II. On the Relative Liability of the Two Sexes to Insanity. By JOHN THURNAM, M.D. Read before the Statistical Section of the British Association at York, September 28. 1844, and originally published in the Journal of the Statistical Society of London, vol. vii., p. 310.

The opinion which appears to have recently obtained, that insanity is more prevalent amongst women than amongst men, has, I believe, originated in an erroneous method of statistical analysis. Dr Esquirol, who appears to have inclined to this view, was at great pains in collecting information as to the proportion of existing cases of insanity in the two sexes in nearly every country of the civilized world; and, having found that, taking the average of different countries, the proportions were those of 37 males to 38 females, he concluded that his inquiry refuted the opinion which has prevailed since the time of Cælius Aurelianus,* that women are a little less subject to insanity than men.† In this view, Esquirol is followed by Drs Copland, Browne, and Millingen; and indeed by every recent writer on insanity. It is, however, well known that, in all European countries, the proportion of adult females in the general population exceeds that of males. In England and Wales, according to the census of 1821, there was an excess, at all ages above 15 or 20 years, of about 4 per cent.; and according to the more accurate census of 1841, an excess of 4 per cent. at all ages, and of about 8 per cent. at all ages above 15 or 20 years. Of this general law, Esquirol was aware; but he does not appear to have known that, from 20 to 50 years of age, when, in this country at least, insanity chiefly occurs for the first time, there is a still greater excess of females; an excess which is higher from 20 to 30 years of age than it is subsequently; it being 12 per cent. from 20 to 30, 6 per cent. from 30 to 40, and 4 per cent. from 40 to 50 years of age. Thus, assuming only a like liability of the two sexes to insanity, we should expect to find a much greater number of cases amongst women, and one corresponding to this excess of the same sex in the general population, at thosc ages when insanity chiefly

occurs.

* Cælius Aurelianus, De Morbis Acutis et Chronicis, Amstel. 1709, 4to, pp. 326, 339.

† Prichard on Insanity, 1835, p. 162. Esquirol, Maladies Mentales, 1838, tome i., p. 37; ii., p. 676.

The only two institutions, however, that I am acquainted with in this country in which there has been any material excess of females admitted during extended periods, are thé hospitals of Bethlem and St Luke; and in these there has been, at different and extended periods, an excess of women admitted, amounting to 20, 30, and even 45 per cent. This, however, may depend on local circumstances peculiar to the metropolis; and, consequently, does not in any degree establish Dr Haslam's opinion, that, " in our climate, women are more frequently afflicted with insanity than men;" a statement which has been recently repeated by Dr Webster in his remarks on the Statistics of Bethlem Hospital.* That there may be something peculiar in the circumstances of the metropolis in connection with the prevalence of insanity in the two sexes, at least as regards the poorer and more dependent classes of the community, is a view which is confirmed by there having been a slight excess of females admitted both at Hanwell and in the licensed metropolitan asylums for paupers; though it is to be observed that, during the last five years, the excess at Hanwell, never very great, has been gradually diminishing, and up to 1843 only amounted to 2 per cent. According to the census of 1841, there appears to be a larger proportion of females living in the metropolis from 20 to 50 years of age, as compared with the kingdom generally; but whether the difference be large. enough to account for the greater number of women admitted into the metropolitan asylums and hospitals is, perhaps, doubtful. The excess per cent., at these ages, of women over men, appears to be in the proportion of 18 in the metropolis. to 8 in the country; that is to say, there were, in 1841, living in England and Wales 100 men to 108 women, and in the metropolis 100 men to 118 women, at from 20 to 50 years of age. At all ages, there appears to be a greater proportion of females in the metropolis than in England and Wales; there having been an excess of 13 per cent. at all ages, and of 19 per cent. at all ages above 20. Whatever may be the cause of the difference in the relative proportions of the two sexes admitted into metropolitan asylums, it does not appear to extend to the middle and upper classes of society; for in the licensed metropolitan asylums for private patients (183340), there has been an excess on the side of males admitted, amounting to 38 per cent.

* Haslam, Observations on Madness, 2d edition, 1809, p. 245. Webster, in Medico-Chirurgical Transactions, vol. xxvi., 1843, p. 380. [See Phren. Jour., vol. xvii., p. 204.]

But there is another fallacy in Esquirol's method of investigating this subject, in consequence of his having compared with each other the existing, instead of the occurring, cases of insanity in the two sexes. Were the progress of insanity the same in men as in women, and our object simply that of determining the relative liability of the two sexes to insanity, the comparison of the cases existing at one time, would serve as well as that of the numbers occurring during any given period. This, however, is not the case; for, as I have elsewhere shewn, the mortality of insane men, on an average, exceeds that of insane women in the public asylums of this kingdom by 50 per cent. Thus we find that the excess in the mortality of males above females is, at the Retreat, at the rate of 37 per cent., in the metropolitan licensed asylums of 63 per cent., at Bethlem of 71 per cent., at Hanwell of 80 per cent., and at the York Asylum of 93 per cent.; the mortality in males being nearly double what it is in females. As the mortality of males in the general population is not more than 7 or 8 per cent. higher than that of females,* it will be evident that, out of equal numbers attacked, the existing cases of insanity in women will accumulate much faster than those in men; and that they will necessarily be much more numerous, as compared with the occurring cases, than will the existing cases in the latter sex. According to the "Report of the Metropolitan Commissioners in Lunacy," there were, in asylums of all descriptions in England and Wales, on the 1st of January 1844

-being an excess on the side of females, of existing cases of insanity, of 4 per cent. in all classes, and of nearly 12 per cent. in paupers.

It may, perhaps, be objected to the results of any inquiry into the liability of the two sexes to insanity which is founded on the proportions of males and females admitted into. public and private asylums, that, from various causes, women are more likely to be detained at home than men. As regards the middle and higher classes, I believe this to be the case; but, as respects the pauper insane, I do not think that such

* The mean annual mortality of England during four years, 1833-41, was 2.31 per cent. for men, and 2.13 per cent. for women.-Fifth Report of Registrar-General, p. xi.

+ Report, 1844, p. 184.

a tendency can affect the results in any material degree. Women are, indeed, sooner rendered entirely dependent, as a consequence of mental disorder, than men; and I should conclude that any greater indulgence to, and tolerance of, the eccentricities of the sex, when the subjects of insanity, will be more than compensated by the frequently greater difficulty of effecting the removal to an asylum of the insane father, husband, or brother.

In order that the comparison of the occurring cases be a strictly accurate one, the proportions of the two sexes, at the several ages, attacked with insanity for the first time, should be compared with the proportions in which the two sexes, at the same ages, exist in the community in which such cases occur. The nearest approximation to this method which we have the means of employing is, by assuming that the proportions of men and women admitted into public institutions during extensive periods represent, as on the whole they probably do represent, the cases which occur for the first time. The following table is calculated on this principle. (See p. 127.)

On an examination of this table, we ascertain that, in 24 of the 32 asylums which it comprises, there has been a decided excess of men in the numbers admitted. In many British asylums, the excess amounts to 25, 30, and even 40 per cent.; and in the whole number of 32 asylums, there is an average excess on the side of the male sex of 13.7 per cent. In the 9 English county asylums, contained in the table, the excess amounts to 12 per cent. Dorset is the only county asylum in which the proportion of women admitted has materially exceeded that of men.

Whether in this asylum an unusually large provision has been made for females, and, consequently, a larger proportion of applications for the admission of men have been rejected, or whether in the county of Dorset any peculiar causes are actually in operation, which are capable of explaining such an exception to a general law, I am at present unable to determine.

Having thus shewn that, in the principal hospitals for the insane in these kingdoms, the proportion of men admitted is nearly always higher, and in many cases much higher, than that of women; and as we know that the proportion of men in the general population, particularly at those ages when insanity most usually occurs, is decidedly less than that of women, we can have no grounds for doubting that men are actually more liable to disorders of the mind than women.

Name of Asylum and Period.

Table shewing the Numbers and Proportion of each Sex, out of 71,800 Cases, admitted into various Asylums.

33. Bethlem, all cases (46 years, 1748-94) 4,042 4,832 45.5 34. St Luke's, curables (82 yrs., 1752-1834) 6,037 8,786 40.7

54.5
59.3

For other Metropolitan Asylums, see also 6, 27, 29, and 32.

Esquirol, Des Maladies Mentales, tome ii., pp. 663 and 668.
Haslam, Observations on Madness, 2d edition, 1809, p. 245.

Webster, Medico-Chirurgical Transactions, vol. xxvi., 1843, p. 381.