ft »3*>>0 » » 3* > o ■■> T> * > ^ > > Jk > X} » )>^» ^ }> 2> > >» 2> '■', »> » >» >>>> "> 2 H -„ - ^ » . "> >i ^ >> j i > ov> > > t>") > ^> >» ?) ~»'\>>.i> ;> > >» -^ vi ^ » > ;> :>i| ^ »> 3> . J> J JOS* > ^> < f JP -1 0) V >» ■> i s .v** -.« » > >» 2^^. 1 >:-£ OX) >>J»> _J >n -> )> > ,>^S> >:-,. > > » ■5 y > » ^Rsv ^■51 ") 5v >>J> -^ »"■ ''^t> >» >*» 1 \3> y >5 * ? ^ »> ■ > » ^.» t > :> > ^ ' ? s | > > DO DO ■ >■> - ? - fj> > >W ; > >- )>^j 32 »2> Jl i>3j> ^<* * .y>i > > ^ s^ V» J >^» ->■> i> »:» > "5, » » >> ^ J> , j> T»> > _; •>^ > > o Tk> ■> > >") o ;~ > i■ ■ > ^ ^> i> .* ) > v .. > > > > » > > » V » i > > .!» > »,> :> "5. i i » . ;> "» > > V ) } > > > ■» ) ^ w ^> >^»- j > » > 30 ^ » ■> » > ^> > > - > ~3H, > !>>>. » ~»3»> > > > > > J3 > k )jm) > »■'Jkwj ___> > ; DDi;^ ^_ ^- )Z^ZQZQZVS ZZQZQZQZDLQZDZ'^ Surgeon General's Office &.____. V* ON THE COMPARATIVE LIABILITY OF MALES AND FEMALES TO INSANITY, AND THEIR COMPARATIVE CURABILITY AND MORTALITY WHEN INSANE. BY EDWARD JARVIS, M. D., of Dorchester, Mass. Read before the Association of Medical Superintendents of American Institutions for the Insane, at Boston, June, 1850. «v,Ti;iuiW L nm: UTICA: PUBLISHED AT THE NEW YORK STATE LUNATIC ASYLTM. 1850. ON THE COMPARATIVE LIABILITY OF MALES AND FEMALES TO INSANITY, AND THEIR COMPARATIVE CURABILITY AND MORTAL- ITY WHEN INSANE. I. THE COMPARATIVE LIABILITY OF MALES AND FEMALES TO INSANITY. In regard to the comparative liability of males and fe- males to lunacy, there have been but few thorough, and no extensive, investigations, and fewer records of reli- able facts. Some authors have given opinions, and they are men whose opinions are not to be lightly questioned, but they, as well as we, have reason to complain of the want of satisfactory data to found their opinions upon. Pinel says, that there are twice as many female as male lunatics in France. Spurzheim says, in general terms, " there are more women than men liable to insanity." * Esquirol, that authority above all others in these mat- ters, says, " that women are more exposed to mental maladies than men," f yet, in another page, he says, " mania is more frequent in males than females." \ But their relative liability differs in different ages and differ- A On Insanity, p. 102. t M:iladies Mentales, i. p. 584. \ Ibid. ii. p. 138, 4 ent places, for he says, "that it is now true that, in Greece and Italy, females are less subject to madness (folie) than males. But in the north of France the con- trary is the fact, for there are more female than male lunatics."* But in England, he says, this is reversed, and the male lunatics are the most numerous. This he ascribes to the belter education of females in England than in France, by which the women of England are protected from some of the causes of lunacy that affect women in France. Unfortunately all our data which should show the number of lunatics among all the people, or the propor- tion of lunatics in the two sexes, are of a secondary na- ture. I have been able to find an accurate census of the lunatics of the distinct sexes f of only one nation, and that is the report of the commission of Lunacy to the Minister of Justice of Belgium, of the number of lunatics in that kingdom. There were males 2,744, females 2,361, in the year 1835, { which shows an excess of about 16 per cent of the males over the females. Even the Metropolitan Commissioners of Lunacy of Great Britain have only reported those lunatics which were in hospitals and work-houses, and under commis- sion. The paupers are probably reported accurately, but the private patients who are at their houses, or in private families are not reported. * Maladies Mentalcs, i. p. 39. t The admirable report upon Lunatics in France, in the " Statistique de la France," published by the French Government from official and reliable inves- tigations, states the number of Lunatics in each Department, and each hospital and place of refuge; but, unfortunately, it does not discriminate the sexes, so that the facts of that report are unavailable for our present purpose. X Rapport de la Commission pour 1' Amelioration de la condition dea Alienes en Belgique, p. 4. ' 5 According to their report, * there were in England and Wales, January 1st, 1844, TABLE I. Males. Females. Total. 2,161 1,911 4,072 7,701 9,120 16,821 Both classes, 9,862 11,031 20,893 These Commissioners seemed to have made no en- quiry in the private families of the prosperous. This statement, therefore, as it does not include the self sup- porting patients who are not in Asylums, cannot be taken as a representation of all the lunatics of England and Wales. Esquirol says, that there were in Norway, 995 male and 895 female lunatics; and in Paris, 6,156 males and 6,713 females insane. + Almost the whole of our data for determining the num- ber of insane in any community or nation, or in either sex, are limited to the observation of Hospitals, and these show, not the whole number of lunatics in any popula- tion, but only the numbers who have been sent to their care for cure or for custody. For want of any accurate census of lunatics among the people at large, Esquirol collected the records of many Hospitals, and ascertained, that there were and had been confined in these during various periods, but equal for both sexes, 38,701 females and 37,825 males, showing a proportion of about 38 female and 37 male lunatics, which, he inferred, was about the proportion in which this disorder affected the two sexes, f * Tage 194. t Annales d'Hygiene, iv. p. 351. X Ibid. Condition of Patients. Private or self- ) supporting, ) Paupers, 6 I have now collected the Reports of 159 Hospitals and licensed establishments, public and private for the in- sane in England and Wales, 8 in Scotland, 12 in Ireland, 37 in Belgium, 11 in France, 2 in Germany, 20 in the United States, and 1 in Canada,—250 in all, which for various periods, but equal for both sexes, have reported the numbers of male and female lunatics admitted. In the Reports of Great Britain and Ireland the re-admis- sions are not included; but as no exception of this nature is made in regard to the Hospitals of other nations, it is probable that the re-admissions are included. The number and sexes of the patients admitted in these 250 Hospitals and establishments are shown in the three following tables :— TABLE II. Male and Female Patients admitted into American Hospitals. * Hospital or Asylum. Location. Time of record. Patient* admitted M^« ,- for 19g ... , . Ye,ra- Male*. Fen-.. Fern. Massachusetts State, Worcester, 1333 to 1849 1,707 1650 McLean, Somerville, Mass. 1818 to 1349 1,661 1371 Xjft' 0 BostoD, Mass. 1839 to 1849 313 298 Maine State, Augusta, 1840 to 1849 474 394 A. Hampshire State, Concord, 184" to 1849 "74 070 Vermont, Brattleboro", 1846 to 1849 309 315 Connecticut Hartford, i824 to 1849 942 955 Bloomingdale, Bloomingdale.N.Y. 1821 to 1849 1 <*>l 85T New York Slate, Utica, 1844 to 1849 1,20~9 1167 New Jersey State, Trenton, i848 47 so Pennsy vama, ™l«telphia. 1811 to 1849 889 710 M^rvland F™nkford, Pa., 1818 to 1849 547 525 Maryland, Ba timore, 1839 to 1849 623 446 Virginia East. State, Wdliamsburgh, 1836 to 1849 650 384 Virgmm \Vest. State, Staunton, 1836 to 1849 410 *66 Louisiana State, Jackson, 1848,1849 73 57 Tennessee State, Nashville, 1844 to 1849 215 101 Kentucky State, Lexington, 1824 to 1849 1,020 48* Indiana State, Indianapolis. 1349 ' ?l « Oh.o State Columbus, 1839 to 1849 716 649 Temp. Asylum, Beauport, Canada, 1845 to 1848 122 112 _____ Twenty-one Asylums, 13^ x~Q ~ * Condensed from the annual reports of these Institutions. 7 TABLE III. Classification of the Asylums in England and Wales. * *'<■• Classes of Asylums. Patients admitted. Males. Females. Total 15 County Asylums erected under Acts > qfi 48 Geo. III. and 9 Geo. IV., \ 9'684 8'976 18>660 2 Asylums madeby local Acts, 9 Geo. IV., 248 293 546 2 Military and Naval Asylums, Chatham \ . OQr 00 t „ andGosport, $ x'~Bb ~~ 1'd08 2 Bethlem and St. Luke's, London, 7,894 11,559 19,453 10 Public Asylums, wholly or partly > .01_ supported by charity, $ *>~Li} d'dJ1 7>546 30 MetropoUtan, licensed to receive \ , „.. Q_„ private patients, } 1,d14 y5d 2'267 3 Do. private and pauper, 2,998 3,065 6,063 51 Provincial,licensed to receive private ? n~C/. n ™, .. „,~ patients, J 2'756 2'061 4>817 44 Do. private and pauper, 5,277 4,645 9,922 359 35,672 34,910 70,582 TABLE IV. Male and Female Patients admitted into Hospitals. Nation. No. ofHo?p. Patients admitted. Males for 100 Males. Females. Females. American, t 21 13,473 11,100 121 English and Welsh, X 159 35,672 34,910 102 Scottish, X 8 2,832 2,429 116 Irish, X 12 6,213 5,752 108 Belgian, $ 37 1,338 1,436 93 French, || 11 4,737 4,295 114 German, 1T 2 521 320 160 250 64,786 60,242 107 These 250 Institutions for the insane received 125,028 patients; of whom 64,786 were males, and 60,242 were * Condensed from the separate Appendix to the report of the Metropolitan Commission- 's in Lunacy. Folio 1844. The number of patients received in the Hospitals of Hanwell, Suffolk, and Lincoln,.in one year, 1844, are added from the reports of those Institutions. t Annual reports. J Statistical Tables of the report of the Metropolitan Commissioners. 4 Rapport de la Commission chargee par M. 'le Miniatre de La Justice, de proposer un plait pour 1' amelioration de la condition des Alienes en Belgique. Folio. Bruxelles: 1843. | Esquirol, Maladies Mentales, ii. ^ Eequirol and Jacobi, p. 296. 8 females. This reverses the proportion given by Esquirol, and shows a preponderance of males. We have no means of determining what proportion of all the lunatics in these several countries respect- ively, the lunatics in their Hospitals represent, nor, whether both sexes are represented equally or une- equally, except in Belgium. In that nation there were 2,744 male and 2,361 female lunatics, * but of these only 1,338 males and 1,436 females were in the Hospitals. This shows a larger proportion of the females than of the males in the institutions devoted to their use, being 60 per cent, of the women and only 48 per cent, of the men who were insane throughout all Belgium. If the same proportion of the lunatics of each sex is sent to the insane establishments in other countries as in Belgium, this would afford a means of calculating their true numbers, and the proportions of male and female lu- natics. Thus, if in America, the numbers 13,473 males and 11,100 females admitted into the insane Asylums re- present 48 per cent, of the former and 60 per cent, of the latter, at the several periods for which these are reported. to be in the Asylums, then the true proportion of lunatics will be as 28,068 males to 18,500 females, or about 151 of the former to 100 of the latter. In Great Britain and Ireland the proportions will be as 93,168 males to 71,801 females, or as 129 to 100 ; and in France as 129 male to 100 female lunatics. But leaving out this calculation, and supposing that the proportion of the insane of both sexes are truly re- presented in the Hospitals, we must yet compare these with the numbers of either sex from which they come. In estimating the comparative liability of the sexes to* insanity, it is not enough to compare the numbers of the * Rapport de la condition des Alienee, en Belgique, p. 4. 9 male with the female lunatics; but we should compare- the proportion which the insane of one sex bear to the whole numbers of that sex, who are subject to this dis- order, with a similar proportion in the other sex. In all established countries which are not peopled, in whole or in part, by recent immigration, there are more females than males, in all ages beyond childhood. Almost all the cases of insanity occur after the age of 20. The proportion of those who become insane, previous to this period, is so small, that it may be left out of the calculation. According to the last census there were in Great Brit- ain and Ireland 6,724,079 males, and 7,309,264 females, above 20 years of age. If the sexes have borne the same proportion during all the periods from which the Hospital reports are taken, then the proportionate liability to insan- ity, so far as can be determined by the admissions into insane Asylums, will not be in the apparent proportion of 44,717 males to 43,091 females, but in the true proportion of 6,6-52 male lunatics to 5,894 female lunatics sent to these Hospitals out of a million of persons of each sex over 20 years of age, throughout the whole Kingdom; or in the ratio of 100 females to 112 males. In the 15 States of this country, from whose Hospitals the sexes are separately reported, and included in this calculation, there were in 1840, according to the national census, 2,687,274 males, and 2,5S1,062 females, over 20 years of age. Then the true proportion of the different sexes, contributed to the lunatic Hospitals, is not as 13,351 males to 10,98S females, the numbers actually received ; but as 4,957 males to 4,257 females from every million persons of each sex over 20 years old ; or as 100 females to 115 males, which is a difference in favor of 10 women, somewhat greater than that in Great Britain and Ireland. In Belgium, according to the census of 1846, there were, over 20 years of age, 1,266,232 males, and 1,280,922 females. The whole number of lunatics in the nation was, 2,744 males, and 2,361 females, and of these 1,338 males and 1,436 females were in the Hospi- tals, which gives in a million of each sex of the liable age, 2,167 male and 1,843 female lunatics in the nation, and 1,056 males and 1,121 females in the Hospitals. Or, the whole amount of lunacy is as 116 males to 100 females; and lunatics under care in Hospitals are as 94 males to 100 females. From this review of the facts which I have been able to obtain, we find that the proportion of males and fe- males received into lunatic Asylums is not the same in all countries. The males predominate in the Asylums of America, England, Scotland, Ireland, and France, and among the people of Belgium. The females predominate in the Asylums of Belgium, among the people of Norway and of Paris, and among the paupers of England and Wales. According to the estimates of authors, there is a similar variety of prevalence in various countries. So far then as is known, we may conclude, that though it seems probable that males are more liable to insanity than females, yet this is not a universal fact in all places and in all ages. In considering the relative liability of the two sexes to insanity, it would seem reasonable first to inquire into their respective anatomy and physiology, but here we look in vain for light; for those works that treat upon these subjects, even those which are devoted exclusively to the description of the brain and its functions, make no 11 distinction, in this respect, between males and females. They all describe the brain as one and the same in both. We can infer nothing from the anatomical structure, or the healthy action of this organ, as to the relative liability of either sex to lesion or functional disorder. Anatomy and physiology, which make no revelation as to any inequality of the powers of the brain in the differ- ent sexes, are equally silent as to any difference in the amount of labor or suffering which either will bear, or of the burden under which either will falter. Seeing then that there is no structural or functional dif- ference of brain of the two sexes, which should lead us to suppose that there is any difference in their liability to mental derangement, we may next look to their temper- ament, their character, or position, which have no rela- tion to their cerebral functions, and see whether there is any thing in these which lead to insanity in one sex more than in the other. The temperament of females is more ardent, and more frequently nervous than that of the males. Women are more under the influence of the feelings and emotions, while men are more under the government of the intellect. Men have stronger passions and more powerful appetites and propensities. Women are more hopeful and confi- ding, especially in what regards the affections, but they are less given to sensual indulgence. Men are more cautious in regard to matters of a social nature. But in regard to the affairs that affect the intellect, they are more bold and less cautious. Their intellectual functions are oftener exercised without reference to the power of the physical organ. Their inclinations and propensities, of whatever nature, intellectual, moral, or physical, are more powerful and uncontrollable, and they are more likely to over-work and disturb the brain than women. 12 Women are more calm and patient, they endure diffi- culties and afflictions better than men, who are more un- easy and impatient under trial. It is said, and with truthj that women sooner yield, but being elastic recover again, while men being more firm, resist longer, and then break without power to rise again as readily as females do, when they are cast down. The position of women exposes them less to many of the causes of insanity, such as some of the varieties and changes in life and fortune, accidents and injuries. The difference of education and tastes, as well as of the habits and temperaments of the two sexes, concur also in producing a difference in exposure to many of the causes of mental disturbance. The character of insanity is not one and the same in all persons. It is very various in its origin, its development, its progress, and its result in different individuals. It may arise out of a lesion of the brain, or merely a func- tional disturbance. There may be a structural change, as a softening or tumor, or watery effusion in this organ, or a growth of bone, or perhaps a malformation of the skull which produces pressure on its contents. Or there may be merely a derangement of function from excessive or wayward mental action or emotions connected with no organic change. This is the most common condition of insanity. Functional derangement may be produced by some cause which does not act directly on the brain, but through some sympathetic irritation from a disturbance in other and even remote organs. Among the prolific sources of the last description are the derangements of the stomach and the bowels, including all the nutritive functions, the irritations of the excretory or- gans, the urinary apparatus, the skin, and the lungs, and 13 also some diseases, fevers, measles, inflammations, &c. These are common to both sexes; but all the various and manifold derangements of the reproductive system, peculiar to females, add to their causes of mental disorder. It will readily be supposed, that these causes of insanity are very numerous. The treatises upon this disease speak of its causes as many. The reports of lunatic Hospitals are intended tostateall the circumstances, conditions, habits, or events, that seem to the physician, or are supposed by the friends of the patients, to be the real causes of their lu- nacy. The reports of the Bloomingdale Hospital mention 85 causes; those of the Western Virginia Hospital mention 75 causes; those of the Utica New York Hospital, 65 ; those of the Pennsylvania Hospital, 34 ; and all the reports of all the lunatic Hospitals of the United States mention 181 different causes of insanity. The reports of some Hospitals reduce these causes to classes, of which 8 are reported from the Hospital at Wor- cester, Mass., 9 from the Hospital at Columbus, Ohio. The British Hospital reports state fewer causes than the American. The report of the Metropolitan Commissioners of Lunacy give from 8 to 16 causes for each Hospital, be- side a class termed physical causes. This class, in those reports, usually includes epilepsy, palsy, injuries, and some- times hysteria, and even puerperal mania, which, however, are sometimes stated separately. Yet these causes of insanity, many as they are, even the 181 of the American reports, are capable of still further sub-division ; and if they were reduced to their simple ele- ments, they would be almost as numerous and various as the unkindly influences that can be brought to act on man- kind. The term ill-health, as a cause of insanity, may be divided into almost the whole range of the nosology. There may be error in these statements of causes in re- 14 gard to some patients. Some of these supposed causes may have been pre-existing, or even merely co-existing facts, rather than productive causes. And possibly some of them may have been the result of the diseased action, and the first manifestation or a part of the insanity. Yet, making all due allowance for the mistakes of friends or the mis- judgment of physicians too eager to find causes, it may be assumed, that most of these facts or conditions had some, if not the principal influence, in the production of the mental disturbance. Whatever truth or error there may be in this imputation of causes, it is the same for both sexes, and they are prob- ably as correct for males as for females. And whatever de- duction is to be made from, or discredit thrown upon, one,, may with equal justice be imputed to the other. It is safe, therefore, to suppose, that the influence of these several causes holds the same ratio in regard to the two sexes as the statements that are published in the reports of Hospitals and the treatises upon insanity. Having premised this, it will be worth while to examine the records of cases, to see how far these several causes have acted upon the brain of men and women, and also to examine each cause or class of causes separately, and con- sider how far either sex, from organization, temperament, education, habits, tastes, or position in life, is exposed to any or all of them. We are reduced to this issue in all our inquiries whether males or females are most liable to become insane ; for, as we have no means of determining, from the nature of the disease, or from anatomical structure, which are the most readily affected with lunacy, we must inquire, which sex is most exposed to the influences that produce it, or which has the most power to resist them. The following table, which is condensed from the Brit- 15 ish, Irish and American reports before quoted, includes the cases of lunacy of which the causes are stated in reference to each sex separately. It will be seen that it contains only a small proportion of those which are given in Table IV., for the reports of many Hospitals do not state the causes in reference to the sexes; some do not state them at all; and all state them for only a part of their patients, giving a very large class, often half, or even more than half, in a class of unknown causes. Table IV. includes the admissions into most of the hospitals during the whole of the period of their existence. This period varies from 92 years in St. Luke's, London, to three months in Britton Ferry. The greater proportion of them have been established within 20 years. But the reports of causes, in the Commissioners' report, cover only a period of five years, ending with 1S43. In America, the reports from the Hospitals of Worcester, Mass., of Utica and Bloomingdale, N. Y., Pennsylvania, Western Virginia, Tennessee, Ohio, and Indiana only, state the causes in reference to the sexes. All these, the British, Irish and American are included in the following table :— table v. Causes of Insanity in Males and Females. Causes. Intemperance, Vice and sensuality, * Masturbation, t Connected with poverty and property, Domestic trouble, grief, loss of friends, disappointed love, &c. Connected with religion, Fright, Bodily disorders, injuries, accidents, { &c, Injury of the head, Excessive study, devotion to theories, specu- lations, politics, &c. Physical causes, palsy, epilepsy, &c., Puerperal, lactation, &c, Hereditary, § 11,686 10,421 Males. Females. •,'.290 606 467 320 . 248 17 1,396 884 1,017 1,856 785 782 167 261 1,718 1,949 381 112 451 153 1,012 745 926 1,754 1,810 * This cause, or class of causes, is given in the British, but not in the American, reports. 16 Among these causes, females are alone exposed to those which grow out of the uterine and mammary structure and functions. The puerperal condition, lactation, and catamenial irregularities, are then so many causes of mental disorder added to them besides those which they are liable to in common with men. In determining the comparative liability of the sexes to lunacy by statistics, all those cases among fe- males that grow out of causes connected with the reproduc- tive system should be deducted frorn the whole number of cases of female lunacy, and the remainder compared with the whole number of male lunatics. Then we should be able to compare the numbers of lunatics of the two sexes whose disorders are produced by causes connected with the or- ganization or functions that are common to both. This would leave a balance considerably in favor of females. Ill-health, without designation, mere invalidity or low vital power, probably including many cases of dyspepsia, constipation, &c, and other derangements arising out of bodily inactivity or want of sufficiently powerful external stimulus of action, without doubt affects females more than males, because their habits and their position in the world expose or leave them in this condition more than men. They are, therefore, more liable to become insane from this cause than males. This inference, which seems to be naturally drawn from the comparative condition and habits of the two sexes, and t Masturbation is in the American, but not in the British, reports. It is pro- bably included there in the class above,—vice and sensuality. X It would have been much more satisfactory to have separated these classes of causes from this connection, and put it with the class below; and then made one class of all sorts of accidents to which males are more exposed than females. But, unfortunately for this purpose, the reports of some hospitals connect them together in this manner, and render it impossible to separate them. § Hereditary is not stated, as a distinct and sole cause, in the American reports, except in those from Tennessee, which include 5 of each sex. 17 from their relative liability to low health, is rendered some- what certain by these Hospital reports, which show that while 1,949 females, only 1,718 males, were admitted intc- these lunatic establishments with disorders supposed to be produced by this class of causes. The affections and tender sensibilities are more active in woman than in man. She finds more of her happiness in them. She cultivates them with greater success. She is more easily wounded through them, and suffers with aiteen- er anguish when they are neglected or abused, or when the expectations founded upon them are disappointed. Thus, disappointed love, sickness or death or absence of friends or kindred, abuse from married partners, misconduct of near or dear relatives, which produce no small proportion of the cases of lunacy, act more frequently upon females than upon males. The reports show that 1,S56 women and 1,017 men became insane from this class of causes. Intemperance is a very prolific source of insanity. Jt is plain, that very many more men than women are addicted to this vice, and by a necessary consequence, it produces more lunacy among males than among females. This is shown by the experience of Hospitals, which report 2,090 male and 606 female lunatics, from this cause. Poverty, destitution, its reality or its fear, anxiety about business, the hopes and disappointments in regard to property, are also prolific sources of mental derangement. But they affect the sexes unequally, for the reason that men are more bent on the acquisition of wealth. They make this the business of their lives, and devote to it their minds and their hearts much more than women ; they are more en- gaged in those pursuits which have an uncertain issue; they have more plans to fail, and hence they are more exposed to disappointments, and misfortunes connected with business, speculation, and money, and they suffer more when these B 18 troubles come upon them. Their minds are therefore more frequently disturbed from these causes than the minds of females. This, which is inferred from a priori reasoning, is demonstrated by the records of the Asylums, which show that 1,396 males and 884 females were made insane from this whole class of causes. It is a common opinion that females are more devoted to religion than males. This is not the place to discuss this question. It may or it may not be true. But it is also gen- erally believed that women are more subject to religious excitements and enthusiasm,—that they are oftener fanatical and extravagant. It is, consequently, supposed that more women than men must become insane from this cause. But the experience of Asylums refutes all such opinions, and shows that while 785 males, whose insanity was charge- able to this cause, were admitted, 782 females were re- ceived whose disorder had the same origin, making, at least, nearly an equal distribution of this class of causes. But if we compare these numbers respectively, with the propor- tion of the two sexes who usually attend upon, and engage earnestly in, religious exercises, there will be a manifest dif- ference in the liability of the two sexes to insanity from re- ligion, and that in favor of the female. Excess of study, excessive devotion to various interests and pursuits, and anxiety about political'or other success, are more common among men than among women. Men are more devoted to books, and investigations, and theories. They are more ungoverned in their ambition and eagerness to accomplish their purposes of gaining knowledge or for the advancement of science. Hence we should look for more male than female lunacy from this class of causes, and the Hospital records show, that 451 males and only 153 females were thus made insane. Fright is an important element among the causes of men- 19 tal derangement. Women are more timid than men ; they are less acquainted with the realities of the outer world, and less used to exposures and dangers; they are more ready to imagine evil when none or little exists or is threatened. Consequently they are more frequently alarmed by imagin- ary danger, and more overwhelmed by real danger. It is therefore reasonable to suppose that they would become more often insane from this cause than men, and the reports state that 261 females and 167 males were made insane by fright. The British and Irish Hospital reports show a large num- ber of insane from vice and sensuality,—467 men and 320 women, which is a probable index of the proportionate pre- valence of vice and sensuality in the two sexes. The American Hospital reports do not state vice and sen- suality as a cause, but they show 248 males and 17 females insane from masturbation, which is not mentioned in the British and Irish reports, but is probably included under the last head. This difference we might naturally infer from the difference of passion and appetite, of sensibility and of self-control in the two sexes. Injuries of the head, and accidents of all sorts, happen to men much more frequently than to women, on account of their difference of position, and the different nature of their employments and tastes. Of course, these causes must make more males than females insane, and hence we find 381 males and 112 females reported as lunatic from this class of causes. A class of physical causes is given in the British and Irish reports, including palsy, epilepsy, &c. I know of no reason in the nature of the sexes to suppose that one or the other would be more liable to insanity from these causes; never- theless the British and Irish records show, that, while 1*012 men, onlv 745 women were made insane from them. 20 Hereditary taint is given as a sole and exciting cause of many cases of lunacy in the British and Irish reports. The Tennessee Hospital only, in America, reports this as a sole cause, and this gives only five males and five females whose lunacy is from hereditary origin alone. The Ameri- cans are accustomed to consider the hereditary taint as merely a predisposing cause, which is, in itself, dormant, and only prepares the ground for some new and exciting cause, which determines the insanity. Certainly but a small proportion of those who are born of insane parentage or ancestry, and therefore inherit the tainted constitution, become insane. The most remarkable family which I have been able to investigate has had insanity in some of its members for four generations. I have learned the history of 69 members of this family. Of these, fifteen are or have been insane, one idiotic, two epileptic, three had delirium tremens, three died of brain fever, one is subject to depres- sion of spirits and unable to attend to business a part of the time, one is subject to frequent and violent headaches, one has nervous trembling amounting almost to constant chorea, and one has low spirits. All the rest, including children, so far as I can learn, are sound. But all these cases are so distin tly referable to some new and exciting cause, that the family deny, that there is any hereditary taint in their blood. The history of other insane families will probably show a still smiller proportion of lunatics among them. The fair inference then is, that the Americans are right in supposing that this hereditary taint is only a predisposing cause, and remains generally, and perhaps almost univer- sally inactive, or certainly ineffectual, until some other cause shall excite the cerebral disturbance. Of course, this cere- bral disorder is more easily produced, and by a smaller cause, in those who are thus predisposed, than in other fa- 21 milies, whose brains are more able to endure or resist the causes of disease. If this be true, and if the causes, or classes of causes, to which the two sexes are respectively exposed, act with equal force on the brain which is hereditarily weak, whether it be of the male or the female, then we might suppose that the numbers of the hereditarily insane in the two sexes, would be in the same proportion to each other as the num- bers of those who are insane without this predisposing cause. There were received into the British and Irish Asylums during the periods herein quoted, 44,717 male and 43,091 female lunatics from all causes; this is in the proportion of 1,870 males to 1,805 females. But the numbers stated to be hereditarily insane are 1,754 males, and 1,810 females. This shows a greater proportion of hereditary insanity among women than among men, who were sent to the In- stitutions in Great Britain. Whether this is an indication, that the hereditary taint descends more to females than to males, or that this taint being equally distributed, the causes that produce insanity among women act with more efficiency on the brains natu- rally weak than the causes that produce insanity among men, we have no means of determining. We have no reason to suppose that the brain of either sex is more or less able to bear any definite amount of irritating cause than the other. It is true, that there are more males than females made lunatic by intemperace, or vice and sen- suality. But the explanation is, not that alcoholic stimula- tion, or sensual indulgence, has more effect on the brain of the male than on the brain of the female, but, that more males than females subject themselves to the influence of these causes, being more frequently intemperate and dissi- pated. 22 Masturbation, excess of study, excessive mental action in business and in politics, disappointments in speculation and in ambition, accidents, injuries of the head, &c, create more lunacy among men than among women,—not because wo- men can bear these disturbing causes better than men, but simply because they are less exposed to them. On the contrary, grief, disappointed affection, domestic trouble, fright, &c, produce more insanity in the female than in the male sex. It must not be inferred from these facts, that the brain of men can bear more grief, disappoint- ment in love, domestic trouble, or fright than women, but merely, that these causes come less frequently upon them. It may be that from something in the very nature of the sexes distinctively, the male hopes for more, and cares for more of that which he cannot always obtain, in regard to property or outward distinction, and is, therefore, more readily overwhelmed when these fail; and that the female expects more, and sets her heart upon more of that which cannot always be obtained, in regard to the affections and domestic and social enjoyments, and is, therefore, more readily cast down when these fail. But the true reason for the greater number of male than of female lunatics from the first and second of these classes of causes, and of the greater number of female than of male lunatics from the third of these classes of causes, is similar to the reason for the greater number of males than of fe- males who are killed by cannon and musket shot;—not be- cause a cannon or a musket ball is more destructive to a man than to a woman, but merely because more men than women go into battle. To the question, whether males or females are more li- able to insanity, no answer can be given from the cerebral organization or functions, nor from inherited weakness* 23 The consideration of the causes alone can solve the ques- tion, and from these a divided answer must be given. In as far as men, from their habits, their position, and their exposures, are more frequently intemperate; in as far as they have more of the sexual passion, and less delicacy of sensibility, and, therefore, are more given to masturba- tion and sensuality; in as far as they are more involved in business, and more interested in property, in politics, in schemes of aggrandizement, and in pursuit of knowledge, and are, therefore, more frequently bankrupt, or disappointed, or over-wrought with labor and anxiety ; in as far as they are more employed with machinery, and with powder, or more frequently travel and go over dangerous places, or are invol- ved in strifes and bodily quarrels, and, therefore/ meet with more accidents, falls,blows on the head, foe, than women ;— in as far as men are more exposed to these exciting causes of insanity, there are more male than female lunatics. But, in as far as females have more sensibility, and stronger affections, and more active sympathies, and, there- fore, suffer more intensely from grief, and loss or sickness of friends, and more from a cause almost peculiar to them- selves, in the want of domestic sympathy, and in the ill- treatment of intemperate or unkind husbands or children or other kindred ; in as far as females are more sedentary, and are, therefore, more frequently dyspeptic, or suffer second- ary irritations from the sympathy with the reproductive system, and have, therefore, more ill-health, and inasmuch as they are more timid, and are, therefore, more exposed to fright; — in as far as these causes operate more upon women than upon men, females are more liable to insanity than males. The general class of physical causes, including epilepsy, palsy, insolation, and often, catamenial disturbance, in the British Reports, produced a large excess of male lunacy. 24 In as far as this class of causes operates in Great Britain, notwithstanding some Hospital reports include uterine and mammary causes in it, men seem there to be more liable to lunacy than females. The question resolves itself into another, that is,—which of these causes, or classes of causes, prevails the most fre- quently and extensively ? And to this the answer must vary with various countries, and in different ages, and dif- ferent states of society. But the general answer now to be given, from the facts which present themselves from Great Britain, Ireland, France, Belgium, and America, is, that those causes of in- sanity which act upon males are more extensive and effect- ive than those which act upon females, and therefore, with- in the periods covered by the reports which I have analyzed, and in those countries from which these reports come, males are somewhat more liable to insanity than females. But this must vary with different nations, different periods of the world, and different habits of the people. Thus the recent investigations corroborate the general truth of what Esquirol said, twenty years ago. " The re- lation of insanity to the sexes varies from north to south, from nation to nation, from province to province. In Scot- land, the sexes have equal proportions of lunacy. In Eng- land, there are less female than male lunatics. In the north of France, the female lunatics, and in the south of France, the male lunatics, predominate. In Naples, there are two female to one male lunatic ; but in Milan, this proportion is reversed." * * Annales d' Hygiene, iv, p. 351, 2. 25 II. THE COMPARATIVE CURABILITY OF MALE AND FEMALE LUNATICS. In this branch of the topic, whether insanity is the most curable in the male or in the female, we have no data to presuppose the facts. We know of no way by which we can determine, in the advance, whether the male or the female will recover most easily from lunacy. Yet we have the record of the experience of the Asy- lums before quoted, from which the facts in the following table are taken. TABLE VI. Admissions and Recoveries in Hospitals. No. Ho ip rule. Patients admitted. * Recovered. RecoT. per cent. Males. Fern. Malea. Fem. Males. Fem. 148 English, 36,013 35,161 13,955 14,976 38.7 42.5 6 Scottish, 2,505 2,173 1,207 1,084 48.1 49.9 12 Irish, 6,213 5,752 3,311 3,351 53.2 58.2 6 French and Belgian, 1,719 1,430 710 647 41.3 45.2 17 American, 11,344 9,430 4,494 3,646 39.6 38.6 189 Hospitals, 57,794 53,946 23,677 23,704 40.6 43.9 These numbers of admissions and cures are those of the same years in regard to each Hospital. Of course, all the persons cured are not precisely those here stated to be admitted. Some were admitted into some of the Hospitals, before the reports, from which these facts are taken, began ; and the cures include some of these. On the other hand, the statements of admissions include some that were yet curable, though not cured at the date of the last report. Nevertheless, the columns of admis- sions and cures are both for the same years in regard to each sex ; and whatever error there may be in respect to * The numbers admitted according to this Table are not exactly the same aa stated in Table IV on page 147. The reports of some Hospitals state the ad missions, but not the recoveries, according to sexes, and the Vermont Asylum states the sexes of the patients admitted, but not of those discharged. 26 one, holds equally for the other; and it is reasonable to suppose, that the cures or curability of the sexes admitted into these Hospitals, bear the same proportion to each other as these figures represent. We see, that in the Asylums of most of the countries here quoted, the proportion of cures to the admissions, and the probable curability, is greater among females than among males, and in the English and Irish Asylums this proportion is materially larger, being an excess of 9- per cent. In France, Belgium, and Scotland, the differ- ence is less, but still in favor of the females. This difference will justify no very bold conclusion in regard to the curability of the sexes, but whatever infer- ence can be drawn is in favor of women. Yet in the United States the preponderance is slightly in favor of the males. Some inference may be drawn from the final results of special causes. Unfortunately very few have published the remote results of the causes of this disorder. The reports of the State Hospitals of Massachusetts, and of Ohio only, have noticed this fact. But taking these few data alone, we have the facts and deductions in the fol- lowing Table. TABLE VII. Relation of Causes of Insanity to Recovery. Causes. Cases admitted Cures. Worcester, Ohio, Per cett. of 1833 to 1848. 1839 to 1849. Total. No. admissions. Ill-health, fever, measles, \ puerperal, wounds, &c, J 443 392 835 588 70 Intemperance, 287 56 343 198 57 Masturbation, 158 44 202 60 29 Epilepsy, 56 52 108 12 11 Palsy, 44 44 7 15 Religious, 196 75 271 197 72 Affliction, disappointments, fear &c., 397 196 593 318 53 Property, poverty, &c., 129 53 182 106 58 27 We see, from this Table, that some of the causes, as ill-health, &c, which act more on women than on men, pro- duce a most curable form of insanity. Under this head is puerperal mania, which is among the least permanent kinds of this disorder. And on the other hand, mastur- bation and epilepsy, which produce the most incurable disorder, act much more frequently on men than on women. It may reasonably be supposed, that that derangement of the brain, which is produced and kept up by the irrita- tion from, or sympathy with, a cause acting in another and remote organ, would be more readily cured by the removal of the active cause, than that cerebral derange- ment which is produced by some disorganization or ex- haustion of the organ itself. If so, then the mental dis- orders arising out of ill-health, or disturbances of ermote viscera, are more curable than those which arise out of masturbation and epilepsy, or even intemperance. The mental disorders that grow out of afflictions, do- mestic troubles and disappointments, which are among the leading causes of female lunacy, seem to be some- what more curable than those that are produced by causes connected with property, business, and poverty, which are prominent among the causes of insanity among men. III. MORTALITY OF MALE AND FEMALE LUNATICS. The question of the comparative mortality of male and female lunatics, must be treated and determined in the same way as the others,—by the results of experience. We have no satisfactory record of the connection of the causes of lunacy with mortality. Yet it is manifest, that in whatever class there is the largest proportion of reco- veries there must be the smallest proportion of deaths- 28 Therefore, if there are more females than males restored out of a definite number of lunatics of each sex, there must be a smaller number of deaths of females. This is as plain as arithmetic can make it; because those who are not restored are left to die in their lunacy; and the larger the number of the uncured, the larger must be the number of deaths. Moreover, if more of one than of the other sex are made insane by removable causes which produce curable dis- ease, as far as these causes operate, that sex is less ex- posed to death in lunacy. Of course, there must be few- er deaths among the lunatics who are made so by general ill-health, than among those whose disease is produced by epilepsy or masturbation. These deductions from causes and recoveries are sub- stantiated by experience. Going again to the analysis of Hospital records we find the following facts :— TABLE VIII. Mortality of Male and Female Lunatics. Hospitals. Patients admitted. * Deaths. Ratio to admission. Males. Fem. Males. Fem. Males. Fem. English, 36,199 35,331 8,428 5,441 23 12 Scottish, 2,505 2,173 418 252 16 11 Irish, 6,213 5,752 1,213 990 19 17 French and Belgian, 1,719 1,477 634 360 39 26 American, 11,344 57,980 9,430 1,618 12,311 1,104 8,147 14 21 11 Total, 54,163 15 This Table corroborates the inference which might be naturally drawn from the statements and arguments in the two preceding branches of this subject,—that females are less liable to death than males while insane. * See note to Table VI page 164. 29 IV. MORTALITY OF MALES AND FEMALES FROM ALL DISEASES OF THE BRAIN AND NERVOUS SYSTEM. The inferences drawn in each of the preceding parts of this report, — that males are somewhat more frequently attacked with insanity,—that they are less curable when insane,—and that they are more liable to death in their lunacy than females,—finds an indirect corroboration in the records of general mortality. I have analyzed the Registration Reports of Deaths, for various years, of England and Wales, of Massachusetts,. of the State of New York, the city of New York and of Philadelphia.* These in all years publish the causes of deaths, but they do not always distinguish the sexes. But these mortuary registers, in those years in which they specify both the diseases and the sexes, re- port the deaths of 2,169,875 persons, including 1,103,198 males and 1,066,677 females; of whom 326,072 died of diseases of the brain and the nervous system. It might be supposed, that these cerebral and nervous diseases would be distributed equally between the sexes, or at least in due proportion to the whole number of deaths, or to the numbers of the living in each sex. But so far from this, 178,255 males, and only 147,817 females, died of neurotic disorders. Comparing these with the total deaths from all causes, we see that 16.15 per cent, of male deaths, and only 13.85 per cent, of female deaths, were produced by this class of diseases. The following facts were condensed from the reports * Reports of the Registrar General, for five years and a half,—1837 to 1842_ ----Registration of Births, Marriages, and Deaths, of Massachusetts, for four years,—1845 to 1848.----Do. of the State of New York, for two years,—1847 and 1848.----Inspector's Returns of the city of New York, for ten years,—1838 to 1848, except 1843.----Bills of Mortality of Philadelphia, for twelve years,— 1835 to 1846. 30 above-mentioned, from countries, states, and cities, con- taining 9,396,835 males, and 9,174,107 females. TABLE IX. Mortality of Males and Females from Diseases of the Brain and Nervous System. Diseases of the brain and nervous Deaths. Ratio, in each sex. system. To 10,000 deaths. To 1,000,000 livin- Males. Fem. Males. Fem. Males. Fem. Insanity, 1,371 1,277 12.4 11.9 145 120 Epilepsy, 4,097 3,481 37 32 425 357 Apoplexy, compression, congestion, \ 19,927 17,979 180 168.5 2,120 1,844 Palsy, 15,807 17,134 143 160.5 1,682 1,757 Inflammation, brain and nervous fevers, \ 10,651 8,754 96 82 1,133 898 Convulsions, 86,433 68,905 783 645.9 9,198 7,068 Hydrocephalus, 30,396 24,444 275 229 3,234 2,507 Chorea, 64 142 .5 1.3 .6' 1.4 Delirium tremens, 2,593 398 23 3.7 275 48 Tetanus, 744 223 6 o 79 22 Hydrophobia, 68 27 .6 .1 7 2 Diseases of the brain and head, \ 6,104 5,053 55 47 649 518 All diseases of brain and nerves, I 178,255 147,817 1,615 1,385 1,893.9 1,529.4 Some of these diseases are almost exclusively those of childhood, and others of manhood. It is well, therefore, to compare these deaths with the number of the living in those periods of life at which these diseases are most usually fatal. TABLE X. Ratio of Mortality of Males and Females to living of each sex. Diseases. Numbers exposed. Period of life. Deaths. Males. Fem. Apoplexy, in 1,000,000 living, over 30 6,005 5,173 Palsy, „ „ „ „ 4,763 4,930 Convulsions, ,, „ „ under 10 35,179 27,987 Hydrocephalus, „ „ „ „ 12,369 9.927 It would naturally be supposed, that more males than females would die of delirium tremens, hydrophobia, and 31 tetanus, on account of their habits, and exposures to ac- cidents and rabid animals. Perhaps a part, at least, of the excess of male deaths over the female deaths from apoplexy and congestion of the brain may be attributed to the more active cerebral action, and the accidents of men. The excess of deaths of females from palsy over those of males must be, in part, ascribed to the excess of fe- male population in the advanced ages at which this dis- ease generally occurs. But the excess of 22 per cent, of deaths from convul- sions and 24 per cent, from hydrocephalus, of males over the deaths of females from the same causes, is not what we were prepared to expect, nor can I find any ex- planation of the causes of these last differences. It is not a little remarkable, that in these registries every one of the diseases of the brain and nervous sys- tem all of those which come under the class of neuroses in the nosologies, except palsy and chorea, were more fatal to men than to women, when compared with the whole number of deaths, and with the numbers of living of each sex. And therefore this registration of general mortality, as far as it goes, shows that the female is much less liable to death, from nervous disorders at least, than the male. We have no means of judging of the curability of these nervous disorders in the two sexes. Not knowing the number of persons attacked with them, we cannot com- pare the successful with the fatal issue, and thus ascer- tain the relative violence of the diseases upon the two sexes, when they come upon them. Nevertheless, there is an agreement between this re- cord of mortality from all disorders of the brain and nerves, and the record of the experience of Hospitals for the Insane. Thev combine together to overthrow the 32 common notion that woman especially is subject to ner- vous disorders, and that man is comparatively exempt from them; and more than this, they show that the re- verse is true,—that man is more exposed to, is less fre- quently cured of, and falls more under the attacks of this class of diseases than woman. k ll^-V fc Ttz. / DR. JARVIS i)N I N S A N 1 T Y IN THE SEXES. Most- ly? Pfo \9S D TccC CC(C S <*-c < c«.Cit <•■ C«C:C ( ^ccc^C( f f K ccc(rct\ i-CC 'CCC c