H.—7.

former methods thai any curtailment of the present policy is unthinkable. Our medical officers do not claim, nor should they l>c expected, to have any superhuman prevision in regard to the way in which a discharged patient or probationer may reaci on regaining his liberty; all that we can do is to exercise a reasonable discretion in the light of one's experience and having regard to the niceties of each case. The Causation of Mental Disorder. The heavy burden imposed on the community by the steadily increasing Dumber of patients maintained in mental hospitals and kindred institutions has become a matter of deep public concern not only in New Zealand, but in most other countries where the present financial stringency has necessitated a Strict scrutiny of public expenditure, and in Crcat Britain a scientific Committee has been set up to go into the matters of causation and possible relief. In Table XII! are set forth the various causes which were assigned at the time of admission as being responsible for the mental breakdown, but experience prevents the acceptance of any single factor and bears out Mercier's dictum that heredity and >ticss an- in inverse ratio. When we regard the list of stresses in the table we cannot but admit that most of them are applicable to the majority of people : we must all pass through the critical periods of life, few of us escape during the whole of our lives from physical ill health or infections, whilst "mental stress," including excitements, disappointments, hates, loves, fears, and the whole gamul of emotions, is a common-place of human existence. What. then, is the conditioning factor which causes these experiences, incidental as they are to the majority to become in others the excitants of mental disease in all its varying phases and manifestations ( Can we doubt that the fault lies in an imperfect development of the higher functions of the central nervous system and that this imperfection is due either to an inherent lack of potentiality for complete development, or to a cessation of development, or to an ill-balanced development brought about by causes operating in the early period of life — intra or extra uterine —before the physical basis of mental function has become fully organized. That a sound inheritance is the best insurance against mental disorder is well exemplified by the selective manner in which certain direct toxins operate. As is well known, alcohol and syphilis can cause profound disintegration of the nervous system with resultant insanity, but many excessive drinkers never become insane, and only 2 per cent, approximately of those who contract syphilis become the victims of general paralysis of the insane. The healthy stable brain is capable of resisting tremendous stresses, as is proved by the. statistics dealing with the after-history of cases of serious head injuries sustained during the war. In the largest military hospital set apart in England for the reception of mental cases, out of over 5,000 admissions, only 2 per cent, had head injuries, and it was estimated that the proportion of cases of head injury that subsequently became insane was only about 0-375 per cent. Contrary to popular belief, serious massed stresses do not produce insanity ; in fact, the evidence is all in the other direction. During the war period the proportion of adult female patients admitted was consistently lower than in normal years, although these, the wives and parents of the men on service, were being subjected to a prolonged and unusual mental stress. So also with the Napier and Hastings earthquake. In Napier a few hours after the catastrophe one saw numerous cases which were indistinguishable from the shell-shock of the trenches, but, so far as severe mental disorder is concerned, there were twenty-two fewer cases admitted from the Hawke's Bay area in the year following the earthquake than in the previous twelve months, and in no individual case could the disaster be ascribed as the cause. One would be tempted to expect that the distress arising from the prevailing economic difficulties would be reflected in an increase in our admissions. Actually the total admissions, including voluntary boarders, are ten less than in the previous year, and one can only surmise that the spirit of altruism, which is always at its height at periods of national danger and anxiety, is working as ii did during the war years. The great occasion is one of real stresses which leave no room for petty vanities and morbid imaginings and introspections: there is a call to ait ion. an exaltation of the community spirit and a self-discipline which tends to sanity. Thk Standard of Nursing in Mental Hospitals. The work carried out by the nursing staffs of our institutions is by its very nature precluded from any great share of public recognition, and it is therefore due that I should record from time to time my appreciation of the way in which our nurses and attendants carry out their duties. The care of the mentally afflicted calls for personal qualifications of a very high order, and. in addition to the possession of such primary essentials as suitability of temperament and self-control, our trainees are required to undertake a serious course of study extending over three fears and to qualify by examination before promotion to a responsible position. These examinations, which are on the standard required by the Royal Medico-Psychological Association of Great Britain, \\ ere instituted in 1907, since when over one thousand nurses and attendants have qualified fof registration. In this, as in any other social service, the work is rendered more congenial and easier in proportion to the intellectual as well as the humanitarian interest which is brought to bear on it. and we have endeavoured during recent years to maintain the training on a high level, particularly by the use of general trained nurses as tutor sisters, who supplement, by practical demonstrations and coaching, the lectures given by the medical stall'. One result of this system which appears likely to be of great benefit to the Department is that several of our nurses on completion of their training with us have applied for leave in order to enter

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