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types of this general class of mental disorders. large proportion of cases, however, the condition is manifested in recurrent or cyclic attacks of mental disorder occurring sometimes after shocks, mental strain, etc., but also very frequently without obvious cause. In other cases the insanity takes on the form of systematized delusions, and in still others the condition graduates into imbecility through such types as the originäre verrücktheit of certain German writers, moral insanity, reasoning mania, etc. A characteristic of this group of insanities is the very general bad neuropathic or insane heredity; they are the most hereditary of all insanities.

There has, as has been already stated, been a general confusion of some of these types with confusional insanity, or perhaps we should express it that confusional insanity has been confounded in some of its types with the commoner simpler type of degenerative recurrent insanity. It is the merit of Kraepelin that he first clearly pointed out the distinction, and recognized the fact that acute mania in its typical restricted sense is properly a degenerative type. We do not here follow him in every particular, but must recognize this fact, which is of importance in estimating the future course and probabilities. A prominent feature of what we may call the lighter forms of the degenerative insanities is their tendency to recurrence, and this may be regular and periodic or irregular, the latter being the character of what, for convenience' sake, we here take and consider as the least markedly degenerative, recurrent maniacal insanity, or simple mania. There is an occasionally recurrent form of melancholia also, but that, when not associated with the maniacal type, is generally, in our opinion, a form due to general neurasthenic weakness in this direction, and not a true degenerative type. An individual may be neurasthenic and naturally below tone, as, in fact, many are, and true melan

cholia of this character forms an occasional episode in his existence, under conditions of stress and overwork. If there is a true degenerative periodic or recurrent melancholia, it is most probably a modified or disguised form of circular insanity with special predominance of the depressive phase. Cases of this kind occur in which only close observation can distinguish the phase of excitement, which nevertheless exists, though not to the extent to render mental disorder very noticeable except to a skilled observer.

The neurasthenic phobias and obsessions have been recognized by some writers as pertaining to the degenerative insanities, but this is by no means the universal. rule; they may occur in individuals who are, to no marked extent at least, degenerates. They are, it is true, most frequently associated with a defective or neuropathic constitution, in which the normal inhibitions to their manifestations or continuance are lacking, but this is not by any means invariably the case. They are best to be considered as a class by themselves, so far as they fall, by their intensity and degree of development, into the actual insanities.

Hysteria is also to be regarded as a degenerative psychosis in many of its aspects, but it is only in its extreme manifestations that it falls within the definition of insanity. Hysteric insanity has been noticed in connection with certain other special neuropathic types, already mentioned in a special group of this general division of mental disorders.

RECURRENT DEGENERATIVE MANIA.

While Kraepelin, whom we follow in placing mania in this general class, has given it the name of periodic insanity, we prefer to use the term recurrent, as better indicating its manner of reappearance. "Periodic" implies a regular return at stated periods;

recurrent" only indicates its tendency to recur, and the general permanent tendency to attacks.

Etiology. The most striking general etiologic fact is the hereditary character of the disorder. When the family history is fully ascertained, it is almost universally found that there has been in the ancestry some degenerative taint, often a direct heredity of insanity or eccentricity verging on mental disorder. In a few cases this cannot be found, but there is frequently, then, some manifestation in the collateral lines that shows the defective nervous organization. In some instances it is possible that a marriage may occur between persons of normal constitution, but so unsuited to each other as to cause serious brain or nerve defect in their offspring, who are, as a result, subjects of this or some other degenerative type of mental disease, without any history of direct ancestral heredity. Such cases are unusual, however, and, as a rule, the record indicates the source of the taint. The immediate exciting cause of an attack of mania may be any one of the ordinary direct causes of insanity-moral or emotional stress, or shock, ill health, the puerperal condition, etc. It is easy to see how any one of these may give rise to the mental disorder in a thus constitutionally predisposed subject. It is a striking fact, however, that in many cases of mania no direct exciting cause whatever can be found for even the first attack. Subsequent attacks may or may not have provocation; not infrequently they occur without warning or apparent reason. The subjects frequently show an instability and excitability of character, but this is not always apparent, nor are there always visible marked degenerative stigmata. The attacks have been said by some to occur in the spring months more than at other times in the year, but such generalizations from partial statistics are not very valuable. The fact that mania has been generally confused up to the present

with the excited types of confusional insanity makes them practically valueless.

Symptoms. The earliest symptoms of simple acute mania vary much in different cases. Often, perhaps generally, there is a stage of restlessness or mild depression preceding the attack for from one to several days, or it may be weeks, but this is often wanting or impossible to be detected. Its occurrence is an indication of the general cyclic tendency of these degenerative insanities. When this is absent, as appears to be sometimes the case, the onset is often immediate and abrupt; the patient passes more or less rapidly into the state of full-fledged motor and mental excitement. In most cases, however, there has probably been some derangement of the bodily functions, not always very obvious, such as insomnia, more or less pronounced, or at least some disturbance of sleep, and constipation is evidently a very common antecedent. Sometimes there is a period in which oscillations of quiet and mild excitement succeed each other, gradually developing into the complete attack. In the most typical form the onset of the symptoms is exceedingly rapid; it may be, as it were, instantaneous; in one case known to the writers the first observable symptoms were the patient's throwing her effects and money out of a car window as she was traveling, and in many instances the outbreak is apparently as sudden as this. We say apparently, for the initial symptoms of unlooked-for outbreaks may easily pass unperceived, but there are probably many cases, as is more often observed in recurrent attacks, where there are practically no premonitory signs whatever.

Whether gradual or sudden in its beginning, the mental condition soon becomes characteristic; the ideation is greatly intensified, the ideas tumbling over each other, so to speak, in their rapid evolution; the attention power lengthened so that the patient is alive