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THE BIRTH OF PSYCHIATRY IN IRELAND
It is not considered desirable in certain circumstances to have a flat-footed man dealt with as lame, but in other circumstances it is considered desirable and it is done. In like manner, in certain circumstances, it is not considered desirable to have a particular kind or degree of mental unsoundness dealt with as lunacy, but in different circumstances this is considered desirable, and it is done.
It is thus plain that the number of registered lunatics in a country is not a fixed figure, which cannot be increased or diminished. On the contrary, it is a figure which can be made to change greatly through the operation of many and varying causes; and it is obvious that this should not be forgotten by those who are deciding what ought to be the relations and duties of the State to the insane.
Committee on Lunacy Administration (Ireland),
Second Report of the Committee Appointed by the
Lord Lieutenant of Ireland on Lunacy
Administration (Ireland) (1891)1
The history of psychiatry is interesting, important and complicated to unravel.2 In Ireland, this history commences with the prehistory of psychiatry in the Middle Ages and early modern era, and continues with explorations of Gleann na nGealt (Glenn of the Lunatics) and Mad Sweeney (in the twelfth century), and Brehon Law (up to the seventeenth century). The emergence of new forms of institutional care is explored, as are the lives and works of Sir William Fownes and Jonathan Swift, both of whom were connected with the establishment of St Patrick’s Hospital, Dublin, in 1746. Burnham’s ‘drama’ of the healer3 features strongly in the form of Dr William Saunders Hallaran and the succession of enthusiasms for new treatments that emerged in Ireland (and elsewhere) in the late 1700s and early 1800s. This is how it all began.
The Middle Ages and Early Modern Era
Early understandings of mental illness in Ireland, as in other countries, focused on supernatural and religious explanations for the unusual beliefs and behaviour displayed by persons who would later be regarded as mentally ill.4 In pre-Christian Ireland, it was believed that druidic priests, acting for pagan deities, could induce madness by throwing a ‘madman’s wisp’ (a ball of grass or straw) in a person’s face.5 Fullon, a druid of Leinster around 600 BC, was reputedly the first to cast such a spell, initially making incantations on the wisp of straw and then throwing it at his victim.6 A similar fate befell Comgan, son of Maelochtair, King of the Decies in Munster in the seventh century, when a young woman he spurned persuaded a druid to throw a magic wisp on him, leading to skin ulceration, baldness and madness, interspersed with periods of lucidity during which the unfortunate but still articulate Comgan robustly declaimed poetry and prophecies.7
The moon was commonly linked with madness in early Ireland and there was a belief that a seaside rock in Dunany, County Louth, known as Cathaoir Ana (Madman’s Chair), attracted the mentally ill, who could be cured by sitting on it three times.8 Conversely, those who were not mentally ill and sat on it might become mad. According to another account, if a mad person sat on the rock during a period of lucidity, that lucidity would be maintained because the mental state of the person at the time he or she sat on the rock would be so fixed for life. Early Irish literature and folklore are full of other references to madness and various unusual psychological states. Stories such as the Cattle Raid of Cooley (Táin Bó Cúalnge), the central epic of the Ulster cycle, as well as many other strands of Irish folklore, present vivid descriptions of altered states of mind and diverse kinds of madness.9
The arrival of Christianity saw the emergence of beliefs that insanity was attributable to possession by the devil or punishment by God, and the phrase duine le Dia (person of God) came into common use for persons with intellectual disability. One story claims that St Mochuda cured a man of madness (owing to demonic possession) by interceding with God.10 Another tells how a Norman archer became mad after entering the sacred area surrounding a perpetually burning fire lit by St Brigid in Kildare.11 This man blew on the fire and became insane, blowing into people’s mouths and running from house to house blowing on every fire he could find. He was seized by his comrades and, at his request, brought to water where, thirsty from all the blowing, he drank so much that he burst and died on the spot. Another man tried to enter the circle around St Brigid’s fire and put one of his legs across the hedge, but was dragged back by his comrades, only to find his leg and foot had withered away; he was lame and intellectually disabled for the rest of his life.
Early Irish law outlined a series of rights for persons of unsound mind and the intellectually disabled, specifying an obligation for families to look after the insane, the elderly and those with physical disabilities.12 Law texts from the seventh and ninth centuries distinguished between a person who was deranged (mer), a person who was violently insane (dásachtach) and a person with intellectual disability (drúth).13 There was a clear distinction drawn between madness and intoxication due to alcohol.14 A person with epilepsy (talmaidech) was regarded as possessing legal competence once he or she was of sound mind; it was, however, imperative that he or she was minded in order to prevent injury to self or others during seizures.
Exploitation of the insane was forbidden; a contract with a person of unsound mind was invalid; anyone inciting a drúth to commit a crime had to pay the fine himself; and there were specific provisions dealing with land owned by the insane.15 There were also provisions dealing with offences committed by persons of unsound mind or a drúth, and provisions governing issues related to childbirth and responsibility for offspring of the mentally ill. Overall, the main concern of these laws was to protect the mentally ill and intellectually disabled from exploitation and ensure that any children were looked after appropriately.
For much of this period, there was a widespread belief that mental illness conferred lightness of body such that affected persons could move from one spot to the next at high speed by merely touching the ground here and there; i.e. essentially flying.16 This was consistent with the belief that madness induced by battle resulted in warriors becoming as light as air and simply floating away from the battlefield, as reportedly occurred to Bolcáin, King of France, at the battle of Ventry when he beheld the ferocious Oscar, son of Oisín, rushing towards him.17
This interesting belief persisted up to the thirteenth century and contributed to the mythic figure of Mad Sweeney (Suibhne Geilt), whose remarkable tale is told in Buile Suibhne, an epic story written in the twelfth century but with origins in the ninth century or earlier. The story of Sweeney is a vivid one, magically retold by Seamus Heaney (1939–2013)18 and brilliantly reimagined in comic form by Flann O’Brien (1911–1966).19 Sweeney, a chieftain, was cursed by Ronan the Fair, abbot of Drumiskin, and condemned to a life of madness, flying and wandering through the world. After wandering for many years, the curse was tragically fulfilled when he was killed with a spear.
Maddened by the slaughter at the battle of Moyrath in 637 AD, Sweeney (Suibhne) flew into the air from the battlefield20 and in this altered state decided to turn away from mankind and live with the birds and animals in the wilderness.21 For many years he wandered from tree to tree (commonly the yew tree), having strange, disturbing visions. In the end, he joined a community linked with St Moling but was speared to death by a swineherd who falsely accused him of adultery with his kindly, charitable wife.
Sweeney’s story is a powerful one, full of tragedy and loss, and for many centuries it underlined the idea of the mentally ill person as a wandering loner, misunderstood, persecuted and cast out. This was a feature of the history and mythology of mental illness in many cultures, not just Ireland.22 In all of its torment, tragedy and isolation, Sweeney’s story reflected not only contemporary views of the dislocation and loneliness of madness, but also tensions between pre-Christian and Christian Ireland, demonstrated vividly in Sweeney’s unresolved disturbance and dislocation.
There were various other local stories and traditions concerning mental illness and intellectual disability. In Kerry, a valley became known as Gleann na nGealt, Glenn of the Lunatics, as it was believed that all the mentally ill would, like Bolcáin and Sweeney, come to live there eventually, if left to their own devices.23 It was thought they would drink the water and eat watercress from the well, Tobar na nGealt, which were said to have cured the madness of Gall, king of Ulster, as well as that of Bolcáin. Those who lost their minds owing to being jilted in love could also seek solace in Gleann na nGealt. There is a nearby stone with a hollow in its centre, known at the Mad Stone, and a river crossing known as Fool’s Crossing.
The valley is still a site of local and tourist interest, as well as the subject of research, most notably in relation to the lithium content of its water.24 This is of interest not only because lithium is now used in the treatment of bipolar affective disorder (manic depression), but also because international studies have suggested that higher concentrations of lithium in drinking water might be associated with lower rates of suicide at population level.25
Biochemical analysis performed for the purpose of this book, however, showed that the lithium content of water from Tobar na nGealt is less than 5 micrograms of lithium per litre of water.26 The same result was obtained for water from a stream near the village of Inch (on the other side of the Dingle peninsula, also in County Kerry); water from Our Lady’s Holy Well at Dromore near Kenmare, County Kerry; and Dublin tap (drinking) water. These concentrations of lithium are significantly lower than the concentrations apparently associated with lower rates of suicide in Austria27 and Japan.28
The concentration of lithium in the water in Tobar na nGealt is also too low to have any detectable therapeutic benefits at the individual level. Even if the water had a concentration more than 200 times greater than it has (i.e. if it had a concentration of 1 milligram of lithium per litre), and a person drank two litres per day, that would still correspond to a daily dose of just 13.8 milligrams of lithium carbonate,29 which is less than two per cent of the usual therapeutic dose for bipolar affective disorder (approximately 900–1,200 milligrams per day for an adult).
Biochemical analysis is, however, neither the only nor the best way to examine the therapeutic value of Tobar na nGealt or other folk cures for mental illness, which find their true value as embedded elements of local traditions and beliefs, and reflect subtle, powerful cultural interpretations of mental illness and human suffering. In Inishowen, Donegal, a well with similar properties was known as Srubh Brain and there was another well at Port an Doras, near Inishowen Head.30 Cures were also reported at Cloc na Madaidh near Malin Head and the sixth-century oratory of St Barry in County Roscommon, where three nights spent in the ruins followed by mass on Sunday were reputed to alleviate madness.31
From a social perspective, the image of the wandering lunatic reflected in the traditions of Sweeney and Gleann na nGealt was a largely accurate one (except for the flying). Although chieftains were said to protect the mentally ill of their kin group, society was generally unwelcoming and unsympathetic.32 Some accommodation was provided for the mentally ill in Irish monasteries during this period, but this was erratic, limited in scope, and did not endure. One such monastic hospital was the relatively large Hospital of St John without the New Gate of Dublin, founded by Ailred the Palmer in the twelfth century.33 The Hospital of St Stephen (where Mercer’s Hospital later stood) may also have housed the mentally ill, although it is unclear to what extent such establishments catered for the mentally ill and intellectually disabled as opposed to those with medical or surgical needs, and the poor.
Overall, since Brehon law focused on protection from abuse rather than neglect, and provision in monastic hospitals was patchy at best, the mentally ill and intellectually disabled in the Middle Ages and Early Modern Ireland tended to live harsh, difficult, brief lives characterised by vagrancy, illness, imprisonment and neglect, especially in times of hardship and famine.34 The dissolution of the monasteries changed this landscape further, resulting in even less accommodation and greater neglect. Interestingly, though, while dedicated provision for the mentally ill was very limited, there is no compelling evidence of widespread witch-hunts against the mentally ill in Ireland, as were reported in other countries during this period.35
Nonetheless, as the 1600s drew to a close, the mentally ill in Ireland tended to be either homeless or confined in prisons, and, despite isolated initiatives,36 their plight clearly presented increasing cause for concern. This concern ultimately led to the beginnings of systemic reform in the early 1700s. One of the key figures in this process was Sir William Fownes, a wealthy, philanthropic landowner whose initiatives were to shape institutional mental health care in Ireland for many decades to follow.
Sir William Fownes:
Providing for the Mentally Ill
Sir William Fownes was a pivotal figure in the history of care for the mentally ill in Ireland. A member of the Irish House of Commons for Wicklow Borough from 1704 to 1713, Fownes became Lord Mayor of Dublin in 1708 and the Fownes Baronetcy, a title in the Baronetage of Ireland, was created for him on 26 October 1724.
Fownes was one of Dublin city’s patriarchs and a wealthy landowner, with a villa adjoining Phoenix Park, a townhouse off College Green, and an estate in Wicklow. Notwithstanding his privileged background, Fownes’s interest in providing for the destitute mentally ill was matched with actions: in 1708, while mayor of Dublin, he initiated the provision of cells for the mentally ill in the workhouse at St James’s Gate.
Some years earlier, in 1684, the master of the City of Dublin House of Correction had requested and received additional payment for maintaining mentally ill persons there37 and, in 1699, an anonymous donor acting through Dr Thomas Molyneux (later state physician), offered Dublin city corporation £2,000 towards maintaining a hospital for aged lunatics and diseased persons.38 While the corporation initially accepted the offer and even agreed to donate £200 themselves, they reallocated the site for the Dublin workhouse, which opened in 1703. In 1701, the problem of mentally ill persons in the House of Correction was again highlighted by its Master, Robert Parkes, and financial support was provided to the tune of two shillings per person per week.39
The six additional cells provided by Fownes for the most disturbed of the mentally ill in 1708 represented the first definite beginning of organised care for the destitute mentally ill in Dublin. In parallel with Fownes’s initiative, in 1711 Lord Justice Ingoldsby persuaded the governors of the Royal Hospital in Kilmainham to provide dedicated accommodation for soldiers who developed mental illness. Mentally ill soldiers continued to be accommodated at Kilmainham until 1849, when provision moved to Yarmouth.
In 1729, the governing body of the Dublin workhouse decided to cease admitting persons with mental illness to the cells that Fownes had established. At that point, there were approximately forty ‘lunatics’ in the workhouse but by then the overall establishment had taken on more of the characteristics of a foundling hospital – albeit one in which children were sometimes locked into cells with disturbed mentally ill persons when they had broken the hospital rules.
It was against this background that, in 1731, Jonathan Swift, author of Gulliver’s Travels (1726) and various other classics of eighteenth-century literature, announced his intention to provide in his will for the establishment of a hospital for the mentally ill. He consulted Fownes, who wrote at length to Swift on 9 September 1732, starting with an account of the current plight of the mentally ill and his own efforts to ameliorate matters at the workhouse at St James’s Gate.40 Fownes went on to tell Swift that he had been initially reluctant to consider the establishment of a public asylum in Dublin along the lines of Bethlem Hospital in London (one of the first asylums in the world, founded in 1247), but had changed his view and now supported such a venture:
I own to you, I was for some time averse to our having a publick Bedlam, apprehending we should be overloaded with numbers, under the name of mad. Nay, I was apprehensive our case would soon be like that in England; wives and husbands trying who could first get the other to Bedlam. Many, who were next heirs to estates, would try their skill to render the possessor disordered, and get them confined, and soon run them into real madness. Such like consequences I dreaded, and therefore have been silent on the subject till of late. Now I am convinced that regard should be had to those under such dismal circumstances; and I have heard the primate and others express their concern for them; and no doubt but very sufficient subscriptions may be had to set this needful work on foot. I should think it would be a pleasure to any one, that has any intention this way, to see something done in their lifetime, rather than leave it to the conduct of posterity.41
Thus reformed, Fownes suggested a site for the proposed establishment, behind Aungier Street, later site of Mercer’s Hospital.42 He proposed that the new asylum should be surrounded by a high wall, have appropriate staff quarters and contain space for patients to walk around, as well as dedicated accommodation for the most disturbed and scope for enlargement.43 Fownes recommended that the establishment should be supported by subscriptions and that the College of Physicians should advise on the work.
When Fownes wrote his letter to Swift in 1732, he was pushing at an open door with the great author: both men were trustees of Steevens’ Hospital in Dublin and both were deeply concerned with the plight of the destitute mentally ill.44 On 3 April 1735, however, less than three years after he wrote to Swift, Fownes died and was buried in St Andrew’s in Dublin. By this time, Swift was already engaged in planning his iconic hospital, later known as St Patrick’s.45 Today, over three centuries after Fownes established his cells for the mentally ill at the Dublin workhouse, there is a ward in the psychiatry unit of St James’s Hospital in Dublin named in his honour, commemorating Fownes’s unique contribution to early psychiatric care.
Jonathan Swift: Author,
Churchman, Pioneer
On his death in 1745, Jonathan Swift famously and generously bequeathed his entire estate to establish a hospital for ‘idiots and lunaticks’ in Dublin, consistent with Fownes’s initiative.46 This establishment would duly become St Patrick’s Hospital, the first formal asylum in Ireland. As a result of his benevolent bequest, Swift occupies a unique position in the history of psychiatry in Ireland.
Swift was born in Dublin in 1667 and gained a Doctor of Divinity degree from Trinity College in 1702. He went on to become a celebrated essayist, novelist, poet, satirist and cleric, serving as Dean of St Patrick’s Cathedral in Dublin from 1713 to 1745. Swift’s interest in madness may have stemmed from family experiences: Swift was raised by an uncle who developed mental disorder and died when Swift was 21.47
Professor Anthony Clare, who himself became medical director of St Patrick’s Hospital in 1989, studied Swift’s writing on madness in A Tale of A Tub (1704) and Gulliver’s Travels (1726) and found much to comment upon.48 A Tale of A Tub, for example, was Swift’s first major work and in it Swift divided madness into three types: religious, philosophical and political. In book three of Gulliver’s Travels, Swift portrays people trying to extract sunbeams from cucumbers and an architect who seeks to build houses from the roof downwards. In The Legion Club (1736), Swift treats the Irish Houses of Parliament as an asylum, complete with madhouse keeper. Clearly, madness and its management were key concerns for Swift and emerged as recurring motifs in his literary and satirical work.
In addition to his writings about madness, Swift was acutely aware of the reality of the plight of the mentally ill. On 26 February 1714, he was elected as a governor of Bethlem Hospital (‘Bedlam’) in London.49 There is no record that Swift actually attended any meetings but in 1722 it is recorded that he used his position as governor to nominate a certain Mr Beaumont for admission, as Mr Beaumont was reportedly riding through the streets on a horse, throwing money around.50 Swift himself, in a characteristic burst of satire, asked whether, once incurable wards were established in Bedlam, he might possibly be admitted there, on the grounds that he was an ‘incurable scribbler’?51
Swift’s interest in madness and its causes was by no means unique among writers of the day: John Locke, Thomas Hobbes, Alexander Pope, Laurence Sterne and Samuel Johnson all wrote about the subject, sometimes at great length. But Swift was notable for the extent to which he matched his writings with concrete actions, most obviously by becoming a governor of Bethlem Hospital and bequeathing his estate for the foundation of an asylum in Dublin.
By 1733, Swift had made the momentous decision to devote his estate to public benefaction and by 1735 he had settled his entire fortune on Dublin city in trust for the erection of an asylum. The following year, Swift’s London publisher, Benjamin Motte, praised his benevolent intentions but warned sternly against permitting the kinds of abuses and maltreatment reported in English private asylums of the times.52 This was a real issue: English private asylums of the 1700s were the subject of considerable concern in relation to the balance between custody and care. The conditions in which patients were kept, as well as their treatment, were the subject of repeated scandal and outrage.53 Swift was fully aware of the risks and took considerable care with his bequest, frequently redrafting his will in order to ensure, as best as possible, that the institution would be run to a high standard.54
Swift’s own mental state was the subject of considerable speculation and discussion both during his life and ever since. Malcolm recounts several opinions that Swift developed mental illness, based on the views of Samuel Johnson, William Makepeace Thackeray and Sir Walter Scott, among others.55 The idea that Swift became a lunatic gained considerable currency following his death, along with the belief that Swift had, in later life, become a patient at the very hospital he founded. In 1849, Dr (later Sir) William Wilde (1815–1876), an eye and ear surgeon, and distinguished author on the subjects of medicine, folklore and archaeology, wrote an entire book about Swift’s health and recounted that it was rumoured that Swift was the first patient at St Patrick’s, although this was not true.56
These tales about Swift had their roots not only in contemporary gossip and innuendo, but also in the fact that, in 1742, a writ, de Lunatico Inquirendo, was issued, declaring Swift ‘a person of unsound mind and memory, and not capable of taking care of his person or fortune’.57 This writ was issued following a petition from Swift’s friends and consideration of medical evidence, and the declaration made by a jury.
Notwithstanding this writ, it is clear that Swift was not truly mentally ill: a lunacy enquiry was the only legal means by which a person incapable of conducting their own business affairs or looking after themselves could be effectively protected.58 As a result, the writ did not necessarily mean that Swift had become a ‘lunatic’, but simply that he was no longer in a position to manage his own affairs and required assistance, most likely as a result of age-related decline. In fact, Swift lived just three years after these events, largely in isolation, and did not write during these later years.
With regard to the specifics of Swift’s health and possible diagnoses, there were suggestions that Swift may have been afflicted with a form of syphilis,59 but it now appears clear that Ménière’s Disease was most likely the central diagnosis.60 Ménière’s Disease is a disorder of the inner ear that affects hearing and balance, and symptoms include vertigo, tinnitus and hearing loss. Various medical examinations of Swift’s life have concluded that he experienced giddiness, nausea, dizziness and tinnitus, all of which are consistent with Ménière’s Disease, especially from the 1730s onwards. In 1736, Swift complained explicitly about some of these symptoms to his friend Alexander Pope, noting that he could no longer write, read or think clearly because of them.61
Swift also experienced severe memory loss from 1739 onward and may have suffered from cerebrovascular disease (impaired blood supply to the brain), further reducing his abilities and cognitive function. Sir Russell Brain (1895–1966), a British neurologist, was of the view that this was the root cause of Swift’s symptoms in later life, especially his aphasia (impairment of language).62 Ultimately, a great number of opinions have been expressed about Swift’s health and the emergent consensus appears to be that he suffered from Ménière’s Disease during his life and cerebrovascular disease towards the end, possibly contributing significantly to his death.63
It is beyond doubt, however, that, towards the end of his life, Swift did not recognise people familiar to him and lost the ability to express himself.64 This must have been an extraordinary frustration for a man so accustomed to thinking, writing and speaking with outstanding passion, clarity and, in relation to the mentally ill, charity.
St Patrick’s Hospital, Dublin:
‘Swift’s Hospital’
Following Swift’s bequest and his death in 1745, on 8 August 1746 a royal charter was granted to St Patrick’s by King George II (1683–1760) and St Patrick’s became the first psychiatric hospital in Ireland, and one of the first in the world.65
On 29 August 1746, the board of governors held its first meeting and the first patients, four women, were admitted on 26 September 1757, at which point the hospital had just sixteen admissions rooms.66 They were joined by five male patients in early October.67 The hospital expanded significantly over the following decades and admitted growing numbers of patients, although reports from the early 1800s indicated difficulties providing treatments and concern about lengths of stay.68
Such concerns were by no means unique to St Patrick’s and, in March 1817, Robert Peel, Chief Secretary, persuaded the House of Commons to set up a select committee to look into the need to make greater provision for ‘the lunatic poor in Ireland’.69 The committee considered all such establishments, including St Patrick’s, and concluded that ‘the extent of the accommodation which may be afforded by the present establishments in the several counties of Ireland’ was ‘totally inadequate for the reception of the lunatic poor’.70
During the course of its deliberations, the committee received a letter from ‘Mr James Cleghorn’, ‘medical attendant’ at ‘Saint Patrick’s or Swift’s Hospital’, dated 17 March 1817, with interesting information about the hospital.71 Cleghorn pointed out that recent years had seen ‘very considerable improvements’ at St Patrick’s, which, by that time, housed 96 ‘paupers’ and 53 ‘boarders’.72 Cleghorn was ‘fully aware of the advantages to be derived from dividing the different description of insane persons into classes, according to the nature and stage of the disease’, but noted that ‘the original construction of Swift’s Hospital does not admit of their separation, as it consists of six very long corridors or galleries, each containing twenty-eight cells’.
Cleghorn ‘was very anxious to have some separate cells for the noisiest of the patients, built apart from the principal building’ but the government did not grant money for this development, citing the ‘great accommodation for the insane, which the Richmond Lunatic Hospital would afford, which was then in progress’.73 Cleghorn regretted the government’s decision:
… the reasonableness of enabling us to adopt the system of classification in the most material point would have ensured to us more extensive aid; medical treatment in maniacal persons, and the insane in general, except in the very early stages of the disease, has ever appeared to me to be of little service towards the cure of it … moral treatment, as it is called, is of much more moment than medical, and I am sure that in this particular, much improvement has taken place of late years; and that the late investigations will contribute much to the amelioration of the state of lunatics.74
Cleghorn was at pains to point out the infrequent use of restraint at St Patrick’s:
The system observed in Swift’s Hospital, before I was concerned in it, was of the most humane kind; and it has always been my object to avoid any other coercion or restraint but what was required for the safety of the patients and those around them. The strait waistcoat and handcuffs are seldom resorted to, and we prefer the latter to the former, as being more convenient for cleanliness, and not so heating; occasional confinement to the cell is the principal restraint which we employ.75
Cleghorn reported, with satisfaction, that he had ‘succeeded, last spring, in prevailing on the governors to take a lease of the ground on the east side of the hospital, containing two acres and a half, and affording a good view into the Phoenix Park, where the greater number of the patients are at liberty to walk about and to take exercise’. Many were also ‘employed, with their own consent, in working the ground, and have been much happier and freer from their malady in consequence of it’.
Cleghorn also addressed distressing allegations regarding transport of mentally ill persons to Dublin from elsewhere in Ireland:
I wish, while writing to you on this subject, to take notice of certain statements which I have seen in the public prints, as having been lately made in the House of Commons, relative to the conveyance of mad persons to Dublin from the country. It has been said, that they have been tied to cars, and so bruised as to render the amputation of their limbs necessary, and that death has ensued from the mortification occasioned by this cruel mode of conveyance, During fourteen years I have attended Swift’s Hospital, I have never known an instance of the kind where any ill consequences have followed.76
Cleghorn heard ‘it rumoured, that it is intended to have either provincial or county asylums for lunatics and idiots: such a design is founded in wisdom and humanity, and will be a great relief to the pressure on the establishments in the capital’. This rumour was correct and, having taken account of the evidence of Cleghorn and others, the 1817 Committee duly recommended that ‘there should be four or five district asylums capable of containing each from one hundred and twenty to one hundred and fifty lunatics’.77
Notwithstanding the later development of these public asylums during the 1800s, numbers at St Patrick’s continued to rise and, by 1857, the profile of patients had changed significantly: in 1800 there had been 106 ‘free’ patients and 52 ‘paying’ patients; by 1857 this balance had reversed, with fewer ‘free’ patients (66) and more ‘paying’ patients (83).78 The Lunatic Asylums, Ireland, Commission of 1858 was not pleased:
We cannot consider this as indicating a satisfactory application of [Swift’s] endowment. It is true that the average payment by boarders is somewhat less than their actual cost in ordinary years, and so far they may be considered as maintained in part by the charity; but if the diminution of free patients and the increase of paying patients are to continue, it may one day result that no inmates of Dean Swift’s Hospital will be maintained entirely out of his bequest, which certainly does not appear to have been in the contemplation of the founder.
It appears by the evidence that the reception of paying patients has been so profitable, that the governors have been enabled to accumulate the sum of £20,000 thereby, the interest of which is available for the support of the institution. We cannot but think that the objects of the endowment would have been more properly carried out, if the income had been entirely appropriated to the maintenance of free patients.79
As regards conditions for patients, although a library was introduced in 1851, along with various other changes and innovations, there were persistent problems with infectious diseases in the hospital.80 The 1858 Commission had several further concerns, including that there was ‘only one fixed bath for 150 patients of both sexes’ and that was ‘out of order’, so that ‘patients wash in tubs in the day-rooms’; ‘the hospital is not lighted with gas’; ‘the hospital cannot be sufficiently warm in the winter months’; and various other issues, which led the Commission to the conclusion that St Patrick’s was, ‘in many respects, one of the most defective institutions for the treatment of the insane which we have visited’.81
To remedy matters, the report recommended that ‘the master of the hospital should be a member of the medical profession’, and that greater control and inspection were needed:
On the whole, the condition of this hospital satisfied us that it is absolutely necessary it should be placed under the control of the Central Board, which may be established for the direction of lunatic asylums in Ireland, and that it should be subject to the visits of the Commissioners as frequently as the district asylums. It is, no doubt, a private endowment, but in former times received large aid (£24,194) from the state; and what, in the interest of the public, we have suggested, should be done for its better government, will be in furtherance of the benevolent intentions of the founder.82
Notwithstanding these concerns, many of which were equally relevant to most other asylums of the day, there is still plentiful evidence that the ‘benevolent intentions of the founder’ of St Patrick’s were being observed in important ways in the early 1800s, although the latter part of the century was to bring more significant problems for the hospital, relating to patient care, financial challenges and structural dilapidation of the building.83
In many respects, the story of St Patrick’s from the mid-1700s to the late 1800s was typical of the trajectory of early asylum care in Ireland, commencing with noble intentions, followed by enthusiasm, and then difficulty sustaining the enthusiasm and standards so clearly required for care of the mentally ill. St Patrick’s was, however, a private, charitable establishment as opposed to a government run institution. The network of public asylums that developed alongside St Patrick’s during the 1800s merits consideration from this perspective too and its inception, was, in significant part, attributable to the work of one especially dominant figure in Irish asylum medicine, Dr William Saunders Hallaran (1765–1825).
Dr William Saunders Hallaran:
Treating the Mentally Ill
The most prominent and prolific Irish asylum doctor of the late eighteenth and early nineteenth centuries,84 William Saunders Hallaran was born in 1765 and studied medicine at Edinburgh. He spent much of his working life as Senior Physician to the South Infirmary and Physician to the House of Industry and Lunatic Asylum of Cork. Hallaran established the Cork Lunatic Asylum during the late 1780s and early 1790s,85 and Citadella, a private asylum in Douglas, County Cork, in 1799 (‘Bull’s Asylum’).86 Throughout his career, Hallaran was not only an industrious, progressive administrator, clinician and teacher, but also a tireless advocate for a more systematic approach to mental disorder and its treatment.
In 1810, Hallaran published the first Irish textbook of psychiatry, titled An Enquiry into the Causes producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with Hints as to the Better Management of Public Asylums for Insane Persons.87 This book outlined many of the central themes that defined his approach to the mentally ill, including explicit recognition of the roles of physical or bodily factors as causes of mental disorder in certain cases; deep concern about the apparent increase in mental disorder in nineteenth-century Ireland; and systematic, scientific engagement with the causes, courses and outcomes.
The recognition of physical or bodily factors (such as infections) rather than just psychological or ‘moral’ factors in causing mental disorder was an especially key theme:88
A principal object of this essay is to point out what heretofore seems to have escaped the observation of authors on the subject, namely, the practical distinction between that species of insanity which can evidently be referred to mental causes, and may therefore be denominated mental insanity, and that species of nervous excitement, which, though partaking of like effects, so far as the sensorium [i.e. mind] may be engaged, still might appear to owe its origin merely to organic [i.e. physical or bodily] injury, either idiopathically [i.e. by unknown mechanisms] affecting the brain itself, or arising from a specific action of the liver, lungs or mesentery [i.e. inside the abdomen]; inducing an inflammatory disposition in either, and thereby exciting in certain habits those peculiar aberrations, which commonly denote an unsound mind. That this distinction is material in the treatment of insane persons, cannot well be denied, any more than that the due observance of the causes connected with the origin of this malady, is the first step towards establishing a basis upon which a hope of recovery may be founded.89
This was consistent with preexisting theories linking mental disorder with, for example, disorders of the spleen – a theory outlined with particular enthusiasm by Sir Richard Blackmore of the Royal College of Physicians in London in 1726.90 Almost a century later, Hallaran’s distinction between causes ‘of the mind’ and physical or bodily causes of mental disorder held clear importance when planning treatment:
In the mode of cure, however, I would argue the necessity of the most cautious attention to this important distinction, lest as I have often known to be the case, that the malady of the mind which is for the most part to be treated on moral principles, should be subjected to the operation of agents altogether more foreign to the purpose; and that the other of the body, arising from direct injury to one or more of the vital organs, may escape the advantages of approved remedies … this discrimination has been found to be of the highest importance where a curative indication was to be looked for, nor need there be much difficulty in forming a prognosis, where either from candid report, or from careful examination, the precise nature of the excitement shall be ascertained.91
In his incisive, often witty, textbook, Hallaran paid particular attention to the role of the liver in causing mental disorder, recommending that ‘the actual state of the liver in almost every case of mental derangement should be a primary consideration; even though the sensorium should be largely engaged’.92 Hallaran finished the opening discussion of his 1810 text by reemphasising both the distinction and the links between the ‘sensorium’ and the body:
Here we have sufficient evidence of the existence of insanity on the principle of mere organic [i.e. physical or bodily] lesion; holding a connection as it would appear, with the entire glandular system. Hence we may be led to suppose than an imperfect or a specific action in certain portions of this important department tends to lay the foundation of that affection, which I would under such circumstances, denominate the ‘mania corporea’ of Cullen; including at the same time within this species, the different varieties of the complaint as described by authors, depending upon the various causes, whether mechanical or otherwise, as affecting the sensorium, and the other important organs of the animal economy.93
‘Cullen’ was Dr William Cullen (1710–1790), a prominent Scottish physician who had substantial influence on an entire generation of prominent asylum doctors including Hallaran, John Ferriar, Benjamin Rush and Thomas Trotter, author of A View of the Nervous Temperament.94 Cullen was the first asylum doctor to use the term ‘neurosis’ which, in contrast with later usage, he used to denote a range of psychiatric disorders that occurred in the absence of pyrexia (i.e. in the absence of raised body temperature).95 Consistent with Cullen’s approach, Hallaran’s distinction between organic (physical) and non-organic (psychological and moral) factors in causing mental disorder was to consolidate the foundation for much subsequent work on determining causes of insanity throughout the nineteenth and twentieth centuries.
Syphilis, for example, was cited as a major cause of admission to psychiatric institutions throughout nineteenth-century Europe,96 despite the fact that accurate diagnosis was not possible prior to the work of August Paul von Wassermann (1866–1925), the German bacteriologist who developed a complement fixation test for syphilis in 1906.97 Nevertheless, Hallaran undertook to gather the first systematic data on the causes of psychiatric admissions in Ireland, and identified, as best he could, that venereal disease accounted for a lower proportion of admissions in Ireland than elsewhere.98
Towards the end of the nineteenth century, several decades after Hallaran’s textbook appeared, the classification of mental disorders underwent further revision as Emil Kraepelin (1856–1926), a German psychiatrist, divided all mental disorders into 13 groups, including two groups of ‘functional psychosis’ (i.e. mental disorders involving a loss of contact with reality but without demonstrable organic or physical cause).99 These two groups were: affective psychosis (in which loss of contact with reality was accompanied by disturbance of mood) and non-affective psychosis (in which it was not).
Kraepelin’s classification, like Hallaran’s approach, recognised the key role of organic or physical factors in producing certain cases of mental disorder, but went a step further by dividing ‘functional psychosis’ into these two separate groups. This classification duly led to the emergence of ‘manic depression’ (bipolar disorder, sometimes involving psychosis with prominent mood disturbance) and ‘dementia preacox’ (schizophrenia, or psychosis without prominent mood disturbance) as substantive diagnostic entities which are broadly still retained in current classification systems.100 The distinction between organic and functional disorders, as emphasised by both Hallaran and Kraepelin, is also retained in diagnostic and clinical practices some two centuries after Hallaran’s text first appeared.
Unsurprisingly, Hallaran was, like virtually all of his peers, deeply concerned with ‘the extraordinary increase of insanity in Ireland’, which he, characteristically, attributed to both ‘corporeal’ (i.e. bodily) and ‘mental excitement’,101 and which he also related to the effects of social unrest,102 ‘terror from religious enthusiasm’,103 and ‘the unrestrained use and abuse of ardent spirits’,104 among other factors. Unlike many of his peers, however, Hallaran brought a great deal of systematic and critical thought to the treatment of mental disorders, expressing scepticism about many of the established remedies of the times and notable enthusiasm for others.
Treatments in the Late 1700s and
Early 1800s: Spin Doctors
In his 1810 textbook, Hallaran provided a careful consideration of many traditional physical treatments for mental disorder (e.g. bloodletting); a detailed exploration of novel treatments (e.g. Dr Cox’s Circulating Swing, which is explored shortly); and a re-evaluation of traditional medicinal remedies (e.g. opium) and various other approaches (e.g. shower baths, diet and exercise).105
These treatments, and Hallaran’s relatively scientific approach to them, represented a shift from older, more traditional practices which, according to Lady Jane Wilde (1821–1896), included placing the mentally ill person in a pit in the ground (three feet wide and six feet deep), with only the head uncovered, and leaving him or her alone for three days and three nights, without food or contact with anyone.106 A harrow-pin (from a harrow, an agricultural instrument) was placed over the person, owing to the alleged mystical properties of harrow-pins. If the unfortunate person survived this dreadful ordeal, it was reported that a cure might be effected, although Lady Wilde conceded that the majority of those who survived emerged from the pit cold, hungry and mentally worse than ever.
Lady Wilde also recounted folk beliefs that madness was both hereditary and caused by demonic possession, and could be cured by drinking honey, milk and salt in a seashell before sunrise.107 Other treatments included exorcism by witch doctor, which involved the local witch doctor drinking whiskey, speaking unintelligibly at some length, throwing holy water over the patient and room, hitting the patient repeatedly with a blackthorn stick (while the patient was held down), and then swirling the blackthorn stick wildly around the room hitting any people or objects it encountered.108 Particular attention was paid to hitting the door through which the demon would allegedly escape. The exorcist was comprehensively fortified with whiskey throughout this elaborate, alarming, brutal process.
It is not entirely clear when this ritual dates from, how long it persisted, or whether it occurred at all, but Lady Wilde goes on to describe a specific example which, she says, took place ‘lately’ (her book appeared in 1890).109 If Lady Wilde’s sources are to be regarded as reliable, this is a most disturbing case. It concerns a man in Roscommon who apparently became mentally ill and was bound hand and foot, foaming at the mouth. He was described as ‘elf-stricken’ as it was believed he had been replaced by a fairy demon. The witch doctor was summoned and concluded that the unfortunate man had been replaced by a horse which needed to be fed oats in order to keep the horse alive and, thus, keep the real man (now in Fairyland) alive too.
At this, the patient was forcibly fed a sheaf of oats while the exorcist and the general company sent for five kegs of poitín (poteen, a strong, distilled, alcoholic Irish beverage) to fortify themselves for the exorcism ahead. A bucket of cold water was thrown on the patient’s head and the exorcism began. In the midst of the ritual, however, the patient was untied and immediately made as if to attack the witch doctor, with the result that the witch doctor and all the others fled the house, pursued by the extremely irate patient. The patient was, however, soon overpowered and again tied up, after which a magistrate ordered that he be brought to Roscommon Lunatic Asylum, where he is said to have died.
By way of contrast with these disturbing, dramatic tales, Hallaran’s treatment techniques in Cork in the early 1800s were significantly less punitive, although they were not entirely without drama either. Turning to traditional physical treatments first, Hallaran expressed particularly little faith in venesection (bloodletting) which was a common treatment for a range of conditions, including mental illness, for many centuries.110 While acknowledging the usefulness of venesection in certain circumstances, Hallaran generally felt that ‘bleeding to any great extent does not often seem to be desirable, and except in recent cases, does not even appear to be admissible’.111 This was consistent with the views of Dr William Battie (1703–1776), influential author of Treatise on Madness, who had written in 1758 that bloodletting was positively harmful if the patient was feeble or suffering from convulsions.112
The administration of emetics, to make the patient vomit, was another common treatment for a range of disorders,113 but while Hallaran acknowledged ‘the use of emetics in all febrile affections’ (i.e. infections producing high body temperature),114 he was cautious about their use in mental disorder: ‘I have been a witness to very disagreeable consequences arising from the want of necessary precaution on this head, which have deterred me from directing full emetics in any case’. Battie was similarly circumspect about vomiting.115
Notwithstanding these views, emetics and purgatives were commonly used for a range of physical and mental disorders in Ireland and elsewhere: in 1810, the same year that Hallaran published his textbook, Dr Martin Tuomy, Fellow of the Royal College of Physicians of Ireland, produced his Treatise on the Principal Diseases of Dublin116 in which he explicitly endorsed the use of purgatives and emetics, which might be administered daily for up to 21 days. As was the case with bloodletting, these treatments were aimed at evacuating noxious ‘humours’ from the body in order to produce clinical improvement. There was, however, growing disenchantment with the indiscriminate use of emetics and purgatives throughout the nineteenth century, and prescriptions for more violent emetic and purgative agents declined as the century progressed.117
Hallaran noted that patients occasionally exhibited ‘excessive obstinacy’118 and, in such circumstances, he recommended the use of the ‘circulating swing’ which had been recently developed by Dr Joseph Mason Cox (1763–1818), a Bristol-born mind doctor.119 Building on the work of Dr Erasmus Darwin (1731–1802) who described a ‘rotative couch’ aimed at inducing sleep,120 Cox suggested suspending a chair from the ceiling by means of ropes; seating a patient securely in the chair; and instructing an asylum attendant to rotate the chair at a given speed, thus spinning the patient around a vertical axis for a given period of time.121 This technique was employed at many asylums throughout nineteenth-century Europe, especially in German-speaking countries.122 It was, according to Cox, ‘both a moral and a medical mean in the treatment of maniacs’.123
In Ireland, Hallaran ‘was not slow in taking advantage of Dr Cox’s observations’124 and assembled an apparatus that was ‘so contrived, that four persons can if necessary, be secured in it at once’.125 Hallaran used this ‘Herculean remedy’ for patients ‘who have been recently attacked with maniacal symptoms, and who, previous to its employment, had been sufficiently evacuated by purgative medicines’.126
In the ‘obstinate and furious’ the swing reportedly generated ‘a sufficiency of alarm to insure obedience’, while in the ‘melancholic’ it generated ‘a natural interest in the affairs of life’.127 Hallaran warned against indiscriminate use of the apparatus, advising particular caution with tall patients and noting that certain patterns of rotation could produce ‘sudden action of the bowels, stomach and urinary passages, in quick succession’.128 Despite these drawbacks, the swing was also a source of entertainment for certain patients who ‘used it sometimes when permitted, as a mode of amusement, without any inconvenience or effect whatever’.129
Despite Hallaran’s awareness of the adverse effects of the swing, his insistence on ‘careful superintendence’130 and his belief that he was acting in his patients’ best interests, it is clear that Cox’s Circulating Swing belonged to an era prior to the development of more humane treatments for the mentally ill and prior to clear enunciation of their rights.131 From today’s perspective, Hallaran’s use of the swing appears misguided: some two hundred years later, it is to be hoped that increased emphasis on the rights of the mentally ill will ensure sustained emphasis on the dignity of patients during treatment and enhance the provision of evidence based therapies that are humane, safe, effective and acceptable to patients and their families.132
Hallaran’s 1810 textbook concluded with detailed evaluations of a range of therapeutic approaches to mental disorder, including traditional medicinal remedies (digitalis, opium, camphor and mercury) and physical treatments for insanity (shower baths, diet and exercise). Digitalis,133 which appeared to act by ‘restraining the inordinate action of the heart and arteries’,134 had, according to Hallaran, substantial ‘merits as an anti-maniacal remedy, on as high a scale as can well belong to any one subject of materia medica’.135 The current understanding of the action of digitalis (chiefly on a sodium pump enzyme) suggests that digitalis may indeed have had an effect on the brain,136 but it was not until the work of Dr William Withering (1741–1799) that the issues of standardised preparation and dose-response characteristics were identified as critical for the safe and effective use of the drug.137
Hallaran believed that opium138 had ‘deservedly obtained a principal character amongst anti-maniacal remedies’139 but that camphor, another common treatment,140 ‘frequently failed altogether’ in the treatment of mania.141 He had similar doubts about mercury142 except, perhaps, ‘as a preparative for the commencement of the digitalis’.143
Hallaran was notably enthusiastic about water treatments,144 maintaining that the shower-bath worked ‘by immediately tranquilising the high degree of febrile action’145 and ‘answers an extremely good purpose in enforcing cleanliness at all seasons’ (a real consideration in large, unhygienic asylums).146 Other water treatments of the day primarily aimed at inducing shock and terror, and included the ‘bath of surprise’ whereby the mentally ill person was thrown from a bridge into running water and caught with a net; being dragged through a river; or being forced into a dark room, one half of which comprised a cistern of water into which the person would inevitably fall while seeking to escape.147
In 1756, Charles Lucas (1713–1771), a radical Irish physician, apothecary and politician, had published an enthusiastic, influential Essay on Waters dealing with ‘simple waters’, ‘cold medicated waters’ and ‘natural baths’:
It will appear strange to every attentive reader, that the most useful and necessary part of the creation, whether economically, physically, or medicinally considered, has been so far, and so long neglected, as to make it, at this day, necessary to compile so large a volume as this, to rectify men’s notions in so interesting a point!
[…] Warm bathing, for the like reasons, had long been an established and approved remedy amongst the ancients, in all kinds of mania or madness; though in this, as well as other respects, it has become so much neglected by the moderns.148
In 1772, a year after Lucas’s death, a similarly themed volume was published in Dublin, titled The Theory and Uses of Baths, Being an Extract from the Essay on Waters by the Late Charles Lucas, Esq., MD, with Marginal Notes by Dr Achmet, Illustrated by Some Annexed Cases.149 The distinctly enterprising ‘Dr Achmet’ (also known as Patrick Kearns and Patrick Joyce) ran the Royal Patent Baths at Bachelors Walk in Dublin, offering a range of water therapies, including hot and cold baths flavoured with putrefying horse manure.150 In the 1772 volume, ‘Dr Achmet’, perhaps unsurprisingly, recounted excellent testimonials from his clients, including the following fulsome account of one water cure:
My case when I began the use of the vapor baths was as follows; the disorder in my head had arose to such a degree, that I was in almost a constant state of delirium, and my mind so full of inquietude and uneasiness, that I could not stand or sit any length of time in one place, and at certain times, my bowels seemed full of pains and inflammations, and an almost constant burning painfulness in my fundament, with a callous lump below my groin; in short, my situation was such, that rest, either day or night, I was a stranger to.
I have now been one month under the doctor’s care [‘Dr Achmet’], in which time he has treated me with the utmost tenderness, attention and care; and since the first week of my residence with him, I have daily continued recovering the use of my senses, and faculties, and my disease seems, in every place that it affected me, to have submitted to the salutary effects of his medicines and vapor baths; in such a manner am I now, that I hope, through the blessing of God, of being as well as ever I was in my life. I must here observe, that when I first went into the vapor, or steaming bath, my time was limited every other day to about an hour, and that in the last week of my being there, I generally spent every day from three to four hours in the said bath …
… I have continued to recover my strength, and am light, supple, and full of spirits at this time …151
Back in Cork, Hallaran, in addition to promoting water treatments, also recognised the importance of diet and described the asylum’s ‘farinaceous diet’ (i.e. consisting of meal or flour)152 in some detail. ‘Animal food’ was carefully restricted to ‘certain seasons of the year’ owing to its tendency to produce a ‘disposition to riot’ and ‘aggravation of insanity’.153 This was an intriguing objection to meat, given the centrality of alcohol (wine, beer, porter, etc.) in asylum diets – for both patients and attendants – throughout much of the 1800s.154 (The cost of wine and spirits could be included in the budget for ‘medicines’, which was helpful).155
Regulation of diet was a key element in programmes of ‘moral management’ which were employed in most Irish asylums throughout the nineteenth century.156 Other elements included regular exercise and gainful occupation.157 This therapeutic approach, along with the principle of the ‘panopticon’ (having a point from which an unseen governor could see all), had a critical influence on the design of many Irish asylums constructed during the great ‘asylum-building era’ of the nineteenth century,158 The ‘moral management’ paradigm actively informed the ‘Kirkbride Plan’, advocated by Thomas Story Kirkbride (1809–1883), a Philadelphia mind doctor.159
Hallaran also paid considerable attention to exercise and gainful activity. He suggested ‘removing the convalescent, and incurable insane, to convenient distances from large cities and towns, to well enclosed farms, properly adapted to the purposes of employing them with effect, in the different branches of husbandry and horticulture’.160 Over the following two hundred years, various developments in the practice of psychiatry (including the introduction of neuroleptic medication) were to tilt the balance away from this broad based, multi-modal approach to treatment recommended by Hallaran. The late twentieth century, however, saw the re-emergence of reenergised models of biopsychosocial psychiatry which emphasised the role of occupational therapies in the process of recovery,161 consistent with the approach outlined by Hallaran almost two centuries earlier.
Developments in England,
France and the United States
As these developments and innovations in treatment were unfolding in late eighteenth- and early nineteenth-century Ireland, especially in Hallaran’s establishments in Cork, they coincided, to greater or lesser extents, with significant shifts in practice elsewhere. In England, the asylums that emerged during the 1700s were mostly highly custodial places and, although there were inevitably pockets of enlightened practice, there were also clear, systematic problems across the emergent system. At Bedlam in London, there were continual reports of abuse and poor conditions, albeit accompanied by contrasting reports of good treatment at times, with the result that Bedlam was subject of interminable speculation among journalists, politicians and the public, to whom it provided endless cause for concern and morbid fascination.162
More broadly, the asylums of eighteenth-century England included a range of different establishments including, for example, St Luke’s Hospital in London, which accepted its first patients in July 1751.163 In what would be a remarkably consistent pattern across institutions and across countries, numbers at St Luke’s rose steadily following its opening. Battie, its founding medical officer and the leading asylum doctor of his day, duly wrote in strong support of confinement as a key element in management of the mentally ill, stating that confinement was always necessary and sometimes sufficient to effect a cure.164 Battie’s uncompromising stance strongly reinforced the emphasis on asylums in the treatment of the mentally ill over the following decades.
In addition to its allegedly unique therapeutic potential, the asylum was also, according to Battie, essential for the education of physicians.165 England’s first provincial subscription asylum was duly established in Newcastle in 1765, and many others followed (e.g. Manchester in 1766, York in 1777). While regulations governing various specific practices were in place in these establishments, restraint, coercion and punishment still featured strongly, at least until evidence of abuses in Bedlam and York were later exposed.166
The most palpable sign of change appeared in the 1790s, when William Tuke (1732–1822), a Quaker tea merchant, founded and opened The Retreat at York following the death of a Quaker woman in York Asylum.167 The Retreat aimed to provide care for the mentally ill in a humane and nurturing setting, and patients were allowed access to the grounds, housed in comfortable settings, and generally treated with sympathy.168
Tuke was an admirer of Dr Philippe Pinel (1745–1826)169 of the Salpêtrière Hospital in Paris, who published an influential textbook promoting principles similar to those that underpinned Tuke’s initiative.170 Many of Pinel’s proposals were later championed by Dr Jean-Étienne-Dominique Esquirol (1772–1840) in Charenton, Paris and at the Salpêtrière. Pinel was an inveterate reformer, rejecting the established practices of bloodletting and purging, and concluding that mental disorder stemmed from heredity or ‘passions’ such as sadness, fear, anger or elation.
Most famously, Pinel became known for removing the chains from female patients at the Salpêtrière in 1800, some three years after his assistant, Jean-Baptiste Pussin (1746–1811), had done so for male patients at the Bicêtre. In fact, Pinel’s initiative commenced in the early 1790s and built steadily over the following years.171 More broadly, it was Pinel’s sympathetic writings about the mentally ill, portraying them as unfortunate persons deserving of respect and sympathy, that likely had the greatest impact on public perceptions of the mentally ill in France and other parts of Europe.172
These shifts in approach, exemplified by Tuke in England and Pinel in France, resulted in greater recognition of the idea that mental illness was a problem for which society had responsibility, and that the mentally ill should be treated with dignity. This idea did not rest easily, however, with the traditions of coercion, punishment and poor treatment that had evolved in many eighteenth-century English asylums.
In Ireland, Hallaran, like Tuke and Pinel, was a key figure in developing progressive, humane approaches to the mentally ill, warning strongly against reliance on simple force, and promoting the idea of speaking with each patient as an individual human being:
Maniacs, when in a state to be influenced by moral agents, are not to be subdued ex officio, by measures of mere force, and he who will attempt to impose upon their credulity by aiming it at too great a refinement in address or intellect, will often find himself detected, and treated by them with marked contempt … I have in consequence made it a special point on my review days, to converse for a few minutes with each patient, on the subject which appeared to be most welcome to his humour. By a regular attention to the duties of this parade, I am generally received with as much politeness and decorum as if every individual attached to it, had a share of expectancy from the manner in which he may happen to acquit himself on the occasion. The mental exertion employed amongst the convalescents by this species of address is very remarkable, and the advantages flowing from it are almost incredible.173
Hallaran’s engagement with each patient on the subject the patient wished to speak about was entirely consistent with the more humane, respectful approach recommended by Tuke and Pinel. In retrospect, Hallaran’s approach is also consistent with twenty-first century ideas about engaging with patients’ symptoms in direct ways,174 as reflected in, for example, the increasing use of cognitive behaviour therapy (a talking therapy focused on thoughts and behaviours) for psychosis in the late twentieth century, focusing on understanding and interpreting symptoms, with patients and therapists working together to co-create a shared dialogue.175
In parallel with developments in Europe, the 1700s also saw several significant moves towards organised care for the mentally ill in the US. In 1729, the first identifiable psychiatric ward was created in the Boston alms house when persons with mental illness were separated from other inmates.176 The mid-1700s saw the establishment of the Pennsylvania Hospital in Philadelphia, which took its first admissions in 1752 and was devoted to the care of the sick and mentally ill.177 Conditions for the mentally ill were, however, generally poor and an admission fee was charged for members of the public who wished to visit the insane wing of the establishment as spectators.
The first hospital devoted exclusively to mental illness in the US, Virginia Eastern Lunatic Asylum in Williamsburg, was established in 1770, and the first patients admitted three years later.178 Notwithstanding these developments, most of the care and support needs of the mentally ill in colonial America were still met by families and communities, albeit increasingly backed up by the alms houses and hospitals that emerged in the later 1700s.179
Subsequent developments in the US during the 1800s, especially the drive to establish mental hospitals, were driven by a range of diverse factors, including demographic changes, growing awareness of the social problems presented by the mentally ill, the philanthropic impulses of various elite groups, and developments in psychiatric practice in Europe and elsewhere. In France, for example, the 1700s had seen care of the mentally ill chiefly located in general hospitals, workhouses and hospices,180 although the Salpêtrière and Bicêtre in Paris would later lead the way in reforming conditions for the mentally ill. Clearly, a time of substantial change had arrived in France, the US, England and Ireland, focusing – chiefly and regrettably – on well-meaning institutional provision for the mentally ill.
Asylums for the Mentally Ill: Inevitable, Inexorable, Unstoppable?
Given these developments in Ireland and elsewhere during the late 1700s and early 1800s, and the long standing, unresolved problems presented by the mentally ill, it is useful to pose the question: was there any alternative to the asylums that emerged so resolutely throughout the 1800s and dominated the history of psychiatry until the late 1900s? Were they inevitable? Inexorable? Unstoppable?
There can be no doubt about the need for some kind of solution to the urgent problems presented by the destitute mentally ill in eighteenth-century Ireland.181 No sooner had a House of Industry been opened in North Brunswick Street in Dublin in 1773, for example, than it needed to deal with an extraordinary influx of destitute persons with mental disorder.182 In 1776, 10 cells were specifically dedicated for the mentally ill; in 1778, an entire extra house was taken over for persons with mental disorder; in 1798, 32 additional cells were required; and 10 years later, 4 more cells were added. Between 1799 and 1802, some 3,679 persons died in this House of Industry, many of them mentally ill.
Nationwide, the Houses of Industry, by 1804, contained disturbingly large numbers of persons with mental disorder or intellectual disability, including 118 in the Dublin House of Industry, 90 in Cork, and 25 in Waterford.183 Conditions in the Limerick House of Industry were particularly brutal, with one 1806 report indicating that mentally ill persons were kept naked, chained, handcuffed and exposed to the elements.184 More specifically, John Carr, in The Stranger in Ireland, described disturbing scenes of mistreatment, neglect and cruelty in the Limerick establishment, which he visited in 1805:
Under the roof of this house, I saw madmen stark naked girded only by their irons, standing in the rain, in an open court, attended by women, their cells upon the ground-floor, scantily supplied with straw, damp, and ill-secured. In the wards of labour, abandoned prostitutes, in rags and vermin, each loaded with a long chain and heavy log, working only when the eye of the superintending officer was upon them, are associated throughout the day with respectable old female housekeepers, who, having no children to support them, to prevent famishing, seek this wretched asylum. At night, they sleep together in the same room; the sick (unless in very extreme cases) and the healthy, the good and the bad, all crowded together. In the venereal ward, the wretched female sufferers were imploring for a little more covering, whilst several idiots, squatted in corners, half naked, half famished, pale and hollow-eyed, with a ghastly grin, bent a vacant stare upon the loathsome scene, and consummated its horror. Fronting this ward, across a yard, in a large room, nearly thirty feet long, a raving maniac, instead of being strapped to his bed, was handcuffed to a stone of 300lbs [136 kilograms] weight, which, with the most horrible yells, by a convulsive effort of strength, he dragged from one end of the room to the other, constantly exposed to the exasperating view and conversation of those who were in the yard. I have been well informed that large sums of money have been raised in every county for the erection of mad-houses: how has this money been applied?185
Clearly, despite the Inspector General of Prisons having the power, since 1787, to inspect all places where the mentally ill and intellectually disabled were kept,186 there were still real problems with conditions of confinement. Walsh summarises the position:
By the closing decades of the 18th century lunacy had become a problem not only for families of property but also for those responsible for maintaining civil order. The first action was taken against lunatics who were vagrants, beggars or thieves. These were sent off to bridewells or jails and left to languish there often until they died. Their general state and condition was subject to the scrutiny of the Inspectors of Prisons, a role which had been created around 1770. Prisons were plentiful in Ireland and no town with any pretensions towards importance lacked one. With the coming of the 19th century, public lunacy became a social problem of some magnitude.187
Against this rather bleak background, it was increasingly clear that the twin problems of destitution and mental illness in nineteenth-century Ireland needed to be addressed both urgently and systematically. But what, precisely, was to be done?
Looking at the management of mental disorder in particular, Battie, in his 1758 Treatise on Madness, set out clear views that while mental illness was still poorly understood,188 it was clear that asylums were absolutely essential for both the treatment of patients and the education of physicians.189 Battie had particular views about the causes of ‘madness’,190 chiefly related to the brain, and emphatically recommended confinement in asylums, ideally far distant from the patient’s home, with spectators banished from the buildings along with any other persons that might excite the patients and impede recovery.191 This regime would bring considerable benefits, according to Battie, who also warned against confining the mentally ill in prisons or regarding them as public nuisances: mental illness was, in his view, both manageable and curable.192
In addition to confinement, Battie dutifully devoted attention to the roles of specific treatments in the management of the mentally ill, such as bleeding, opium, mineral waters and vomiting.193 But the chief argument in his Treatise on Madness concerned asylums, which he felt should be places of treatment rather than simple confinement, and where conditions should be hygienic, therapeutic and markedly different to those prevailing in prisons.
Battie was a leading figure of his time, a fellow of the Royal College of Physicians in London and physician at St Luke’s Hospital, and his views were highly influential. Shorter goes as far as to argue that the birth of psychiatry commenced in earnest with Battie.194 Given his strong promotion of asylums, his broad professional influence, the clear social problems presented by the mentally ill, and the philanthropic impulses of the governing classes of the 1800s, the die was soon very firmly cast in the form recommended by Battie: the 1800s were to be the century of the asylum.
