According to this table, the proportion between the admissions into the sick-house from the W. H. and from O. D. (their own homes) has been nearly stationary. If we take the eight terms of the table in the fourth column (differences), and divide them into two sets of four each, we shall find the upper four terms of difference amounting to 112-7, and the lower four terms to 106 7, being not far from equality. The domestic accommodations of the W. H. have not been stationary, yet their enlargement has been inadequate, amounting to some 150 beds only, I think. The site of the W. H. is the property of the Duke of Portland, held on lease terminating some 30 years hence; which circumstance naturally creates an unwillingness to undertake a large outlay for new buildings.

Mortality.

The mortality in the 63 years on the admissions into the physicians' wards amounted to 21 per cent., and that occurring in the surgical wards to 31 per cent. ; the mortality on both to 12 per cent. The mortality of those London hospitals which admit the general run of diseases, and therefore, most nearly correspond in their practical working with the infirmary, which admits all sorts without any other exception than small-pox, is well known to vary little from 10 per cent. The annual loss of life in the wards of the Middlesex, North London, St. George's, Westminster, and London Hospitals, amounts usually to between 9 and 11 per cent. St. Bartholomew's and St. Thomas's, which receive a large per centage of venereal cases, yield a smaller gross mortality; St. Bartholomew's, for example, contains in its foul wards some 150 beds. Now the mortality in those wards must fall short of 1 per cent., since the mortality of the Lock Hospital is usually under that proportion the gross mortality of that noble institution must, consequently, be very materially lightened by the admission of, perhaps, 1000 or 1200 venereals annually; and this is, I think, confirmed by the fact (if I am rightly informed) that the mortality of St. Bartholomew's, if we exclude the foul wards, does not differ in any material degree from those of other hospitals.

But the chief reason of the relatively high mortality of the infirmary is the admission into its wards, indifferently, of all cases of pauper sickness, whatever may be the ages between birth and decrepitude-whatever be the stages in point of advancement, or the durations in months or years, or the nature and ulterior prospects (excepting only small-pox)—provided the applicant has a legal or apparent claim for parochial medical relief. It is not necessary to dwell on the invariably high relative mortality amongst nurslings and persons of extreme age under disease. But with respect to chronic organic diseases, which are de jure and de facto received as readily as any other cases into the infirmary, I shall stop for a moment to observe that 20 to 30 per cent. of our whole mortality is attributable to tubercular disease of the lungs, against the admission of which, as such, the doors of general hospitals are nearly closed according to rule, and, practically speaking, may be said to be held ajar, to be opened for their admission or gently closed in their faces, according to the exigencies or humour of the hour. The admissions of pulmonary tubercular disease mostly in advanced stages, and as such, into the infirmary, were in 1840 = 121 cases, and in 1842 = 129 cases. (I have not, unfortunately, the figures for any other year at hand, but as regards

such cases those were ordinary years.) Of these 94 died each year, leaving only some 30, who were sufficiently improved to be able to return to their occupations, or, as happened in a few instances, who preferred to retire from the infirmary in order to die at home in the bosoms of their families.

An additional circumstance contributing to our superior mortality is the retention of patients, if wishing to stay, until complete recovery, or death. Without assuming anything as between rate-payers and rate-receivers, I may say that, in point of fact, the man that is sick and poor and in possession of parochial rights does usually obtain admission into the infirmary, if he seek it, and that once admitted he usually remains there, if willing, until recovered or sufficiently relieved, or beyond human pain or help. The influence of this indefinite duration of treatment in the infirmary over the per centage of mortality need not be insisted on.

The surgical mortality of the infirmary, it has been stated, is somewhat less than half that of the surgical wards of our general hospitals, viz., between 3 and 4 per cent. instead of some 10 per cent. The reason is twofold:-1. Accidents are, in point of fact, comparatively, rarely received in the infirmary; and, exclusively of accidents, surgical practice always yields a much lighter amount of deaths than medical practice. Now accidents are a peculiarly favoured class of cases in our hospitals, and are provided for with an extra facility of admission into their wards, which is beneficial to all parties, but is not extended to other, often graver though less striking affections. Owing, then, to the high mortality of the class "accidents" amongst surgical complaints, the surgical mortality in our hospitals is comparatively much augmented, while on the contrary the surgical mortality of the Infirmary is relatively much lowered by the scanty admission of such cases. To this if we further add that about one-half of the patients admitted on the surgeons' side consists of persons (mostly children from the W. H. schools) suffering from chronic cutaneous affections, yielding no mortality of their own, viz., porrigo, psora, impetigo, lepra, &c., the account of our surgical mortality will stand thus;-viz. on one-half of the surgeons' cases there is, usually and properly speaking, no mortality; on the other half of their admissions the amount of deaths must be about 6 per cent.

Number of Patients and Duration of Treatment.

There remain but two topics for remark, viz., the average number under treatment and the average stay. From the table so often referred to (No. XI.), it appears that the average number of physicians' patients under treatment during the 6 years was 103.5, and the average of surgeons' patients 114; the number varied little during the period. If we add together the four upper terms (1837, 38, 39, and 40), and in like manner add together the four lower terms (1841, 42, 43, and 44), and divide each by 4, we find the daily averages as follows: for the former 3 years, physicians' 986, surgeons' 1225; for the latter 3 years, physicians' 108 3, surgeons' 105 5. The physicians' daily patients, however, rose in the latter years about 10 per cent., and the surgeons' daily patients declined about 15 per cent. in the same period.

It appears from this table that the average stay (in the house or under treatment) varied little during the 62 years on the physicians' side, and was for the whole 62 years 25 5 days; but that the average stay on the surgeons' has been reduced nearly 30 per cent., viz., from 41·6 days,

=

which is the average of the former four terms (1837, 38, 39, and 40), to 29.3 days, which is the average for the latter four terms (1841, 42, 43, and 44).

Summary.

It appears from the columns of the 11th table, taken in connexion with each other:-1. That during the 63 years which it covers, there passed through the Infirmary every month nearly 220 (219-5) patients; -2. That of these about 140 (after deduction for "casuals") were from the W. H. (workhouse), and 79 from O. D. (their own homes) ;— 3. That 127 of them were admitted under the physicians (exclusively of the puerperals), and about 92 under the surgeons;-4. That 144 of them eventuated in cures, 26 of them in deaths, and the remainder proved incurables, or voluntary retirements, or "irregulars."-5. It appears further, from Table III. (page 296), that of those 2195 about 96 were males and about 122 probably females ;-6. And that about 16 were under 5 years of age, 86 under 15 years of age, and 34 over 60 years of age.-7. It appears also that about 11 were cases of pulmonary tubercular disease, and nearly 8 were discharges from the vesanial wards.*

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 28th, 1844.]

In

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.‡ this view Esquirol is followed by Drs. Copland, Brown, 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 eight 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

*For some years the expences of the sick-house (so far as they can be distinguished from those of the workhouse generally) have amounted to about 5s. weekly per patient, all ages and both sexes included.

+Cælius Aurelianus, "De Morbis Acutis et Chronicis," Amstel. 1709, 4to., pp. 326, 339. "Maladies Mentales,"

Prichard, "On Insanity," 1835, p. 162. Esquirol, 1838, tome i., p. 37; ii., p. 676.

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 those ages when insanity chiefly occurs.

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 the 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 own 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.

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 shown, 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 Haslam, "Observations on Madness," 2nd edition, 1809, p. 245. Webster, in "Medico-Chirurgical Transactions," vol. xxvi., 1843, p. 380.

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 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. 313.)

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.

* The mean annual mortality of England during four years, 1838-41, was 2.31 per cent. for men, and 2.13 per cent. for women.-" Fifth Report of RegistrarGeneral," p. xi.

† Report, 1844, p. 184.