and the best hygienic regulations. I give alcoholic stimulants

much less freely than formerly.

R. W. MATHEWSON, M.D.

Reporter for Middlesex County.

MORTALITY OF THE INSANE.

BY JAMES OLMSTEAD, M.D.,

First Assistant Physician Connecticut Hospital for Insane.

Some of the tables prepared in connection with the annual or biennial reports of hospitals for the insane are based upon matters of fact, e. g., the age, residence, and civil condition of the patients; others are based upon matters of opinion, e. g., the cause of the insanity alleged by the patient's friends, and the duration of the disease; yet others embrace both matters of fact and opinion, e. g., the table of the "causes of death." When the cause of death is proved by a post-mortem examination, it may fairly be regarded as a settled fact. Otherwise it is sometimes (not always) a matter of opinion, which may or may not be correct. As long as man is fallible, so long will the most skillful diagnosticians make mistakes, and almost every experienced physician can recall instances in which a diagnosis so careful as to leave no apparent room for doubt, was blasted by the disclosures of the necropsy. Inasmuch, then, as certain arguments based on these tables might be of doubtful value, it is intended to limit ourselves to such general deductions as may safely be drawn from the premises.

With the natural desire of comparing one's self with others, Table I was several months ago collated, after a return from. visiting most of the New England hospitals for the insane. The comparison herein presented has the advantage that certain influences (climatic and social), which might otherwise demand consideration, may be eliminated as practically identical in the different New England States, and the discussion is thus simplified. At the time the table was prepared reports from other hospitals covering the greater part of the year 1876 were the latest readily accessible, and these were compared with ours for the year 1876-7.

Perhaps the first fact attracting notice is the long list of diseases which have proved fatal in ten hospitals for the insane during only one year. But on looking more closely we find that symptoms as well as diseases are incorporated in the list. Thus exhaustion is a prominent symptom in many diseases, and is not uncommonly the mode of death, but it cannot, without qualification, be considered a cause of death. When, as is observed in Table I, out of a total of 54 deaths 21 are referred to "exhaustion," and none to any form of insanity, we may reasonably surmise that probably a majority of the 21 persons died of mania and melan

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cholia. Ascites too is, strictly speaking, a symptom usually traceable to visceral disease. If this, in an insane patient, cannot be ascertained during life, surely there is an imperative demand for a post-mortem examination which shall unravel the mystery. Organic disease of the brain" is seen to cause nearly a quarter of the deaths at one hospital. But what variety of organic disease? Not general paresis, for that presents its quota separately. If, as is sometimes done, we qualify by saying "obscure" organic disease, we only deepen the obscurity of the expression, but can congratulate our brethren on having in the midst of so much obscurity a fine field for pathological study. Again, when "cancer contributes to the mortality, would not the value of statistics be enhanced if the variety or site of the malignant disease were specified?

Flaws such as these are pointed out not with any intention of especially disparaging sister institutions, for, so far from hospital men being the chief of sinners in this matter, one doubtless need only look over the records of the Registrar's office in any of our cities or large towns to be convinced that a certain looseness of diction is far too general. Moreover, for such criticisms as are made we have the authority of no less note than Dr. Isaac Ray, who thirty years ago, in an article for the American Journal of Insanity, wrote, "To call exhaustion a disease, when in so far as its phenomena meet our observation it is merely a loss of muscular power incident upon a specific disease, is either to use language in a sense very different from its ordinary acceptation, or to thoroughly confound causes and effects with an utter disregard of every principle of sound pathology,”—and further, "It might be asked why in the same table some deaths are attributed to general paralysis, which is a specific form of mental disease, and not to 'disease of the brain,' which may be as properly applied to it as to mania." As a matter of professional pride we are all interested in defending a nomenclature as absolutely accurate as possible.

On the other hand, one observes in Table I the gratifying fact that the mortality from infectious diseases is very insignificant. That the particular period under consideration is not exceptional in this respect, a glance at reports for other years would abundantly prove. In the Middletown hospital, for example, no patient has ever died from typhoid fever or diphtheria; only a few from dysentery and erysipelas. This happy result is no doubt attributable, in part at least, to the attention paid to cleanliness, ventilation, and sewerage in all hospitals for the insane.

It will also be noticed in Table I that there is considerable diversity in the death-rate in the hospitals compared. From calculating the ratios between the total number of deaths and the average daily number under treatment, i. e., the hospital population, it was found that the death-rate ran from 15.40 per cent. in one hospital, down to 5.82 per cent. in another. It is no more than fair to remark in passing that only in two previous years has the death-rate at Middletown been lower than the

TABLE I.

NECROLOGY OF TEN NEW ENGLAND HOSPITALS FOR THE INSANE, DURING ONE YEAR.

NOTE. During the latter half of this biennial period, the average resident population at the Vermont Hospital was 479, and there were 28 deaths; ratio 5.82.

above; still the mortality here has always been favorable. A similarly satisfactory statement may be made with reference to the Hartford Retreat. The total number of deaths is varied from year to year by transient, often trivial causes. Thus at Middletown last year an unusual number of old persons chanced to reach the end of their course, and sufficed to raise the percentage of deaths a little above the average. Again, the high death-rate at McLean Asylum, Somerville, may be partly explained by the fact that, for the year under consideration, out of 92 admissions 74 were recent cases-an unusually large ratio; and it is generally recognized (see Griesinger, New Sydenham edition, p. 448,) that in hospitals for recent cases the mortality is greater than in asylums proper. Dr. Thurman, in his "Statistics of Insanity," makes this remark, quoted by Dr. Mortimer Granville in "Care and Cure of the Insane," Vol. I, p. 144: "The mortality is generally more favorable during the early history of an asylum; and during the first twenty and even thirty years of its operations, as the proportion of recent cases admitted increases, and as the old cases [admitted during the first years of the asylum die off, it usually continues to undergo a material increase, which often amounts to 50 or 100 per cent. upon the mortality of the first five years."

Table I also indicates that the major causes of death in the nine hospitals whose reports specify them were, (omitting as indefinite "exhaustion" and " organic brain disease,") phthisis and tuberculosis, chronic mania, general paresis, apoplexy, acute mania, epilepsy, pneumonia, and senility. Tuberculosis is classed with phthisis because, although acute tuberculosis is an acknowledged pathological entity, it is comparatively rare, and in these hospital cases there is every reason to believe that the morbid process was chronic; chronic tuberculosis is nowadays considered by authorities (Rindfleish and Delafield, for instance,) as a variety of phthisis. The above diseases are named in the order of fatality, and form the link connecting Table I with Table II.

TABLE II.

CAUSES OF TEN OR MORE DEATHS AT THE CONNECTICUT HOSPITAL FOR INSANE, APRIL 30, 1868-NoVEMBER 30, 1878.

CAUSES.

DEATHS.

M.

F.

Total.

Total deaths in the above period from all causes,
Ratio to total admissions,

In preparing this table from the entire death record of the hospital as given in Dr. Shew's last report, it was thought that the representative mortality would be best expressed by ignoring comparatively rare causes of death, and tabulating those only which had acted in ten or more instances. It was thus found that the same agents as named above had in the Middletown hospital produced a majority of the deaths, and had been active in nearly the same degree. Here is observed the well-known fact so universally true, that among the insane more men than women die within any given period, and the statement that 19 per cent. of the males admitted and 14 per cent. of the females admitted during ten years have died in the hospital, is simply in accordance with general testimony. Dr. Pliny Earle, the veteran superintendent of the Northampton hospital, in certain elaborate statistics prepared years ago, reaches the same conclusion, and, not venturing to assign any especial reason for the fact, simply regards it as a certainty that when the statistics of insanity are properly perfected "it will be demonstrated that the average duration of life is longest among women" (Seventeenth Annual Report, 1873). Without an absolute demonstration, part of the difference is commonly explained on the ground that the most invariably fatal form of insanity-general paresis-attacks males often, females hardly ever. Again, Table II shows that the unequal mortality of the sexes from epilepsy (seven males, four females) agrees nearly with the unequal admissions (forty-nine males, nineteen females). Finally, the physicians experience is in accord with the opinion of most systematic authors (see Sidell on Apoplexy, p. 32) that males are more liable than females to be attacked with apoplexy. That the inequality between the two sexes in this respect is greater among the insane than among the sane is seemingly indicated by our table, however it may be accounted for.

From Table II one would reasonably judge (1) that most of the hospital deaths are the result of chronic affections; and (2) that insanity and other diseases of the nervous system and diseases of the respiratory system kill pretty nearly all of our patients who do not die of sheer old age. That these inferences would not be far from the truth is shown in Tables III and IV. The terms "acute" and "chronic" are here used in their ordinary loose acceptation, except that, in speaking of the different forms of insanity, the former adjective has ordinarily a fixed signification-meaning that the insanity has lasted less than one year.