CAUSES AND PREVENTION OF INSANITY. 103 



recover only exceptionally " (Practical Manual of Mental Medicine, 

 page 54). The latter are known by such specific names as paranoia, 

 chronic mania, chronic melancholia, insanity of doubt, circular 

 insanity, hereditary insanity, and the like. What makes such a di- 

 vision of insanities into these two classes- significant is not only that 

 those of the first class get well and the others do not, but that, gen- 

 erally speaking, these latter are so founded in the constitution of the 

 individual that they can not recover, let everything as yet possible 

 be done for them as it may. Probably there are exceptions to this; 

 but, if so, they are not very often met with. All these cases seem 

 to be doomed from the very first either to follow a slowly down- 

 ward grade to the very end, or else to manifest a series of alternate 

 better and worse stages, which, while giving rise to bright hopes of 

 ultimate recovery, nevertheless just as surely tend more or less 

 rapidly downward, in pretty strict accordance with the rule. In 

 passing, it may be noted that not only the tragedy of such alternations 

 of emphatic despair and delusive hope constitutes not the least of the 

 wretchedness involved in the history of these cases, but that it is by 

 no means the easiest thing about them to manage; for, in the earlier 

 stages, it is almost impossible to make associates or relatives under- 

 stand the full meaning of the disease, or to take a correct view of its 

 probable outcome. Even much later on they cling to the possibility 

 of recovery, which is as delusive as it is painful, for the disease goes 

 on, nevertheless, with varying stride and manifestation, until it finally 

 becomes evident that hope is almost absolutely without any real foun- 

 dation. 



Now, when a case of persistent or recurrent but really irrecover- 

 able insanity is studied, with respect not only to the life of the indi- 

 vidual affected but to the lives of his ancestors, both remote and 

 near, and in sufficient detail, it is seen that the causes of the present 

 breakdown have been long and surely operative in those from whom 

 he has inherited certain unfavorable characteristics, and at whose 

 hands he has had his bringing up and education; and this even much 

 more weightily than in himself or the life which he has lived. So far 

 as the patient's own responsible life is concerned, the common causes, 

 such as accident, infection, overwork, mental and moral strain in 

 fact, all the usual forms of stress have, of course, been just as vari- 

 ously to blame, and in just the same way as they have been in the pro- 

 duction of insanities in other individuals who finally recover. But 

 even in respect to these latter, it probably may be most frequently 

 discovered that the harmful effects of certain so-called exciting causes 

 have been experienced, not because of the common emergencies and 

 exigencies of life so much as because of some peculiar but unrevealed 

 characteristics which have produced and maintained a sort of vicious 



