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VII.—PHYSICAL INFIRMITIES.

The physical infirmities with which alone we are concerned are blindness, deafness, and mental derangement. We fear that the returns of persons suffering from these several defects, and especially of those suffering from the two last-mentioned, are in all probability excessively inaccurate.

In the first place there is the difficulty of deciding, in the absence of a fixed standard, what degree of impairment of sight hearing, or mental capacity constitutes blindness, deafness, or insanity.

No person is absolutely blind who can perceive, however faintly, a ray of light, however brilliant; but, for practical purposes, anyone may be considered blind who is unable to direct his path by means of sight; and it is probable that much slighter defects in vision than this will have been held sufficient by many sufferers to justify themselves in stating that they were blind. Similarly with deafness; if the standard of absolute deafness, that is the complete inability to perceive sounds, however loud, be once abandoned; no definite line can be insisted upon, on one side of which is deafness, on the other hearing; and each person Will draw the line differently.

Secondly, there is the very general unwillingness of persons to admit, either as regards themselves or their children, the existence of any serious infirmity, bodily or mental. This cause of error in the re burns scarcely, perhaps, applies to the blind, or, at, any rate, applies to them in a much less degree than to the deaf and the insane; and, Consequently, it is probable that the returns of the former are much less inaccurate than those of these latter. Parents are often not aware of the deafness of their infants; and, even when an impartial observer would have no doubt as to the fact, the parent not unnaturally shuts his eyes to the evidence, hopes on against hope, and refuses to acknowledge as a fact to be entered on a schedule that which he as yet refuses to accept as a certainty even to himself. How largely this vitiates the returns of the deaf-mutes, in. the earlier age-periods, we shall see when we come presently to deal with them. So also with the insane; rightly or wrongly, parents cannot be induced to write on the schedule "idiot" or "insane from, childhood," against the name of their child. In the report on the Census of 1881 we gave very clear proof of this. We obtained from the managers of a large idiot asylum the names and addresses of the families of all those patients who had been admitted into the institution in the year commencing with the date of the Census. We then examined the schedules given in by these families, and found that in exactly half of the oases of such of these indisputable idiots as were from 5 to 15 years of age no mention was made in the schedule of any mental incapacity. Above the age of 15, the returns, so far as we could judge from the very insufficient data, were fairly correct.

1. The Blind.

Diminished amount of blindness

The total number of persons returned as afflicted by blindness was 23,467, being in the proportion of 809 to 1,000,000 of the population, or 1 blind person in every 1,236. The proportion of the blind to the population has fallen at each successive enumeration since 1851, in which year account of those suffering from this infirmity was taken for the first time; but the decrease has been much greater in the last two decennia than in the preceding intercensal periods, as may be seen in the following table:—

YEAR. NUMBER of BLIND. BLIND, per MILLION,
ENUMERATED.
PERSONS
ENUMERATED to
ONE BLIND PERSON.
1851 18,306 1,021 979
1861 19,352 964 1,037
1871 21,590 951 1,052
1881 22,832 879 1,138
1891 23,467 809 1,236

This continuous decrease can scarcely he attributable to other causes than the greater precautions taken to prevent the ravages of purulent ophthalmia, the improvement in the surgical treatment of affections of the eyes, and the diminished prevalence of such diseases as small-pox, to which a not- inconsiderable amount of blindness was formerly due. But that even now, in spite of these improvements, a considerable proportion of blindness is due either to purulent ophthalmia or other diseases that specially affect children may be inferred from the fact, that, of the 23,467 blind persons of all ages, 4,005 were stated to have been blind from childhood, and that) among; these 4,005 were 1,188 children still under 10 years of age.

Blindness in relation to sex

Of the blind, 12,281 were of the male and 11,186 of the female sex, being in the proportion of 874 males and 748 females per million living of each sex. Thus 1 in every 1,144 males was blind, but only 1 in every 1,336 females. This greater liability of males than of ft/males to blindness, which has been noted in each previous Census, and is, moreover, not peculiar to England but a phenomenon presented by most, though not, all, other countries, is doubtlessly in part attributable to the differences between the two sexes in regard to their occupations and their exposure to accidents; but some of it- must apparently also be due to the greater liability of male children to almost all kinds of diseases; for, if the comparison be limited to those whose blindness dates from childhood, and therefore came on before differences of occupation or of liability to accidents can have come into operation, the sexual disproportion is quite as great as among those whose blindness came on at a later date. Among males 150 per million were returned as blind from childhood, which may be taken as from some time or other in the first 10 years of life, while among females the proportion was only 121 per million.

That to be blind from childhood is a most serious impediment, barring the entrance into almost all occupations, is, of course, obvious; but to what extent, if any, does it operate in shortening the term of life? If it does so in any notable degree, it is plain that the proportion of those who suffer from it, to the total population of the same age, should become smaller and smaller with the successive age-periods, and such does in fact appear to be in some degree the case; for if we begin at the age of 15-20, we find that 151 per million living at that age have been blind from youth, while in the next period, 20-25 years, the proportion falls to 140, then at 25-35 to 126, and then becomes successively, decenniuin after decennium, 118, 113, 124, 106, 106, and finally in the 85 and upwards period, where, however, the figures are much too small for safe estimation of rates, rises to 114. Disregarding trifling irregularities, it is plain that the proportion declines continuously, from which it must be inferred, supposing the returns to be trustworthy, that those who are blind from youth are, on the average, less healthy than those who are not so afflicted.

While the proportion of the "blind from childhood" to the total number of persons living thus continuously decreases in the successive age-periods, the proportion of those who have become blind at any age as continuously increases, as the following table shows, which gives for the three last censuses and for each sex the proportion of blind at successive age-periods per million living of corresponding age and sex.

BLIND per MILLION of corresponding ages.

Age-period. 1891. 1881. 1871.
PERSONS. Males. Females. PERSONS. Males. Females. PERSONS. Males. Females.
All Ages 809 874 748 879 953 809 951 1,029 876
1— 155 168 142 166 172 161 185 189 180
5— 238 255 220 288 312 263 306 345 267
15— 370 419 322 388 449 328 404 451 358
20— 385 457 321 422 491 359 451 513 390
25— 585 721 460 641 800 494 680 871 506
45— 1,555 1,864 1,278 1,625 1,947 1,336 1,720 2,002 1,459
65— 4,133 4,343 3,962 } 6,915 6,897 6,929{ 5,000 5,123 4,893
75— 9,849 9,693 9,967 11,655 11,785 11,551
85 and upwards 19,073 17,940 19,742 24,133 21,450 25,810

Occupations of the blind

The occupations open to those who have been blind from childhood though more varied than might be supposed, are not very numerous; and the great majority of those thus afflicted, and especially of those who are of the female sex are returned as unemployed. The occupations of the remainder are given in detail elsewhere (see Vol. III p. lx,), but may be summarised as follows:—

  Males. Females.
Basket maker, chair caner 203 58
Musician, music teacher 184 26
Pianoforte tuner 43
Musical instrument dealer 2
Brush maker 45 20
Mat maker 41
Knitter 65
Street seller 21 7
Newsagent, newspaper vendor 13
Teacher, schoolmaster 11 12
Other occupations 139 44
Unoccupied 1,492 1,579
     
Total 2,194 1,811

2. The Deaf.

Deaf and dumb mutes

In previous Census Reports the number of persons returned as Deaf and Dumb has been given, but no account has been taken of those returned simply as Deaf independently of mutism.

It has, however, been strongly urged upon us by those who are specially interested in the statistics of this affliction, that deaf-mutism only differs from deafness without loss of speech in that its deafness dates from an earlier period of life, being either congenital or having occurred before the power of speech has been fully acquired or established; and that what is wanted for their purposes is the total number of deaf persons of all kinds, with a distinction of those whose deafness dates from childhood.

While we admit the logical force of this contention, and are desirous as far as possible to meet the wishes of the experts in this matter, we cannot but think that the condition of deaf-mutism is practically so different from that of simple deafness, that it is advisable to keep the figures relating to it apart; and the more so, inasmuch as there is less difficulty in determining whether a person is a deaf-mute than whether his partial loss of hearing is such as to justify his being returned as deaf; so that the returns of the deaf and dumb are likely to be much more accurate than those of the deaf only.

We have, therefore, divided the deaf into three groups, (1) the deaf and dumb, (2) those stated to have been deaf, without statement of mutism, from childhood, or from before the end of their tenth year of life, and (3) those persons, above ten years of age, who have been simply returned as deaf.

Deafness in relation to sex and age

The total number of persons returned as deaf, with or without loss of speech, was 29,280, of whom 13,947 were of the male and 15,333 of the female sex, being 1 in every 1,008 males, and 1 in every 975 females. There is, however, a striking contrast in this respect between the deaf-mutes and the deaf with speech. Among the deaf-mutes, as is the general though not quite universal rule among those who suffer from various forms of congenital malformation, the males far outnumber the females, and this is the case not only in England and Wales but generally in all countries, for which we have the figures. But among those who are returned simply as deaf, without loss of speech, the females largely outnumber the other sex, there being 8,848 of the former and only 6,240 of the latter, or 592 females and 444 males per million living of each sex. This difference is partly explicable by the fact that deafness becomes more and more common as age advances, and that owing to the greater average length of female life there are many more old women than old men. This, however, is by no means a sufficient explanation. For the proportion of deaf to equal numbers living is higher for females than for males, not only for all ages in the aggregate, but for each successive age-period after childhood is past, as is shown, in Columns 3 and 4 of the following table.

Per Million living of corresponding Sex at each Age-Period.

Ages. DEAF AND DUMB. DEAF ONLY. DEAF including
DEAF AND DUMB.
Male. Female. Male. Female. Male. Female.
Columns. 1. 2. 3. 4. 5. 6.
0— 131 106 15 19 146 125
5— 619 461 64 61 683 522
10— 749 549 120 149 869 698
15— 599 514 232 258 831 772
20— 584 468 263 328 847 796
25— 563 447 322 408 885 855
35— 618 499 497 606 1,115 1,105
45— 585 456 805 996 1,390 1,452
55— 570 448 1,317 1,764 1,887 2,212
65— 530 415 2,289 2,829 2,819 3,244
75— 433 439 4,448 4,955 4,881 5,394
85 and upwards 493 364 8,260 10,543 8,753 10,907
             
All Ages 548 434 444 592 992 1,026

The differences in the figures for the two sexes are both too constant throughout the successive age-periods, and too great, to be accounted for by any hypothetical errors of, statement; for, uncertain as statements of deafness may be, the uncertainty, so far as can be seen, would equally affect both sexes; and yet the results of this tabulation are in direct contradiction of the opinions of aural experts, who one and all assert, without however giving distinct statistics, that acquired deafness is more common in the male than in the female sex.

Not improbably the apparent contradiction may be explained by considering that aural surgeons naturally base their conclusions upon the cases of deafness that come before them, and that men will apply for advice for much slighter degrees of deafness than will bring women to the consulting room; inasmuch as slight deafness interferes as a rule much more seriously with the occupations of men than of women.

Deaf mutism in relation to sex and age

If we now turn to Columns 1 and 2 in the same table, in which are given the numbers of deaf-mutes per million living at successive ages for each sex, we find a very different state of things. Here, as before stated, the male rate is much higher than the female rate at each and all ages. Moreover, while the proportion of the deaf without muteness to the population goes on increasing with the advance of age, the opposite is the case with the deaf-mutes, putting aside for the present the children under ten, concerning whom, the returns made by their parents, still hoping that the condition is only temporary, are, as before explained, utterly untrustworthy. Putting these children aside, the proportion of deaf-mutes in each sex to the total population of the same age and sex decreases gradually, though with some irregularity, with the advance of age; this gradual decrease being a token that deaf-mutes, as might be expected, die off more rapidly than their fellows of the same age.

The decline, it is true, is not quite regular; and especially it is noticeable that the proportion becomes higher, and this for each sex, in the 35-45 years period, and remains high in the next decennial period. This appears to be only explicable on the assumption that there was some cause or other in operation 35 to 55 years before the Census of 1891, leading to a larger proportion of deaf-mutism among infants or young children than has since been the case. For had there been no such larger proportion, there would be no way of explaining the increased rates among persons of from 35 to 55 years of age, without supposing that deaf-mutes were more likely to survive than those not so afflicted, which is incredible.

Similar considerations render it impossible to accept as accurate the deaf-mute rates for boys and girls under ten years of age, which, as given in the table, are far lower than for those between ten and fifteen. As already explained, this is due to the unwillingness of parents to recognise the existence of the aural defect in their children. The rates at 0-5 and 5-10 years can hardly be less than the rates among those of from 10 to 15, and probably are considerably higher. If, however, we assume that they are merely as high, namely, 749 and 549 per million living of the respective sexes, we can Correct our figures sufficiently to give a much more nearly approximate statement of the total number of deaf-mutes than is given by the uncorrected returns. Applying, then, this method of correction, we find that the number of deaf-mutes under ten would be 2,592 for boys and 1,915 for girls, instead of 1,280 and 975 as returned; and this addition would raise the total numbers of deaf-mutes at all ages to 16,444, of whom 9,019 would be of the male and 7,425 of the female sex.

Occupations of deaf mutes

There are, of course, some occupations from which deaf-mutes are necessarily debarred by their infirmity. These, however, are but few, and most occupations can be persued by them, though doubtlessly with some disadvantage as compared with those competitors who can hear and speak. The female deaf-mutes, at any rate, find apparently no great difficulty in getting employment; for 32.4 per cent. Of those of them who were 10 years of age and upwards were returned as having some special occupation a proportion which does not fall far short of that of the general female population of the corresponding ages, of whom 35.0 per cent were returned as specially occupied. The male deaf-mutes, on the other hand, seem to be at a not inconsiderable disadvantage, for only 61.2 per cent of those of them who had finished their tenth year were engaged in definite occupations, against 83.9 per cent in the corresponding general male population.

The occupations for which deaf-mutes show preference, or which they find most suitable to their condition, are naturally such as can be followed by individuals independently and do not require frequent communication with fellow workers. Agricultural or general labour, shoemaking, and tailoring are the chief occupations of the men; while dressmaking and sewing, domestic service and charing, washing, and, in Lancashire, work in cotton mills form the main occupations of the women. The following is a brief abstract of the chief occupations of these deaf-mutes:—

MALES. FEMALES.
Artists 59 Domestic servants 321
Agricultural and general labourers 713 Charwomen 88
Gardeners 60 Washerwomen 138
Printers and lithographers 114 Textile hands 240
Carpenters 147 Tailoresses 106
Painters, glaziers, and plumbers 98 Milliners 528
Saddlers and harness makers 62 Seamstresses 77
Textile hands 176    
Tailors 391    
Shoemakers 518    
Ironworkers and blacksmiths 125    
Cabinet makers 131    
Miners 79    
All other occupations 1,260 All other occupations 286
       
    Total employed 3,933     Total employed 1,784
    No stated occupation (adults) 2,494     No stated occupation (adults) 3,726
    Children under 10 1,280     Children under 10 975
       
  7,707   6,485

3. The Insane.

Total number of insane

The total number of persons returned as suffering from insanity was 97,383, of whom 7,722 were either still under 10 years of age or were returned as having been mentally deranged from childhood. An examination, however, of the age-distribution of these 7,722 persons shows that the returns must be most inaccurate. This is evident not only from the small number returned as being 0-5 years of age, which, as already explained, is due to the disinclination of parents to recognise the physical defects of their children, but by there being a very much larger number both in the 15-20 and the 20-25 age-periods than in the earlier 10-15 period, which is practically quite impossible, unless the mentally deranged have far higher vitality than the sane. We shall ignore, therefore, in our comments the distinction as to the time when the malady commenced, and shall deal with the insane of all kinds as one group.

The total number, then, of the insane was 97,383, being in the proportion of 3,358 per million persons living, or one person of unsound mind to every 298 of the population.

Comparing these figures with those of the two preceding censuses, we have following results:—

DATE. TOTAL INSANE. INSANE
per MILLION
POPULATION.
PERSONS to ONE
INSANE.
1871 69,019 3,034 329
1881 84,503 3,253 307
1891 97,383 3,358 298

Increase in proportion of lunacy

If then, the returns are trustworthy, the proportion of insane persons in the population has been increasing progressively since 1871, which is as far hack as the available data will carry us, the Census of that year having been the first in which account was taken of the total number of the insane. Even at that date, however, there was a prevalent belief, based on the returns of the numbers of inmates of asylums, that lunacy was becoming more common. In the Census Report of that year an optimistic view was taken of the apparent increase, and it was explained as being probably due in great part to greater use of asylums for the reception of the insane, which would cause a fuller and more accurate return of those afflicted, and to the diminished rate of mortality among those thus afflicted; and it was given as the result of examination of the facts, that

"upon the whole, notwithstanding an impression to the contrary, we think that an increase of persons afflicted with mental disease cannot from the facts before us be assumed to have taken place among the population of England and Wales"

Twenty years have passed since that opinion was expressed, and though the causes which led to an increased use of asylums, which was very properly pointed out as a possible explanation of the apparent growth of insanity, are now of comparatively ancient date, the increase still goes on, and it has become difficult to attribute it any longer to what was then deemed an adequate cause. There remains, however, the question whether the apparent increase may not be accounted for by another contributory cause, which has also been mentioned above as having been suggested in the Census Report of 1871, namely the diminished mortality among the insane. The apparent increase in the proportion of the insane has not been very great, rising from 3,034 to 3,253 in 1871-80, and then from 3,253 to 3,358 per million in the next ten years, and it would take but a very small diminution in the annual lunatic mortality to produce, such an increase as this, by causing accumulation of those who with the higher death-rate would have disappeared from the account. Besides the death-rate there is, moreover, another factor to be taken into consideration, namely, the ratio of recoveries. If this increases, the number of the insane will manifestly fall off, while the contrary will be the result if the ratio undergoes diminution. The death-rate and the recovery-rate taken together may be conveniently called the discharge-rate, and the question to be answered is whether this discharge-rate has altered, and whether the alteration, if it has occurred, has been such in direction and amount as to account for the increase in the actual number of living lunatics.

Now it appears from the successive Reports of the Lunacy Commissioners that the discharge-rate by death or recovery of all lunatics and idiots concerning whom they had information averaged 19.00 per cent. annually in 1871-80 while in 1881-90 it averaged only 17.83. The rate, therefore, had altered, and the alteration was in the direction required to account for the increase on the hypothesis of simple accumulation. It remains, therefore, only to consider whether the amount of change in the discharge rate was sufficient to account for the increase in living lunatics, and a simple arithmetical calculation shows that it was so. For it will be found on calculation that, with an annual "discharge-rate" of 19.00 per cent. of lunatics living at the beginning of the year, it would require an addition each year of 689 fresh cases per million population, spread evenly over the year, to raise the ratio of living lunatics from 3,034 per million, as it was in 1871, to 3,253 per million, as it was in 1881; but that to raise the ratio from this level of 3,253 to 3,358, ten years later, as it stood in 1891, would require, with a discharge rate of 17.83 per cent., an annual addition of only 661 new cases per million population.The returns, then, if correct, or if equally incorrect in the two successive decennia, so far from showing that lunacy, as measured by the proportion of new cases annually occurring in the population, is on the increase, show the contrary, and lead to the conclusion that there has been a slight decline. for the average annual new cases in 1871-81 must have been 689 per million persons living, or one fresh case of insanity yearly to 1,451 persons; while in 1881-91 the proportion must have been only 661, or one fresh case of insanity each year to 1,513 persons.

The only assumption in this calculation is that the percentage of deaths and cures together, or what we have termed the discharge-rate, has been the same among all lunatics as it was among those of them that were known to the Lunacy Commissioners, and, as these latter form 90 per cent. Of the whole, such an assumption is quite justifiable.

Insanity in relation to sex

Similar considerations have been taken into account when we attempt to determine from the returns which sex is the more liable to mental derangement. Of the 97,383 persons returned as insane, 45,392 were males and 51,991 were females, being in the proportion of 3,230 in the former and 3,478 in the latter sex, in each case per million living.

Thus in one sense it is indisputably true that there is more insanity among females than among males, namely in the sense that out of equal numbers living of each sex and at all ages there are more insane females living than insane males. This, however, as will be apparent from what has already been said, by no means necessarily implies that women are more liable to this affliction than men; the difference may simply be due to the discharge-rate of males being higher than the discharge rate of females. For it appears from the Lunacy Commissioners' Reports that the proportion of male lunatics who were discharged on an average in the year by death or recovery during 1881-90 was 18.91 per cent. of those living at the commencement of the year, while the percentage of women similarly discharged was only 16.91.

Assuming, as before, that these discharge-rates were true for all lunatics in the country, and not only for those nine-tenths of them that were on the registers of the Lunacy Commissioners, we obtain by arithmetical computation the following Results, that the rise of the male lunatic rate from 3,148 per million living, as it was in 1881, to 3,230 as it stood in 1891, implies an average annual addition of 677 new male cases per million living; while the annual quota required to raise the female lunatic-rate from 3,353 in 1881 to 3,478 in 1891 was no more than 646 per million living; or, in other words, that for equal numbers living the occurrence of lunacy is nearly 5 per cent more common in the male than in the female sex. As the returns for the preceding decennium when treated by the same method give practically the same result, we may accept this conclusion as fairly established, or at least as having a high degree of probability.

The greater number, then, of female than of male lunatics is simply due to accumulation of the former, who either die off or are cured less rapidly than are the latter, and this conclusion squares with the figures in the following table, from which it appears that it is only in the later age-periods that the proportion of female insane exceeds that of the male insane, the opposite being the case at each age up to 35 years. The male excess in the earlier age periods is doubtlessly in great part due to the much greater frequency of congenital idiocy, as of most other congenital defects, among boys than among girls.

Insanity in relation to age


NUMBER of INSANE, MALE and FEMALE, at succesive AGE-PERIODS,
per MILLION living of corresponding AGES and SEX, 1891

Ages. Males. Females.
All Ages 3,230 3,478
     
0— 88 82
5— 614 444
10— 1106 806
15— 1926 1385
20— 2728 2089
25— 4060 3761
35— 5719 6022
45— 6870 8053
55— 7530 9060
65— 7669 9454
75— 6792 9786
85 and over 6781 9635

Of the 97,383 persons of deranged intellect, 80,068, or 82 per cent., were inmates of public or private asylums or other institutions, while the remaining 17,315, or 18 per cent., were under domestic supervision. As the following table shows, a somewhat larger proportion of the female than of the male lunatics were in institutions. This is readily understood, when it is remembered that among the males there is a much higher proportion of children, owing to the greater frequency of congenital idiocy in that sex, and that a great many of such children would be kept at home by their parents; and that, on the other hand, there are very many more lunatics of advanced age among the females, and that the aged are the most likely to be without relatives to look after them, and, consequently, to have no other refuge than the asylum.

PUBLIC LUNATIC
ASYLUMS.
WORKHOUSES,
WORKHOUSE
INFIRMARIES.
PRIVATE LUNATIC
ASYLUMS
(Licensed Houses).
OTHERS. ALL.
Persons 59,098 16,375 4,595 17,315 97,383
           
Males 27,138 7,383 2,004 8,867 45,392
Females 31,960 8,992 2,591 8,448 51,991

Per 1,000
Persons 607 168 47 178 1,000
           
Males 598 163 44 195 1,000
Females 615 173 50 162 1,000

In explanation of the foregoing Table it should be stated that:—

PUBLIC LUNATIC ASYLUMS include County and Borough Asylums; State Asylums; Lunatic Hospitals registered under Lunacy Acts; Idiot Asylums registered under the "Idiots Act, 1886"; and the Criminal Lunatic Asylum at Broadmoor.

WORKHOUSES AND WORKHOUSE INFIRMARIES include also the metropolitan Asylums for Idiots and imbeciles.

PRIVATE LUNATIC ASYLUMS include all the Metropolitan and Provincial Licensed Houses, and a few houses containing several persons returned as Mentally Deranged which do not appear to be Licensed Houses; and that under the heading "OTHERS" are returned all persons described as mentally deranged who are not included under the other headings.

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