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
