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ASYLUM REPORTS.

Nottingham City Asylllln, Mapperley Hill (-ltrtnal Reportfor j!90).—The daily average number of patients residentduring the year was 757, comprising 366 males and 39females. The admissions during the year amounted to 160-viz., 77 males and 83 females. Of these 140 were firstadmissions. Mr. Evan Powell, the medical superintendent,states in his report that, though the number of activelysuicidal cases was more than the usual amount, and therewere numerous other patients of a feeble constitutionliable to accidents, the year has passed without the occur-rence of a serious accident or casualty. " It seems to me

that, as the years go by, the character of the disease withwhich we have to contend," says Mr. Powell, " is becomingless and less amenable to treatment, and consequently ourrecovery-rate is diminishing. I mean by this that the

proportion of incurable cases, such as congenital imbeciles,epileptics, general paralytics, organic dements, and senile

cases, is steadily growing greater." Out of the 160 casesadmitted during the year less than 60 per cent. presentedany chance of recovery. Among the causes of insanity inthe admissions were alcoholic intemperance, worry ard ’

anxiety, and hereditary predisposition. 18 cases were

directly caused by drink, "and again I have to record thefact that almost as many women became insane in Nottinghamfrom this cause as men." The number of cases discharged asrecovered during the year amounted to 47-viz., 22 males and25 females, or 6’ 2 per cent. of the average number resident.The deaths during the year amounted to 76, or 10 per cent.as calculated on the same basis. Of the deaths three weredue to cancer, four to pneumonia, five each to renal diseaseand senile decay, six to pulmonary and other forms oftuberculosis, 11 to cardiac disease, 19 to general paralysis ofthe insane, and the rest to other causes. The recovery-ratewas the lowest with two exceptions since the opening of theasylum. " This is entirely due to the fact of the very largeproportion of hopeless cases admitted. The rate of recoveryin the other asylums of the country is steadily coming downand undoubtedly from the same cause." There was an entirefreedom from any of the common zymotic diseases but therewere a few cases of colitis, one of which proved fatal."Stringent precautions were taken at the beginning of the

year to prevent the introduction of small-pox, which was soprevalent in the town of Nottingham, by adopting a com-plete system of revaccination and by stopping all visiting.These precautions fortunately proved successful." The Com-missioners in Lunacy state in their report that the day roomsof the asylum were, notwithstanding the cold weather,warm and comfortable, that the dormitories were clean andwell ventilated, that the bedding was in proper condition,that the wards were bright with flowers and decorations,that the patients appeared to be dressed neatly, and that themedical records and case-books were very well kept.Additional exit doors to be used in case of fire have been

provided to the new ground-floor dormitories. The use of the

temporary dormitory, in which 40 females sleep under super-vision, should, say the Commissioners, be discontinued and asimple and cheap structure of brickwork substituted. Thecommittee of management states in its report that the

weekly charge for city patients remains at 10s., that a newnine-inch water-main has been laid to a tank in the asylumgrounds for the purpose of giving a sufficient water-supplyin case of fire, and that the temporary female dormitory ofwood and iron will be replaced by a permanent structure.

Belfast District Asylurn (Annual R(’port for 1903).-Theaverage number of patients resident during the year was1021, comprising 484 males and 537 females. The admissionsduring the year amounted to 250-viz., 120 males and 130females. Of these 204 were first admissions. Dr. WilliamGraham, the medical superintendent, states in his report thatit is worth noting that while there seems to have been a realincrease of insanity during the past ten years, yet in thecity of Belfast there has been a perceptible decrease duringthe past year. As far as the Belfast district is concernedthe ratio of increase of the insane over that of the generalpopulation its enough," says Dr. Graham, " to warrant themost searching investigation into its etiology and pre-vention." The greatest misconceptions prevail as to heredityas a cause of insanity. Man inherits, says Dr. Graham, notinsanity but "an ill-adjusted nervous system, which mayeasily collapse beneath an unaccustomed strain. Of six

children born with a neuropathic temperament, one or twomay end their career in an asylum....... That heredity marksout the lines along which the chartered curses of humanityfind easy progress we must believe. Many cases of insanity, ifthoroughly studied, can be shown to be the result of causeslong in operation in men and women....... Given, there-fore, the fact and potency of heredity, all the more needexists to bring to bear [upon persons with a ten-

dency to insanity] those educational and disciplinaryinfluences which may modify or change the inheritedcondition." Alcoholism is a frequent cause of insanity but,says Dr. Graham, it is " more frequently the symptom of analready existing degeneracy of the brain and nervous

system." The labourers and artisans of Belfast formerlymade porridge, milk, and potatoes, with an occasional pieceof fish, their staple food. Now instead of these they try todo their work by the aid of stimulants, such as tea, stout,and other artificial drinks. Excessive tea-drinking causesmalnutrition, ’’ especially in the case of children reared onthis beverage, supplemented by white bread," says Dr.

Graham, and such dietary develops "all kinds of neuroticaffections which lay the foundation for the pathological evilwe are trying to extirpate." The terrible increase of generalparalysis is " difficult to speak of without seeming to exag-gerate. During the years 1894 to 1897 the cases of generalparalysis admitted to the asylum numbered only nine. Inan equal number of years, 1900 to 1903, there were 57admissions. This terrible scourge-the by-product of moderncivilisation-is the result of causes that are preventable."The number of patients discharged as recovered during theyear amounted to 85-viz., 44 males and 41 females, or

8 ’ 3 per cent. of the average number resident. The deaths

during the year amounted to 83, or 8’1 per cent. as calcu-lated on the same basis. Of the deaths, two were due tocancer, six to cardiac disease, seven to epilepsy, eight tosenile decay, ten to pulmonary and other forms of tuber-culosis, and 19 to general paralysis of the insane. The

general health of the patients throughout the year has beengood. The Inspector of Lunatics states in his report thatthe number of cases of general paralysis continues toincrease. He adds that the management of the institutionis marked by ability and good sense, that the wards werebright and comfortable, that the patients seemed contentedand pleased with their surroundings, that the beds and

bedding appeared clean and comfortable, that the medicalcase-books were very fully and accurately kept, and thatuseful and interesting pathological work was being carriedon at the laboratory. Reference is made to the presence ofidiot and imbecile patients in the wards of the asylum andthe hope is expressed that the representations of the Boardof Lunacy will result in the establishment of special institu-tions for such patients, in the form of training schools andfarm colonies, in Ireland.

THE TRAINING AND SUPPLY OFMIDWIVES.

A MEETING was held at the Westminster Palace Hotel onNov. 4th by the Association for Promoting the Training andSupply of Midwives. Princess Henry of Battenberg waspresent and the Archbishop of Canterbury took the chair.The object of the gathering was to place before the publicthe urgent need of training an adequate supply of mid-

wives for the poor in order to meet the requirements of theMidwives Act of 1902.

In the beginning of the proceedings the ARCHBISHOP ofCANTERBURY welcomed delegates from 15 county councils,12 borough and town councils, and 12 district councils. He

pointed out that for the most part those representativeswere medical officers of health and their presence was themore valuable because they could instruct as well as assistthe association in its objects, which were to extend thework carried on by the home opened at East Ham last yearand bv cooperation with local organisations to assist in

meeting the requirements of the Midwives Act of 1902.The following motion was then proposed by Dr. C. J.

CuLLINGWORTH and seconded by the Rev. C. SINGER:-That in view of the urgent need that exists in this country for a

supply of properly trained midwives who, in working in conformitywith the provisions of the Midwives Act, 1902, will help to reduce the

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present high mortality of lying-in mothers and their children amongstthe poor, this meeting cordially supports the Association for Promotingthe Training and Supply of Midwives and earnestly commends its workto the generous sympathy of all who are interested in the welfare ofthe country.

Dr. CULLINGWORTH, in moving the proposition, showedthat there were about 450,000 births every year in Englandand Wales and about 60 per cent. were as a rule attended bywomen only. In 20 counties it was estimated that three-fourths of the present number of midwives did not care towork under the simple rules and regulations provided by theMidwives Act of 1902. Thus urgent need had arisen for thegap to be filled and for suitable women to be trained asmidwives for the work.

Dr. F. H. CHAMPNEYS, chairman of the Central MidwivesBoard, speaking in support of the motion, reminded hisaudience that though the Midwives Act was not perfect ithad enabled those interested in the matter to grapple to acertain extent with an extraordinarily difficult subject. Theterrible loss that occurred at childbirth was not generallyrecognised before that Act had been passed and, unfortu-nately, he had to add that that loss of life continuedunchecked, as the statistics of puerperal mortality, in spiteof the introduction of antiseptic methods, did not show

any improvement during the last 30 years. By the year1910 there should not be such a person as a midwifeof the old school existing, but that implied the obliga-tion of care being taken that proper substitutes shouldbe ready, for if the law refused to allow a woman to

have a dirty midwife a clean midwife must be pro-vided. It was obvious that unless adequately trained mid-wives were supplied the last state of the country would be,if possible, worse than the first. In regard to the questionof State aid, Dr. Champneys reminded those present thatthe French physicians and surgeons who had lately visitedLondon did not in any way consider that the absence of Stateaid over here was a matter to be deplored.

Mr. W. E. BAXTER, coroner for the Eastern District ofLondon, dealt with the question by quoting the facts andfigures that had come under his own notice. He showedhow tetanus was caused by the ignorance of dirty midwivesand declared that with proper skill and cleanliness the lossof life could be averted. A large number of the women

acting as midwives for small payments had no qualification,no skill, and no training. Mr. Baxter’s remarks contained aserious warning that unless properly trained midwives weresupplied a great deal of suffering would be inflicted on thepoor.Among the other speakers who supported the motion

was Dr. W. WILLIAMS, medical officer of health of the

Glamorgan county council, who read a paper of considerablelength, quoting figures and facts from the Milroy lectureswhich he delivered this year at the Royal College of Phy-sicians of London on Deaths in Childbed, and which werepublished at full length in the columns of THE LANCET,

ROYAL COLLEGE OF SURGEONS OFENGLAND.

THE annual meeting of the Fellows and Members will be Iheld at the College in Lincoln’s Inn-fields on Thursday,Nov. 17th, 1904, at 3 o’clock P.M., when the report of theCouncil will be laid before the meeting. Copies of the reportcan be obtained by Fellows and Members on application tothe secretary and they can, if they wish, register their namesso as to receive the report annually. We hope that a largenumber of Fellows and Members will be present as the pro-ceedings are always interesting and, moreover, this is the

only occasion on which the body corporate is called togethereach year. A copy of the agenda will be issued to anyFellow or Member who may apply for one on or afterNov. 14th.

LITERARY INTELLIGENCE —Messrs. Kegan Paul,Trench, Trubner, and Co. will shortly issue a Manualof Fever Nursing. It is written by Professor ReynoldWebb Wilcox, Fellow of the American Academy ofMedicine and Professor in the New York Post-GraduateMedical School and Hospital. It deals with fevers, theircauses and symptoms, and their treatment in accordancewith the present state of practice.

VITAL STATISTICS.

HEALTH OF ENGLISH TOWNS.

IN 76 of the largest English towns 8774 births and 4372deaths were registered during the week ending Nov. 5th.The annual rate of mortality in these towns, which hadbeen 15’2, 15’9, and 15’0 0 per 1000 in the three precedingweeks, further decreased last week to 14’9 per 1000, InLondon the death-rate was 14’ 9 per 1000, being equal to themean rate in the 75 other large towns. The lowest death-rates in these towns were 5’ 8 in Croydon, 6’ 4 in Hornsey,7’0 in Walthamstow and in Barrow-in-Furness, 7’9 inMerthyr Tydfil, 9’ 5 in Smethwick, and 9 6 in Reading ; thehighest rates were 20’0 0 in Liverpool, 20’2 in West Bromwich,20’ in Rotherham, 21’6 in Middlesbrough and in Tyne-mouth, 21’ in St. Helens, 22’0 in Stockton-on-Tees, and23’ in South Shields. The 4372 deaths in these townslast week included 425 which were referred to the principalinfectious diseases, against 573, 532, and 394 in the three pre-ceding weeks ; of these 425 deaths, 109 resulted from measles,106 from diarrhoea, 72 from diphtheria, 58 from scarletfever, 44 from "fever" (principally enteric), 34 fromwhooping-cough, and two from small-pox. No death fromany of these diseases was registered last week in Croydon,Walthamstow, Hastings, Bournemouth, Southampton, Hands-worth (Staffs.), King’s Norton, Aston Manor, Stockport,Wallasey, Warrington, Barrow-in-Furness, or Gateshead ;wnne tney caused tne Highest death-rates m Wolver-

hampton, Grimsby, Liverpool, Salford, Oldham, Burnley,Middlesbrough, and Stockton-on-Tees. The greatest pro-portional mortality from measles occurred in East Ham,Grimsby, Liverpool, Bootle, Burnley, Middlesbrough,Stockton-on-Tees, and Tynemouth ; from scarlet fever in

Northampton, Wolverhampton, West Bromwich, Hudders-field, and York; from diphtheria in Hornsey, Portsmouth,Derby, Bradford, Stockton-on-Tees, and West Hartlepool;from whooping-cough in Oldham, Sunderland, and SouthShields; from "fever" in Rochdale; and from diarrhoeain Hanley, Walsall, Oldham, Burnley, Preston, Middles-brough, and Merthyr Tvdfil. One fatal case of small-poxwas registered in Halifax and one in Leeds, but nonein any other of the 76 large towns, and only one case

of small-pox remained under treatment on Saturday,Nov. 5th, in the Metropolitan Asylums hospitals. Thenumber of scarlet fever patients in these hospitals and inthe London Fever Hospital at the end of the week was 2782,against 2516, 2687, and 2725 at the end of the three pre-ceding weeks ; 294 new cases were admitted during the week,against 377, 389, and 305 in the three preceding weeks. Thedeaths in London referred to pneumonia and diseases of therespiratory system which had been 194, 251, and 289 inthe three preceding weeks, declined again last week to 285,but were 13 in excess of the number in the corre-

sponding period of last year. The causes of 37, or 0’ 8 percent., of the deaths in the 76 towns last week were notcertified either by a registered medical practitioner or by acoroner. All the causes of death were duly certified inWest Ham, Bristol, Leicester, Nottingham, Manchester,Salford, Leeds, Newcastle-on-Tyne, and in 51 other smallertowns ; the largest proportions of uncertified deaths were

registered in Birmingham, Liverpool, Bootle, Bradford, andHull.

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HEALTH OF SCOTCH TOWNS.

The annual rate of mortality in eight of the principalScotch towns, which had been 15 8, 16’ 5, and 16’ 7 per1000 in the three preceding weeks, further rose to 17’8 8per 1000 during the week ending Nov. 5th and was

2’ 9 per 1000 above the mean rate during the same

period in the 76 large English towns. The ratesin the eight Scotch towns ranged from 13’6 inLeith and 14’ 4 in Dundee, to 21’ 1 in Paisley and21 . 7 in Greenock. The 588 deaths in these towns in-cluded 21 which were referred to diarrhcea, 17 towhooping-cough, nine to measles, eight to diphtheria,two to "fever," and one to scarlet fever, but none

to small-pox. In all, 58 deaths resulted from theseprincipal infectious diseases last week, against 75, 70,and 63 in the three preceding weeks. These 58 deathswere equal to an annual rate of 1’8 per 1000, which was0’ 3 per 1000 above the mean rate last week from the samediseases in the 76 large English towns. The fatal cases of