ragtime. Improvement came slowly, and as in other cases amnesia remained.

Two similar cases failed to recover. J. H. had pneumonia, gr out of bed, was unreasonable and violent, called out the window to friends both dead and alive. She was semistuporous for a while, heard funny voices through the wall. Then she admitted having been mixed up in the head, but was averse, sometimes resistive, always silly and indifferent. So she remains. N. H. had hallucinations and did very peculiar things a half year before commitment, but was employed at her occupation of nurse, when an infected finger led to a further mental upset. She was de pressed, confused, apprehensive, talking of visits at night from her dead mother, the Virgin passing hands over her face, prospec tive death by murder. Her delusions grew more absurd and extensive and are now incoherent. She talks incessantly without goal. On account of the development during septicemia of the trouble that led to her commitment her psychosis was at first thought to belong to this group.

The next is a transition case to the third-the stuporousvariety. A. G. was nursing her three-months-old infant in spite of deteriorating health when she began to speak of extensive purchases and to say she felt as if going crazy. She thought every. body was talking about her and that the landlord had an ambulance waiting for her. Vivid hallucinations and fear of death succeeded; then for ten days she did not speak. She passed through several fantastic experiences, being put through a boiler and down a tunnel. When other patients spoke on indifferent topics they seemed to be defaming her. For a time her orientation was obscured. D. K., during lactation and hard work dreamed of ghosts and coffins, saw men walking on the ceiling and her children jumping out the window. Voices threatened to cut her head off and bury her. Everything was "doubled." Two months she was mute. A. B. had longstanding uterine trouble. She heard neighbors planning to rob her flat and appealed to the police for protection, but grew rapidly confused and incoherent, and sus picious and fearful by reason of her hallucinations. Though willing to talk she could not control the train of thought. For three weeks she did not speak and for some time longer showed variable responsiveness. C. B. had pericarditis and mistook identities,

1

complained that her father was talking about her, shouted incoherently at times, but soon sank into stupor, retaining saliva and urine, resisting passively and requiring to be fed by spoon. When in other regards improving she still thought she was to be killed. F. H., while in hospital with superficial infection after hysterTectomy, became confused in speech and expected to be killed. She screamed with terror, resisted attention violently, repeated phrases but did not answer questions. More than a year has elapsed and she is still mute, inactive, resistive.

Fourth stage-violent excitement: L. M. had a post-partum hemorrhage. She was urged to get up and bathe on the seventh day, and attacked her mother-in-law with an axe. She passed quickly through a wild, apprehensive excitement associated with evanescent hallucinosis. She was kept in the hospital some time after apparent recovery, but on the fourth day after discharge got confused and noisy while out walking, and after a week of violent excitement died suddenly. S. S., after suffering some months from an exhausting vaginal discharge, spoke incoherently and with many repetitions, rushed about shrieking wildly, reacting to fearful auditory hallucinations. The degree of excitement fluctuated but was always notable. Gradually she became quiet and gained insight.

This brings us to a patient who exhibited flight at one time, depression later. M. D. during puerperium said she was the Virgin, abused everybody, did not sleep, refused food. She showed tremendous excitement with fear. A few fair samples of flight were recorded. After three days out of bed she entered another excitement in which she talked with her father under the bed, misidentified, had many rapidly changing delusional ideas. On emerging from this she was unduly sober and felt unable to do things.

A possible amentia in Kraepelin's sense, but without adequate physical basis and with only moderately upsetting mental factors, was the psychosis of L. B., who thought that everybody was dead, that they wanted to kill her. She seemed dazed, commented on all that happened, but evidently could not grasp the situation. Hallucinations were present, orientation much disturbed, and her ideas changed rapidly. Death in various forms was threatened, and she thought that injury had already been done to her children.

Clearly the subdivisions overlap. Let me instance a case that fits in nowhere. M. W. went home from a general hospital after typhoid, apparently well. A week later she began to do peculiar things, such as to demand, "Look at me!" without giving a reason. She would not believe that her brother had left the house and searched for him in drawers and under the bed. Solemnly she confessed various imaginary wrongdoings. Four months she was in another institution; we do not know what happened there, but on transfer she was much befogged, did not recognize her brother and on the trip to New York repeated monotonously, Open the door!" For hours she would chant a few sentences monotonously; at times the productions could be influenced by what was said to her. In a few days she became accessible and showed defective orientation and amnesia for some four months. She was removed from the hospital without insight and in an irritable frame, but was reported later as having recovered.

A difficult question is the separation of deteriorating cases from recoverable. As you have observed, several of these patients did poorly; some of these had a mild delirium, some a moderate, some a severe. It would have been easy to add others in which the diagnosis infective-exhaustive psychosis was made at one time or another, but without what now appears satisfactory reason. Among them typhoid fever, pneumonia, postoperative infection appear as etiology, but this does not help us; in the same series are recovered cases with typhoid and puerperal infections. Nor can we say as yet that the previous mental makeup determines: P. M. was headstrong, F. H. secretive; but among the recovered cases F. K. was unreasonable to the point of violence, A. S. stubborn and not given to forming friendships. Perhaps if the study of the mental makeup were carried further it might yield the same help as in other fields. We can at present say only that delirium is so natural and fundamental a reaction to severe disturbance of the human economy that it is quite unsafe to attempt prognosis or more than tentative diagnosis till the affair has had time for the causal lesion to be repaired and for incidental features to disappear. Let us accumulate careful observations; the last word on delirium is not spoken. For subdivisions of the group some simple scheme of degree of severity seems as useful as anything more elaborate and etiological when admissions are sifted as are those in New York city.

STUDIES IN HEREDITY WITH EXAMPLES.*

BY WILLIAM C. SANDY, M. D.,

Assistant Physician, State Hospital, Trenton, N. J.

Heredity has long been recognized as an important etiological factor in mental disease. The term, however, has been loosely applied and indefinitely stated. It is usually considered sufficient to state the percentage in which hereditary influences appear in the different psychoses without any attempt to specify the character of these defects. In the present paper an attempt is made to determine more definitely what psychoses or peculiarities are found in the families of a series of cases in the institution with which the writer is connected.

At the very onset it is well to consider the difficulties encountered in such a study. The hospital records constitute one of the important sources of information. One who has had any experience with old asylum histories, however, need not be told that these are often meagre and valueless. Moreover, when an honest effort is made to obtain useful data the informant is frequently unreliable. He may be ignorant or may purposely distort or conceal the real facts. Even if the informant be reliable, yet there is no standard in measuring mental conditions. One must consider also the education of the individual, his environment, opportunities, and so forth, before an equitable judgment of his mentality can be made. Again it is difficult to decide the relation of the peculiarity in ancestors to the psychosis in the case at hand. The fact that a history of insanity or peculiarity may be obtained, after careful search, in the families of many normal individuals must be borne in mind, and the danger of a post hoc propter hoc argument avoided.

The biologists are accomplishing much, which will doubtless help to solve the problems of the hereditary etiology of mental disease. A number of analogies may be found between the unit characters of the anatomical and those of the mental make-up. The time may come when, as Prof. Davenport has said, if the

* Read at the sixty-fifth annual meeting of the American MedicoPsychological Association, Atlantic City, N. J., June 1-4, 1909.

characters of the parents are known, it will be possible to predict the kind of children.

In this regard it is important to make careful and minute studies of individuals in families in respect to certain traits or unit characters and their transmission, disappearance, or change in successive generations. In order to eliminate, so far as possible, the element of difference in education, environment, and opportunities, Strohmayer suggests that the families studied should be from a small little-fluctuating community.

The problem then is extremely complex. The present examination scheme, as usually followed, is not sufficient to collect really valuable data to establish the influence of heredity. To one in search of facts, even the so-called well-worked-up records are exceedingly disappointing.

Besides studying the psychoses in relatives and endeavoring to show in this way a real hereditary influence, it is also well to consider to what extent acquired conditions may affect the descendants. Although some writers dispute the possibility of the transmission of acquired characters, yet it must be acknowledged that such habits as alcoholism in the ascendants leave their mark upon the inheritors. Alcoholism in the parents, especially at the time of conception, has been shown, by more than one authority, to result in the propagation of defectives.

In the examination of the present series of three hundred and eighty-six cases, two hundred and twenty-nine men and one hundred and fifty-seven women, special attention has been paid to the psychoses, peculiarities or toxic habits in paternal and maternal grandparents, uncles and aunts, parents, brothers and sisters. Many of the statistical findings are not greatly different from those of numerous writers on the subject. Of the three hundred and eighty-six cases, one hundred were in the manic depressive group, sixty-eight dementia præcox, fifty-two alcoholic insanity, eighteen general paresis, twenty-three epileptics, six narcotic inebriety, nine imbeciles and one hundred and ten cases in which there was found to be apparently very little hereditary influence and which are grouped together. Ninety-five cases, or a percentage of 24.61 of the whole number, showed undoubted heredity, such as psychoses or eccentricity in ancestors. If those