relevance to the treatment of clinical cases with which all the energies of psychiatrists were engaged at the time.

    Nevertheless, this theory should be seen in its historical context. As a general theory of neurosis it bridged the gap between the earlier period when many believed neurosis to be due to the operation of specific psychological traumata in childhood and the neo‑Freudian concept of ego‑psychology with its emphasis upon the strengths and weaknesses of ego‑structure which determine adaptive capability, and the later realisation that neurotic phenomena are ubiquitous and general. It also can be seen as the theoretical precursor to the modern psychological and psycho­physiological techniques of studying individual differences to stress.

    In 1946, after the conclusion of hostilities, Slater was appointed Physician in Psychological Medicine to the National Hospital for Nervous Diseases, Queen Square. This famous neurological hospital had for years had a psychiatrist on its staff. Bernard Hart had been a predecessor. Now, however, a department was to be established with its own ward accommodation and outpatient clinic. Slater entered his new appointment with enthusiasm, for he believed that the psychiatry of organic diseases of the C.N.S. was very important. He assembled around him a group of young research workers of talent, including Alick Elithorn, Malcolm Piercy, George Ettlinger, John McFie, and persuaded Oliver Zangwill from Cambridge to set up within the department a section of clinical psychology to promote research. From the first it had been anticipated that when the opportunity arose the subject at Queen Square would be represented by a professorial unit. But the hospital was slow in accepting academic units even in neurology and neurosurgery, and when a volun­tary foundation finally offered to provide the financial support for a chair of psy­chiatry, which Slater was so eminently suitable to hold, the hospital rejected the offer under the terms in which it was made ‑ to the great dismay of many, but particularly of Slater himself, who in consequence resigned prematurely in 1964.

    The post at Queen Square had always been one of great potential, but was not without its hardships. To meet the needs of his colleagues Slater was persuaded to engage in some private practice, which he disliked greatly, feeling he was not very good at it and that his temperament was unsuitable for its objectives. While Slater's main interest always lay in his genetical work ‑ and this he was able to pursue throughout the whole period by his appointment at the Maudsley and at the Insti­tute of Psychiatry ‑ the Queen Square period, largely as the result of his clinical experience, elicited the study on hysteria (given as the Maudsley Lecture in 1960), the work on leucotomy for intractable physical pain, and, most important of all, the comprehensive description and analysis of the schizophrenia‑like psychoses of epilepsy. As usual these studies provoked controversy. In claiming that hysteria was "not a syndrome," he based his belief on the demonstration that he could not find concordance for the condition in either identical or non‑identical twins. It could not therefore be a genetically‑given form of behaviour, and therefore hysteria seemed to be nothing very much at all. This to Slater's critics was a form of psychiatry without a psychology with a vengeance. The fact that, after years of follow‑up, patients who had presented with hysterical symptoms were later found to have other conditions, including organic disease of the C.N.S., schizophrenia, and other functional psy­choses was no surprise to him.

    There can be no doubt that through his general writings Eliot Slater has in­fluenced British psychiatry very profoundly. The publication with William Sargant of the small text on Physical Methods of Treatment soon after the war, came as a boon to a generation of young psychiatrists who based their thinking on the medical model of psychiatric illness, and provided a concise, practical and very readable guide to therapeutic practice in this developing field. More important and more influential was the appearance, with Willi Mayer‑Gross and Martin Roth as co­authors, of the large text on Clinical Psychiatry in 1954. This was the most up‑to­date, erudite, and brilliantly written account of the subject as it had developed from the work of the German and Scandinavian schools of psychiatry which were based upon the Kraepelinian system. It became essential reading, and a valuable source of reference to every psychiatrist in training in the country. The neglect of the psycho­dynamic and social determinants of personality, the study of personality itself, and ‑ as some saw it ‑ the savage and ill‑informed attack on psychoanalysis could all be forgiven. The book contained the most comprehensive, brilliant account of the clinical phenomena of schizophrenia and other psychotic conditions which had yet been written in the English language. It was the epitome of a psychiatry based on the natural sciences. In 1961 the Royal Medico‑Psychological Association appointed Slater Editor‑in‑Chief of the (then) Journal of Mental Science. The journal had fallen into decrepitude, the published papers were of a very varied quality, its reputation was low. In Slater's hands this journal, now the British Journal of Psychiatry, has been transformed into one of high scientific quality ‑ I would claim one of the world's leading psychiatric journals. Slater has of course given it the impress of his own orientation ‑ his own high standard of what constitutes scientific evidence, his demand for new knowledge based on measurement and verification rather than description and supposition, his deep antipathy to what he conceived as the "crazy structure" of psychoanalysis and the "panpsychic" explanation of psychodynamic formulations of aetiology. Few papers by psychoanalytical authors have appeared in the journal. Perhaps few have been submitted; yet I know from having served with Slater as co‑editor for a period, no paper with this orientation has been rejected by him upon his own responsibility alone.

    It is of course for his original and far‑reaching investigations into the genetics of schizophrenia that Slater has won an international reputation. Despite the evidence from successive studies by other authors that show a lesser concordance of the condition in identical twins, Slater holds to his original monogenic theory of aetiology. Without the pathogenic gene, schizophrenia cannot occur, and this claim would seem vital to sustain the strongly held view that the search for the biochemi­cal anomaly or abnormality in schizophrenia must be pursued ‑ research which has hitherto been so disappointing. In 1959, the Medical Research Council, recognising Slater's pre‑eminence in his subject, invited him to form a Psychiatric Genetics Research Unit, and to head it as Director. This was given a home at the Institute of Psychiatry, and he collected around him a small group of workers, which included James Shields and Valerie Cowie. Upon his retirement from the Directorship it was decided to publish the present volume of his selected works.

    This is not the place or time to attempt any assessment of Slater's place in the scientific history of our subject. He is still actively pursuing his research; he is still a great influence in psychiatry both nationally and internationally. He has always been a controversial figure ‑ a clinical scientist dedicated to the pursuit of biological knowledge, but also a man concerned about the social and political ideas of the times, always seeing them as a biologist equipped with his own skills and insights and his own frame of reference. But there are ambiguities and contradictory aspects of his personality. The personal problems of individual patients cannot rate high in the work of the clinical scientist, yet Slater has nevertheless always felt a deep sympathy for them. Surprisingly, in 1967 he reviewed Konrad Lorenz's book On Aggression with great enthusiasm. In accepting with Lorenz that human aggression is a biologi­cal drive which must be "discharged," that present day civilized man suffers from an insufficient discharge of his aggressive drive, Slater finds himself in a new position, not so different from that which Freud first adopted in his first account of instinc­tual activity in man. Slater has never lacked critics, even among those who most value his friendship; and even when the differences go deep, the integrity and quality of the man ensure that disputation does not affect personal relationships ‑ indeed it is of the essence of his intellectual life.

    This book will be valued by the many who know of his work, but have never had the opportunity of seeing it in the round. To many more it should prove a source of stimulation and knowledge ‑ the account of an intellectual journey in pursuit of biological understanding in psychiatry, a record of achievement over thirty‑five years in which the author has always applied to his data and to his own hypotheses the same scientific rigour and criticism which he has expected from others.