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THE NINETEENTH CENTURY:

GROWTH OF THE ASYLUMS

… it is of the utmost importance that cases of insanity should as speedily as possible be removed to an asylum.

Lunatic Asylums, Ireland, Commission, Report of

the Commissioners of Inquiry into the State of the

Lunatic Asylums and Other Institutions for the

Custody and Treatment of the Insane in Ireland:

with Minutes of Evidence and Appendices (1858)1

For the mentally ill, the tone of the turbulent nineteenth century was set firmly by the Criminal Lunatics Act 1800, implemented following the attempted assassination of King George III at the Drury Lane Theatre, London in May 1800 by James Hadfield, a dragoon suffering from mental disorder and, possibly, brain injury.2 The legislation established a procedure for the indefinite detention of mentally ill offenders and led to state funding of accommodation for apparent criminal lunatics at Bethlem in London.

In Ireland, the Hospitals and Infirmaries (Ireland) Act 1806 enabled Grand Juries to present money for wards for lunatics in connection with County Infirmaries and for the maintenance of asylums in connection with the Houses of Industry.3 There was still enormous pressure on the House of Industry in Dublin and in 1810 monies were made available for the building of a public asylum, named the Richmond Asylum, in honour of the Duke of Richmond, Lord Lieutenant of Ireland. The establishment was later known as the Richmond District Lunatic Asylum (from 1830), then as Grangegorman Mental Hospital and, from 1958, as St Brendan’s Hospital.

In the early days of the Richmond, Dr Alexander Jackson (1767–1848), a physician at the House of Industry, had an especially keen interest in the mentally ill, having visited asylums abroad and provided advice on the new Richmond building.4 The architect was Francis Johnston, whose other work includes Dublin General Post Office, and the asylum was built on a plan similar to that of Bethlem. The first patients from the House of Industry were transferred in 1814 and the Richmond was officially opened the following year, when an act was passed establishing its governors as a corporation with perpetual succession.5

The new Richmond Asylum, with Jackson and Hugh Ferguson as physicians, and Andrew Jackson as surgeon, was determined to provide enlightened care to the mentally ill and avoid the use of physical restraint wherever possible. Initial reports were duly positive, noting that no more than one patient in twenty was confined to his or her room, and in most of those cases the reason for confinement was physical illness rather than disturbance due to mental disorder.6 In the early 1830s, the Richmond Asylum, valued with its furniture at £80,000, was handed over from the government to the District, comprising counties Meath, Wicklow, Louth and Dublin.7 In 1846, the Inspector of Lunatic Asylums reported positively:

I have been in the habit of visiting this institution frequently during the last year, and of inspecting it very minutely, and have also had the pleasure of attending the Board of Governors on various occasions. It is unnecessary for me to add, that the general business is most satisfactorily performed […]. The Asylum continues to maintain its high character as being one of the best-managed institutions in the country; and also for the great order, regularity, and state of cleanliness in which it is kept. The beds and bedding are kept always very clean.8

The Inspector, Dr Francis White, felt it was ‘necessary to enlarge the Richmond Asylum by the addition of a wing to accommodate 100 patients, and also of an infirmary, so that the Asylum, when enlarged, may altogether be adequate to the accommodation of 400’.9

Throughout the early decades of the 1800s, the Richmond Asylum was at the forefront of both therapeutic enthusiasm and efforts to reform and expand Ireland’s emerging asylum system. This initiative built on progress elsewhere, especially the humanitarian approach of Pinel in Paris, who pioneered less custodial approaches to asylum care, and Tuke’s York Retreat, based on policies of care and gentleness, as well as medical supervision.10

From its establishment, the Richmond pioneered ‘moral management’ in Ireland. Esquirol, in France, had defined moral management as ‘the application of the faculty of intelligence and of emotions in the treatment of mental alienation’.11 The moral management approach represented a significant break from the past which had emphasised custodial care rather than engagement with each patient as an individual. In more recent decades, the moral management approach might well be compared with ‘milieu therapy’ involving a group-based approach to recovery and establishment of therapeutic communities,12 or occupational therapy.

Although its precise meaning was, at times, rather vague, moral management had the key benefit of representing a significant (although by no means complete) move away from traditional treatments such as bloodletting, routine confinement and restraint. Elsewhere in Ireland, mechanical restraint was an especially disturbing feature of asylums, initially involving manacles, hoops, chains and body-straps, with the emphasis moving to straitjackets in the early 1800s.13 Physical or bodily restraint was also used, as was chemical restraint, involving bromides, paraldehyde and chloral, among other substances. The moral management approach sought to reduce or end such practices, and strongly emphasised having a good diet, exercise and occupation, as well as reason and human interaction.14

The moral approach significantly influenced asylum design during this period15 and, to emphasise its commitment to the new model, the Richmond was run chiefly by moral governors during the first half of the nineteenth century; these included Richard Grace (1815–30) and Samuel Wrigley (1831–57), separated by a brief interlude during which Dr William Heisse (1830–1) ran the asylum. Heisse was removed from his post rather dramatically in June 1831, apparently owing to the poor condition of the institution.16

Notwithstanding the emergence, growth and relatively enlightened approach of the Richmond in the early 1800s, however, it was soon apparent that further, systematic provision was needed across Ireland for the care of the destitute mentally ill. In what would become a recurring paradigm in Irish mental health care, a committee was established to produce a report about the problem and, presumably, try to advance provision.

Select Committee on the Lunatic Poor in Ireland (1817):

‘Totally Inadequate for the Reception of the Lunatic Poor’

In March 1817, the indefatigable Robert Peel, Chief Secretary, persuaded the House of Commons to set up a select committee to look into the need for greater provision for ‘the lunatic poor in Ireland’.17 This followed on from the work of Sir John Newport (1756–1843) examining the plight of the ‘aged and infirm poor of Ireland’, including the mentally ill,18 but the 1817 initiative focused more specifically and emphatically on the ‘lunatic poor’. The committee heard a broad range of evidence, relating to many institutions, and the evidence that Mr James Cleghorn presented to the committee regarding St Patrick’s Hospital has already been explored in Chapter 1. The first paragraph of its final report stated the committee’s central finding bluntly:

Your Committee have enquired, as to the extent of the accommodation which may be afforded by the present establishments in the several counties of Ireland, and are of opinion, that those establishments are totally inadequate for the reception of the lunatic poor. An hospital attached to the House of Industry in Dublin, was originally the only receptacle in that city for persons of the lower class, who were afflicted with mental derangement; and the cells attached to the infirmaries or poor houses in some of the counties were by no means calculated for the restoration to sanity, or even for the safe custody and care of the unhappy persons who were suffering under so dreadful a malady.19

The committee noted that, in 1815, 170 persons with mental disorder were moved from the Dublin House of Industry into the newly established Richmond Asylum which, like the asylum established by Hallaran in Cork, appeared to be generally well run. The Richmond, however, was already full ‘and as the majority of patients are sent from the remoter parts of the country, it is in vain to hope to diminish it, unless by the establishment of other asylums’:

Your Committee beg leave to call the attention of the House to the detailed opinion expressed by the governors of the Richmond Asylum, that the only mode of effectual relief will be found in the formation of district asylums, exclusively appropriated to the reception of the insane. They can have no doubt that the successful treatment of patients depends more on the adoption of a regular system of moral treatment, than upon casual medical prescription … there should be four or five district asylums capable of containing each from one hundred and twenty to one hundred and fifty lunatics.20

The evidence presented to the committee about the desperate plight of the mentally ill outside asylums, which led to their call for more asylums, was, by any standards, compelling.21 John Leslie Foster, one of the governors of the Richmond, told the committee about conditions in the Dublin House of Industry which were, for many, ‘as defective as can possibly be imagined’.22 The committee asked if he thought ‘the accommodation in the House of Industry for lunatic patients is so defective that upon the whole it is a less evil to exclude them than to admit them?’ Foster responded:

I have seen three, I think, certainly two lunatics in one bed in the House of Industry. I have seen, I think, not fewer than fifty or sixty persons in one room, of which I believe the majority were insane, and the rest mere paupers not afflicted with insanity. I have seen in the same room a lunatic chained to a bed, the other half of which was occupied by a sane pauper, and the room so occupied by beds there was scarcely space to move in it …23

In other parts of the country, provision for the destitute mentally ill was simply non-existent: James Daly, another witness, was asked ‘what provision exists in the county of Galway for lunatic paupers?’ He responded: ‘None; any patients that I have known, it was necessary for them to be sent to Dublin’.24 The committee also heard there was no accommodation for ‘pauper lunatics’ in Cavan or Kerry, and that accommodation in Clare comprised ‘seven cells, adjoining to the House of Industry, together with a room for convalescent patients, which I deem totally inadequate’.

In a similar vein, Colonel Crosbie confirmed that there was a county infirmary in Kerry but when asked if there was ‘any separate accommodation for pauper lunatics’, he responded: ‘None that I am aware of’.25 Asked ‘would there be any difficulty in attaching a separate asylum to the present infirmary for lunatics’, Colonel Crosbie was emphatic: ‘None whatever; there is a large yard in which it could be erected’.

The 1817 committee also heard at some length from the illustrious Thomas Spring Rice (1790–1866), ‘life-governor, and member of the regulating committee for [Limerick] Lunatic Asylum for the last three years’, who, in 1815, ‘visited the asylums of Cork, Waterford, Clonmel and Limerick’.26 The asylum in Cork was ‘the best managed, not only that I had ever seen, but ever considered or heard of’.27 But Rice warned that the Cork establishment ‘derives everything, that can be derived from humanity and skill, from the physician who is at the head of it’28 (Hallaran, Chapter 1). The Cork arrangement was not, in Rice’s view, a solid basis for establishing a broader system of asylums; dedicated, systematic, legislative reform was needed at national level.

The situation in Cork contrasted sharply with that in Waterford, where Rice reported there were ‘a few miserable cells attached to the House of Industry, resembling an ill-constructed gaol rather than a retreat for lunatics’.29 In Clonmel, ‘so little understood was the management of the insane that they were unable even to keep them clothed, and some were lying in the yard upon straw in a state of nakedness’.30

Matters were worse again at the ‘Lunatic Asylum of Limerick, in which the accommodation afforded to the insane’ was ‘such as we should not appropriate for our dog-kennels’. There was no heating or ventilation, and the mentally ill were ‘exposed during the whole of the winter to the extremities of the weather’, resulting in amputations (owing to ‘that mortification in the extremities, to which the insane are peculiarly liable’) and deaths (owing ‘to the extreme coldness of the situation’):

… two, and sometimes, I believe, three of the insane have been condemned to lie together in one of those cells, the dimensions of which are six feet by ten feet seven inches; some of them in a state of furious insanity. In order to protect them from the obvious results, the usual mode of restraint was by passing their hands under their knees, fastening them with manacles, fastening bolts about their ankles, and passing a chain over all, and then fastening them to a bed. I can assure the Committee, from my own knowledge, they have continued for years, and the result has been (and I believe an honourable friend of mine may also have witnessed the fact) that they have so far lost the use of their limbs, that they are utterly incapable of rising.31

Other parts of the Limerick establishment were designated for the physically ‘sick, as well as for such insane as may be trusted at large without actual danger’:

In one of these rooms I found four-and-twenty individuals lying, some old, some infirm, one or two dying, some insane, and in the centre of the room was left a corpse of one who died a few hours before. Another instance was still stronger: in the adjoining room I found a woman with the corpse of her child, left upon her knees for two days; it was almost in a state of putridity. I need not say the woman was almost in a state of distraction; another was so ill that she could not leave her bed; and in this establishment, with governors ex officio, and with all the parade of inspection and control, there was not to be found one attendant who would perform the common duties of humanity.32

To compound matters, Rice reported that during a period of ‘fever’, ‘all medical attendance had been discontinued’ and prescriptions were issued from ‘a mile and quarter distance’. In addition to poor conditions and neglect, there was also evidence of active abuse, as ‘the keeper of the lunatics claimed an exclusive dominion over the females confided to his charge, and which he exercised in the most abominable manner; I decline going into the instances, the character of which are most atrocious’. While Rice reported that, since these events, there had been changes in personal and practice at the Limerick establishment (on the advice of ‘Dr Hallaran in Cork’), the committee was clearly still deeply impressed by Rice’s compelling evidence.

Against this background, the committee, in its conclusions, had no doubt but that a properly governed network of district asylums was needed in order to remedy the plight of the destitute mentally ill, an issue which was, they noted, ‘so materially importing the character of the country, and so deeply interesting to humanity’:

Your Committee have observed with satisfaction, the disinterested labours of those who have superintended the Asylums in the cities of Dublin and Cork; and if they were to go into any detail of the principles on which the establishments which they propose might be best administered, they would earnestly recommend an entire conformity to the system laid down and acted on in the Richmond Lunatic Asylum, as that system appears to have been considered with great anxiety and acted on with signal success.33

John Leslie Foster, one of the governors of the Richmond Lunatic Asylum, gave evidence to the committee about the background to the Richmond’s approach and Foster’s evidence, like that of Rice outlining abuses in Limerick, shaped the committee’s thinking substantially. Foster reported:

Until within these very few years a much greater degree of coercion has been generally applied in the treatment of lunatics, than is now found to be necessary; a few years ago Mr Pinel, a French physician [Chapter 1], who had the charge of the principal receptacles for the insane at Paris proposed and published a more gentle mode of treatment. It appears in his hands to have been attended with great success; this mode was introduced into this country, I believe, in the first instance in the Quakers Asylum near York; the good effects of which are illustrated in a publication of a Mr Took [sic],34 the manager of that asylum; and this system appearing to the governors of the Richmond Lunatic Asylum to be founded in good sense, they determined on trying the experiment in their new institution. I beg to add as a proof of this, that there is not in the Richmond Lunatic Asylum, to the best of my belief, a chain, a fetter, or a handcuff. I do not believe there is one patient out of twenty confined to his cell, and that of those who are confined to their cells, in the greater number it is owing to derangement in their bodily health, rather than to the violence of mania.35

The stirring endorsement of the Richmond’s approach in the 1817 report led to the passage of the Asylums for Lunatic Poor (Ireland) Act 1817 which was amended by the Lunatic Asylums (Ireland) Act 1820, and both of which were then repealed by the Lunacy (Ireland) Act 1821,36 which aimed ‘to make more effectual provision for the establishment of asylums for the lunatic poor, and for the custody of insane persons charged with offences in Ireland’. More specifically, the 1821 Act stated that ‘it shall and may be lawful for the lord lieutenant by and with the advice and consent of his Majesty’s privy council in Ireland, to direct and order that any number of asylums for the lunatic poor in Ireland shall be erected and established in and for such districts in Ireland, as to the said lord lieutenant and privy council shall seem expedient’.37

On the heels of this provision, a mere four years after the hard-hitting 1817 report, the creation of Ireland’s district asylums commenced in earnest: four district asylums were rapidly completed during the remainder of the 1820s (Armagh,38 Belfast,39 Derry and Limerick) and five more by 1835 (Ballinasloe, Carlow, Waterford, Maryborough (Portlaoise) and Clonmel).40 Together, these establishments had the capacity to accommodate 1,062 patients in all. This development was consistent (although not continuous) with the emergence of various medical hospitals supported by the professional and merchant classes in the 1700s, the establishment of further ‘voluntary’ medical hospitals in the 1830s, and widespread provision of ‘fever hospitals’, along with increased organisation of the medical profession, especially dispensary doctors, during this period.41

All of these developments represented significant changes for the poor, the ill and the excluded in nineteenth-century Ireland: social problems were pressing; institutions were the answer; and the mentally ill were among those most desperately in need of care. The era of the asylum had well and truly arrived.

Treatment in Asylums: ‘Education and Training

form the Basis of the Moral Treatment’

The establishment of Ireland’s asylums was accompanied by a significant consolidation and expansion of the roles of doctors in the treatment of the mentally ill and management of the new institutions. At the Richmond, Dr John Mollan (a native of Newry, educated in Edinburgh) was appointed as ‘physician extraordinary’ in January 1836 owing to his medical experience across various Dublin hospitals and a particular interest in the insane.42 Two years later, Mollan presented a detailed ‘statistical report on the Richmond Lunatic Asylum’ at the Evening Meeting of the Royal College of Physicians on 26 March 1838.43

Mollan commenced his overview by emphasising that the Richmond was intended not just for the safekeeping of the insane, but for their rational treatment and cure. The Richmond was, he said, the first institution in Ireland specifically constructed for the classification of the insane, with a view to the provision of better, more appropriate care. Mollan was a strong proponent of laborious employment and, in 1838, 60 men were involved in cultivating the Richmond asylum grounds; 15 were employed in various trades (e.g. tailors, shoemakers, carpenters); and others were engaged in activities such as making mats and domestic work. Female patients were occupied with spinning, knitting, needlework, washing and other domestic tasks.

Mollan, who was instrumental in establishing a patients’ library in 1844, became senior physician at the asylum in 1848, following the death of Dr Alexander Jackson.44 Mollan was a remarkable figure who had previously assisted with the fever epidemic in Galway (1822) and went on to serve as president of the King and Queen’s College of Physicians in Ireland (1855–6).45 He took an active part in the formation of the Royal Medical Benevolent Fund and was noted for his charitable works. In 1852, Mollan was also involved in efforts to establish a school at the Richmond, an initiative which was taken up with enthusiasm by Dr Joseph Lalor, RMS from 1857 to 1886,46 who wrote:

I consider that education and training are most valuable agents in the treatment … and that it expresses in name and substance what has been long known in reference to lunatics in general as to their moral treatment … starting with the proposition that education and training form the basis of the moral treatment of all classes of the insane.47

Under Lalor, the school at the Richmond taught a broad range of subjects including reading, writing, arithmetic, algebra, geometry, geography, drawing, needlework and various arts and crafts:48

In reference to the education or training of the insane, no matter of what class or age, I wish to state that I try to have the patients engaged in the same pursuit for not more than from one to one hour and a half consecutively. Monotony, whether of work, education, or recreation, appears to me to be injurious to the insane of all classes and ages. I consider the alternation of literary, aesthetical, moral and physical education, with industrial employment and recreation (so as to produce variety of occupation), to be of great advantage in the treatment of the insane, whether the particular form of the insanity be mania, melancholia, monomania, dementia, idiotcy, or imbecility.49

Professional teachers were employed and the National Board of Education recognised the classes in 1862. Lalor was extremely proud of the school:

Summarizing what I consider some very important items of our system here, I note that out of 479 male patients in the house on the 17th May [1878], 400 were employed either at school or industrially, or both combined, and only 79 were wholly unemployed; 45 of the unemployed were so in consequence of being under medical treatment, leaving only 34 men unemployed purely owing to their state of mind. Of 553 female patients in the house on the same day, 448 were employed either at school or industrially, or both combined, and 105 were wholly unemployed; 89 of the unemployed were so in consequence of being under medical treatment, leaving only 50 unemployed purely from the state of their mind.50

Lalor was a major figure in the Irish asylums,51 as evidenced by his influence on other doctors such as Dr Joseph Petit, who was appointed as Lalor’s assistant in 1874 and went on to serve as RMS in Letterkenny and Sligo.52 Throughout this period, however, Lalor had an extraordinarily complex relationship with the governors at Grangegorman (who had excluded him from meetings since 1871) and a deeply conflictual one with the Inspector, Dr John Nugent, who was continually involved in asylum management; all of which led to an enquiry in 1883, clearly vindicating Lalor.53

In 1861, Lalor became the eighth president, and first Irish president, of the Medico-Psychological Association (MPA), which held its annual meeting in Dublin, providing a significant opportunity for Lalor to promote the importance of resident medical superintendents (rather than ‘visiting physicians’) in the Irish asylums.54 This was one of many themes that exercised the energetic Lalor; another was – inevitably – the self-reportedly progressive approach to management that he recounted from the Richmond:

The total disuse of restraint, and the very infrequent use of seclusion – the freedom allowed to all our patients to exercise and have various sorts of games on the open grounds, in place of enclosed yards – are very gratifying features. The number and cost of our staff, estimated per head on the daily average number of patients, is less in this than in the other district lunatic asylums of Ireland, and this fact, taken in connection with our large teaching and training power, shows that education and industrial employment carried out, as they are here, systematically, by skilled hands, do not necessarily increase expense. […] The amount of quietude and good order, of literary and industrial occupation, and of contentment, cheerfulness, and amusement here is very satisfactory.55

Dr Daniel Hack Tuke (1827–1895) wrote approvingly of the Richmond schools in the influential Journal of Mental Science:

To myself, the schools which are in active operation there under Dr Lalor were of deep interest, and I venture to think that some useful hints may be gathered from what we witnessed on the occasion. Indeed so valuable did the system pursued appear to me to be, that I stayed another day in Dublin in order to see more of the working of the schools […]. The pupils are divided into three classes on both sides of the house, there being three male and three female trained teachers […]. The patients stood in circles marked out by a chalk line, presenting a very orderly appearance, while the teacher asked them questions on geography, &c., or gave them an object lesson. While of course there was a great difference in the expression of those who were being taught, and in their responsiveness to the questions put to them, there was a general air not only of propriety but of interestedness which was very striking. Some, in fact, were extremely bright and lively …56

Following Lalor’s death, his obituary in the Journal of Mental Science described him as ‘excellent and kind-hearted’ and highlighted his achievements with the school at the Richmond:

It is stated on good authority that [prior to Lalor’s appointment to the Richmond] refractory patients were confined in cells for most of the day as well as the night, receiving their food in such a way as best suited the convenience of the attendants. Open-air exercise was rarely permitted, and then only in the dark confined yards or sheds surrounded by stone walls. All this was changed by Dr Lalor; better grounds were prepared, games were introduced, and the general comfort of the patients was attended to. Dr Lalor, as is well known, enthusiastically carried out the school system […].

It should be stated that for two years before he became Superintendent a school had been in operation on the female side under an excellent school mistress. It was Dr Lalor who introduced the same system for the male patients, and he obtained additional teachers, trained under the National Board, for the female school. Singing and music were much cultivated, while object and picture lessons were given, as well as others in natural history and geography. At the Exhibition held some years ago in Dublin, drawings, paintings, and industrial work, all executed by the patients, attracted considerable attention. Along with the schools, concerts were given every fortnight, or even weekly …57

Similar sentiments were expressed in the Irish Times, which paid generous and deserved tribute to Lalor’s foresight and perseverance.58 Throughout this period, the educational approach advanced by Lalor was not, however, the only therapeutic paradigm in evidence at the Richmond or elsewhere. As Cox notes, the use of moral management did not exclude the employment of various additional medicinal treatments such as purgatives, bloodletting and emetics, which continued until the late 1870s.59

Notwithstanding this persistence of older medicinal paradigms in the asylums, Lalor was by no means alone in trying to improve matters for the mentally ill in a fashion that was as enlightened as the institutional framework of the times permitted, even if Lalor and others clearly failed to challenge that framework sufficiently at the time. Such initiatives were heavily influenced by developments in England and elsewhere, and were duly reflected in the literature of the time, including Sir Alexander Halliday’s General View of the Present State of Lunatic Asylums in Great Britain and Ireland and in Some Other Kingdoms, which stated confidently that a new era of enlightenment and rational treatment had now finally arrived.60 It hadn’t, but there were increasing signs of progress in that direction as evidenced by, for example, the careful, thoughtful writings of John Cheyne.

Cheyne (1777–1836), another leading British physician, worked in Dublin and is best remembered for his description of a breathing pattern seen in conditions such as chronic heart failure, now known as Cheyne-Stokes breathing.61 Cheyne suffered from depression and in 1843 wrote a striking book titled Essays on Partial Derangement of the Mind, in Supposed Connexion with Religion.62 Cheyne’s monograph was notable for his detailed engagement with the signs and symptoms of insanity, based largely on his conversations with persons who were mentally ill63 but also drawn from his personal experience of depression, which he attributed to a life of overwork.64

More specifically, Cheyne rooted his reflections in what he had ‘learned from observation; from having long witnessed the passions and affections in unrestrained action; from having long viewed the drama of life from behind the scenes, and attended to the manifestation of character in health and disease; from his having been for some years in superintendence of considerable number of insane persons, nearly one hundred; and, lastly, from introspection, especially while suffering from lowness of spirits, arising from dyspeptic nervousness, aggravated by the wear and tear of a life of continued over-exertion’.65

Based on his affecting phenomenological descriptions of various disturbed states of mind, Cheyne concluded that ‘mental derangement’ could arise:

First - From a disordered condition of the organs of sense.

Secondly - From a disorder of one or more of the intellectual faculties.

Thirdly - From a disorder of one or more of the natural affections and desires.

Fourthly - From a disorder of one or more of the moral affections.

Fifthly - From groups of faculties and affections being disordered, thereby involving derangement of the whole mind.66

Cheyne presented four overall conclusions, based on his clinical work and the observations outlined in his book, generally linking mental illness with physical disorders:

I.That mental derangements are invariably connected with bodily disorder.

II.That such derangements of the understanding, as are attended with insane speculations on the subject of religion, are generally, in the first instance, perversions of only one power of the mind.

III.That clergymen, to whom these essays are particularly addressed, have little to hope for in placing divine truth before a melancholic or hypochondriacal patient, until the bodily disease, with which the mental delusion is connected, is cured or relieved.

IV.That many of the doubts and fears of truly religious persons of sane mind depend either upon ignorance of the constitution and operations of the mind, or upon disease of the body.67

Cheyne’s work is notable for the careful attention he devoted to the signs and symptoms of mental disorder,68 the links he drew between mental symptoms and physical illness, and his identification of the role of alcohol in precipitating mental disturbance, leading him to advocate abstinence for those with alcohol problems.69

Despite the relatively (if selectively) progressive approaches of Cheyne, Lalor, Mollan and various others, however, it remains the case that the number of mentally ill persons in institutions continued to rise alarmingly during the nineteenth century and conditions of detention were very, very poor. In November 1844, the inspector, Dr Francis White, found that conditions in Wexford were filthy and patients half starved.70 By1892, the Richmond’s problems had increased greatly too, owing chiefly to overcrowding. The inspector was beside himself:

During the year no relief has been obtained as regards the overcrowding of this asylum. The number of patients now almost reaches 1,500, whereas the asylum only accommodates about 1,100. It is therefore not to be wondered at that the general health of the institution is far from satisfactory, and that the death-rate, as compared with other Irish asylums, is high, amounting to 12.5%, the average death-rate in a similar institution in this country being 8.3%. Constant outbreaks of zymotic disease [acute infectious diseases] have occurred. Dysentery has for many years past been almost endemic in this institution – 73 cases with 14 deaths occurred last year, and it may be mentioned that in no less than three of these cases secondary abscesses were found in the liver.71

Clearly, further, systemic reform was needed at national level to provide appropriate care to the mentally disturbed and minimise the ill effects of Ireland’s large scale institutions. One of the key mechanisms used to pursue this goal throughout the 1800s was revision of mental health legislation. This constant, restless process of legislative change72 was ultimately carried to a point that managed to be industrious, obsessional and almost certainly counterproductive, and was continually accompanied by a rhetoric of care and compassion that rested uneasily with the gargantuan institutions it created and sustained. These matters are considered next.

Mental Health Legislation in the 1800s:

The ‘Dangerous Lunatic Act’ (1838)

Among all of the many pieces of mental health legislation passed in nineteenth-century Ireland, the best known and most notorious was the Dangerous Lunatic Act of 11 June 1838, formally titled ‘An Act to make more Effectual Provision for the Prevention of Offences by Insane Persons in Ireland’. The 1838 Act, as Parry notes, ‘formed the basis of the judicial committal procedure which became the most important mode of admission to Irish asylums’:

In essence, this Act was to a large degree similar to its English predecessor, being introduced following the murder of a citizen by a man who had been earlier refused entry to the Richmond Lunatic asylum. The Act provided for the detention of persons denoting ‘a Derangement of Mind, and a purpose of committing some Crime’, or indeed the detention of persons who were believed, on the basis of other proof, to be insane and hence dangerous. From the beginning committal was notoriously easy to obtain, and for relatives there were considerable advantages in using the Act for it did not require a commitment to take the lunatic back following treatment.73

The Act, which followed from the murder in July 1833 of Nathaniel Sneyd, bank director with the House of Sneyd, French and Barton, by John Mason, and the subsequent newspaper publicity, was passed without parliamentary debate.74 The primary purpose of the Act was to protect the public from the dangers allegedly posed by the mentally ill; its terms of confinement were extremely broad and vague; and, since it permitted the confinement in district asylums of prisoners who appeared mentally ill, people were initially confined to county prisons or bridewells, and then transferred to asylums (often after long delays, sometimes of several years duration).

During the committal process, medical evidence could be heard (and generally was) but was not mandatory, and certificates were signed by two magistrates. The 1838 Act soon became the admission pathway of choice for families seeking institutional care for relatives and a habit grew of encouraging a mentally ill person to commit a minor offence in order to facilitate committal under the Act.75 Discharge from the asylum was only possible when the patient’s sanity was medically certified to the Lord Lieutenant.

Once the Act was passed, transfers from prisons to asylums commenced at once: in the first fortnight of July 1838, 13 people were referred from jails to the Richmond.76 This caused immediate problems because the Richmond was already full but, in January 1839, the Chief Secretary, Lord Morpeth, stated that such transfers were to be accepted anyway, regardless of the number of patients already in the asylum. The asylums further objected that some of the transfers were not suitable for asylums and that inpatient numbers kept on rising, especially since discharge required the authority of the Lord Lieutenant. These very real problems, robustly highlighted by Mollan and others at the Richmond, were largely ignored by the government. Objections in the House of Commons and an 1843 amendment requiring at least one credible witness in each case made little difference either: the 1838 Act quickly became the main mechanism for asylum admission and a key contributor to the intractable overcrowding that blighted Irish asylums throughout the 1800s.77

As Finnane points out, between 1854 and 1856, committals of ‘dangerous lunatics’ accounted for 41.8 per cent of male and 31.8 per cent of female admissions to district lunatic asylums; by 1890–2, these proportions had risen to 75.7 per cent for men and 67.3 per cent for women, with some regional variation.78 To make matters worse, approximately 17.1 per cent of all male patients and 18.2 per cent of female patients were discharged from district lunatic asylums in 1851, and these annual proportions fell steadily to 7.7 per cent for men and 7.4 per cent for women in 1911.79 In that year, readmissions accounted for 21.9 per cent of male and 21.0 per cent of female admissions, while 5.9 per cent of male and 6.2 per cent of female patients died in the asylums (down slightly since 1851, when the proportions dying were 7.6 per cent for men and 6.4 per cent for women).80 By 1914, Ireland’s population had declined by a third since the Great Irish Famine (1845–52, Chapter 3) but the number of ‘insane’ persons in public asylums had increased sevenfold.81

If there was one single, standout event among the many factors that set Ireland on a course towards mass institutionalisation of the mentally ill, it was the 1838 Act.82 Asylum doctors, including Woods in Killarney and Garner in Clonmel, objected vociferously, to little avail.83 The legislation was ill conceived, poorly implemented and grossly unjust,84 and, even after it was revised later in the 1800s, its echoes reverberated through the asylum system for much longer, setting the tone for the dominance of asylum care for the mentally ill and intellectually disabled well into the twentieth century.

Lord Naas attempted to enact reforms with the Lunacy Law Amendment Bill 1859, following the commissions of enquiry of 1858. He was, however, unsuccessful at that point, so it was not until 1867 that the 1838 Act was finally amended, with the effect of ending confinement in gaols prior to asylums and requiring magistrates to call a dispensary medical officer to examine the patient and sign the certificate.85 Many decades later, when introducing the 1944 Mental Treatment Bill for a second reading in Dáil Éireann (part of the Irish parliament), the Parliamentary Secretary to the Minister for Local Government and Public Health, Dr Conn Ward, summarised the revised process, post-1867:

The committal order was made by two peace commissioners or a district justice after the person concerned had been certified as a dangerous lunatic by a dispensary medical officer. The expenses connected with the committal, including the payment to the medical officer for his services, were defrayed by the local public assistance authority […]. The procedure under the Act of 1867 is that the Gárda apprehend the person and bring him before two peace commissioners before whom evidence is given that the person is dangerous and likely to commit an indictable crime. When it is proved to the satisfaction of the peace commissioners that the person was discovered and apprehended under circumstances denoting derangement of mind and a purpose of committing an indictable offence the peace commissioners call to their assistance the dispensary medical officer and if he certifies that the person is a dangerous lunatic or a dangerous idiot the peace commissioners, by warrant, direct the person to be taken to the district mental hospital for the district in which he was apprehended. This procedure has much in common with that followed in a criminal case. The patient is dealt with as if he were suspected of being guilty of a crime.86

While the 1867 amendment excluded doctors in private practice, it meant that local dispensary medical officers were required to sign certificates, even if asylum staff had provided evidence during petty session hearings. These measures, along with further amendments in the Lunatic Asylums (Ireland) Act 1875, improved the certification process but certainly did not eliminate errors or misuse. The fundamentally flawed and deeply unjust Dangerous Lunatic Act remained in place until the advent of the Mental Treatment Act 1945. Therefore, while the 1838 Act did not represent the only admission pathway during this period – and Cox devotes much needed attention to the ‘ordinary’ certification procedure and its increased medicalisation in 1862 – it was the Dangerous Lunatic Act that firmly set the tone for asylum care in nineteenth-century Ireland and accounted for the majority of admission in the early twentieth century.87

Against this distinctly dispiriting legislative background, there were three identifiable waves of asylum building in Ireland. The first wave saw, in addition to the Richmond, the construction of four district asylums during the 1820s and five more by 1835.88 Legislation in 1845 made provision for the Central Criminal Lunatic Asylum in Dundrum, Dublin89 and a large, 500 bed establishment in Cork, the Eglinton Asylum, which opened in the early 1850s. Originally in three blocks, which were later joined together, the Eglinton Asylum formed the longest façade of any building in Ireland.90 Various other asylums were also opened during this, the second phase of asylum building, including establishments in Mullingar (1855) as well as Letterkenny (1866) and Castlebar (1866), both of which were designed by George Wilkinson (1814–1890), known for designing workhouses. There was considerable controversy about various aspects of the asylum building process in the 1850s, resulting in a highly critical report by London architect T.L Donaldson and James Wilkes, medical officer at Stafford Lunatic Asylum, supporting local concerns about how the building work was being directed from Dublin.91 Problems persisted, and delays with progressing the asylum in Castlebar, for example, were publicly reported and lamented.92 The Castlebar asylum was predated by ‘the Chatterhouse’, a bridewell on Station Road (‘Mad House Hill’) where patients were held before the Royal Irish Constabulary (RIC) transported them to Ballinasloe for admission.93 Eventually, ‘the Chatterhouse’ was replaced by the Castlebar asylum proper, which opened on 5 March 1866, at a cost of £34,906.

The growth of the asylums was unstoppable. The third phase of asylum building involved a range of individual architects and included the asylum in Ennis (with its Florentine palazzo, in 1868), the Monaghan asylum (the first to adopt a villa or pavilion format, in 1869) and the auxiliary asylum to the Richmond, in Portrane, County Dublin.94 In 1900, the Building News and Engineering Journal reported that Portrane was ‘constructed to accommodate 1,200 patients which [sic] are divided up into four classes – viz., chronics, melancholic and suicidal, recent and acute, the epileptic and infirm […]. The total cost, when completed, will probably be about £250,000’.95 The building contract for Portrane was the largest ever awarded to a single contractor in Ireland (the Collen brothers of Portadown). A further asylum was opened in Antrim in 1899, and, as Walsh and Daly point out, by 1900 approximately 21,000 people, 0.5 per cent of the population of the 32 counties of Ireland, were accommodated in the district asylums, with a small number of the mentally ill still in workhouses.96

Private Asylums in Ireland:

‘Sent by an All-Bounteous Providence’?

In parallel with the steady and genuinely alarming expansion of Ireland’s public asylum system, a limited, although by no means insignificant, network of private asylums also emerged and carved out a role for itself in Irish medicine and society. In 1799, Hallaran opened a private establishment, Citadella, near Cork, and further private asylums were established in Carlow, Downpatrick and Portobello in Dublin (Dr Boate’s asylum).

One of the more dramatic episodes in the history of private asylums in Ireland concerns Dr Philip Parry Price Middleton who blew up Carlow Castle in 1814, when attempting to remodel the imposing, historic thirteenth-century building near the River Barrow. Middleton had earlier cofounded ‘Hanover Park Asylum for the Recovery of Persons labouring under Mental Derangement’ in Carlow town, with two surgeons, Dr Clay and Charles Delahoyd.97 An 1815 pamphlet about the establishment emphasised that the ‘humane means’ used at Hanover Park had the ‘safe and positive powers of readily tranquilising the most furious maniac’:98

The unequivocal results arising from the humane means employed by the Conductors of this Institution, for regenerating Reason and Health, in that once wretched portion of our fellow-creatures, who had long been deemed incurable; and consequently doomed to rigid confinement, constant coercion, and hopeless misery, in this life as though Insanity were a Crime, instead of a Calamity, naturally excited the most lively Interest in the minds of all ranks of the Community in the Metropolis of the British Empire: it was there hailed as a celestial meteor, sent by an all-bounteous Providence, to illumine the dark and dreary destiny of the unhappy sufferers, by restoring them to the long-lost faculty of Reason, and the wonted energies of the Soul.99

The vision underpinning Hanover Park was, it seems, enlightened to the point of utopian:

This institution, emanating from the one at Iver, near London, under the direction of A. Hutchinson, M.D. F.R.C.S. &c.; is established here, for the accommodation of this part of Ireland; combining, at once, all the domestic comforts of a private family, and well-regulated society; formed into select classes, according to the progressive stages of convalescence. By the new mode of treatment adopted in this Institution, every kind of coercion is entirely laid aside, as no longer necessary; while innocent amusements, with the salutary agremens of a carriage, are employed to renovate general Health.

The situation also, in point of salubrity, cannot be excelled by any in the United Kingdom; and independently of the Principal edifices, the park will be studded with detached Pavilions and flower Gardens, for Patients of both sexes, in spacious and separate walled enclosures, for Pedestrian recreation; under the immediate superintendence of Dr Myddelton, and an experienced resident Surgeon.100

Middleton was well established as principal medical superintendent at Hanover Park before turning his entrepreneurial eye on Carlow Castle. His injudicious use of blasting powder, however, resulted in an explosion early on the morning of 13 February 1814: the castle’s two eastern towers collapsed, as well as part of the adjoining walls.101 Middleton’s subsequent career was marked by further controversy and litigation, although he did publish, in 1827, a noted ‘essay on gout’.102

By 1825, there were at least five private asylums in Ireland, in addition to charitable asylums in Dublin.103 As well as Hallaran’s Citadella in Cork, there were three private asylums in Finglas, County Dublin (including asylums managed by Dr William Harty and Mr Gregory) and one in Downpatrick (Mr Reed). From 1826, it was necessary for the Inspector-General of Prisons to visit and report on asylums kept for profit every two years.104

The situation for private asylums changed significantly in 1842 when the Private Lunatic Asylums (Ireland) Act made it unlawful for anyone to keep a house for two or more insane persons unless that house was licensed.105 Patients could only be detained on foot if a certificate signed by two doctors and medical input was required at the establishment. Harty, in Finglas, objected strenuously against official interference in private asylums, penning a pamphlet addressed to Sir Robert Peel arguing that private asylums were well conducted and under the control of doctors.106 Ironically, Harty’s own establishment was subject to court proceedings in 1842, when the Lord Chancellor directed Harty to release a woman patient after Harty had refused to allow visits by her brother and her doctor. Further controversy followed and Harty’s establishment soon vanished from the list of private asylums.

In addition to the private asylums, paying patients were accepted into the Carlow, Maryborough and Richmond asylums during the 1840s.107 Other asylums were less enthusiastic: the first paying patients were admitted to Cork in the 1870s and, even then, initially on a small scale.108 By the end of 1862, there were some 21 private asylums in Ireland and the inspectors (Drs John Nugent and George Hatchell) found that the quality of care varied considerably between them. Mauger, in a superb study of private asylums in Ireland, notes that the number of such establishments generally increased from 1820 onwards, in notable contrast to England and Wales, reflecting differing legislative provisions.109 The increasing importance of this sector in Ireland was highlighted by the 1842 Act, the first legislative measure exclusively devoted to private asylums, which for the first time provided for the licensing and regulation of these establishments. While they catered chiefly for the Irish upper classes, this did not mean restraint was not used or that the private asylums were free from allegations of poor conditions, although, for the most part, conditions were generally reported as acceptable.110

Private asylums continued to operate throughout the latter part of the 1800s and early 1900s. By 31 December 1929 there were 841 patients (333 males, 508 females) in private establishments, of which eight were ‘licensed in pursuance of the provisions of the Private Lunatic Asylums (Ireland) Act, 1842. The remaining four (Bloomfield Institution, St Patrick’s Hospital, St Vincent’s Institution, and Stewart Institution) being “charitable, institutions supported wholly or in part by voluntary contributions and not kept for profit by any private individual” [were] exempt from licensing. Licences were granted in 1929 for the reception of 553 patients, an increase of 20 compared with the previous year’.111

Private asylums played important roles in both providing care and developing the profession of psychiatry during this period. Prominent establishments included Dr Osborne’s Lindville Private Lunatic Asylum on Blackrock Road in Cork112 and Verville Retreat in Clontarf, Dublin. By 1930, Lindville, then under the stewardship of Mrs Elizabeth E. S. Osborne, received a generally positive report from the Inspector of Mental Hospitals:

The demeanour of the patients, as well as their neat appearance, reflects credit on the management of this institution. Concerts, dances and card parties are held. One patient required restraint. Catholic and Church of Ireland clergy visit the house frequently. A number of patients are allowed out on parole and some occupy themselves at gardening and fancywork.113

At Verville, Dr Patrick Daniel Sullivan was elected to the Irish Division of the MPA in 1922.114 In 1929, the Inspector reported that Verville was ‘well kept’ and the ‘general health’ of the patients ‘remarkably good’;115 by 1933 a veranda had been erected, ‘restraint or seclusion was not necessary in any case’, and ‘some of the patients attend cinema performances’;116 and in 1934 it was noted that ‘several patients go for walks and motor drives in the country’.117 In April 1949, the Irish Division of the RMPA held its Spring Quarterly Meeting in Verville, at the invitation of Dr Mary Sullivan.118 Thirty-six members and two guests attended. Dr M. O’Connor Drury read his ‘Report on a Series of Cases Treated by the ECT-Pentothal-Curare Technique’ and Dr Gilmartin gave a clinical demonstration of the use of curare and pysostigmine to produce a modified seizure in ECT (Chapter 5).

In that year, Verville had 30 patients, all female, including 7 women detained under the Mental Treatment Act 1945.119 The Inspector provided a positive report with particular emphasis on the use of ‘modern treatment’:

This home was well maintained. Re-decoration of some rooms had been carried out. Patients appeared to receive excellent nursing and many took part in outdoor recreation. All forms of modem treatment were applied with very good results.120

By 1949, Lindville had forty-one patients (including eight men), of whom eight were detained.121 Both Lindville and Verville would later close as mental hospitals, but back in the mid-nineteenth century, these kinds of private asylums were a key part of Ireland’s complicated, emergent ‘system’ of care, which was becoming noticeably more medical in nature with each passing year.122 A general lack of enthusiasm among governors for attending board meetings was another factor in shaping the evolving asylums:123 many governors never visited the institutions or attended any meetings, seeing their appointments simply as expected recognition of their positions in the local ascendancy.124

But, as Parry notes, it was, above all else, the advent, in 1843, of the General Rules for the Government of All the District Lunatic Asylums of Ireland125 that was pivotal in setting developments on their distinctively medical trajectory:

A major advance in the medical take-over of Irish asylums was the passing into law of the General Rules for the Government of all the District Lunatic Asylums in Ireland on March 27th 1843 … the 1843 rules gave the visiting physician complete authority in Irish district asylums. Describing the duties of the various offices on the district asylums, the Rules state that the manager should ‘under the direction of the Board, and subject to the directions of the Physician as to the treatment of the Patients, superintend and regulate the whole of the Establishment’126 […]. The physician henceforth was ‘to direct the course of Moral and Medical treatment of the patients’.127 The first victory of the Irish medical profession regarding madness was complete.128

The 1843 rules indeed placed very many responsibilities on the physician, who was ‘to attend on three days (to be named by the Board) at least in each week, and on every day at such Asylums in which the number of Patients shall exceed 250’:

•He shall also visit on particular occasions, when called on by the Manager, and shall prescribe for all Patients and Servants who may require Medical aid, and for the Resident Officers who may request Medical assistance. […]

•He shall attend daily on cases of Fever and on any other cases of an urgent nature.

•He is authorized to order such Diet as he may think necessary for any particular case, having, however, due regard for economy in each Article.129

•He should always visit every Patient under restraint, and, when he deems it safe, require such Patients to be temporarily relieved from restraint, and examine them so as to ascertain that they are not cramped or injured; and he should frequently go round the Asylum so as to see the state and condition of every Inmate.130

The asylum ‘manager’ was also accorded a broad range of roles under the 1843 rules, including oversight of the use of ‘restraint’:

He [the manager] is to take charge of the instruments of restraint, and is not under any pretence to allow the unauthorized use of them to any person within the Establishment; all cases placed under restraint, seclusion, or other deviation from the ordinary treatment, are to be carefully recorded by him in the daily report, with the particular nature of the restraint or deviation resorted to. But in no case shall the Shower Bath [Chapter 1] be used without the authority of the Physician.131

Other rules related to the asylum governors, matron, apothecary, clerk and storekeeper, servants, gardener, gatekeeper, hall porter, keepers, nurses, assistant nurses, cook and laundress.132 An addition to the rules in 1853 concerned chaplains, who were ‘to afford Religious Instruction and Consolation to all patients, except such as shall be declared by the Physician to be unfit and incapable of understanding the nature of the Service, and of appreciating the effects of Religion’.133 In addition, ‘controversial subjects shall be scrupulously avoided, both in public service and in private visitations’.

The 1843 rules also laid out regulations governing admissions, placing strong emphasis on the signing of ‘a bond for the removal of the Patient’ in due course:

Every Patient to be admitted upon a special direction by the Board, unless in cases of urgency, when the Physician may admit upon his own authority, stating on the face of his order the grounds upon which he acts. In every case a bond for the removal of the Patient, when required by the Board, to be signed by some responsible person, before the admission of the Patient, unless the Board upon any ground, or the Physician in cases of urgency, shall dispense with the same, or postpone the time for the execution of such Bond.134

And who was to be admitted?

Idiots, as well as Lunatics properly so called, are to be admissible to every Asylum, and so also are Epileptic persons, where the fits produce imbecility of mind as well as of body.135

Clearly, then, admission criteria were broad and the 1843 rules clearly set the scene for the continued growth of Ireland’s increasingly medicalised asylum system throughout the 1800s.

James Foulis Duncan:

‘The Spirit of Innovation is Abroad’

Among the medical professionals and asylum doctors of the mid to late 1800s, the figure of James Foulis Duncan (1812–1895) looms large among his peers.136 While the Richmond was being built in 1813, Dr Alexander Jackson, with the Reverend James Horner, opened a small private asylum in Finglas, County Dublin and, after the Richmond opened with Jackson as physician, Jackson sold Farnham House to James Duncan, a Scottish doctor, in 1815.137 James Duncan, a keen hunter, athlete and traveller (he visited Syria and Algiers), died in March 1868, aged 82 years. His son, James Foulis Duncan, born in 1812, spent much of his childhood at the Finglas asylum.138 Many decades later, in his presidential address to the MPA in 1875, Duncan reminisced about his unusual upbringing:

It is now exactly sixty years since I was first brought – a child of only a few years old – to the asylum then recently placed under my father’s management. My mother was dead, and owing to the circumstance that my father never kept a separate table for his family, I was thrown into closer contact with the inmates of the establishment than usually falls to the lot of children similarly circumstanced; and although there are drawbacks and dangers inseparably connected with such a life, I am here to say that it is not all gloom nor all disadvantage. It has its bright side as well as its dark. In almost all similar institutions of any size there are to be found some of the best and noblest of our race – men of gifted intellect, of high attainments, and of blameless lives. We know not why it should be so, but in the mysterious providence of God the shadow of this cloud is occasionally permitted to darken the path of some eminent for their virtues and their piety. It was my privilege to be indebted to some of these for many acts of kindness, and for much pleasant companionship. My earliest lessons in the Latin language were imparted by one during the short period of his residence at Farnham House, whom I shall ever remember with affection and esteem. Another instructed me, at a later period, in mathematics and the higher branches of science. Many others shared with me all the pleasures of my boyhood. These things have made an impression on me which I can never forget …139

Building on this unusual but effective educational foundation, Duncan was awarded an MD (Medicinae Doctor; Doctor of Medicine) by Trinity in 1837 and became first physician to the staff of the reopened Adelaide Hospital in Dublin in 1858. Throughout his career, Duncan displayed several interesting qualities: he was acutely socially aware, especially of the effects of poverty on health; he supported the use of scientific comparisons to test treatments (in language that prefigured later ideas about clinical trials in medicine);140 and he was highly religious in his views on many matters, including mental ill health, as evidenced in his 1852 publication, God in Disease, or, The Manifestations of Design in Morbid Phenomena.141 From a clinical perspective, Duncan championed both medical and moral treatments for insanity, and Farnham House remained in the Duncan family for over 50 years, providing just such treatment.

Duncan himself achieved considerable prominence in his profession and became president of the MPA in 1875.142 In his presidential address, delivered on 11 August 1875 at the Royal College of Physicians in Dublin, Duncan emphasised the changes occurring in Irish asylum medicine:

The time is not so very long gone by since everything connected with the management – I cannot say treatment – of the insane was a matter of general reproach, and everyone who devoted himself to the pursuit was avoided as much as possible. They were looked on as left-handed neighbours, very useful in their way, because their assistance could not always be dispensed with, but whose acquaintance no respectable person was expected to acknowledge. Too often they were men of inferior social position, low-minded in their taste, imperfectly educated, and with nothing in their character to command respect, even from those who employed them. Sordid in disposition, their only object was to make money out of those entrusted to their charge, and that at the least expense and trouble to themselves. In the present day all this is changed. […]

Insanity in its various forms is now universally admitted to be a disease – differing, indeed, from ordinary disease as to its nature and phenomena – but a disease notwithstanding, and therefore to be viewed in the same light and treated on the same principles as those which regulate medical practice in other branches. […]

Hence the propriety, rather, I should say, the absolute necessity of these cases being handed over to the care of members of the medical profession, who by the nature of their everyday duties are the best fitted to unravel the mysteries of their phenomena – to investigate the intricate chain of circumstances connected with their origin – to discriminate the relative importance of their various symptoms – to estimate the effect of remedies – and above all, to keep steadily before them in despite of every discouragement and disappointment the recovery of the patient as the one great object to be continually aimed at.143

Duncan was nonetheless concerned about the state of Irish asylum medicine, lamenting ‘that the Irish contingent of this Association [the MPA] has hitherto done so little for the practical advancement of the science’, a deficit he linked with the fact that ‘only four out of our twenty-two district asylums are provided with a second resident medical officer’, which greatly hampered the publication of clinical observations and research,144 as well as attendance at MPA meetings.145

In his 1875 address, Duncan emphasised the importance of education for doctors involved in the committal process146 and devoted considerable attention to the role of prevailing social circumstances (‘an artificial state of living’)147 in causing mental disorder:

A striking feature of the present age is that it is one of incessant mental activity. All is hurry, bustle, and excitement. Men have become restless, and are ever seeking some new stimulus in the way of enjoyment, or some new discovery in the path of science. Formerly they were satisfied to jog on quietly in the easy way their fathers did before them; they lived in the same houses, cultivated the same farms, and followed the same fashions they were accustomed to from childhood. They had no real ambition; none of that feeling of discontent with present things which lies at the basis of all improvements. They did not hatch eggs by steam, or make calculations by a machine. They had implements, but no machines. They disliked new-fangled ways, and when they were told of improvements they were reluctant to adopt them. Now all is reversed. The spirit of innovation is abroad. New inventions are continually chronicled, and everyone is anxious to secure the advantage for himself before his neighbour gets a chance. Is it necessary to prove that the greater the activity of the brain the greater must be its liability to disease, and therefore to insanity?148

Continuing in this vein at quite remarkable length, Duncan vehemently denounced a great many features of nineteenth-century life, ranging from ‘the substitution of machinery for handicraft labour’149 to ‘the employment of children in factories’,150 and the consequent ‘loosening of the family bond’ and ‘perversion of the natural feelings and affections’ which ‘indicates a state of mind very favourable to the development of insanity, when circumstances arise calculated to produce it. It lies at the very root of Socialism’:151

I think I am warranted in concluding that there is an amount of brain work going on in the present age far different in kind from, and far greater in degree than, any that was ever known before, and which must play a very important part in predisposing the subjects of it to attacks of insanity. And when we come to ask ourselves the question, What can we do to counteract the evil? I fear the answer to be given is, that, practically, we can do very little. The whole is the result of forces far beyond our power of alteration or control. We can no more change the mechanical and commercial character of the age than we can arrest the sun in his course, or put back the hands upon the dial plate of time. Nor, even if it were possible for the world to return to the condition it was in a century ago, would any of us be willing to give up the advantages of our present state to secure such a result. It must not be forgotten that the evil complained of arises, not from mechanical contrivances in the abstract, but from the abuses connected with their working and incidental to their introduction.152

Duncan was not, however, a man to be easily defeated, not even by the great, unstoppable forces of history. The solutions he proposed centred on various forms of education: medical education,153 public education,154 and a particular form of moral education of the young which he felt held the greatest hope for preventing mental disorder:

Sickness and disease often come in spite of all the precautions that may be taken against them; so completely are the causes producing them beyond the cognisance and control even of those who suffer from their ravages. And if this is so as regards the ordinary ills that flesh is heir to, it is still more remarkably the case as regards the various forms of insanity. Legislative interference here is altogether powerless in providing any prophylactic. Whatever steps are to be taken with a view of securing this end must be the result of individual effort in the education of the young – by which I do not mean merely the kind and amount of information crammed into the head of the pupil, but the whole system of training required to produce a well-adjusted balance between all the intellectual and moral faculties of which man’s higher nature is composed and that physical development of the entire system which reason and observation have shewn to be the best safeguard against the occurrence of such a calamity in after life.155

Duncan’s presidency of the MPA was a significant achievement: the MPA was an important organisation in the development of the profession of psychiatry in Ireland and elsewhere, introducing the Certificate in Psychological Medicine in 1885 and adding general legitimacy to the doctors’ search for professional recognition and prestige during the latter part of the nineteenth century.156 Duncan was a good example of these developments, as he served not only as president of the MPA, but also as president of the King and Queen’s College of Physicians in Ireland (1873–5), and generally typified a certain model of nineteenth-century asylum doctor: enterprising, powerful, prolific and keen to promote asylum medicine in the eyes of other doctors and the public. Duncan died on 2 April 1895 at the age of 83, many years after retiring from active medical practice. His obituaries in the British Medical Journal and Medical Press noted the professional esteem in which he was held, as well as his devotion to the promotion of religion and reputation as a man of charity.157

Ultimately, Duncan embodied a disquieting paradox that lay at the very heart of Irish asylum medicine throughout the 1800s. While his heartfelt, fluent and humane rhetoric was both scientific and compassionate, it coexisted with the growth of an increasingly large, custodial system of asylums ranged across the country. And while Duncan explicitly promoted efforts to prevent mental disorders (in apparent conflict with the interests of those who ran asylums), he lived during a time when the number of asylum beds – and thus inpatients – rose at a genuinely alarming rate, to a level that was as unjustifiable as it was unsustainable.

This yawning chasm between rhetoric and reality was demonstrated vividly in 1843, when a select committee of the House of Lords provided another chilling report on the ‘state of the lunatic poor in Ireland’. Despite the best intentions of Duncan and colleagues, things just kept on getting worse for the mentally ill.

The State of the Lunatic Poor in Ireland (1843):

‘I Could Not Describe the Horror’

The 1840s were an important and formative decade for the Irish asylum system. In 1843 a select committee of the House of Lords provided yet another incisive, disturbing report on ‘the state of the lunatic poor in Ireland’. The Committee noted the recommendations of its predecessor, the select committee of 1817:

On the 4th March 1817 a Select Committee of the House of Commons was appointed to consider the expediency of making further provision for the lunatic poor of Ireland. It was then stated that, with the Exception of one institution in Dublin, one in Cork, and one in Tipperary, there was not a provision made for more than 100 lunatics throughout all Ireland. This Select Committee reported (25th June 1817), ‘that the only mode of effectual relief would be found in the formation of District Asylums exclusively appropriated for the reception of the insane; that, in addition to the asylums in Dublin and in Cork, there should be built four or five additional asylums, capable of containing each from 120 to 150 lunatics’. It further recommended that powers should be given to the government to divide Ireland into districts, and to select the site for an asylum in each, and that the whole expense of the new establishments should be borne by the counties included within the several districts.158

While the 1843 select committee found that significant action had been taken based on the 1817 report, substantial challenges remained:

It has been unfortunately found, that although the accommodation provided in the ten District Asylums very considerably exceeds that which was contemplated by the Committee of 1817, it is very far from meeting the necessity of the case. The asylums were originally intended but for 1,220 patients; they now contain 2,028; various additions have been made to them [providing] for the reception of 264 patients; but the increased and rapidly increasing number of incurable cases have lamentably diminished the efficacy of these asylums as hospitals for the cure of insanity.159

The select committee noted that, for the most part, the ‘system of management adopted in the District Asylums’ was ‘very satisfactory and successful’, involving ‘a humane and gentle system of treatment’, with ‘cases requiring restraint and coercion not exceeding two per cent on the whole’.160 The select committee was, however, at pains to point out that the apparent success of Ireland’s District Asylums provided no reason for complacency, as there were various other institutions that presented cause for concern:

The House must not, however, imagine that the District Lunatic Asylums are the only establishments in which pauper lunatics are confined in Ireland. Besides Swift’s Hospital, which is supported by the private endowment of the eminent Dean of St Patrick’s, there are other public establishments provided for the custody if not for the cure of insanity, and which are supported by local taxation. Connected with some of the old Houses of Industry in Ireland, cells or rooms were provided for the insane. Local asylums still subsist at Kilkenny, Lifford, Limerick, Island Bridge, and the House of Industry in Dublin. With the exception of the last two, these miserable and most inadequate places of confinement are under the general authority of the Grand Juries, the funds for their support being raised by presentment or county rate. The description given of these latter most wretched establishments not only proves the necessity of discontinuing them as speedily as accommodation of a different kind can be provided, but also exemplifies the utter hopelessness, or rather the total impossibility, of providing for the due treatment of insanity in small local asylums. No adequate provision is made or is likely to be made, in such establishments, for the medical or moral treatment of the unfortunate patients; no classification; no employment; no sufficient grounds for air or exercise. Hence the necessity of a coercive and severe system of treatment. The chances of recovery, if not altogether extinguished, are at least reduced to their very lowest term.161

The select committee went on to demonstrate its point by citing specific evidence it received relating to conditions in Kilkenny, Wexford and Lifford. In the case of Wexford, the committee drew attention to the evidence of Dr Francis White, Inspector General of Prisons, who reported that ‘the state of the Wexford lunatics in the local asylum is most disgraceful; nothing could equal the state in which I found that asylum; it is part of the old House of Industry’:

The number amounted to fourteen males and seventeen females; the place was quite dilapidated; the yards gloomy; the dinner rooms equally so; the cells were the worst I ever saw. There were two patients under restraint, one of whom was chained to a wall. When I went to his cell, with the keeper and the medical officer, I asked to go in. The keeper said it would be dangerous and frightful to go in. However we went in. He was naked, with a parcel of loose straw around him. He darted forward at me, and were it not that he was checked by a chain which went round his leg, and was fastened by a hook to the wall, he would have caught hold of me, and probably used violence. I asked how it was possible they could allow a man to remain in such a state; they said they were obliged to do so, as the funds were so limited that they had not money to buy clothes for him, and that if they had clothes they would have let him out. Now, the consequence of this treatment was, that the man became so violent that his case was made tenfold worse. I went to another cell, and though the individual there was not chained, he was nearly in as bad circumstances as the other. One of the two was once a respectable person. Altogether, those two cases were the most frightful I ever witnessed; I could not describe the horror which seized me when I saw them.162

When asked if there was ‘any moral superintendence’ at the Wexford establishment, White was blunt: ‘There was both a male and female keeper, but they appeared to me totally unfit for the discharge of their duties’. There were similar problems with staffing at other locations. An appendix to the select committee report recounted that in Clonmel District Lunatic Asylum163 efforts to recruit appropriate staff were ‘a sad calamity’, and Dr James Flynn, manager, reported that ‘the majority of attendants had to be removed, after my appointment, for drunkenness, cruelty to and neglect of patients, and a total disregard for order and discipline’.164

To illustrate the difficulties faced, Flynn presented three examples of objectionable behaviour in Clonmel:

I visited the Female Refractory Ward, as usual, on 13th September 1841, and found a patient crying bitterly. I had before asked the reason, and received an indefinite reply; however, I examined on this day the cause, and found her arm had been broken for a period of four days, and no report whatever made by the nurse in charge.

I visited the Male Refractory [Ward] on the night of the 6th of October 1841, and found all the keepers of the House, save one, playing cards; the one not so occupied was stupidly drunk in an adjoining bath room.

I visited the Female Tranquil Ward on the night of the 19th December 1841, at 10 o’clock, and found the assistant nurse perfectly intoxicated.

Having considered evidence relating to all places of confinement of the ‘lunatic poor’ in Ireland, ranging from District Asylums to prisons, the 1843 select committee made a series of recommendations:

1.The necessity of discontinuing, as soon as practicable, the committals of lunatics of gaols and bridewells.

2.The necessity of amending the Act of the 1 Vict. Cap. 27. [Dangerous Lunatic Act 1838], which appears, on the Authority of the Lord Chancellor of Ireland, to have led to the most serious abuse.165

3.The inexpedience of appropriating the Union Workhouses as places either for the custody or the treatment of the insane, for both which purposes they appear wholly unsuited.

4.The necessity of providing one central establishment for criminal lunatics, under the immediate control and direction of the government of Ireland, to be supported from the same funds and under the system adopted in respect to criminal lunatics in England.

5.The necessity of increasing the accommodation for pauper lunatics in Ireland, and of providing for the cases of epilepsy, idiocy and chronic disease, by an increased number of the District Asylums, by an enlargement of those asylums, or by the erection of separate establishments specially appropriated for these classes of patients.166

Following its completion, Lord Eliot, the Chief Secretary, sent the select committee’s report to the governors of the District Asylums, seeking their comments. The report was discussed by the governors of the Richmond District Asylum, Dublin on 3 January 1844 and, while they supported the call for asylums for criminal lunacy, epilepsy, idiocy and chronic insanity, the Richmond governors suggested that, since these measure would take time, District Asylums should be offered some measure of relief by permitting the admission of harmless and chronic patients into workhouses.167

Overall, however, the 1843 select committee saw expanding the public asylum system as the key solution to the problems presented by the mentally ill, recommending more public asylums, larger asylums and specialist asylums for certain groups of patients.168 This was a familiar response to the problems presented by the mentally ill and it defined public mental health services in Ireland for almost a century after the 1843 report. The ‘criminally insane’ were one of the groups most affected by this trend and these are considered next.

Central Criminal Lunatic Asylum (Ireland) Act 1845: Insanity and Criminal Responsibility

The idea of reduced criminal responsibility among the mentally ill and intellectually disabled has a long history in most societies for which there is recorded history, stretching from ancient Greece and Rome to contemporary Europe and the US.169 This idea was also reflected in early Irish law which specified that responsibility for an offence committed by a person of unsound mind devolved to their guardian, and injuries caused by missiles thrown by a drúth (person with intellectual disability) did not require compensation: it was the responsibility of the passer-by to keep out of the way.170

In more recent centuries, defences based on insanity were presented in the Irish courts with varying degrees of success.171 One of the most celebrated was that of Captain William Stewart, whose ship, the Mary Russell, sailed into Cork Harbour from the West Indies on 25 June 1828. On board, seven crew members had been brutally killed by the Captain, who appeared insane.172 The Reverend William Scoresby, a fellow of the Royal Societies of London and Edinburgh and Member of the Institute of France, was one of the first eyewitnesses on the vessel, and described it as ‘a scene of carnage so appalling … as to render, by sympathy, association and memory combined, the impression indelible’.173

At Captain Stewart’s trial, medical evidence of insanity was compelling and the jury returned a guilty verdict but added that they believed Stewart to have been insane at the time.174 The Chief Baron at the trial rejected this verdict; it was argued that the law did not recognise this as guilt because the act was committed while the person did not know right from wrong. The jury promptly altered its verdict to ‘not guilty’ owing to Stewart’s insanity. This change of verdict in the early 1800s prefigured the verdict of ‘not guilty by reason of insanity’ outlined much later in Ireland’s Criminal Law (Insanity) Act 2006 (Chapter 7).175

Internationally, the field of forensic psychiatry took significant steps forward in the mid-1800s with the publication of Dr Isaac Ray’s ‘Treatise on the Medical Jurisprudence of Insanity’ in 1838176 and the emergence of the McNaughton Rules which proved hugely influential as the insanity defence became more widely used in the courtrooms of Great Britain, Ireland, the US and elsewhere in the latter part of the 1800s.177 Against this background, the Central Criminal Lunatic Asylum (Ireland) Act 1845178 was introduced to establish ‘a central asylum for insane persons charged with offences in Ireland’. More specifically:

Whenever and as soon as the said central asylum shall be erected, and fit for the reception of criminal lunatics, it shall be lawful for the lord lieutenant [chief administrator of government in Ireland] to order and direct that all criminal lunatics then in custody in any lunatic asylum or gaol, or who shall thereafter be in custody, shall be removed without delay to such central asylum, and shall be kept therein so long as such criminal lunatics respectively shall be detained in custody.179

The 1845 Act also permitted the Lord Lieutenant to direct ‘that any person who might be detained in custody in any gaol by virtue of any such warrant as aforesaid should be removed to the [local] lunatic asylum [and] remain under confinement … until it should be duly certified to the said lord lieutenant, by two physicians or surgeons, or a surgeon and physician, that such person had become of sound mind’.180 Convicts who were certified insane could also be removed to the new asylum and then returned to prison or discharged (as appropriate) if medically certified as now being of sound mind.181

The 1845 Act was also notable for making provision for one or two suitably qualified persons to act as Inspectors of Lunatics in Ireland, to take over relevant duties from the Inspectors General of Prisons.182 In 1846, the first person appointed to this position was Dr Francis White (1787–1859), a remarkable physician who had opened a hospital and anatomical school on Ormond Quay earlier in his career and had been an Inspector General of Prisons since 1841.183 A second inspector, Dr John Nugent, was appointed in 1846, having previously served as travelling physician to Daniel O’Connell (1775–1847), an Irish political leader.184 Nugent had no experience managing the mentally ill and there were various complaints about his performance.185 The inspectors’ first report appeared in July 1846 and Nugent was later knighted by the Lord Lieutenant.186

The other historic outcome from the 1845 Act was the establishment of the Central Criminal Lunatic Asylum in Dundrum, Dublin, which was erected relatively swiftly at a cost of £19,547.187 Individuals were admitted if they were charged with an offence in court and deemed insane at trial or developed symptoms of mental illness while in prison. The asylum opened for admissions in 1850 and by 1853 there were 69 male and 40 female inpatients.

Patients admitted to the Central Criminal Lunatic Asylum generally presented complex combinations of psychiatric, medical and social need, often including poverty.188 For example, 70 women were admitted between 1868 and 1908, most of whom were Roman Catholic and single, with an average age of 33 years.189 Over half were charged with or convicted of killing, mostly child killing.190 Almost one woman in 10 was declared ‘sane’ on admission, but might have seemed mentally ill at the time of offence or trial. Among the others, ‘mania’ and ‘melancholia’ were the most common diagnoses. Approximately 15 per cent of these women died at the asylum; almost 50 per cent were eventually transferred to local asylums; 12 per cent were transferred to prison; and others were released to family or friends.

Between 1910 and 1948, a further 42 women were admitted, a majority of whom were detained ‘at the Lord Lieutenant’s pleasure’ (i.e. indefinitely).191 The most common diagnoses were ‘mania’ or ‘delusional insanity’ (38 per cent) and ‘melancholia’ (24 per cent); 7 per cent were ‘sane’. The average duration of detention was almost six years, after which 28 per cent were transferred to district asylums and the remainder released under various different circumstances.192 Overall, the average length of stay for women charged with infanticide or the murder of their child between 1850 and 2000 was 9.3 years, although it ranged from three months to 38 years.193

There was a complex mix of social, psychiatric and medical problems in evidence among both male and female patients, including mental disorders ranging from ‘mania’ to folie à plusieurs (when several people share delusions or fixed, false beliefs),194 various issues relating to intellectual disability,195 and physical illnesses such as syphilis196 and tuberculosis.197 Given this complicated combination of factors, it is unsurprising that there were substantial changes in admission practices over time as rates of admission fluctuated, and the use of ‘fitness to plead’ procedures in the courts varied significantly, peaking during the period from 1910 to 1920.198

Recurring issues at the Central Criminal Lunatic Asylum included the overcrowding that was so widespread throughout the asylum system during the 1800s and early 1900s;199 the tangled relationship between gender and the insanity defence;200 and the troubling matter of persons who were committed to the asylum but appeared sane by the time they actually arrived there.201 These issues – and many others – were readily apparent throughout the asylum system in general as early as the mid-1850s, when they elicited a by now familiar response from the authorities: the establishment of yet another commission of inquiry and the production of yet another report. But first, however, in 1854, the 1851 Census of Ireland led to the emergence of a fascinating Report on the Status of Disease which presented important, formative information about the mentally ill and intellectually disabled in Ireland.

The 1851 Census of Ireland and

a ‘Report on the Status of Disease’

The Census of Ireland performed in 1851 provided a wealth of fascinating data and reasons for continued concern regarding mental disorder in Ireland. A Report on the Status of Disease, based on the census and co-authored by Dr William Wilde, who was knighted in 1864 owing in large part to his work on the census, was published in 1854.202 Wilde’s biographer, Dr T.G. Wilson, wrote that he was especially fascinated by the statistical side of the census, which complemented Wilde’s work with individual patients and gave him a broader view of population health.203

The Report concluded that there were 5,074 ‘Lunatics’ and 4,906 ‘Idiots’ in Ireland, and that ‘many individuals in both these classes were also affected with epilepsy’.204 This meant that ‘there was 1 Lunatic in every 1,201 inhabitants, and 1 Idiot in every 1,336 of the population of the entire country’:

In the provinces, the proportions of both classes to the general mass of the community are least in Connaught, being but 1 in 1,022, and greatest in Leinster, where they amount to as many as 1 in 484. The returns of the province of Connaught exhibits a remarkable immunity from both Lunacy and Idiocy. In Ulster we find a proportion of 1 in 679, and in Munster 1 in 729. It would appear that Lunatics prevail most in the cities, but this arises in part from Asylums being located therein, many of the inmates belonging to which could not, from want of proper information on the subject, be distributed according to their native places. Among the counties, the greatest number of Lunatics, in proportion to their populations, were to be found in Dublin, Wexford, Carlow, Westmeath, and Kildare. Idiocy was found to prevail most in Louth, Kildare, Wexford, Monaghan, and Cavan. Both classes taken together prevailed most in the counties of Wexford, Dublin, Kildare, Westmeath, Louth, Queen’s [Laois] and Longford. With respect to the sexes, we find among the Lunatics 100 males to 102.72 females, and of the Idiotic class 100 males to 84.02 females.205

The report went on to analyse ‘2,164 cases in which the cause of disease has been investigated, and an opinion offered thereon’.206 Proposed causes were grouped into three categories: ‘physical causes’ (44 per cent, with males outnumbering females), ‘moral causes’ (39 per cent, with females outnumbering males) and ‘hereditary taint or family predisposition’ (17 per cent, with females again outnumbering males). ‘Physical causes’ included ‘congenital disease’ (‘specified as malformation of head, and composed chiefly of Idiots’), ‘intemperance’, ‘epilepsy’, ‘disease of the brain’, ‘paralysis’, ‘fever’, ‘injuries of head’, ‘puerperal mania’, ‘the effects of climate, including sunstrokes’, ‘disease of the brain’ (owing to ‘cerebral affection’), ‘mercury’, ‘uterine derangement’, ‘venereal excess’, ‘dyspepsia’, ‘rape and seduction’, and ‘violent hysteria’. ‘Moral causes’ included ‘grief’, ‘reverse of fortune’, ‘love and jealousy’, ‘terror’, ‘religious excitement’, ‘study’, ‘anger or excessive passion’, ‘ill-treatment’, ‘anxiety’, ‘pride and ambition’, ‘political excitement’, ‘music’, and ‘remorse’.

In some cases, information was provided on specific diagnoses:

Among the insane, Mania was the form of disease manifested in about four-fifths of the whole: of these 669 instances were induced by moral, and 400 by physical causes, while 222 were attributed to hereditary taint. In 44 cases the Mania was of a suicidal character, grief and reverse of fortune being the chief causes which conduced to this phase of disease. Out of 417 persons affected with Dementia, in 73 cases the disease was attributed to moral, and in 69 to physical causes; while in 32 it was traced to hereditary disposition.207

This diversity of cause and diagnosis was reflected in asylum case books for many decades to follow.208 The 1854 report also provided a brief, fascinating account of the ‘origin and history of public Asylums for Lunatics and Idiots in Ireland’209 and a valuable summary of ‘popular and Gaelic terms for Insanity and Idiocy’:

Insanity is known under the synonymes and popular terms of mania, monomania, dementia, puerperal mania, madness, lunacy, melancholy, dejection, derangement, out of the mind; and among the Irish-speaking population, as Gealtaigheacht, when the madness is believed to result from lunar influence; when the insanity is of a violent and furious character, Dasaht; but Buile or Baile are the terms applied to madness generally.

The number of wandering Idiots in Ireland have frequently been remarked upon; and the fact of this class being regarded by the lower orders with somewhat of a superstitious veneration, has rather encouraged their exposure than the contrary. The analogous terms for Idiocy are fatuous, foolish, simple, silly, an innocent, an idiot, &c. In Irish, the term Baosradh, or silliness, is frequently employed, but the terms in more general use are Amadanacht and Oinsigheacht, the former expressive of Idiocy in the male, and the latter in the female sex.210

Commission of Inquiry on the State of Lunatic Asylums in Ireland (1858): ‘Places Merely for the Secure Detention of Lunatics’

Against the background of the consolidating asylum system, and the alarming information provided by Wilde and colleagues in their vivid 1854 report, there were, throughout the 1850s, continual complaints about asylum conditions in Ireland, so in 1856 a fresh commission of inquiry was established by the government to look into the matter yet again, for the umpteenth time.211 The commission assembled in Dublin on 16 October 1856 and comprised five persons: Sir Thomas Nicholas Reddington, who had been Irish Under-Secretary from 1846 to 1852; Robert Andrews (counsel), Robert Wilfred Skeffington Lutwidge (barrister), Dr James Wilkes (medical officer to Stafford County Lunatic Asylum) and Dr Dominic John Corrigan (physician to the Dublin House of Industry Hospitals).

Following an extensive process of investigation and inquiry, two years of work and three extensions of its deadline,212 the commission finally presented its conclusions in 1858 in the Report of the Commissioners of Inquiry into the State of the Lunatic Asylums and Other Institutions for the Custody and Treatment of the Insane in Ireland: with Minutes of Evidence and Appendices.213 The commission commenced by sketching out the magnitude of the problem, concluding that ‘the insane poor of Ireland, maintained at public cost, or at large’ numbered 9,286 on 1 January 1857, distributed as follows:

In district asylums	3,824
In workhouses	1,707
In House of Industry (Hardwicke Cells),214 and at Lifford	108
In the Central Criminal Asylum	127
In gaols and government prisons	168
‘At large and unprovided for’	3,352215

The commission went on to discuss ‘public institutions for the insane’ in some detail, examining the position of the mentally ill in district asylums, workhouses, gaols and the Central Criminal Asylum in turn. The commission devoted particular attention to the establishment of the district asylums and was sharply critical of the process:

It thus resulted that, without any communication with the Grand Juries of the several counties, or any other parties representing the ratepayers, and without any specific statement of the probable cost, to the Privy Council, who directed the establishment of these institutions in the several districts, large and expensive asylums have been erected, and the first public intimation of the charge, thereby imposed upon the district, was the warrant for the repayment of the outlay forwarded to the Grand Juries, on whom such repayment was imperative. This has naturally led to very general discontent, more especially as just cause for complaint also existed of the imperfect manner in which the works had been executed, in the asylums recently erected […].

[…] We cannot think it right that the ratepayers, or those who represent them, should be excluded from all voice in the determination of questions in which they are so deeply concerned; and although stringent enactments may be required to secure proper provision being made for the lunatic poor, yet it seems to us that it is only when the local authorities obstinately refuse to discharge their duty, in this respect, that power should be given to the Executive to supersede their action, in order that the benevolent object of the legislature may not remain unfulfilled. We shall be prepared therefore to recommend an alteration of the law in this particular, as well as in the constitution of the Central Authority, which is to superintend and direct the erection, establishment and regulation of lunatic asylums.216

The commission also recommended changes with regard to inspections. Despite the ‘zealous anxiety of the Inspectors’, the commission recommended that inspections should be annual rather than biennial, and should ‘report specifically on each institution’, rather than reporting generally.217 In addition:

The Inspectors of Lunatics were, in 1852, appointed governors, ex officio, of all the district asylums, and, as such take part in proceedings, in every respect, as ordinary governors. We consider this position quite inconsistent with that of an Inspector, whose duty it is to report on the state and condition of institutions in the government of which he thus personally shares the responsibility.218

The commission noted the existence of regulations permitting the formation of ‘rules and regulations for the good conduct and management of district asylums in general, or any asylum in particular’ but ‘this most important measure for securing the good government of these institutions appears to have been imperfectly carried out for several years’:219

The principal defect in the rules, as regards the existing state of things in the asylums, is that the ‘duties’ assigned to the manager have been drawn up in contemplation of that officer not being a member of the medical profession. Fully concurring in the propriety of the asylums being in charge of professional persons, as our subsequent suggestions for their improvement will indicate, we regard a total alternation of that portion of the rules which affects the manager and physician as absolutely requisite.220

More specifically, the commission was unanimously ‘of opinion that the resident physician should have charge of the asylum, and be responsible for the treatment of the inmates as regards their insanity’:221

We think the resident physician should be relieved from all duties of a civil character connected with the management of the institution, which might interfere with the devotion of his time to his more proper duty, the care and treatment of the inmates. Leaving him the chief officer of the asylum, with authority over all the other officers, except the consulting physician, we propose that his civil duties should be transferred to the officer to be called the clerk.222

The commission also made several other recommendations, including better record keeping,223 changes relating to the appointment and conduct of governors,224 and review of the wages paid to asylum workers:

Another point, to which we desire to draw attention, is the small amount of wages given to the attendants in some of the asylums. The duty of the persons so employed is at all times disagreeable and irksome – frequently dangerous and disgusting. It requires intelligence, temper, and kindness, on the part of those discharging it, or the conduct of the attendant may undo all the judicious treatment of the manager. A higher class of servants, therefore, should be sought, and care should be taken, in their selection, not alone that they are possessed of the qualities above described, but that they are sufficiently educated to be enabled to contribute to the recreation of the patients by reading for their amusement. Such occupations will beguile the wearisomeness of their watching in the wards, and, helping to cheer and tranquilize the patients, will render their attendance a more grateful task.225

The commission lamented variations in admission practices across asylums and recommended that ‘there should be one rule, rigidly enforced, for regulating admissions’ and that ‘idiots, as well as epileptics, where the fits produce imbecility of mind as well as of body, should be admissible’.226 The commission felt that the ‘Resident Medical Manager’ should have authority to admit patients between meeting of the Board because ‘it is of the utmost importance that cases of insanity should as speedily as possible be removed to an asylum’.227

As regards ‘paying patients’, the commission noted that ‘there is no fixed rule in district asylums’ as ‘some boards decline to receive them; others receive them at a charge equal to the cost of maintenance; and in others the annual payment demanded is regulated at the discretion of the Board of Governors’:228

We are of the opinion that the admission of paying patients should be distinctly recognised, but that it should be subject to such restrictions as the Central Board, which we shall propose to establish, may lay down, both as to the class of patients and the proportion of such cases to be admitted into the asylums, so as at the same time to protect the ratepayers from undue taxation, and the lunatic poor of the lowest class from unfair encroachment upon the accommodation intended more especially for them.

The class of patients to be admitted ought not to comprise those who, from the means which they possess, should be maintained in a private asylum.229

After considering the various laws and regulations governing asylums, the commission then turned its attention to the ‘general condition of the asylums’, and found plenty of causes for concern including, inter alia, ‘cold and cheerless’ airing courts;230 ‘imperfect or ill-planned’ sewage arrangements; ‘defective’ water supplies; ‘inattention to cleanliness’; ‘privies … so offensive as to be absolutely injurious to the health of the inmates’; ‘improper occupation of inmates’; poor heating and ventilation; bedsteads ‘of bad and objectionable construction’;231 ‘neglect of school instruction’;232 misuse of restraint in certain asylums;233 and a ‘general want of’ recreation and amusement for patients:

At present, whatever attempts have been made in a few instances, and especially at Richmond and Sligo, in the way of evening entertainments, & c.,234 nothing has been done to mitigate the bare and cheerless character of the apartments usually occupied by the inmates. In corridor or day-room, the lunatic sees nothing but the one undiversified white wall – giving to these hospitals, intended for the restoration of the alienated mind, an air of blankness and desolation more calculated to fix than to remove the awful disease under which it labours.

It cannot be denied, notwithstanding the care and attention which appear generally to be given by the managers and visiting physicians to the patients under their charge, that, on the whole, the lunatic asylums of Ireland wear more the aspect of places merely for the secure detention of lunatics than of curative hospitals for the insane.235

After this rather damning consideration of district asylums, the commission next examined the position of the mentally ill in workhouses, and concluded that ‘there can be no more unsuitable place for the detention of insane persons than the ordinary lunatic wards of the union workhouses’.236 On this basis, the commission outlined a proposal ‘to appropriate unused workhouse accommodation for certain classes of insane’:

It should be competent to the Board of Governors of any asylum to direct the admission of any lunatic of the above class237 belonging to the district into the workhouse asylum; and, on the recommendation of the resident physician of the asylum, to admit directly to such workhouse asylum any such lunatic then in gaol or workhouse, or for whom admission to the district asylum may be sought. The governors should also have power to transfer patients, when necessary, from these auxiliaries to the district asylums.238

Notwithstanding its approval of ‘workhouse asylums’, the commission did not approve of the idea of ‘provincial asylums’, recommending instead that ‘as far as possible, all cases should be treated in the district asylum’.239 The commission advised clarity on the role of the Central Criminal Asylum and, specifically, that ‘a law should explicitly define who is to be detained in the criminal asylum; and as cure is not the only object with which such an institution has been founded by the state, the incurable inmate should not, because his case is hopeless, and he may himself be harmless, be again remitted to association with lunatics who are not criminal’.240 Other recommendations included establishment of a ‘central board’ to control and direct asylums;241 various changes to the establishment and conduct of ‘private asylums’242 and the role of chaplains;243 and the ‘desirableness of benevolent institutions for the insane’;244 and various other suggestions.245

Many of the commission’s conclusions were not new: it recommended expansion of the asylum system (e.g. through ‘workhouse asylums’) and strongly endorsed the idea of permanent segregation as a key element in management.246 More progressively, however, it drew attention to the importance of the asylums ‘as educational establishments, for the purpose of extending a knowledge of the nature and treatment of insanity’:247

We feel confident that, if the lunatic asylums of Ireland were made places of instruction, medical science would be improved and humanity benefited; and that the benefit would not be limited to Ireland, but that the blessing of a humane and enlightened treatment of the insane would be extended through other countries […].

We cannot doubt that, if proper exertion were made, students in medicine, or graduates who had just completed their course, would seek for appointments as residents in asylums, as the knowledge thus acquired, and the certificates they would obtain of such residence, would be esteemed recommendations in many positions in which they might afterwards be placed. We would recommend that, in the first instance, the experiment of such appointments should be made in the asylums of Dublin (St Patrick’s and the Richmond), of Cork, and of Belfast, in which towns there are large medical schools […].

Such resident pupils might be appointed by the Board of Governors, on the recommendation of the resident physician, and should be subject to his direction. Their duties would consist in keeping notes of the cases admitted, and their treatment, in seeing to the due administration of medicines, baths, & c., and in a general care of the inmates and patients in the intervals of the visits of the resident or visiting physician; in short, in discharging towards the inmates of the asylum such duties as are now performed by resident pupils towards the sick in general hospitals.248

This was an innovative, progressive proposal, aimed at improving standards of care in the longer term, and clearly in line with the commission’s other recommendations for greater medical involvement in the asylums and improved education of staff. Overall, however, the commission’s recommendations were strongly in the direction of an expanded asylum system and permanent institutionalisation for certain patients. Scant attention was paid to the possible merits of other possibilities (e.g. treatment at home),249 as the commission emphatically endorsed the fundamental tenet that ‘it is of the utmost importance that cases of insanity should as speedily as possible be removed to an asylum’.250

Case Studies: Restraint,

Neglect and Cruelty

The 1858 commission’s strong endorsement of asylums as the central element of care for the mentally ill was all the more remarkable in light of the disturbing low standards and gross abuses revealed in their report. This was most evident in relation to the use of restraint, a topic to which the commission devoted particular attention:

We feel it is our duty also to notice the culpable disregard with which the 23rd Rule of the Privy Council has in many instances been treated. This rule requires that ‘The manager is to take charge of the instruments of restraint, and is not, under any pretence, to allow the unauthorized use of them to any person within the establishment; all cases placed under restraint, seclusion, or other deviation from the ordinary treatment, are to be carefully recorded by him in the daily report, with the particular nature of the restraint or deviation resorted to; but in no case shall the shower-bath be used without the authority of the physician’.251 And, by rule 4, he is to enter in the Morning Statement Book ‘the names of those under restraint or seclusion, and the causes thereof’. In some instances, the managers informed us that they were not even aware of the rule, although a printed copy of the Privy Council regulations was furnished to every asylum; in others, that they deemed it a sufficient compliance with the rules to leave the instruments of restraint in charge of the keepers, trusting to their integrity to report the cases in which they were used.252

The commission was especially disturbed by specific examples of restraint in Armagh Asylum, examples which some readers might find disturbing. One ‘patient, on the female side, was strapped down in bed, with body-straps of hard leather, three inches wide, and twisted under the body, with wrist-locks, strapped and locked, and with wrists frayed from want of lining to straps; this patient was seriously ill. There was no record of her being under restraint in the Morning Statement Book, as required by the order of the Privy Council. Another female was in the day room, without shoes or stockings, with strait waistcoat and wrist-locks; she had been two years in the house, and almost continually kept in that state day and night’.253

The most egregious abuse, however, was seen in the case of a male patient in Armagh, whose situation was outlined in detail by the commission and which, again, some readers might find disturbing:

A male patient, in Ward No. 2, was found at our visit, strapped down in bed; in addition, he was confined in a strait waistcoat, with the sleeves knotted behind him; and as he could only lie on his back, from a contrivance we shall presently describe, his sufferings must have been great; his arms were, moreover, confined with wrist-locks of hard leather, and his legs with leg-locks of similar kind; the strapping was so tight that he could not turn on either side; and any change of position was still more effectually prevented by a cylindrical stuffed bolster of ticken,254 of about ten inches thick, which ran round the sides, and top, and bottom of the bed, leaving a narrow hollow in the centre in which the lunatic was retained, as in a box, without power to turn or move. On liberating the patient, and raising him, he was very feeble, unable to stand, with pulse scarcely perceptible, and feet dark red and cold; the man had been under confinement in this state for four days and nights, being merely raised for purposes of cleanliness.255

The commission was deeply affected by this case and all the more alarmed to discover that ‘the manager stated he was aware of the man being in bed, but not of his having all these instruments of restraint upon him. No record of the case of restraint appeared in the Morning Statement Book’. They concluded that ‘neither the manager nor physician had seen or visited this patient while under confinement, or even been aware of his state’. The manager in Armagh was Thomas Jackson, who, some thirty years earlier, had worked to improve conditions in the old Dublin House of Industry; clearly, decades spent working in institutional conditions had greatly limited the effectiveness of his reformist zeal.256

Unsurprisingly, the commission found similar problems elsewhere:

We may here mention that in Omagh Asylum we found a bed in use for refractory patients, thus described by the resident physician: ‘It is a wooden bed in the sides, and there is an iron cover which goes over both rails; it is sufficiently high to allow a patient to turn and twist, but he cannot get up … the bars are from twelve to fourteen inches above the patient’s head’.257

Faced with these damning examples of the use, overuse, misuse and abuse of restraint, the commission felt it was ‘scarcely necessary to say that we recommend that the most strict observance of the rule should be enforced; that all instruments of restraint should be kept solely in the custody of the manager or resident physician; that their unauthorised use shall never be permitted, and that all cases of restraint should be daily visited and recorded’.258

These violations of standards regarding restraint were especially disappointing given the emergence of a strong ‘non-restraint’ movement in the late 1830s, some twenty years prior to the commission’s report. Progress in certain English asylums had been significant, if incomplete: the use of mechanical restraints was abolished at the Lincoln County Asylum in 1838; Northampton Asylum (now St Andrew’s Hospital) was the first institution to advocate non-restraint as a philosophy from the time it opened, in 1838; and non-restraint was introduced in Hanwell Asylum by Dr John Conolly (1794–1866) in the summer of 1839.259 Interestingly, the position was very different in the US, where asylum managers were explicitly hostile towards the English ‘non-restraint’ movement.260 In Ireland, however, the Report from the Select Committee of the House of Lords Appointed to Consider the State of the Lunatic Poor in Ireland noted, in 1843, that, for the most part, the ‘system of management adopted in the District Asylums’ in Ireland involved ‘a humane and gentle system of treatment’, with ‘cases requiring restraint and coercion not exceeding two per cent on the whole’.261

Given the stark contrast between, on the one hand, the non-restraint movement in England in the 1830s and apparently low rates of seclusion in Ireland in 1843, and, on the other, the commission’s damning report of 1858, it is unsurprising that the commission’s findings regarding restraint were highlighted in the Journal of Mental Science in January 1859, by Dr John Charles Bucknill (1817–1897), founder of the journal (as the Asylum Journal) in 1853 and editor until 1862.262 In an incisive commentary, Bucknill also drew attention to various other aspects of the 1858 report and the publicly expressed view of Dr Nugent, Inspector of Lunatic Asylums, that the commission’s report was excessively negative and one sided.

Overall, however, despite the objections of Nugent and others,263 and despite the apparently caring attitudes of certain asylum managers, doctors and governors, the picture painted by the commission was undeniably horrific. As the asylums had grown, grotesque institutional apathy had commonly replaced the relatively enlightened ideals of moral management. A bill aimed at remedying matters by implementing the commission’s recommendations was introduced by Lord Naas, the Chief Secretary, in 1859 but did not progress owing to the fall of the government. In 1860, Lord Naas’s successor, Edward Cardwell, made some progress on the matter by having an order in council made by the Lord Lieutenant, establishing a new Board of Correspondence and Control, made up of the two inspectors of lunatic asylums, the chairman and a commissioner of the Board of Works. Real, systematic reform of the asylums would, however, take much longer to achieve.

Life and Death in the

Nineteenth-Century Asylum

A significant step forward was taken on 16 January 1862, when new Privy Council rules were issued, designed to improve the running of district asylums in Ireland and to pacify both visiting and resident physicians.264 These General Rules and Regulations for the Management of District Lunatic Asylums in Ireland covered a broad range of areas, including the role of the Board of Governors; procedures for admission, treatment and discharge of patients; the posts of Resident Medical Superintendent (RMS) and ‘consulting and visiting physician’; and the astonishing range of other posts in the asylums, including chaplains, matrons, apothecaries, clerks, storekeepers, servants, attendants, cooks, laundresses, porters, land stewards, gardeners and gatekeepers.

Particular attention was paid to the precise roles of the RMS and visiting physician, the latter of whom had to visit the asylum three days each week, and every day if the number of patients exceeded 200. Either the RMS or visiting physician had to examine the mental state of each patient at least once every fortnight. Discharge, for the most part, required an order from the board on a certificate signed by both medical officers, but discharge of a ‘dangerous lunatic’ required a joint certificate from the medical officers that the patient was no longer dangerous. The 1862 rules, which strongly favoured the RMS (‘he shall superintend and regulate the whole establishment’),265 were warmly welcomed in the Journal of Mental Science, which noted that the previous rules (1843) were contradictory and generally unsatisfactory.266

The rules were revised again in 1874 and admission procedures laid out clearly:

Persons labouring under mental disease, for whom papers of application are filled up in the prescribed forms, to the satisfaction of the Board, and who shall be duly certified as insane by a registered physician or surgeon, who shall state on the grounds on which he forms his opinion, shall be admissible into District Asylums, after having been examined by the Resident Medical Superintendent or, in his absence, by the visiting physician or surgeon.267

[…] No patient, other than a ‘dangerous Lunatic’ shall be admitted without the sanction of the Board, except by order of the Lord Lieutenant, or of the Inspectors of Lunatics or one of them, or in case of urgency, when any three Governors or the Resident Medical Superintendent, or in his absence, the Consulting and Visiting Physician of the Asylum, may admit upon their or his own authority, stating on the face of the order the ground thereof, provided always that when a patient has been admitted under this rule, the Resident Medical Superintendent, or in his absence the Visiting Physician, shall submit that case to the special consideration of the Board at its next meeting for the decision of the Governors thereon.268

Various other regulations governed conditions and procedures within the asylums, and provide a valuable insight into the recommended patterns of asylum life:

•‘The patients shall, on admission, be carefully bathed and cleansed, unless the Resident Medical Superintendent shall otherwise direct. They shall be treated with all the gentleness compatible with their condition; and restraint, when necessary, shall be as moderate, both in extent and duration, as is consistent with the safety and advantage of the patient’.269

•‘Patients, except when special reasons to the contrary may exist, are to be clad in the dress of the institution, and their own clothes are carefully to be laid by, to be returned to them on their discharge’.270

•‘Strict regularity shall be observed with respect to the hours for rising in the morning and retiring for the night; that for rising being fixed at six o’clock from the 1st of April to the 30th of September, called the Summer six months, and for retiring at an hour not earlier than half-past eight o’clock nor later than nine for the same period. During the Winter six months the patients shall rise at seven, and retire not earlier than seven nor later than eight o’clock’.271

•‘The like regularity must be observed with respect to meals; in no case shall the ordinary number of meals be less than three, and they shall be supplied during the Summer six months at the following hours, viz: breakfast at eight o’clock; dinner at one o’clock; and supper at six o’clock; – and during the Winter six months at the following hours, viz: breakfast at nine o’clock; dinner at two o’clock; and supper at six o’clock; but patients actively employed in or out of doors may have an additional allowance of food between the usual meals by direction of the Resident Medical Superintendent’.272

•‘On the admission of a patient the Resident Medical Superintendent, or if he shall be absent on leave, the Consulting and Visiting Physician, shall make himself acquainted as far as possible with the history of the case, and note the same down in the General Registry; he shall also examine into the bodily condition of the patient, who is to be placed in an appropriate division, and carefully attended to both medical and personally’.273

•‘Patients may be visited from time to time by their friends, with the permission of the Resident Medical Superintendent, and as a general rule between the hours of noon and 4 o’clock, P.M.’.274

These revised rules were certainly much needed as there was, during the 1860s and 1870s, a compelling and recognised need for better regulation of the asylums. John A. Blake (1826–1887), MP for Waterford and a governor of Waterford Asylum, was especially outspoken about asylum conditions, which, he claimed, had not improved despite the stark findings of the 1858 commission. In the early 1860s, Blake drew particular attention to the low quality of asylum staff, arguing that both staff selection and working conditions were deeply unsatisfactory.275 He also highlighted the lack of recreation or employment for patients, which impacted greatly on their wellbeing. Other problems included violence towards staff and between patients, sometimes resulting in death by, for example, choking (in Ballinasloe, 1873).276 A chamber pot was a common weapon: one female patient killed another with a chamber pot in the Richmond in July 1889,277 while five years later, in the Cork asylum, a male patient died owing to a combination of ‘shock’ and being hit on the head by another patient with a delf chamber utensil.278

There were many other problems in the asylums too, not least of which were various illnesses and the relatively high risk of death as an inpatient.279 In the Richmond, for example, numerous patients were affected by a mysterious illness in the summer of 1894, and several died of the disorder which appeared to involve inflammation of the nerves. The RMS, Conolly Norman, consulted various experts, including Dr Walter G. Smith (president of the Royal College of Physicians of Ireland) and Sir Thornley Stoker280 (president of the Royal College of Surgeons in Ireland and brother of Bram, author of Dracula),281 among others. Though the condition was initially deeply puzzling for the physicians it ultimately proved likely that the asylum diet (low in fruit and vegetables and high in white bread) had led to beri beri,282 stemming primarily from a nutritional deficit in vitamin B1 (thiamine). While this mysterious episode remains the subject of scholarly study,283 it did, at least, draw considerable attention to the importance of diet in the asylum and highlighted the need for good physical healthcare for patients.284

Tuberculosis, too, presented significant challenges to physical health in nineteenth and early twentieth-century Ireland, both inside and outside the asylums. By 1904, tuberculosis accounted for almost 16 per cent of all deaths in the Irish general population.285 Staff and patients in asylums were at particular risk and in 1901 tuberculosis accounted for 25 per cent of deaths in Irish asylums, with an average age of death of between 37 and 39 years.286 This problem was by no means exclusive to the Irish asylums: tuberculosis was also the leading cause of death in South Carolina Lunatic Asylum at the turn of the century.287 In Ireland, progress with tuberculosis was slow, but the start of the twentieth century saw renewed public health initiatives,288 dedicated legislative measures, such as the Tuberculosis Prevention (Ireland) Act of 1908,289 and changes in sociopolitical circumstances that helped alleviate matters somewhat.290

Even so, death rates in Irish asylums still presented a substantial cause for concern throughout this period. In 1893, the Inspector of Lunatics reported a national death rate of 8.3 per cent in the asylums; this figure was derived by dividing the number of deaths in Irish district asylums in 1892 (995 deaths) by the daily average number of asylum residents; on 1 January 1893, that number stood at 12,133.291 Of those who died in district asylums, 198 (19.9 per cent) underwent post-mortem examinations which were, in the Inspector’s opinion, ‘of so much importance for the protection of the insane and for the furtherance of the scientific study of insanity’.292

Death rates varied between asylums, with, for example, the Richmond in Dublin reporting a death rate (12.5 per cent) higher than the national average (8.3 per cent), possibly related to particular problems with overcrowding and infective illnesses at the Richmond.293 Comparable rates were, however, reported in other jurisdictions, with a 14 per cent death rate in South Carolina Lunatic Asylum between 1890 and 1915.294 Similarly, one third of men and 21 per cent of women admitted to the Toronto Asylum between 1851 and 1891 died there.295 At the Central Criminal Lunatic Asylum in Dublin, 42 per cent of individuals committed following a court finding of mental disorder between 1850 and 1995 died there,296 and 27 per cent of women committed following infanticide or child murder between 1850 and 2000 died there.297

Walsh and Daly studied admissions to Sligo District Lunatic Asylum between 2 February 1892 and 6 May 1901, during which period there were 454 admissions with sufficient details for analysis.298 Of these, 75 per cent were male, 64 per cent single and 86 per cent Roman Catholic. Among those for whom family history was recorded, some 87 per cent had a family history of mental disorder. The most common recorded causes were heredity, alcohol, and domestic issues or financial worries. The most common diagnoses were mania (40 per cent) and melancholia (28 per cent). The most frequent recorded causes of death were tuberculosis and phthisis (probably pulmonary tuberculosis; 23 per cent), exhaustion (16 per cent) and dementia (9 per cent).

Serious challenges with physical health continued into the 1900s, with the influenza epidemic of 1918299 hitting the asylums especially hard: a fifth of all patients in Belfast asylum died of it, and one patient in every seven in the asylums in Kilkenny, Castlebar, Maryborough and Armagh fell victim.300 Against this rather bleak background, there were, nonetheless, continued efforts to ameliorate the problems in the asylums, with Norman at the Richmond, for example, doggedly (if unsuccessfully) promoting ‘boarding out’ in the late 1800s and early 1900s.301 In addition, outpatient clinics were promoted in the early 1900s and the Society of St Vincent de Paul was later approached to set up an after care committee.302

Notwithstanding these efforts, conditions in Irish asylums remained very difficult throughout the late 1800s and early 1900s, owing to toxic combinations of mental disorder, physical illness, overcrowding, suicide, and violence – the latter involving both patients and staff, and often resulting in physical or chemical restraint.303 In the early 1900s, a night nurse in Castlebar was violent towards a patient with a poker and was found guilty of burning the patient, resulting in a sentence of 18 months hard labour.304

From the outset, medical conflicts were common in the asylums, especially between visiting physicians and resident medical superintendents: in 1862, the latter was accorded superiority305 and in 1892 the post of visiting physician was abolished in new rules drafted by the Inspectors of Lunatics (then including Dr E.M. Courtenay); this was a defining moment in the emergence of the profession of psychiatry in Ireland.306 The new specialists, increasingly trained in the asylums themselves,307 were immediately confronted with complex tangles of psychiatric, medical, social and legal challenges in many individual cases, with no immediate solutions to hand, apart from further institutional care. These challenges are well illustrated by some interesting cases of folie à plusieurs, a rare but fascinating psychiatric syndrome, drawn from the archives of the Central Criminal Lunatic Asylum in the 1890s.

Case Studies: Folie à Plusieurs

Folie à deux is a rare psychiatric syndrome in which two individuals share symptoms of mental disorder, most commonly paranoid delusions. While there were several clinical descriptions of the syndrome throughout the seventeenth and eighteenth centuries,308 the term folie à deux was coined in the 1870s309 and translated as ‘communicated insanity’ by William Wetherspoon Ireland, a Scottish polymath, in the 1880s.310

The term folie à plusieurs refers to cases of ‘communicated insanity’ in which symptoms are shared by three or more individuals. There tends to be one ‘primary’ patient, whose symptoms are ‘transmitted’ to ‘secondary’ patients. The majority of cases of induced psychotic disorder occur within families and involve, most commonly, mother and child, wife and husband, or woman and sibling.311 Treatment involves identifying the primary patient312 and treating their mental illness and physical disorder (if present); the secondary patient may not require specific treatment following separation from the primary patient. The concept of Capgras à plusieurs (a shared delusional belief that a person has been replaced by a double) has been invoked in relation to the celebrated case of Bridget Cleary, burned to death in 1895.313

From the outset, there were reports of forensic or criminal complications of ‘communicated insanity’,314 including theft, violence,315 attempted murder316 and murder.317 One Irish case from the late 1800s involved two brothers admitted to the Central Criminal Lunatic Asylum on the same day in 1896. Both were single farmers who lived on a family farm. They were charged with the murder of another brother and detained in the Central Criminal Lunatic Asylum ‘at the Lord Lieutenant’s pleasure’ (i.e. indefinitely).318 Patrick, the elder, was 36 years of age and admission notes described him as ‘industrious, honest … timid and nervous’. At the time of admission, Patrick had ‘two brothers and a sister in an asylum’ because ‘all the family became insane at the same time’. Patrick himself was ‘timorous and sleepless, watching an insane brother for about 12 days’. He was diagnosed with ‘acute delusional mania, convalescent’. The cause was ‘hereditary’.

While physical examination on admission to the Central Criminal Lunatic Asylum was normal, the Prison Surgeon’s Report from four months earlier (when the brothers were in prison awaiting trial), noted that they were ‘wild and haggard-looking’. Patrick’s temperature was 100º Fahrenheit (38º Celsius) with a pulse rate of 116 beats per minute (i.e. raised). At night time, the brothers’ conditions worsened: Patrick became ‘wildly delirious, believed there were devils in his cell, sprinkling bed and cell with water, praying constantly, pupils dilated, voice hoarse, spitting frequently … hallucinations of sight and hearing, refused food, slept none that night, were placed in muffs …’

Over the following days, Patrick began to recover, although ‘he remained in a state of the most extreme collapse for some weeks, tongue white and furred, complained of headache and giddiness. Prisoner was kept quiet in hospital and given plenty of milk beef tea and two bottles of stout daily’. Apparently, ‘delirium occurred at night in the different police barracks where [the brothers] were confined previous to committal to prison’.

When Patrick was ‘charged with the murder of his brother’ he said that his (now deceased) ‘brother was insane for ten days previous’. At his trial, Patrick was charged with murder and detained indefinitely at the Central Criminal Lunatic Asylum. Clinical notes record that he ‘recovered from the attack of acute mania from which he suffered while in [prison] and for some days previously; he accounts for the insanity in his family (which occurred almost suddenly) being brought on by “something” they all partook of while at meals, but is unable to say what the nature of this “something” was. He recognises perfectly the crime that both he and his brothers committed and is fully aware that he was at the time “out of his mind”. He has a somewhat down-cast appearance, a slow slouching gait and is depressed in manner and appearance’. He ‘never presented any symptoms of insanity’.

Patrick’s younger brother, John, was admitted on the same day in 1896 with a very similar history. John was diagnosed with ‘acute delusional mania, convalescent’ and he, like Patrick, soon ‘recovered from the attack of acute mania from which he suffered at the time of committing the murder of his brother and afterwards while in [prison]. Patient is very quiet and well-conducted, is in fair health, takes his food well and sleeps soundly. Has been sent with his brother [Patrick] to work on the land and they are both satisfied and pleased to do so’.

Later in 1896, a third brother, Brendan, was also charged with the murder of his brother and detained ‘at the Lord Lieutenant’s pleasure’. Admission notes describe Brendan as ‘very quiet, well-spoken and most respectful; both in manner and appearance he much resembles his brothers … He presents no symptoms of insanity. I consider him perfectly sane; but like his brothers he suffered from an attack of acute mania while in [prison] … He is quite unable to in any way account for the insanity which occurred in his family, he feels deeply the great misfortune which has befallen them and is depressed when speaking of his brother … who was the unfortunate victim of their insanity’.

On admission, Brendan had a history of ‘phthisis’ (tuberculosis) which worsened in the hospital. In 1897, the medical officers wrote to the Inspector of Lunatics stating that Brendan was ‘suffering from effects of detention and presents symptoms of incipient phthisis. We strongly recommend his discharge on the grounds that his disease will be aggravated by his detention’. Despite treatment with cod liver oil, medical notes recorded that ‘phthisis makes itself more evident each day’. The medical officers again wrote to the Inspector of Lunatics stating that Brendan’s ‘condition has become critical and that if he is to be discharged, he should be released at once, as in our opinion, he will soon become too ill to be removed. His temperature at night has reached 102 [º Fahrenheit (39º Celsius); i.e. raised] and in our opinion he will not survive this winter’. After two more weeks, Brendan was discharged to the care of his sister, but died three months later, in late 1897.

Neither Patrick nor John showed any convincing signs of mental disorder during their time at the Central Criminal Lunatic Asylum. In 1898, the medical officer sent a report to the Inspector of Lunatics stating that both brothers were ‘suitable for discharge. They both have been industrious and extremely well behaved since admission here. The only distinction I wish to make is that detention is having a bad effect on John’s health and he may become ill in the same manner as his brother Brendan, who died soon after his being released from here’. Four months later, the medical officer sent an additional report stating that John was now ‘in very delicate health and threatened with phthisis and we consider that he will die from this disease if not discharged soon. We also certify that he may be discharged with safety to himself and others’. Later that year, John was ‘discharged in care of sister’ and three years later Patrick, too, was discharged ‘in care of his sister’, after more than five years in the asylum.

Overall, these cases demonstrate clear forensic complications of folie à plusieurs, involving, in this case, the killing of a family member. These cases occurred in the 1890s, just a decade after the clinical syndrome of folie à plusieurs had been described in detail by Ireland in his collection of clinical vignettes illustrating both clinical and forensic aspects of the syndrome.319 Three years after Ireland’s publication, Dr Daniel Hack Tuke, formerly of the York Retreat,320 also published a detailed account of folie à deux or ‘double insanity’ in the respected journal Brain.321

These cases of the three brothers are particularly interesting in light of indications that they suffered from an acute physical illness with delirium, which accounted for their delusions and other psychiatric symptoms. Their treatment in hospital was described as ‘moral supervision and dietetic’, an approach which involved regular exercise, gainful employment and an emphasis on healthy diet,322 all of which were consistent with the principles of ‘moral management’.323 Other activities the Central Criminal Lunatic Asylum during this period included were ball games, dancing, music, evening parties and reading books and newspapers (although many patients were unable to read).324

These cases also demonstrate the problems with tuberculosis (‘phthisis’) in the Irish asylums in the late 1800s and early 1900s:325 at least one of the three brothers, Brendan, died of the disease. Interestingly, one of the other brothers, Patrick, contended that their illness was ‘brought on by “something” they all partook of while at meals, but is unable to say what the nature of this “something” was’. This is consistent with evidence from another case of folie à plusieurs described by the remarkable Dr Oscar T. Woods, medical superintendent of the Killarney Asylum, in 1889 and, later, president of the MPA,326 in which bad food was also seen as a contributory cause.327

Overall, the cases of the three brothers demonstrate many of the challenges that ‘communicated insanity’ presented to mental health and judicial services in nineteenth-century Ireland and which remain relevant in the 2000s. Over a century after these cases, the optimal balance between punishment and treatment still continues to be difficult to achieve in contemporary mental health services,328 and both treatment329 and community reintegration present ongoing challenges, especially in cases with substantial forensic dimensions.

Women and Mental Illness in

Nineteenth-Century Ireland

Women with mental disorder were treated differently than men throughout the nineteenth and twentieth centuries by the Irish criminal justice and psychiatric systems.330 Following committal to the Central Criminal Lunatic Asylum in Dundrum, for example, women generally experienced shorter periods of detention and were more likely to be discharged than men.331 This might be attributable to the nature of offences committed by women: 54 per cent of women detained at the Central Criminal Lunatic Asylum between 1868 and 1908 (a total of 70) were charged with or convicted of killing, of which a majority (70 per cent) involved child killing.332

Issues related to menstruation, pregnancy and childbirth were significant factors in determining how these women were viewed in many jurisdictions, including Ireland.333 Parry writes that Hallaran’s ‘emphasis [in 1810] on childbirth and menopause as factors which led to insanity in women was the beginning of what would become medical orthodoxy – the link between female biology and insanity. The work of Thomas More Madden, at the end of the century, shows how this opinion of the causes of insanity had gained wide acceptance. Madden, who was physician to St Joseph’s Hospital, Dublin, argued forcefully that insanity in women was caused by their reproductive capacity’.334

In a similar vein, Dr Fleetwood Churchill wrote, in the Dublin Quarterly Journal of Medical Science in 1850, that cyclic changes in bodily health affected women more than men, with consequent effects on mental activities, and that menstruation, conception, pregnancy and childbirth could all produce disturbances which could amount to insanity.335 In Great Britain, Dr Henry Maudsley (1835–1918) agreed, pinpointing irregularities of menstruation as known causes of mental disorder which could generate suicidal or homicidal impulses.336

Similar emphasis was placed on menstruation as a cause of mental disorder or disturbed behaviour in the US.337 In 1865, one female defendant was found insane at the time of a particular shooting owing to apparent insanity resulting from a combination of romantic problems and dysmenorrhea.338 Dr Isaac Ray (1807–1881), founding father of forensic psychiatry in the US, in his Treatise on the Medical Jurisprudence of Insanity, described an apparent association between menstruation and fire setting, citing several cases ‘in which the incendiary propensity was excited by disordered menstruation, accompanied in some of them by other pathological conditions’.339

One particular case involved a 22-year-old woman who ‘committed three incendiary acts’ but ‘had had a disease two years before, that was accompanied by violent pains in the head, disordered circulation, insensibility, and epileptic fits; and that since then menstruation had ceased’:

That the evolution of the sexual functions is very often attended by more or less constitutional disturbance, especially in the female sex, is now a well-established psychological truth […]. Any irregularity whatsoever of the menstrual discharge, is a fact of the greatest importance in determining the mental condition of incendiary girls.

Ray also described a link between ‘the propensity to steal’ and ‘certain physiological changes’ in women, including pregnancy. He outlined the case of one ‘pregnant woman who, otherwise perfectly honest and respectable, suddenly conceived a violent longing for some apples from a particular orchard … and was detected by the owner in the act of stealing apples’. The woman was ‘convicted of theft’ but a ‘medical commission was appointed’ to review the matter:

Their enquiries resulted in the opinion that she was not morally free, and consequently not legally responsible while under the influence of those desires peculiar to pregnancy; adding that if Eve had been in the condition of the accused, when she plucked the forbidden fruit from the tree, the curse of original sin would never have fallen on the race.

Medical and judicial views on menstruation, pregnancy and childbirth were to remain highly relevant to issues of criminal responsibility in women throughout the remainder of the nineteenth century, especially in relation to infanticide. This emphasis was not, however, limited to the field of forensic psychiatry. Parry notes that the very idea of ‘moral insanity’ had particular implications for women in the Irish asylum system:

The concept of moral insanity, in essence denotes the re-conceptualisation of madness as deviance from socially-accepted behaviour, that is to say, traditional society was defined as normal, and violations of it labelled deviant. For women, this meant the risk of being labelled mad if one stepped outside the bounds of a very narrow definition of femininity […]. Moral management was designed to re-educate the mad into the conforming to society, in the case of the female, into conforming to the notion of the ‘ideal woman’.340

This situation had clear implications for treatment, as ‘moral management aimed to re-educate deviant women to conform to Victorian society. Of necessity, this meant educating women to conform to the ideals of the prevailing ideology of femininity. As a result of this, the treatment women received in Irish asylums, being orientated to this end, was essentially gendered’.341

The issue of gender was raised explicitly in 1891 by the Inspectors of Lunatics who reported that in Ireland 54 per cent of ‘pauper patients’ were male, compared to just 49 per cent in Scotland and 45 per cent in England:342

That the number of males admitted should exceed the females cannot be explained by any difference in the form of disease occurring in Ireland. On the contrary, we find that General Paralysis [neuropsychiatric disorder resulting from late stage syphilis] – a disease to which the male sex is particularly prone – occurs with much greater frequency in England and Scotland. […] The explanation of this relative excess of male patients would appear to us to be found in the cumbrous and difficult procedures necessary to obtain admission to public asylums in Ireland; so that the women, more easily controlled in their homes or contributing less to family support, remain at home or gravitate to the workhouses.343

The links between gender and women’s asylum experiences and, indeed, risk of committal, was by no means limited to Ireland, as interpretations of psychological distress in women differed systematically from those in men in many countries, especially as the profession of psychiatry emerged and established itself within the medical firmament during the 1800s and 1900s.344 This persisted beyond the 1800s: Hanniffy, for example, notes a diagnosis of ‘climacteric insanity melancholia’ in the records of St Fintan’s, Portlaoise in June 1924, apparently the first occurrence of a diagnosis linked to the menopause in the asylum’s books.345

More broadly, writing in the context of Enniscorthy Lunatic Asylum between 1916 and 1925, McCarthy notes that admissions of women were commonly related to menstruation, childbirth or miscarriage, and that single women often ended up drifting into the asylum in a lost, purposeless and generally unwanted state.346 In all, 56 per cent of women admitted to Enniscorthy between 1916 and 1925 were single and, like others so committed, they often struggled with impossible combinations of family misfortune, strict behavioural codes and expectations, economic uncertainty and social powerlessness.

Indeed, Parry argues that, from a gender perspective, the asylums ‘replicated the social structure of wider society’:

The administration of the system was predominately in the hands of men. Each asylum had a Board of Governors, made up of prominent men from the surrounding county. Rarely, if indeed ever, did a woman feature on these Boards – the prevailing ideology of femininity held women to be mentally and physically unsuited to public life, and hence to holding public posts. Except for the position of Matron, all top staff positions (Medical Superintendent, Clerk, Storekeeper) were all held by men. In the early days of moral management, when asylums were run by a Moral Governor, women had a certain amount of power in the asylum system in that the Governor’s wife usually superintended over the female wards. However, lay managers of asylums were gradually replaced by doctors as the century progressed, and simultaneously the role of matron declined in status. Medical superintendents believed they held their posts based on specific expertise, and hence could not justify their wives, in the absence of any expertise, holding any sort of managerial position in the asylum system.347

The fate of women in Irish asylums and the ways in which gender affected the development of the asylum system are fascinating themes that merit greater consideration.348 Particular attention could usefully be paid to specific, albeit difficult to research aspects of these themes such as the fate of babies born in the asylums349 and the experiences of children admitted to them.350 These are stories that need to be told.