By SMITH BAKER, M. D.

It is being found out that cases of insanity may of themselves fall naturally into two classes: the first comprising those who get well, and the second those who do not. To the first class belong the deliriums of fevers and other like diseases, and also certain acute manias and melancholias and the so-called generalized insanities. In the second class are included the insanities which last indefinitely, or, if seemingly cured, which, in the proportion of from twelve to fourteen per cent, come back again one or more times, and finally do not recover. Says Regis: "Out of all forms of mental alienation or insanity only the generalized types—i. e., mania and melancholia—are curable. The systematized insanities are essentially chronic and 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 division 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, generally 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 downward 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 understand 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 foundation.

Now, when a case of persistent or recurrent but really irrecoverable insanity is studied, with respect not only to the life of the individual 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 variously to blame, and in just the same way as they have been in the production 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 maelstrom into which have been attracted all the detrimental influences that have accidentally or intentionally come within reach. For instance, such persons are almost always predetermined to grow up into harmful bodily and mental habits. Says Peterson: "Among all degenerates there is a taste or appetite for certain foods or drugs which tend to favor their dissolution (alcohol, morphine, cocaine, and the like)" (State Hospitals Bulletin, vol. i, p. 372). So also are they apt to be wrongly educated, or to draw around them harmful associates; to develop the most wearying and exhausting enthusiasms, or to choose a business and place of residence to which they are not adapted; to marry some one who will chiefly wear and burden them; to assume responsibilities and positions out of keeping with their native strength and endurance; in fact, to get entangled in all the affairs of life in just the very way calculated to bring about the one thing which should have been, by every known means, sought to be avoided. It is in this way that "physiological fate" unconsciously spins the web which ultimately fastens its own doom. That such a pernicious course should eventually result in disaster is no wonder at all; for when investigated deeply and comprehensively enough, it is seen that of all possible persons, such are, by birth, the very least calculated to endure the wear and tear thus engendered and maintained; while, as scarcely a word is ever heard and scarcely an effort is ever made as to the necessity for so training and educating and inspiring these people that the defects of heredity will be remedied, it follows that the most ordinary ventures of commonplace life are by far more dangerous to them than to their better-endowed fellows.[36] When properly endowed by heredity, and adequately bred and educated, it is almost beyond wonder, the amount and character of persistent stress which human nature can triumphantly endure. When otherwise, however, it is no wonder at all that sooner or later serious breakdown comes to pass.

The importance of saying this is obvious when we consider that as a rule active life is allowed to be entered upon without adequate preparation and intelligent adaptation of either bodily or mental strength to the stress that is likely to be encountered. Always it is asked, if anything is asked at all, "Has he the skill to make his way?" instead of, "Has he the prospective endurance required by what he purposes undertaking?" while, if the latter chances to be considered at all, the conclusion is most usually based upon present appearances rather than upon past tendencies or actual developments. Elsewhere I have said: "In almost every instance (of breakdown) I have come across the result of some big educational blunder, owing either to the system in vogue or else to those who execute it." (See Steps toward Insanity, New York Medical Journal, August 14, 1897.)

There is one fact about heredity which seems not to be commonly considered—namely, that each individual is really the descendant of not only his immediate parents, but of the two lines of ancestry indefinitely far back and widespread. Thus, in many instances, the dominating characteristics are not those of father and mother, but of grandparents, or of some other antecedent or collateral relatives instead. In fact, each individual in its development from the germ to adulthood passes through not only many animal forms, but through many ancestral phases of character as well. And, as in the first case, the size and strength of adult physical features depend on the stage at which growth becomes abnormally extended, perverted, or arrested, so, with regard to mental and moral qualities and their persistence under stress, the outcome mostly if not entirely depends upon the extent to which they are allowed or constrained to develop, or the reverse. Here we often see the absolutely limiting influence of "atavism," or what is characterized as "reversion," to generations further removed than the parental, but which really is the result of an exaggeration or a stoppage, or a perversion of development before the stage of parental dominance is finally reached. In this way the featural and mental characteristics of relatives as far removed as great-grandparents or great-granduncles, as well as grandparents and uncles, are seen to appear in children even when young, to be finally either accentuated and made prominent, or else possibly outgrown or otherwise overcome as the years go by, and as the later parental determining powers and the corresponding environment come to manifest their influence.

With this view of heredity in mind, it is easy to see how the real basis of every mental breakdown may be and probably is simply an overdoing or perversion or other irregularity at some premature or "atavistic" stage of development; and that anything and everything which may have had to do in causing this should be considered as a primary step toward the insanity itself. But easy as it is to see this theoretically, it does not necessarily follow that it is easy to get hold of the real facts or to help the matter in any given case. Many times families are loath to reveal things which might indicate such a basis of the dreaded disease. Many times they do not recognize the necessity of telling what they would otherwise be willing enough to reveal. Many things are absolutely forgotten or have been at best only vaguely comprehended. Sometimes conscious deception is practiced; at others, the party who really has known the facts is dead or is otherwise inaccessible. But more often, and more interfering still, is the unconscious perversion of facts, either from the false meanings which, owing to specific views and predilections and fears, are read into them, not only by the laity, but often by the profession, or else from the wrong deductions derived from actual facts clearly understood. Try as one may, it is often most difficult to get a sufficient number of clearly defined facts to enable even the most expert to form a true and comprehensive idea of the case in hand.[37] This leads to the remark that what is now absolutely needed is some form of record-keeping which shall become a general practice on the part of heads of families and their physicians, and which may be handed down from generation to generation; and not only this, but that these shall be so accurately and fully kept that they may be worthy of consideration as the best and in fact the only basis of a scientific generalization in case of mental or moral emergency. That people as a rule would probably resent this, as constituting an undue interference with the sanctity of personal and family rights, while undoubtedly rendering it practically nugatory for the time being, does not in any good sense militate against either the scientific need or the great good which would accrue from the use of such family records faithfully and intelligently kept. It is encouraging to note that already the way for such records is being opened in the demands made by the various questionnaires sent out by Dr. G. Stanley Hall and others who are interested in the scientific study of children. (See various issues of the American Journal of Psychology, and of the Pedagogical Seminary, for pertinent suggestions and results. Also an article by Dr. William H. Thomson, in the Yale Medical Journal for April, 1898.) Much more useful and in general satisfactory would this be than the blind staggering after elusory causation now so universally and yet so futilely pursued.

And the same may be said with reference to statistics as commonly tabulated. These having reference but to the surface showings, the after-the-mischief-is-done results, and so often obtained under misleading constraint or other unfavorable influences, are scarcely capable of even hinting the significance of real conditions, and especially of tendencies that have existed antecedent to the individual breakdown. For instance, such statistics as those compiled by Dr. Wise (see State Hospitals Bulletin, vol. i, page 157), when subjected to the requirements of an accurate causative consideration, easily lend themselves to the criticism made by the author himself, who says, "The careful inquirer can receive no reliable information from the study of insane hospital statistics except the bare fact of the number of insane persons under care and treatment." Yet a glance at his tables shows that forty-two per cent of the cases admitted to the New York State hospitals for the year ending September 30, 1895, are to be noted as suffering from constitutional degeneracies, and so presumably to be incurable. The more than twenty per cent of cases of insanity reported to have had hereditary antecedents, although undoubtedly as accurate as possible under the circumstances, merely chronicle the more obvious matters, and must necessarily have left out of account all the less obvious but in many respects even more important ones. And so with all the other series thus far published. They are good as indicating where we are to look for some of the steps toward insanity, but for the most part they are quite inadequate for a basis of comprehensive discussion or anything like accurate conclusion.

The pressing need, then, is that there shall be obtained a series of statistics which shall be founded upon the most definite, penetrating, and far-reaching studies of cases that it is possible for the trained scientist, with the help of an intelligent, willing laity, to make. In this respect it may be said that the assistance of the latter is just as essential as the painstaking devotion of the former; for it is upon the facts which an intelligent laity can observe and report that the scientist can bring his training to bear in such a way as to arrive eventually at accurate and therefore most useful generalizations. But such concurrent observation and study will never be until the public shall have come to look upon insanity as merely an unfortunate disease instead of a stigmatized disgrace, which, with certain exceptions, it should not be considered to be. Nor will this be the case until professional examiners in lunacy shall regularly ask for such family records, and thus create a need for their being made. When both the public as well as the profession lay aside entirely the common notions of a transcendental origin of insanity, and set to work to study the perfectly natural steps through which degeneration and breakdown eventually come to be, all will see the desirability of such health records being accurately and fully kept, not only as a help toward determining the nature and prospects of any given case, but also toward preventing the development of those constitutional tendencies which lead to trouble, as well as in helping on those that provide against it.

When we come to study the causes of insanity with a view to successfully preventing it, we are led to the supposition that the nearer to very first steps we can push our investigations the greater will be our service. Remembering that the well-born, well-bred personality generally bears almost every sort of stress with comparative impunity, it becomes us to ask just how does the opposite—the ill-born, ill-bred—constitution come so to be, and hence to break down so easily. Certainly, the weak, easily breaking strains must have their origin and growth just as definitely as the more enduring ones, and if we can get an accurate notion of such origin and the conditions of subsequent growth, it seems probable that useful knowledge will thus be attained.

With this object in view an investigation was undertaken which should cover the life histories of a series of families with sufficient detail and extension to warrant at least tentative conclusions as well as also to indicate probable lines for future work. So far as possible, inquiries were pushed along collateral as well as direct lines of ancestry; and not only ill health but common habits and experiences were, so far as possible, given the consideration strictly their due. In every way the attempt was made to properly estimate the factors appertaining to the more intimate personal life as well as those that were more obvious and impersonal. Often, however, the completed record proved to be more or less broken; more often still, important items—the most important of all, in fact—could only be obtained under promise of absolute secrecy as to future use. So, as matters of absolute science, the following conclusions must stand chiefly as challenges for future confirmation or change. But, so far as they can be allowed to go, they may be accepted as pretty thoroughly based in ascertained fact and legitimate generalization.

The very first conclusion, so far as the natural history of the steps toward insanity is concerned, is that the weak constitutional strands and tendencies have their beginnings in those ancestral marriages which, chiefly for educational reasons, I have chosen to call "unphysiological."[38] By an unphysiological marriage one need not mean a marriage between people obviously deformed or imbecile or insane, or otherwise permanently unfitted, but rather between people who are found to be not well adapted to each other in some important sense. Thus, too great physical disproportion; too great disparity of age, or of temperament, or of family or of natural tendencies; or, on the other hand, too near a sameness, either through consanguinity or other sources; or too fixed constitutional characteristics; or even too great differences of education, religion, taste, or ambition. In fact, it seems probable that anything and everything which difficultly amalgamates in marriage, and as surely fails to blend in progeny, may be considered as unphysiological in this connection. As I have said elsewhere: "The parties entering into such an unphysiological marriage may both be normal individually, but yet not physiologically marriageable, because they are either too distantly or too nearly, or in fact too unphysiologically, related, either physically or psychically. In such cases the ultimate outcome is almost absolutely certain, and is noted chiefly by a definite class of tensions and reactions of both mind and body which invariably impress themselves upon progeny, and which for the most part are made obvious in this particular way. No matter how unphysiological such marriages may be, however, they do not necessarily or very often result in the evolution of insanity in the parties contracting them, but rather they do lay the foundation of degenerative tendencies which almost invariably predetermine the development of this affection in more or less remote succeeding generations. Nor do the children of such marriages necessarily or generally become insane, although they sometimes do; but, impressed as these are by the degenerative malnutritions and tensions and reactions of their parents, they tend to exhibit arrests and eccentricities of development, which in turn become intensified in the next, and again, in turn, in all the generations following, until the instability becomes so marked that explosion occurs. In passing, it may be said that the most frequent source of the initiatory tensions and reactions resulting from unphysiological marriage is undoubtedly found in abnormal cohabitation, and the unrest and unsatisfaction and exhaustion resulting therefrom. Such a condition of things begets in perfectly normal people an irritating, nagging, exhausting, persistent erethism, which in time involves the whole organism and deflects it from its norm. Two people enmeshed in such a bond always go to excesses and irregularities, either in abstinence or indulgence; or, if not this, then the whole matter becomes aversional, with straining antipathy, perverting practices, and ideational distrusts and loathings more and more predominating. No wonder that such people predetermine succeeding generations to abnormal sensitiveness, irregular growth, and erratic manifestations in both mental and physical spheres." (See New York Medical Journal for August 14, 1897; also Journal of Nervous and Mental Diseases, vol. xvii, page 669.)

Now, the outcome of such marriages seems to be a vitiated stream of tendency, which carries with it in its progress from generation to generation certain elements which predetermine to still fuller vitiation, even with incurable insanity, as noted above. Thus, people endowed with such natural characteristics, being altogether too prone to gravitate toward each other, eventually marry, and thus emphasize in progeny the vitiation already doubly initiated. Nature's course demands that such people marry, if at all, into the healthiest, most corrective stock possible. But here immediately there arises not only a scientific prohibition, but an ethical question which should be heeded: Should such people really marry even the best of stock, with the probability of thus vitiating a stream which until this time has evidently been becoming clearer and stronger? Again, people who are constitutionally tending to mental breakdown are very apt to load themselves down with duties and get themselves into situations which must necessarily prove to be too onerous and too perplexing for their poorly developed strength and skill. Of course, circumstances often require this. Many times, however, there is a kind of impulsive restlessness coupled with a short-sighted optimism, both constitutional, which, altogether more than ordinary circumstances, are to blame for undue assumption of work or care, and whose effect is, perhaps, best seen in the persistent tendency of such people to originate and perpetuate exhausting habits, both of mind and body. Thus, the habit of self-poisoning from poorly digested and poorly assimilated food is easily acquired by such people, and always becomes a source of progressive brain starvation and often of consequent mental breakdown. Says Dr. A. S. Thayer (Journal of Medicine and Science, vol. iii, page 173), "There is ground for belief that exhaustion—fatigue—is dependent upon poisoning of the cells of the brain, muscles, and other tissues by the waste products of functional activity."[39] Again, as already noted, perversions of the natural instincts—of appetite for food, of desire for gain, of social or other ambitions, and especially of the sexual impulse and its habitual indulgence—fasten themselves upon such individuals with a permanence and destructiveness that must almost of necessity lead to disaster.[40] And so we may see that as a most natural, although often a far-removed, result of unphysiological marriages, proceeding through generations which have been thus predestinated to weakening choices and practices, insanity finally appears to mark the ultimate extent both of the mental disorganization and bodily inefficiency, which extent is owing not only to the original initiating steps, but also to subsequent stages of causation, progressively developed from generation to generation.

Another great source of vitiation of the stream of tendency is found in two people who marry in a truly enough physiological sense, but who find or force themselves in lives of wear and tear which progressively unfit them for childbearing and child nurture. Poorly calculated ambitions, unexpected difficulties to be surmounted, depressing oppositions, with perhaps more or less actual disease or accident, largely account for this in a general way. Obviously, during the child-rearing age, the effect of what parents are obliged to endure and execute upon the fortunes of progeny becomes a matter of far-reaching importance. That anything which persistently exhausts or overstrains the parents must tell in the later dynamic tendency and development is premised at least by certain recent studies, especially those of Hodge on the influence of fatigue, and of Van Gieson on the effects of exhaustion and intoxication upon the nervous elements. (See also Peterson, op. cit.) In no sense can parents be said to live for themselves chiefly. Always the influence of their own health, happiness, and prosperity upon their children should be remembered, and should be made as constructive as possible. That this can be consciously attempted with commensurate results is more or less evidenced not only by common observation but by investigation. Not, however, in the sense that parents are always able to endow children with some particular, much-wished-for characteristic, as so many suppose—for it must be remembered that perhaps pretty fixed tendencies for several generations may have to be overcome and reversed before such special results can be obtained, but in the much better sense of giving such an impetus healthward and strengthward and lifeward as may later on be the beginning of a constitutional foundation that shall support many generations of full health and longevity.

If, then, the first steps—and, generally speaking, the most important steps—are discovered in the unphysiological marriage and its influence upon the bearing and rearing of progeny, then it is obvious enough that prevention of incurable insanity should begin with giving adequate attention to this phase of the subject, and this first and emphatically. Already the law says that certain peculiarly afflicted individuals can not marry; and probably this is about as far as the law can helpfully go until, at least, public intelligence as well as private sentiment will sustain it in going further. So we must look to these latter—a widespread intelligence and a corresponding earnest sentiment founded upon such intelligence—for the means of making progress toward the prevention of insanity. But how can this needed knowledge and helpful sentiment come to be? Certainly not by perpetuating the present notions of so-called "modesty" and "purity," which, as now held, must always interfere with the study and practice necessary for ascertaining the truth, and for applying it to the needs of race-building. The time ought to come soon, very soon, when matters of such serious content shall not be so absolutely subject to the dominance of conventionality and guesswork and recklessness as now, but shall instead be subject to the sway of accurate science and its careful adaptation to human conditions. Every marriage now is at best but an experiment—blind and chance-taking often, in a most wasteful and dangerous sense. Let it remain, if it must, an experiment still, but one which shall be henceforth conducted with such foresight and skill, and withal with such intelligent purpose, as shall certainly point to improved results from generation to generation. Experience shows that it is comparatively easy to ascertain what marriages, generally speaking, are prone to result in obviously vitiated progeny; or if not in these, then, to some extent at least, in the progeny which, being unnaturally constituted, are prone to develop their weaker strands of personality, and so to break down in the end. But to this course neither prudery nor superstition nor selfishness will ever assent; it must be pursued in spite of these, and by the only method which science now recognizes—namely, accurate observation, careful record, and the most comprehensive, skillful comparison, all in order that truthful inductions may be finally secured. That parents should train up their children to look forward to marriage not as the acme of personal indulgence and satisfaction, but as a most responsible partnership for the developmental keeping of unborn fortunes, and the proper nurturing of the children that may come to them, is no longer speculation, but a science-founded fact. Undoubtedly the highest state of adult satisfaction will always be closely associated with what may be characterized as child completion. Moreover, that an educational system which so thoroughly ignores this most important of all educational subjects must, in time, be subjected to the criticism which science may justly develop, is amply borne out by the cases studied. Often, indeed, has it appeared that had a modicum of real knowledge been at hand, most disastrous results would naturally have been obviated. Educators lead the day; why not they lead in directions which shall most truly correct the results of physiological ignorance and daring? That no man or woman should go forth from college with such vital knowledge unlearned is probably the first and most important means of preventing incurable insanity conceivable; and that these in turn should never hesitate to diffuse popularly that which they have been so favored in the learning, implies a duty which the intelligence itself makes clear.

So, too, if persistent overstrain and exhaustion of parents, either prospective or actual, leads directly to starvation of their own structural elements, how probable that the initiating and bearing and nurturing of children is to a like extent detrimentally interfered with in any given case through the development of an "erratic cell growth." Certain it is that completeness of development depends on two things—namely, nutrition and exercise. In a biological sense both these are dependent upon a right adjustment of supply to demand. Hence starvation or engorgement, inactivity or overwork, each may lead to the same dynamic result—that is to say, to an interference with the proper growth of the organism. That due heed, then, should always be given to the necessary health preservation of those who essay to become parents, not only in preparation for but during the whole so-called childbearing period, is so scientifically deducible that it may be for all practical purposes considered as axiomatic. The way to have healthy, long-lived, and happy children is for parents to be healthful and intelligently careful themselves; while the whole science of health must eventually consist in the science of such symmetrical and high development as will enable individuals to endure necessary strain, resist disease, and rapidly and fully recover from accident and infection.