ing one-eighth of the aggregate, furnishes one-third of the insane population, is misleading. Nine-tenths of all insanity occurs in adults, less than one per cent. occurs in persons under 15; and the foreign-born population, as is shown above, makes up over one-fourth of our adult population. The real facts are, then, that about one-fifth of the persons of the age susceptible to insanity are foreign-born, and these furnish a little over onefourth of the insane, or a little over their just proportion.

The ratio of foreign-born insane to the foreign-born adults is .047% and the ratio of native insane to native adult whites is .041%, and to total native adults .036%.

A concrete illustration of this line of reasoning is shown in Massachusetts, in a study of the nativity of 7963 cases of insanity admitted to State asylums from 1871 to 1880, inclusive (Folsom, Pepper's System of Medicine, Vol. V., p. 117).

This shows that the percentage of foreign-born population in the total population above the age of 15 is 37%, while the percentage of foreign-born insane in State asylums is 43%, a difference of 6% against the foreign-born.

When it is remembered that these figures are for State asylums and that in the private asylums and in families the natives have a larger preponderance, the figures become still more significant. The following table gives statistics for nearly all the northern States (compiled from U. S. Census, 1880).

This table, of which the statistics are trustworthy, shows that the immigrant population contributes only a little above its fair share in many Eastern and Middle States, and a somewhat larger excess in Western States. In some States (Connecticut, Maryland), the proportion of foreign-born is even below the number that would be expected from the adult population.

The table also shows that States having a large proportion of immigrants do not necessarily have a large proportion of insane. For example, Maine has ten per cent. foreign population, and a ratio of sound to unsound minds of 1-226. Minnesota has a per cent. of 52 of foreign-born, and a ratio of 1-416, or five times as many foreign-born and one-half as many insane proportionately.

There can, of course, be no doubt that immigrants ão increase the amount of insanity somewhat, because they, as a class, suffer from poverty, exposure, venereal disease, and the effects of alcoholic indulgence, or, in other words, from the exciting causes of insanity; and because certain races of immigrants, probably,

to this country unequal to the struggle for existence in America. For there is no doubt a racial element, as I shall show later, in the production of the excess of insanity and nervous disdisease in America. Insanity is the product, almost equally, of environment and hereditary tendency. Some races, owing to inferiority of nervous constitutions, are especially susceptible to the influence of environment, and propagate and accumulate morbid tendencies.

Nations and races in their development also appear like individuals to have physiological crises of birth, adolescence, climacteric and senility when decay is present. All races develop mental disease in excess during these times. America is in its adolescent crisis, and in its social life there are more exciting causes of insanity than among the maturer nations of Europe.

On the other hand, France seems to be in a climacteric period, for she develops an extraordinary number and variety of the degenerative, nervous disorders. It has seemed to me that England is nearing this period. The Irish have an abnormally excitable, nervous system and a phenomenal amount of insanity. Certain portions of the Hebrew race appear to be in the degenerative stage of racial life.

I am sure, however, that the majority of our foreign-born population brings with it no psychopathic tendencies.

The exact influence of different immigrant people in modifying the forms (not the total amount) of insanity is difficult to estimate exactly. According to Mr. Wines's statistics (U. S. Census, 1880), the foreign-born increase the proportion of mania, and, perhaps, of general paresis and alcoholic insanity in our asylums. In particular, according to Spitzka, the Anglo-Saxon race develops general paresis, the Germans melancholia, the Jews hebephrenia, and epileptic insanity.

II. AS TO THE QUESTION OF IMMIGRATION AND NERVOUS DISEASES. The vital statistics of the last United States Census give us the mortality-rate from nervous diseases in the different States, in the principal cities and in persons of Irish and German parentage. The only way in which we can arrive at conclusions regarding the foreign-born is by comparing the death-rates in cities where the percentage of foreign-born is great with that of cities, and in the country where it is small; also by comparing the rates in different States; as, for example, in certain New England States, where the percentage of foreign-born is only ten with that in other Northern States, where it is over fifty. In order to exclude the error due to the fact that there is smaller proportion of foreignborn minors, and that a large part of nervous mortality occurs in children, we can compare the mortality ratios of certain special nervous diseases which cause death chiefly among adults.1

Finally, in a few cities of which New York is an example. We have the mortality-rate from different diseases and the nativity given also.

A few words may be said first with regard to the general prevalence of nervous diseases.

In England the percentage of mortality from these diseases, on the total death-rate, is 13.4; in the United States, 15.4. So far as I have been able to collect the facts, they show that the percentage has been gradually increasing in both countries in the past thirty years, and that this country has an unusually high as well as progressively increasing death-rate from these disorders. This rate is a poor index, however, of the actual amount of nervous diseases which affects native Americans, since a great proportion of this class of troubles are functional in character, and are not fatal.

1 Four-fifths of deaths from epilepsy and 99.7 per cent of deaths from apoplexy and paralysis occur in adults. 60 per cent. of deaths from nervous diseases occur in persons under ten years of age.

Since over half of the nervous mortality is from convulsions and meningitis occurring in children, it is only a study of the death-rates of special diseases such as occur in adults, that will furnish much direct help, in the matter under consideration.

The following table, compiled from the U. S. Census, shows the percentage of foreign-born population, the percentage of deaths from nervous diseases in the total deaths, and the percentage of deaths from apoplexy and epilepsy in the total deaths from nervous diseases.

These figures have no great claim to accuracy and can only be looked upon as suggestive. So far as they go, they appear to show that the death-rates from all nervous diseases, and from special diseases like apoplexy and epilepsy, is not much greater, on the whole, in States with a large foreign population than elsewhere.

The census statistics show a larger proportion of deaths from nervous disease in the country than in large cities, a fact due to the larger number of adults proportionately in cities.

The only functional nervous disease which causes death very often is epilepsy. Mr. Wines's tables show that epileptic insanity is common in native Americans, they furnishing five-sixths of the

mortality from this disease. (See later.) The reports of the New York City Board of Health show that the mortality from this disease and chorea is rather less proportion among natives than among the foreign born of this city. The mortality from serious organic diseases of the nervous centres, such as inflammations, degenerations, and apoplexies has been steadily greater in this city among the foreign-born.

The only conclusions to be reached regarding this part of our subject are (1) that evidence exists showing a greater proportional mortality in large cities from nervous diseases of adults among foreign-born than native adults; (2) in the whole population, the death-rate from all nervous diseases is much greater among natives, because of the excess of such deaths among children; (3) the data on which to draw further conclusions are, as yet, meagre; but, so far as they go, they indicate that outside of large cities, the death-rate from the nervous diseases of adults among immigrants is proportionately low.

III. IMMIGRATION AND THE SICK-RATES OF NERVOUS DISEASES.

In studying this part of my subject, I have tried first to determine the ratio of natives to foreign-born among those who seek medical help in our northern hospitals and dispensaries.

The following table shows the relative proportion of native and foreign-born patients among 25,169 patients in general hospitals in Cincinnati, Boston, and New York.

This gives a ratio of native to foreign-born of about five to

seven.