Extraordinary deaths of asylum inpatients during the 1914-1918 war.

During the 1914-1918 war there was, from year to year, a mounting number of deaths among the inpatients of some (but not all) English asylums. By the beginning of 1916 the Board of Control, the small government office responsible for offering guidance to managers and monitoring the proper running of asylums in England and Wales, was perturbed and puzzled by the figures.' The most important function of such institutions is to keep their inmates alive. The Board recognized that the rising death rate was in some way connected with the special conditions of war-time, but could not identify what was at fault and recommend correction. Nationally, in the 97 pre-war asylums the annual death rate ran steadily at about 10 per cent to 11 per cent of the resident population. In 1915 it was already 12.1 per cent, in 1916 12.6 per cent, in 1917 17.6 per cent, in 1918 over 20 per cent2 and then fell back to its old level in 1919 and 1920. Individual asylums showed great variation, however. Some, scattered across the country, had much higher death rates than even the national average (Table 1), while others showed little or no rise from the pre-war period and these differences did not appear to be related to the size or age of the asylum, or to overcrowding. In early 1915, so that the Army could use them as military hospitals, 9 asylums were emptied of patients, who were transferred into the remaining 88 institutions, but asylum deaths really increased only afterwards, in the years up to 1918. The lack of male nurses, many of whom had enlisted, was not a convincing underlying cause either, since female and male patients, nursed only by their own sex, died in approximately equal numbers. When the medical causes of death were examined, none of the common illnesses, such as pneumonia, dysentery or enteric fever stood out, with the exception of two: "senility" and tuberculosis. Senility was hardly a diagnosis, meaning simply old age, but tuberculosis was a national enemy, endemic in asylums and among the industrial poor, and a notable cause of death among all classes throughout the nineteenth century. In 1918 it was responsible for about a quarter of all asylum deaths.3