H.—7

4

748. Though below the death-rate in English asylums (which in 1906 was 9"85 per cent.) the figures show a progressive increase which a study of the following table will explain: —

Table to illustrate Causes operating to bring about an Advancing Death Rate: Showing in Quinquennial Periods the Percentage Proportion of Admissions according to Age Groups; of Deaths, in Causation, Age, and Length-of-residence Groups; and of Patients on Register on 31st December of each Year in Age Groups.

The significance of the increase of admissions of persons above the ugo of sixty has been already dealt with in regard to recoveries, and a glance and a passing thought should suffice to indicate that many persons if not actually labouring under senile decay on admission will be so in a few years. The increase in the proportion of deaths in persons over seventy years of age is very marked, an age at which, speaking generally, treatment is only palliative and death inevitable. Obviously this larger proportion is due to the larger number resident at that age (vide last section of table), resulting both from a larger number of such admissions, an has been demonstrated, and the aging of the unrecovered of earlier years, whiich is seen by the longer residence at death. It may be assumed that had the ages of patients stood as they were in the quinquennium 1882-86 there would have been a considerable reduction in the number of deaths. Not that the rate is high at present when one considers that 730 per cent, of our patients are over seventy years of age, while 739 represents the deaths from all causes, and when one gives weight to the fact that an insane population is a sick population—a fact so often and so quickly lost sight of that its restatement upon occasion becomes necessary. Insanity is a bodily disease which may render a patient more liable to the invasion of some other forms of disease, it may weaken the forces which resist the attacks of disease, and it may in itself prove fatal. In this connection the large proportion of deaths within one year of admission, when the type of insanity is more acute, finds a ready explanation. In the last report I dealt at some length with the proportion of the sexes among the insane, and their condition as to marriage. These matters need not be repeated. Since then a new Act is upon the statute-book which makes ground for divorce insanity, if deemed to be incurable, which lias lasted for ten years in the twelve preceding the filing of the petition. It would be out of place for me to criticize so recent an Act; but naturally I must regret it from the patients' standpoint. A case was recently brought to my notice by her husband of a patient whose recovery had been retarded by gossiping discussions of the Act among her fellow-patients raising suspicion as to his fidelity and intentions. It lias been argued that this Act would limit the procreation of the unfit. A misconception dies hard, and that statement has been repeated so often and by such responsible persons that one is in duty bound to point out its irrelevancy. In so far as a serious attack upon heredity is expected to be one of the consequences of the Act, the Act is merely paring the nails of the monster. In the year under review 299 persons (m., 160; f., 139) were discharged as recovered, and returned to their homes as free agents; and of this number, including 4 at the age of puberty, 256 (m., 147; f., 109) were able to reproduce their kind, and of these only one unmarried man and one married Chinaman fulfilled the condition of having been insane for ten years during the preceding twelve. True, the one married man may have been divorced, and may have remained a celibate; but what of the other 255 ! Here is a real problem, but one, I fear, which must be left for some future generation to solve. ' Causes of Insanity. —These though recorded in our statistics as isolated factors seldom operate singly, and even in combination would be almost impotent unless (lure were a predisposition inherited or acquired. Insanity is a somewhat rare malady in the absence of heredity, whether the heredity be direct, of other neuroses, or even the expressed error of sickly or ill-matched parentage. A nearly allied condition, one of lessened resistance, may be acquired by early or prolonged malnutrition, giving the term its widest application. Undoubtedly ;i potent underlying cause of unsuspected weaknesses must be sought in early malnutrition. Care during the formative periods may do much towards combating evil heredity, but ignorance assails a goodly heritage. Indeed, so accustomed are we to inherent weaknesses that, instead of combating danger, we find ourselves avoiding it instinctively in the fancied manner of the ostrich with its head in the sand. Table XIII must be accepted with such limitations because our information is not sufficiently accurate to give even approximate value to predisposing factors. Hereunder this table is epitomised, the percentage calculations being made only on those admissions in which a cause is assigned for the insanity.

Admissions. Death. Pi remaii of es itients ling at End ich Year. Period. i Pn P' Under 20. Lge of: IT Cent. Cans Proportioi le of: ns per Cent. I Pn l" ige at: •portions sr Cent. Length of Residence at: Proportions . per Cent. A( Proi pei les of: lortionB r Cent. 20 to Over 60. 60. Senile Decay. Tubercular Disease. General Paralysis. Other CauBes. Underl 20. 20 to 70. Over 70. Under 1 Year. lYear to IS Yrs. Over 15 Yrs. Under 20. 20 to 70. Over 70. 1882-86 1887-91 1892-96 1897-1901 1902-6 1907 England and Wales for the year 1906 .. 7-31 7-98 6-94 8-08 6-76 7-16 86-62 84-29i 82.32: 79-66 77-45 78-33 6-07 I 7-73 10.74 12-26 15-79 114-47 6-58 9-79 7-38 911 1401 26-52 11-76 9-41 9 84 15-36 10-84 913 17-65 10-55 9-84 9-89 10-84 8-26 64-01 70-25 72-94 65-64 64-31 56-09 5-31 4-38 3-89 3-55 3-37 3-46 87-451 87-14! 83-19 1 81-85 76-89 69-27 7-24 8-481 12-92 14-60I 20-24 27-27' 11-90. 39-24. 89-18 86-96 37-97 28-19 55-24 '52-84 48-68 147.97 44-80J 49-79 2-86 7-92 12-17 15-07 (17-23, 22-02! 3-88 3-27 3-65 319 3-03 3-20 94-58 94-43 93-13 93-98 91-25 89-50 154 230 3-22' 388 5-72 7-30 10-24 15-79 16-77 55-17