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.[A] 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.[B]
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."[C] 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."[D] 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.[E]
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.