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PSYCHIATRY AND SOCIETY IN THE 1800S

Every Physician holding or accepting of an appointment [in a District Lunatic Asylum in Ireland], is requested to bear in mind that the object of the Government is not simply to have the bodily ailments of the Patients attended to, but to assist their recovery by moral or medical means, and to advance Medical Science in cases of Lunacy through the great range of experience which the Public Asylums afford.

Lord Lieutenant and Council of Ireland, General

Rules for the Government of All the District Lunatic

Asylums of Ireland, Made, Framed and Established

by the Lord Lieutenant and Council of Ireland (1843)1

The avowedly humanitarian approach to the mentally ill adopted by Hallaran in Cork in the late eighteenth century,2 consistent with Pinel in France3 and Tuke in England,4 was much needed in nineteenth-century Ireland owing not only to under provision for the mentally ill, but also the Great Irish Famine (1845–52). The Famine was one of the most devastating natural disasters in the history of modern Europe: between 1841 and 1851, the population of Ireland fell by approximately 20 per cent.5 Over a million Irish people died as a result of the Famine and one million more emigrated in its immediate aftermath. Given the Famine’s seismic impact on nineteenth-century Ireland, its effects on psychiatry are considered next.

The Great Irish Famine (1845–52):

‘Weak Minded from the Start’

Interestingly, the Great Irish Famine is generally under-represented in the historiography of mental disorder in Ireland. This is likely attributable, at least in part, to the broader literature’s strong focus on the building of asylums which occurred around the same time. There is, however, little doubt that the Famine increased reliance on various forms of social support among the Irish population in general,6 including those with mental disorder,7 as was duly noted by asylum doctors at the time.8 But did the Famine itself actually increase the rates of occurrence of mental disorder?

Evidence from other countries suggests that this is certainly possible: certain cohorts of people, who were in gestation during the Dutch Winter Hunger of 1944 and born shortly afterwards, were found to have twice the risk of schizophrenia in later life compared to those not exposed to famine conditions during pre-birth development.9 This is likely attributable to the effects of hunger and stress on the developing brain prior to birth, leading to altered patterns of brain development in childhood and adolescence and increased risk of schizophrenia in young adulthood.10 Did something similar occur in Ireland during the Famine?

Walsh used data derived chiefly from the Annual Reports of the Irish Inspectors of Lunacy on the District, Criminal and Private Lunatic Asylums, adjusting nineteenth-century diagnostic labels to elucidate, as best as feasible, if the Famine increased rates of schizophrenia in Ireland.11 He found that while there was indeed an increase of 86 per cent in first admission rates for apparent schizophrenia between 1860 and 1875 (when those in gestation during the Famine reached the high risk age for developing schizophrenia), admissions with other diagnoses (chiefly ‘melancholia’) also increased, and similar increases were evident in other jurisdictions over the same period. These results are, therefore, inconclusive.

The absence of any dramatic trend in Walsh’s work is consistent with the views of Torrey and Miller, who suggest that the effect of the Famine on committal rates was minimal, as admissions simply continued to rise steadily during this period anyway.12 Given the devastation wrought by the Famine and the fact that the asylum system had been firmly established by the late 1830s,13 the continued rise in admissions is unsurprising: in times of unprecedented difficulty and distress the asylum offered, at the very least, food and shelter for those in need. In 1844 there were 2,136 ‘mentally ill’ persons resident in public asylums on the island of Ireland and by 1855 this had risen to 3,522.14 This trend, however, continued long after the Famine: by 1900, the number had reached 16,404.

Given these generally increasing admission rates over the course of the 1800s, is there any other way of looking at existing data so as to elucidate further any possible links between the Famine and admission patterns? First, it is useful to note that, although no part of Ireland fully escaped the effects of the Famine, not all counties were affected equally. Counties in the west of Ireland, such as Galway, Mayo and Roscommon, were particularly badly hit: the death rate in County Mayo between 1846 and 1851 was approximately 60 per 1,000, while the death rate in Kildare and Wexford was under 5 per 1,000.15 Western counties had a particular reliance on potato crops, so when the crops failed from 1845 to 1849, western subsistence farmers and their families were especially vulnerable.

Grimsley-Smith, in a fascinating analysis of admission rates over the decades following the Famine, notes a significant and sustained increase in admissions of 20- to-30-year-olds between 1857 and 1868 in Connaught (the area worst affected by the Famine) but not in Ulster, Leinster and Munster.16 She also points to the 1914 report of the Inspectors of Lunatics who examined statistics from this period and concluded, subject to certain caveats, that there seemed to be ‘an exceptional number of insane and idiots derived from the population born during the decade 1841-51’:

It seems probable that children born and partially reared amidst the horrors of the famine and the epidemics of disease that followed it were so handicapped in their nervous equipment as to be weak minded from the start or to fall victims to mental disease later.17

This supports the idea that, in the areas worst affected, the Famine altered early human development in such a fashion as to increase risk of mental disorder later on, in young adulthood. There are, of course, many challenges associated with reaching such a conclusion, not least of which are the potentially confounding effects of concurrent changes in committal practices, rates of co-occurring physical illnesses, patterns of migration, changes in population structure, declining rates of marriage, and various other demographic factors. There are, in addition, great challenges associated with interpreting diagnostic categories from the past and translating them into contemporary diagnostic categories, even on an approximate basis.18

Even in light of these issues, however, it still appears reasonable to conclude that the Great Irish Famine, like the Dutch Winter Hunger, increased risk of mental disorder among persons who were in gestation during the Famine and born during it or shortly afterwards. Other, variously related factors, such as family structure, family conflict and emigration, were also relevant to committal practices in post-Famine Ireland.19 There may also have been transgenerational effects which affected patterns of illness many decades later, and this possibility richly merits, and is the subject of, further study.20

Finally, it is readily apparent that, at the time of the Famine, both starvation and prevailing deprivation acutely increased social need among the mentally ill21 and also likely led to a worsening of psychiatric symptoms among people with pre-existing mental disorder, both of which increased pressure on asylums to admit people with starvation related distress and intensified mental disorder.22

Analogous evidence for the latter is available from studies of the ‘famine’ which occurred in French psychiatric hospitals between 1940 and 1944, when France was under Nazi rule and rations to French asylums were reduced to levels incompatible with life.23 This resulted in increased mortality in French asylums and a sharp intensification of all forms of mental disorder. The philosopher Simone Weil (1909–1943), herself in an English hospital at the time, died of starvation, possibly in solidarity with the conditions endured by her compatriots in France.24

The famine in French asylums was a specific, demarcated phenomenon which only affected individuals already in asylums, at a particular moment in France’s history. Nonetheless, the deterioration in mental health produced by the lack of food in French asylums provides strong evidence that famine conditions have adverse effects on mental health, at least amongst the mentally ill. This was also the case in Ireland, where persons with worsening mental disorder and starvation related distress sought not only to enter the asylums but also the workhouses, which, despite their drawbacks, at least provided a certain level of care for those with nowhere else to go.

Workhouses and the Mentally Ill:

‘Little More Than a Dungeon’

Even prior to the Famine, destitute persons with mental disorder or intellectual disability had commonly been admitted to workhouses and various charitable establishments, especially during times of social or economic difficulty.25 In 1708, the Dublin workhouse built six cells for persons with apparent mental disorder, intellectual disability or epilepsy.26 The number of places increased to approximately 40 by 1729, but conditions were dreadful: the inmates were chained in foul, unglazed, underground cells with little light or freedom.27

In 1787, the Prisons Act empowered Grand Juries (county administrative and judicial bodies) systematically to establish lunatic wards in houses of industry, and dictated that such wards would be subject to inspection by the Inspector General of prisons.28 The wards were to house insane persons or ‘idiots’ who had to be certified by at least two magistrates.29 The initial response to the 1787 legislation was relatively modest, however, and lunatic wards were only established in Dublin, Cork, Waterford and Limerick.30

As a result, Dublin House of Industry became a major centre for admission of ‘lunatics’ from all over Ireland: between 1811 and 1815, some 754 of its 1,179 admissions came from outside Dublin.31 The investigation ordered by Robert Peel in 1816 recommended that more extensive provision be provided in Cork and Belfast.32 Several decades later, the Commission of Inquiry in the State of Lunatic Asylums in Ireland (1858)33 looked into the matter again and found that the ‘wretched inmates’ in the Hardwicke Cells, connected with the Dublin House of Industry, were ‘in a most unsatisfactory state’. In 1857, these inmates were removed from this ‘disgracefully conducted’ establishment to a ‘new establishment at Lucan’ which was ‘commodious, airy, and cheerful, and every care and attention appeared to be paid to the wants of the inmates, of whom there were ninety-eight at the period of our visit’.

As the 1800s progressed, the Poor Law Act (1838) was introduced to relieve the distress of ‘deserving’ poor in Ireland.34 The system initially consisted of 130 Poor Law Unions, aimed at providing accommodation, food and medical care to the poor of the area. Despite the establishment of several new asylums for the mentally ill during this period,35 many persons with mental disorder or intellectual disability still had to enter the workhouses,36 which generated even greater fear than the asylums did.37 The food was reportedly better in the asylums, compared to workhouses.38

By 1844, there were 957 ‘mentally ill’ persons in workhouses or poorhouses on the island of Ireland and by 1851, towards the end of the Famine, this had increased to 2,393.39 The number continued to rise throughout the remainder of the 1800s, reaching a peak in 1892, when there were 4,198 ‘mentally ill’ persons in workhouses. The previous year, there were some 1,170 ‘idiots’ in workhouses.40 Interestingly, while males tended to outnumber females in public asylums throughout the 1800s,41 ‘mentally ill’ females outnumbered ‘mentally ill’ males in workhouses.42

It is difficult to gain a systematic picture of the specific experiences of the mentally ill in workhouses throughout the 1800s, although conditions were generally very poor and designed to repel,43 as was vividly outlined in the 1817 Report from the Select Committee on the Lunatic Poor in Ireland.44 Efforts were, however, made to improve matters in at least some establishments, albeit with limited success. Ballinrobe Poor Law Union in County Mayo, for example, was located in one of the areas worst affected by the Famine and commonly received persons with mental disorder. In August 1846, a man ‘who was confined to the workhouse as a cured patient from the Castlebar Lunatic Asylum took his discharge and went to his home’; there is no record of his mental state on departure or any attempt at follow up.45 In October 1896, the Ballinrobe workhouse employed ‘a woman at a shilling a day to mind … a woman who is insane’.

Conditions in workhouses were very difficult, not least owing to illnesses such as cholera, typhus and dysentery.46 As a result, there was significant public and official concern about the plight of the mentally ill in the workhouses,47 and it is notable that, unlike the English commissioners in lunacy, Irish inspectors did not approve particular workhouses as suitable for the mentally ill.48 Nonetheless, workhouses rapidly became de facto elements of the system of ‘care’ for the mentally ill during the 1800s,49 as patients were routinely admitted from workhouses to asylums50 and discharged from asylums back to workhouses.51 Relations between the institutions were commonly strained: in 1881, there were 148 persons with intellectual disability or mental illness huddled together in grossly unhealthy conditions in Cork workhouse, and they suffered further during a bitter dispute between the workhouse and the asylum over who was responsible for them.52

Against the background of this close, conflicted relationship between asylums and workhouses, the problem of the mentally ill in workhouses persisted well after the Famine had eased. In 1895, at a meeting of the Irish Division of the MPA in the Royal College of Physicians, Kildare Street, Dr Oscar Woods (secretary of the division) ‘introduced the question of dealing with lunatics in workhouses, and after some discussion, in which the following – Drs Drapes, Finegan, Lawless, John Eustace and the president – joined, the following resolution was unanimously adopted: “That the time has arrived when provision should be made for the large number of lunatics in the workhouses of the country at present uncertified for, not properly cared for, and treated not as lunatics, but merely as paupers, and that a copy of this resolution be sent to the Inspectors of Lunatics”.’53

The concerns of the MPA were strongly supported by admission statistics: Walsh, in an especially valuable study of the Ennis District Lunatic Asylum, County Clare, and the Clare Workhouse Lunatic Asylums in 1901, notes that there were eight workhouse asylums in Clare, housing a total of 263 residents.54 From a diagnostic perspective, 41 per cent had ‘dementia’; 30 per cent were ‘idiots’ or ‘imbeciles’; 20 per cent had ‘mania’; 6 per cent had ‘melancholia’; and 2 per cent suffered from epilepsy. There is also evidence that persons with other conditions, such as delirium tremens (from alcohol withdrawal), were admitted during the 1890s.55

In 1907, at a meeting of the Richmond District Asylum Joint Committee (in Grangegorman, Dublin), the chairman highlighted the magnitude of the issue at the Richmond:

A large number of our admissions come here direct from workhouses. I have looked up the exact numbers and find they average about 30% of total admissions. During the last four financial years 709 patients came from workhouses. I do not think I would be very much in error in estimating that 50% of these 709 admissions would come under the head of Chronic and Harmless Lunatics, and probably at the present time there are not far short of 700 or 800 cases in the whole institution who could be so classified. The 76th section of the Local Government Act of 1898 provides for the establishment of auxiliary asylums for such cases.56

The Richmond Joint Committee dutifully appointed a ‘special committee’ to look into the matter, and the committee visited asylums at Youghal,57 Cork and Downpatrick, and inspected Union Workhouses in North and South Dublin.58 The committee examined patient numbers, clinical conditions and financial arrangements and reported back to the Richmond Joint Committee on 19 December 1907.

Downpatrick Asylum was of particular interest because ‘Down County Council in 1901, after the fullest examination into the fiscal aspect of the question, decided to enlarge the Downpatrick Asylum for the reception of the insane then located in the workhouses’.59 The committee presented details of the accommodation provided at Downpatrick and agreed with the Inspector of Lunatics who, on 16 November 1906, concluded that ‘this county is amongst the few in Ireland which has made full provision for all the insane chargeable to it […]. Nowhere are the insane better housed in bright, cheerful, well-furnished and well-heated wards, where they are properly cared for, well fed, and well clothed’.60

The committee also visited North Dublin workhouse, where they found ‘that the provision for the inmates of the lunatic departments is truly deplorable. The overcrowding is very marked, and calls for prompt relief’.61 The female ward for ‘healthy lunatics’ is ‘little more than a dungeon, ventilation is inadequate, and the beds are laid upon wooden trestles. The patients are obliged to take their meals in this repellent place’.62 The male wards ‘are much overcrowded […]. Forty-two of the patients are confined to bed, 20 of them being of the dirty class. Ten patients have to be spoonfed’. The committee concluded that ‘all buildings occupied by the lunatic patients are deficient in light and air’ and ‘all lunatic inmates of the North Dublin Union Workhouse ought to be removed as speedily as possible’.63 Dr Fottrell at the workhouse ‘supplied us with a list of 60 patients, 20 males and 40 females, with an urgent request that these be provided for without delay’.64 The committee also visited South Dublin Union Workhouse where their ‘experiences were much more agreeable’.65

In the end, the committee made four recommendations to the Richmond District Asylum Joint Committee. First, they urged the Joint Committee ‘to assume the full responsibility imposed upon them by the Local Government Act of 1898 with respect to pauper lunatics within the district’.66 Second, they recommended ‘that provision for the 600 patients should be made by the erection of suitable buildings at Portrane, where ample space for that purpose is available’.67 Third, they concluded that ‘a thorough classification and segregation of our existing inmates at Richmond and Portrane would secure an immediate reduction in our cost of maintenance’. Finally, ‘inasmuch as the condition of things in the North Dublin Union Workhouse requires prompt remedy’, they suggested ‘that the Portrane Committee be instructed to make immediate provision in the temporary buildings at their disposal for the patients whose removal is applied for by Dr Fottrell’. The Joint Committee adapted all four recommendations on 19 December 1907.

Notwithstanding these measures, the problem of the mentally ill in Irish workhouses remained a concern well into the 1900s. In 1913, for example, despite the transfer of 58 patients from the South Dublin Union to the Richmond Asylum, the number in the Union continued to increase, to 202.68 There were similar problems at the North Dublin Union. Clearly the workhouses presented a persistent problem, regardless of how large the asylums themselves became.

Ultimately, the number of ‘mentally ill’ persons in workhouses finally began to decrease from the highs of the 1890s down to 1,821 in 1919, and generally declined further (in analogous establishments) throughout the 1920s, 1930s and 1940s.69 Notwithstanding this reduction, however, a range of challenges remained, not least of which was the plight of the intellectually disabled in the asylums and various other establishments in the early 1900s. These are considered next.

The Intellectually Disabled in the Nineteenth Century: ‘Verily We Are Guilty in This Matter’

The fate of the intellectually disabled in early-nineteenth-century Ireland was similar in many respects to that of the mentally ill. There was minimal dedicated provision, with the result that intellectually disabled persons were cared for at home, admitted to workhouses or, increasingly, committed to the growing number of asylums for the mentally ill.70

The 1843 rules for the operation of asylums provided specifically for the admission of the intellectually disabled and it was estimated that there was a total of 6,127 intellectually disabled persons in Ireland at that time.71 Precise numbers varied, but the Inspectors of Lunatics calculated that, in 1851, there were 3,562 ‘idiots’ ‘at large’; 202 in asylums; 13 in prisons; and 1,129 in workhouses, yielding a total of 4,906.72 By 1861, the number in asylums had doubled (to 403) and the total number risen to 7,033.

During the 1860s, Cheyne Brady, a member of the Royal Irish Academy, governor of the Meath Hospital,73 and prolific author on social matters, was notably exercised by this issue and wrote a pamphlet on The Training of Idiotic and Feeble-Minded Children, grimly outlining the position of the intellectually disabled in nineteenth-century Ireland and elsewhere (using contemporaneous terminology that some readers might find disturbing):

It is not very long since we used to see boys and girls, and sometimes stunted men and women, running wild in our streets and villages in a state of idiocy […]. They were carefully avoided, as the continual worrying of the village urchins had soured their tempers and rendered them in some cases dangerous.

Then, again, on visiting the poor, we have from time to time seen a bundle of rags in a corner, and, on inquiry, have ascertained that it contained an idiot child, living in dirt and degradation, worse than one would permit his dog or pig to live in.

Prejudice and popular ignorance respecting them have led to strange treatment of this afflicted class. By the Hindoo [sic] they are superstitiously venerated, while by many Europeans these helpless creatures have been regarded as human beings without souls. Some poor parents fancy that, as their children cannot remember what they hear, their brain must be soft, and apply poultices of oak-bark in order to tan or harden the fibres; others, finding it impossible to make any impression on the mind, conclude that the brain is too hard, and they torture their unhappy offspring with hot poultices of bread and milk, or plaster the skull with tar, keeping it on for a long time. Others, again, give mercury to act as a solder to close up the supposed crevices in the brain […]. The utmost stretch of humanity has hitherto thrust them out of sight in our workhouses, where they are suffered to exist uncared for and untaught.74

Brady presented a call to action, suggesting the opening of asylums for the intellectually disabled, as had already occurred in Bath (1846), Highgate (1848) and elsewhere:75

And if it cannot be gainsayed that the condition of the idiot and imbecile can be thus improved, is not our duty plain?

But what shall we answer for our past neglect? Verily we are guilty in this matter.

The future, however, is before us. Shall we not redeem the time, and gird up our loins to make up for past deficiency by a strenuous effort on behalf of this neglected class?

There are three courses open for adoption:-

I.The foundation of a general institution for the reception of all degrees of idiocy, from the hopeless to the most improvable.

II.The opening of an asylum for the pure idiots, who are not susceptible of much improvement, but who can be housed, cared for, and cured of bad habits.

III.The establishment of a training school for the improvable cases, where, as in the asylums of which I have attempted a description, they may be trained to habits of usefulness, rendered able to earn a livelihood, and be taught the way of salvation.76

Brady’s words inspired immediate activism on the part of George Hugh Kidd, an obstetric surgeon in Dublin,77 who penned An Appeal on Behalf of the Idiotic and Imbecile Children of Ireland, seeking the building of an asylum for intellectually disabled children, in line with Brady’s suggestion.78

One of the key supporters of Kidd’s proposal was a certain Henry Hutchinson Stewart (1798–1879), second son of Reverend Abraham Augustus Stewart, Rector of Donabate, County Dublin.79 Stewart, a key figure in the history of the intellectually disabled in Ireland, was born on 23 June 1798 and, shortly after the Duke of Richmond came to Ireland as Lord Lieutenant in 1807, was appointed as a page to the Duchess. Stewart later studied medicine, taking his MD in Edinburgh in 1829 and obtaining the Licentiate of the Royal College of Surgeons in Ireland.

Stewart worked in Killucan Dispensary District in County Westmeath before taking Fellowship of the Royal College of Surgeons in Ireland in 1840 and being appointed Governor of the Hospital of the Houses of Industry in North Brunswick Street in Dublin. He was medical attendant to the School for the Sons of the Irish Clergy at the original Spa Hotel in Lucan, County Dublin.

In the mid-1850s, when the Commission of Inquiry in the State of Lunatic Asylums in Ireland80 found that the ‘wretched inmates’ in the ‘Hardwicke Cells’, connected with the Dublin House of Industry, were ‘in a most unsatisfactory state’, it was Stewart’s suggestion in 1857 that they be moved to a ‘new establishment at Lucan’, where he established an asylum at Lucan Spa House.81

Against this backdrop, Stewart was a predictable supporter of Kidd’s calls for an asylum for children with intellectual disability and of the work of the related committee set up by Lord Charlemont. Stewart went on to propose giving his asylum at Lucan for this purpose, together with a donation of £4,000, provided the asylum’s work was continued and its profits used for the maintenance of an institution for the intellectually disabled.82 Premises were duly acquired in Lucan, on the same plot of ground as Stewart’s Asylum at the Crescent, and made ready to receive 12 pupils in 1869.

Two separate institutions were established: the Stewart Institution for Idiots, based on Protestant principles, and the Stewart Asylum for Lunatic Patients of the Middle Classes, with no religious distinctions.83 Dr Frederick Pim became medical director and, despite complexities involving the Catholic primate, Cardinal Cullen, by 1870 the premises were quickly oversubscribed and overcrowded. Later in the 1870s, the establishment, now termed the Stewart Institution for Idiotic and Imbecile Children and Middle Class Lunatic Asylum, moved to the mansion and 40 acre demesne of the late Lord Donoughmore in nearby Palmerstown.84

In parallel with this dedicated but isolated development, persons with intellectual disability continued steadily to be admitted to workhouses and asylums throughout the rest of Ireland.85 By 1908, the Royal Commission on the Care and Control of the Feeble-Minded estimated that, based on the 1901 census, ‘there were 5,216 idiots in Ireland, of whom 3,272 were at large, 1,181 were in workhouses, and 763 in asylums’:

As regards the existing accommodation in Ireland, we have shown that the accommodation for these cases in workhouses is absolutely unsuitable; that the provision for those in asylums, although more suitable is by no means ideal, and is unnecessarily expensive; while of the cases ‘at large’ although a minority may be suitably provided for at home, there is ample evidence to show that in the majority of cases the unfortunate patient at home is even in a worse plight than the patient in the workhouse.

With the exception of the Stewart Institution for Imbeciles at Palmerstown, which is entirely supported by charitable donations, and only provides for 103 inmates, there is absolutely no special provision in Ireland at the present time for probably 64 per cent of the uncertified idiots, imbeciles and feeble-minded, or for the majority of the 763 certified idiots in asylums as returned in the Census, 1901.86

Overall, it is likely that the institutional experiences of the intellectually disabled in late nineteenth-century Ireland were similar, in at least some respects, to those of individuals without intellectual disability who were similarly institutionalised and who tended to experience lengthy periods of detention in poorly therapeutic facilities, poor mental and physical health, and a high risk of dying in the asylum: once a person had been detained in an Irish asylum for more than five years, it was almost inevitable that he or she would die there.87

The institutional experiences of the intellectually disabled in Ireland were similar to those in other jurisdictions.88 In Great Britain, the late 1800s saw the management of the intellectually disabled move increasingly out of the private, family sphere and into the public sphere, thus becoming a ‘social problem’, presumed to necessitate the development of institutional provisions.89 This period also saw the emergence of the principle of ‘segregation’ of the intellectually disabled from the rest of society, and a particular commitment to permanent ‘segregation’, deemed to be in the best interests of both the individual and society.90

These public and professional attitudes resulted in widespread institutionalisation of the intellectual disabled throughout the 1800s,91 focused, in Ireland, on the workhouses and emerging asylum system. It is worth noting, however, that the precise nature of the psychiatric institutions across Ireland varied considerably, and there were significant pockets of enlightened practice scattered across the country, where staff sought to humanise conditions and improve outcomes for their patients. The asylum in Enniscorthy, under the punctilious superintendence of the prolific Dr Thomas Drapes, is a good example.

Dr Thomas Drapes:

Asylum Doctor Extraordinaire

Dr Thomas Drapes (1847–1919) was RMS of the Enniscorthy District Asylum in County Wexford from 1883 to 1919, and one of the leading figures in Irish asylum medicine for several decades.92 Drapes’s career was as complex as it was noteworthy, and his legacy was to help shape Irish psychiatry for several decades to follow.93

Drapes was born in Lakeview, Cavan on 17 January 1847, the third son of Dr Thomas Drapes who died shortly after Drapes’s birth.94 His mother moved the family to Kingstown (Dún Laoghaire), County Dublin, and Drapes spent time at a preparatory establishment in Derbyshire before completing his early education at Mr Wall’s private school. In 1864, he went to Trinity College Dublin, from which he graduated in Arts in 1867. He then studied medicine at the Trinity College Medical School and the City of Dublin Hospital. Drapes took the first Medical Scholarship at Trinity College Medical School in 1869, as well as the Purser Studentship and Clinical Medal at the City of Dublin Hospital, before attaining the degree of MB (Bachelor of Medicine; Medicinae Baccalaureus) in 1871. In the same year, Drapes took the Licence of the Royal College of Surgeons in Ireland and the Licence in Midwifery of the Rotunda Hospital.

After completing his training, Drapes was appointed as visiting and consulting physician to Enniscorthy District Lunatic Asylum in County Wexford. Enniscorthy Asylum had opened in 1869, one of 21 such institutions built during this wave of asylum building.95 In 1883, following the death of Dr Joseph Edmundson, Drapes became RMS, a position he held until his retirement on 15 May 1919. As with all asylums during this period, admission rates increased at Enniscorthy, from 4 per 100,000 population in 1871, to 6 in 1911.

The positon of RMS was an extraordinary and, in many senses, impossible one. In 1874, revised General Rules and Regulations for the Management of District Lunatic Asylums in Ireland specified that the RMS was to ‘superintend and regulate the whole establishment, and is to be intrusted with the moral and general medical treatment of its inmates, for whose well-being and safe custody he [sic] shall be responsible; and he shall at all times devote his best exertions to the efficient management of the institution’:96

He shall, before one o’clock, P.M., and also occasionally at other times, inspect the whole establishment, daily – dormitories, – dining-rooms, – kitchen, – laundry, – stores, and other places. He shall go through all the divisions, and see that they are orderly, clean, well ventilated, and of a proper temperature. He shall carefully examine each patient who may seem to require his advice, or to whom his attention may be directed. When going round the female division he shall be accompanied by the Matron or Head Nurse of the division, who shall direct his attention to any matter worthy of attention.97

[…] He shall also visit the male divisions after the patients have retired to rest, and satisfy himself that they are safely and comfortably located for the night.98

Other regulations related to communication with the ‘Consulting and Visiting Physician’ in ‘complicated or difficult cases of mental disease, or any case requiring particular treatment’;99 the RMS being absent from the asylum for a night, which required ‘special leave from a Board of Governors or the Inspectors’;100 the keeping of books101 and minutes;102 ‘disbursement of money’;103 and various other matters. The role of RMS was clearly an extensive and responsible one, both in local asylums and in the criminal asylum at Dundrum.104

During his time as RMS in Enniscorthy, Drapes, in addition to his daily duties, introduced improvements to the establishment including the addition of two new wings, a laundry, kitchen, new drainage system, new water supply, a general heating plant and a mill to supply electricity at an economical rate. Drapes remained, however, primarily a physician, noted for his kindness to patients,105 albeit within the context of the times when institutional practices such as withholding patients’ letters were routine elements of asylum life in Enniscorthy as elsewhere.106

Once he became RMS, Drapes joined the MPA and became an exceptionally active member and enthusiastic contributor to the MPA’s Journal of Mental Science.107 Drapes was elected president of the MPA for the term 1911–12 but declined on health grounds. In 1912, he was unanimously elected as co-editor of the Journal of Mental Science, to which he devoted his considerable energies and intellect: in 1917, the Journal published Drapes’s translation of a paper by Yves Delage, titled ‘Psychoanalysis, a new psychosis’ (‘Une psychose nouvelle: la psychoanalyse’).108 Both the breadth of Drapes’s learning and his myriad intellectual gifts were clear in his deft rendering of Delage’s coruscating critique of psychoanalysis.

In addition to his duties with the MPA and Journal of Mental Science, Drapes took a keen interest in many other matters relating to mental disorder and its treatment. These ranged from the ‘alleged increase in insanity in Ireland’109 to the role of trauma in producing ‘hallucinatory insanity’.110 Throughout his contributions to these debates, Drapes was unafraid to challenge theories he believed to be unhelpful or wrong. This was most apparent in his views on emergent classification systems for mental disorder, systems which he felt should not proceed until there was better definition and use of key terms, such as ‘hallucinations’ and ‘illusions’.111

Drapes was especially unimpressed by Kraepelin’s proposed division of ‘functional’ psychosis into manic-depressive illness (bipolar affective disorder) and dementia praecox (schizophrenia);112 Drapes, like a number of significant others,113 preferred the idea of a ‘unitary’ psychosis.114 This stood in contrast to those who supported the German approach,115 including the influential Norman (RMS at the Richmond), who read a paper titled ‘variations in form of mental affections in relation to the classification of insanity’ before the Medical Section of the Academy of Medicine in Ireland on 28 January 1887.116 In his engaging paper, Norman described previous diagnostic systems as metaphysical and fanciful, rather than clinically meaningful, and welcomed the new, emerging systems.

Unafraid of controversy, Drapes published a paper in the Journal of Mental Science addressing the use of ‘punitive measures’ in asylums117 and, while punishment was used in many asylums in order to maintain order during this period, the Inspectors of Lunatics, following their inspection of Enniscorthy on 4 July 1913, reported a notably low rate of restraint there.118 Even in 1916, by which point the Enniscorthy asylum was ‘considerably overcrowded’, the institution was still maintained ‘in very good order’.119

The following year, at the spring 1917 meeting of the Irish Division of the MPA, Drapes, as chairman, heard a detailed account of the Richmond War Hospital (1916–19), and went on to reflect on the folly of ‘psychophysical parallelism’, or the spurious division between mental and physical symptoms in medicine.120 Given Drapes’s prominence in Irish and British medicine at the time, his emphasis on the continuity between physical and mental symptoms was both influential and prescient, and prefigured many of the developments in psychiatry following the end of the First World War.

Indeed, this issue, the spurious division between mental and physical phenomena, was to remain a theme in clinical practice for many decades to follow and was a key element in the false dichotomies in psychiatry identified by Andreasen, editor-in-chief of the American Journal of Psychiatry, almost a century later.121 Drapes’s insight remains highly relevant to clinical practice today.122

Despite his general independence of judgment, Drapes was not immune to passing trends in medical thought. At the 1910 Spring meeting of the Irish Division of the MPA, in response to a paper by Dr H.M. Eustace on the ‘prophylaxis of insanity’, Drapes spoke about measures proposed elsewhere to prevent the occurrence of mental disorder:

Dr Drapes said that [Dr Eustace’s] paper was highly suggestive. The nineteenth century had been eminent in preventive medicine and hygiene, but mental hygiene had been omitted – Hamlet without the Prince. Medical examination before marriage was good in theory, but stopping marriage would not stop procreation. The public must be educated, and the teaching of the structure and function of the body should commence from infancy. Sterilisation would be even more necessary in improvable cases, those which were discharged quasi-recovered, and these should be given the choice of sterilisation or perpetual detention. He also alluded to the necessity for better teaching of medical men in psychology and psychiatry.123

Like many others who proposed measures such as sterilisation of the mentally ill, Drapes was chiefly motivated by the size of the asylum system and the perceived increase in rates of insanity that underpinned it. Similar measures had been proposed and even adopted elsewhere (e.g. certain parts of the US) at this time.124 Even so, Drapes’s endorsement of sterilisation was a rare and regrettable misstep for one of the leading independent thinkers in asylum medicine in Ireland and Great Britain. Despite advocacy from certain asylum doctors in Ireland, such as Dr William Dawson, eugenics did not gain widespread support in Ireland and the movement did not generally progress.125

In his personal life, Drapes was active in the Church of Ireland and sought to combine adherence to scientific medical principles with commitment to the tenets of Christianity.126 He was on the Synod of his diocese, took a keen interest in temperance activities, and was secretary of the local choir union for some 30 years. The emphasis that Drapes placed on religion was duly reflected in the Enniscorthy asylum, as the Inspectors of Lunatics noted following their 1913 inspection:

Religious ministration receives careful attention. One hundred and forty-one men and 127 women [49% of the patient population] were able to be present at Divine Service on last Sunday. A Roman Catholic and a Protestant Chaplain visit the institution at least twice in the week.127

Drapes’s other interests included chess, croquet and golf. Drapes retired from the Enniscorthy Asylum on 15 May 1919, and though he appeared active and in good health, he died of double pneumonia on 5 October 1919. In his obituary in the Journal of Mental Science, Dawson deeply mourned the loss of an outstanding figure in Irish and British asylum medicine.128 Dawson was, himself, a remarkable figure in Irish psychiatric history, appointed by the War Office in 1915 as a specialist in nerve disease for the British army in Ireland, having previously served in many other prominent roles, including Inspector of Lunatic Asylums in Ireland and president of the MPA (1911).129

Overall, Drapes represented a broadly progressive strand within Irish asylum medicine, focused on patient care and recovery, albeit still within the confines of the custodial Irish asylum system and with the caveat that he was not opposed to considering sterilisation as one way of addressing the apparent increase in insanity that troubled him so much.130 Like many leading figures of his day, Drapes’s thought was dominated by the size of the asylum system and the perception that rates of insanity were increasing uncontrollably.131 This perception, and the debates it stimulated, were a defining feature of this phase in the history of psychiatry in Ireland.

‘The Increase of Insanity in Ireland’ (1894)

Even in the early 1700s there was clear recognition that the needs of increasing numbers of mentally ill persons were not being met by existing provisions in workhouses, prisons or hospitals.132 Concern about the apparent increase in insanity in Ireland grew steadily throughout the 1700s and 1800s, despite efforts to increase provision through the opening of St Patrick’s Hospital, Dublin, in the mid-1700s and various developments and initiatives at workhouses, such as that in Cork, at the turn of the nineteenth century.

By 1810, elucidating the ‘cause of the extraordinary increase of insanity in Ireland’ was a key concern for Hallaran in Cork. In his celebrated textbook, An Enquiry into the Causes Producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with Hints as to the Better Management of Public Asylums for Insane Persons, he wrote:

It has been for some few years back a subject of deep regret, as well as of speculative research, with several humane and intelligent persons of this vicinity, who have had frequent occasions to remark the progressive increase of insane persons, as returned at each Assizes to the Grand Juries, and claiming support from the public purse. To me it has been at times a source of extreme difficulty to contrive the means of accommodation for this hurried weight of human calamity!133

Hallaran believed that the reasons for this apparent increase in insanity related to both ‘corporeal’ (physical or bodily) and ‘mental excitement’ (in the mind),134 as well as ‘the unrestrained use and abuse of ardent spirits’ (i.e. alcohol):

So frequently do instances of furious madness present themselves to me, and arising from long continued inebriety, that I seldom have occasion to enquire the cause, from the habit which repeated opportunities have given me at first sight, of detecting its well-known ravages.135

When an individual had developed ‘the habit of daily intoxication’, Hallaran noted that ‘the countenance now bespeaks a dreary waste of mind and body; all is confusion and wild extravagance. The temper which previously partook of the grateful endearments of social intercourse, becomes dark, irritable and suspicious’.136 The challenges of treatment were only too apparent: ‘Perhaps there is not in nature a greater difficulty than that of restoring a professed drunkard to a permanent abhorrence of such a habit’.137

In Hallaran’s view, the solution to the problems presented by alcohol lay in reforming revenue laws, limiting availability and optimising the quality of alcohol consumed:

As I have every reason to suppose that the revenue laws, so far at least as they relate to this part of the Empire, give ample opportunity of regulating and inspecting the quantum of this valuable commodity, at its first shot, I would also consider of the possibility of officers in this department laying such restraint upon it, as must effectually prevent its making further progress in society […]. I would therefore, at the fountain head, commence the measures of reform, by enforcing the necessary limitations to its unreserved dispensation […]. If then we must admit the expediency of indulging the lower orders with a free admission to the bewitching charms of our native whiskey, let it be, in the name of pity, in the name of decency and good order, under such stipulations, as that it may at least be dealt out to them in its purity, free from those vicious frauds which not only constitute the immediate cause of the most inveterate maladies in the general sense, but also render them particularly liable to the horrors of continued insanity.138

Hallaran identified ‘terror from religious enthusiasm’ as another cause contributing to apparently increasing rates of ‘mental derangement’:

On the whole, I am much inclined to indulge the hope, that however well-disposed my fellow countrymen may be, to cherish and hold fast the full impression of a pure and rational religion, still, that possessing a strong and lively discriminating faculty, they will continue to resist all charlatanical efforts to dissuade them from the substantial blessings which they now enjoy: either by submitting themselves to the distorted doctrines of the libertine, any more than to the circumscribed dogmas of our modern declaimers.139

Hallaran was by no means alone in his concerns: the apparent increase in insanity became the leading concern among asylum doctors in Ireland and Great Britain throughout the 1800s. In 1829 there were 2,097 ‘mentally ill’ persons in institutions in Ireland and by 1894 this had increased to 17,665.140

In 1887 the Inspectors, John Nugent and G.W. Hatchell, maintained that this increase in numbers was, at least in part, attributable to ‘better and more generous treatment of the insane’ in the asylums.141 They reported that, in 1887, the ‘lunatic population of this country under Governmental supervision’ stood at 14,702, comprising 10,077 in district lunatic asylums, 602 in private lunatic asylums, 3,841 in poorhouses, 172 in the Central Lunatic Asylum, 9 in Palmerston Private Asylum and 1 in gaol.142 This was an increase from a total of 14,419 the previous year and the Inspectors linked the increase with the quality of care provided:

With regard to the condition of the 10,077 patients in district asylums on the 1st of January in the present year [1887], the probably curable, or perhaps, more cautiously speaking, those who admit of hope of recovery, were estimated at 2,228, and the incurable at 7,779, each class, it may be added, needing an equal professional care and domestic supervision; for it should be remembered, that though alike innocuous and tranquil when properly attended to, if neglected they may become dangerous and unmanageable; perhaps, too, of all others, those whose insanity is less varied, and those whose reasoning powers, save on special subjects, are scarcely impaired.

Such being the case, it cannot be a matter of surprise, if for its own protection, and that of the public, a continued deprivation of personal freedom is entailed on an innocent community, and, at the same time, if owing to a better and more generous treatment of the insane, their longevity is notably increased, that additional provision should be made to meet growing requirements.

Hence the progressive enlargement of public asylums has become a necessity. Twelve years ago the accommodation in them was limited to 7,000 beds; it has been since increased by over 2,600 and even now there exists a marked deficiency.

The same process which has obtained here is strongly evidenced in England, particularly in its most populous and manufacturing districts.’143

Drapes,144 writing in the Journal of Mental Science in 1894, noted that between 1859 and 1889 the rate of increase in certified ‘lunatics’ in England had decreased, but in Ireland had increased, a difference that Drapes found difficult to explain:

If we take the 30 years from 1859 to 1889 we find that in England the ratio of total lunatics to population increased in the first decade by 526 per million, in the second by 361, and in the last by 211, denoting a very large diminution in the rate of increase. On the other hand, if we take a similar, though not exactly corresponding, period in the case of Ireland, viz., 1861 to 1891, we find that the ratio of lunatics increased in the first decade by 600 per million, in the second by 510, and in the last by 940. So that while in England the rate of increase during the period mentioned fell continuously from 526 to 211 per million, or to considerably less than one-half, in Ireland it rose from 600 to 940, an advance of over 50 per cent – a truly remarkable difference.145

In the same year, Dr Daniel Hack Tuke (1827–1895),146 also in the Journal of Mental Science, noted that both the numbers certified as ‘insane’ and the numbers admitted to asylums had risen in Great Britain, a situation apparently attributable to increases in the causes of insanity, new forms of mental disorder, and premature discharge from asylums at the request of families.147 Having considered a range of arguments and positions on the topic, Tuke concluded that (a) there had been a large increase in the number of patients in asylums and workhouses, especially the former, since 1870; and (b) there had been a considerable, but not as great, rise in admissions to asylums; but (c) this did not indicate increased susceptibility to insanity in the population because the increased numbers were attributable, at least in part, to increased appreciation of the value of asylums, movement of patients from workhouses to asylums, and increased registration of persons with mental disorder who had not previously been so registered.

With regard to Ireland in particular, Tuke, in a separate Journal of Mental Science paper devoted to the ‘alleged increase of insanity in Ireland’, noted the emphasis that RMS Norman at the Richmond in Dublin placed on social attitudes in increasing rates of presentation to asylums:

Although the number of persons under treatment in the Dublin Asylum has risen from 1,055 in 1883 to 1,467 at the end of 1892 (or 412 more) the medical Reporter, Dr Conolly Norman [below], observes: ‘At the same time, as the result of much consideration, it is not thought that the facts warrant the conclusion that there has been during the period any very marked increase in the tendency to insanity among the inhabitants of the district’. So far as there is an apparent increase, Dr Norman attributes it to: (1) Decreased prejudice against asylums; (2) The friends of patients being less tolerant of having insane persons in their midst; (3) Poor-Law Authorities being more sensible of the unsuitability of most workhouses to provide for the insane; (4) The fact that the increase is almost confined to Dublin itself, where the population is increasing. The death-rate and the recovery-rate have also decreased, and will largely account for the accumulation of cases, though, as I have already said, not for the rise in admissions.148

Tuke himself explored a range of possible contributory factors including selective emigration of the mentally healthy, which, he concluded, could result in an increase in the proportion of the population that was mentally ill, but not an increase in the absolute number. He did, however, draw attention to the possibilities that the emigration of mentally healthy persons placed increased pressure on those left behind; evictions could have a negative effect on mental health; political tumult could increase rates of insanity; and abuse of alcohol or tea might also be relevant. Considering all these factors together, Tuke concluded that there was indeed an actual as well as apparent increase in insanity in Ireland, even after taking account of the accumulation of mentally ill in the asylums over time.

Tuke’s specific concerns were shared, to varying degrees, by asylum doctors throughout Ireland. In Castlebar District Asylum, Dr G.W. Hatchell complained in 1893 that the habit of drinking tea was being encouraged by travelling salesmen driving in carts throughout the countryside, and the addictive qualities of tea were also noted by Dr William Graham of Armagh and Dr E.E. Moore of Letterkenny, who believed that heredity was the predisposing cause of insanity in 70 per cent of admissions.149 Tea was, however, also implicated.

Ireland and Great Britain were by no means alone in experiencing these problems with increased rates of committal. There were similar trends apparent in other countries, including France, England and the US,150 but Ireland’s rates were especially high at their peak, and especially slow to decline.151 Doctors and commentators elsewhere considered proposed contributory factors similar to those considered by Hallaran, Drapes, Tuke and Norman in Ireland, and many, like F.B. Sanborn, previous Inspector with the Massachusetts State Board of Health, Lunacy and Charity, concluded that there was a real increase in incident cases of insanity in their areas too, even after various other factors were taken into consideration.152

The extent of alarm produced by this apparent trend in Ireland is evident in the broad range of solutions proposed (ranging from increased institutional provision to sterilisation), and the publication, in 1894, of the Special Report from the Inspectors of Lunatics to the Chief Secretary: Alleged Increasing Prevalence of Insanity in Ireland.153 Even relatively enlightened figures, such as Drapes, were sufficiently alarmed that their generally humane approach was regrettably affected by the prevailing sense of panic about the key unresolved question that dominated, and still dominates, the history of Irish psychiatry: was there really an increase in mental disorder in nineteenth-century Ireland?154

Why did the Asylums Grow so Large?

In considering whether or not there was a true increase in the incidence of mental disorder in nineteenth-century Ireland, it is useful first to examine other, relatively clearer reasons why the Irish asylums grew so large in the 1800s and early 1900s.155 Was this development really due to increased rates of mental disorder or were these other factors more relevant?

Taking a bird’s eye view, it appears highly likely that a variety of related and mutually reinforcing circumstances contributed to the growth of the Irish asylums, including (1) increased societal recognition of, and diminished tolerance for, the problems presented by mental disorder; (2) mutually reinforcing patterns of asylum building and psychiatric committal, underpinned by continual, almost obsessional legislative change;156 (3) changes in diagnostic and clinical practices (including the search for professional prestige among clinical staff); and (4) possible epidemiological change, owing to sociodemographic changes in Irish society and/or unidentified biological factors leading to altered patterns (although not increased incidence) of mental disorder.157

In the first instance, the end of the eighteenth century saw substantial changes in societal attitudes to mental disorder throughout Europe. The growing humanitarian approach of the early-nineteenth-century greatly increased efforts to provide care to persons with mental disorder, resulting in an apparent increase in incidence owing to increased diagnosis,158 as suggested by Tuke in 1894.159 This change in attitude was evident not just in Ireland but throughout Great Britain and Europe, and led to considerable systematic governmental reform in many countries, including Great Britain.160 In Ireland, the 1804 Select Committee of the House of Commons recommended the establishment of four provincial asylums dedicated to the treatment of the mentally ill161 and in 1814 one such establishment, the Richmond Asylum, finally opened in Dublin.162 While it is difficult to quantify the precise role of changes in professional and public attitudes in these developments, it is inevitable that, at the very least, they contributed to increased recognition and diagnosis of mental disorder and, in turn, increased rates of presentation to the newly established asylums.

The latter part of the nineteenth century was also a time of industrialisation, resulting in significant reconfigurations at family, community and societal levels in many European countries, albeit somewhat limited in Ireland. Nonetheless, structural community changes associated with this era of history increased the visibility of individuals with mental disorder in Irish communities, resulting in increased presentations to asylums and an apparent (although not actual) increase in rates of mental disorder for this reason.163

This is consistent with Tuke’s observation that Norman, at the Richmond Asylum, emphasised the centrality of social attitudes, such as decreased prejudice against asylums and reduced tolerance for mental disorder in communities, in increasing presentations.164 These changes in social attitudes, community structures and patterns of presentation, as well as changes in diagnostic practices, represented significant modifications in the interpretation and experience of mental disorder at both individual and societal levels, contributing to increased presentations to asylums. Various complexities relating to land, marriage, family relations, inheritances and emigration were also likely relevant in different ways in specific cases.165

The second key factor that contributed to increased rates of presentation was the elaborate process of legislative reform and asylum building that commenced in the early 1800s and gathered extraordinary pace as the nineteenth century progressed. The Lunatic Asylums (Ireland) Act 1821 authorised the establishment of a network of district asylums throughout the country and within fifteen years there were large public asylums established in Armagh, Limerick, Belfast, Derry, Carlow, Portlaoise, Clonmel and Waterford.166 The reports of the Inspectors of Lunatics for this period demonstrate that these asylums were rapidly filled to capacity soon after opening.167 As Finnane demonstrates in his brilliant, path-finding book, Insanity and the Insane in Post-Famine Ireland, this process was much more centralised in Ireland compared to England,168 resulting in greater institutionalisation.169

In any case, there can be little doubt that the sudden availability of hundreds of asylum beds led to increased rates of presentation by mentally ill individuals who had previously lived with families, lodged in workhouses, languished in prisons, or been homeless. The Great Irish Famine also played a role in increasing social need and pressure for accommodation and food (as well as potentially affecting future mental health needs). It remains unclear, however, precisely what proportion of asylum admissions was truly suffering from mental disorder, what proportion was admitted for other reasons (e.g. intellectual disability or social problems), and what proportion was admitted owing to misuse of the ‘dangerous lunatic’ procedures which offered several practical advantages to families seeking to have family members committed (e.g. the asylum could not refuse to admit a ‘dangerous lunatic’).170

It is clear, however, that the rapid overcrowding of asylums was related not only to increased rates of presentation, but also prolonged length of stay and accumulation by non-discharge. Between the years 1850 and 1890, the excess of admissions over discharges was approximately 200 annually; i.e. there were, potentially, 200 new long stay patients created in district asylums each year,171 which further increased occupancy and pressure on beds.

Changes in diagnostic and clinical practices are the third factor that contributed to increased rates of psychiatric hospitalisation in the 1800s, in addition to increased recognition of the problems presented by mental disorder and mutually reinforcing patterns of asylum building and psychiatric committal, underpinned by a constant churn of legislative activity (Chapter 2).

Diagnostic practices are constantly changing in psychiatry with the result that there are significant difficulties establishing the contemporary equivalents of diagnoses made in the nineteenth century, especially when retrospective diagnostic endeavours are based on inconsistent, incomplete medical records.172 There were likely at least four nineteenth-century terms that correlated with diagnoses that are now known as ‘functional psychoses’ (i.e. schizophrenia and bipolar affective disorder): mania, melancholia, monomania and dementia.173 The confusion and conflation of these terms in the literature adds greatly to the difficulties of interpreting statistics from the 1800s and early 1900s. Some of these diagnostic challenges, along with the difficulties separating mental disorder from socioeconomic concerns, are demonstrated by the case of Mary, outlined here based on her original case records from the Central Criminal Lunatic Asylum, Dublin.174

Mary was a 40-year-old ‘housekeeper’ with seven children who was charged with the manslaughter of her 4-year-old child in the mid-1890s. She was ‘acquitted on the grounds of insanity’ and detained at the Central Criminal Lunatic Asylum ‘at Her Majesty’s Pleasure’ (i.e. indefinitely). Mary’s admission diagnosis was ‘chronic melancholia’, attributed to ‘heredity’; admission notes record that she had a sister in a district asylum.

Medical records note that Mary’s ‘expression of face, attitude and gestures are characteristic of melancholia; she is emotional at times. [She] does not exhibit any delusion’. Her notes also, however, record that ‘she takes an interest in her surroundings and associates with the other patients; readily enters conversation. Appetite good, sleeps well, clean and tidy in dress and person. [She] is bad tempered and inclined to sulk if corrected. [She] does needlework and house cleaning’.

Subsequent entries confirm that Mary was ‘well-behaved, quiet and respectable’, and ‘an excellent worker’. Much of this is not consistent with the diagnosis of ‘chronic melancholia’. Notes from almost two years after her admission specify that Mary ‘will cry when meditating on her misfortunes’; this reaction appears understandable, given Mary’s situation, following the loss of her child and her indefinite detention at the hospital.

Clinical notes from six years after Mary’s admission record that ‘this patient is perfectly sane and is most anxious for her discharge but there is some difficulty as her husband is in a workhouse and she has no friends sufficiently well off to provide for her’. Two years later, however, Mary, then described as ‘perfectly harmless’, was ‘discharged … in care of her daughter’. In this case, the diagnosis of ‘chronic melancholia’ appears, by today’s diagnostic criteria, largely unsupported by the clinical details recorded in the sparse notes documenting Mary’s stay in the Central Criminal Lunatic Asylum.

Despite these difficulties with the interpretation of clinical records, some general conclusions can still be drawn about changes in diagnostic practices throughout the nineteenth century. There is, for example, strong evidence of a diagnostic shift from intellectual disability (‘idiots’) towards mental disorder (‘lunatics’) during the latter part of the 1800s. In 1893, the Inspectors of Lunatics presented findings from the General Report of the Census Commissioners demonstrating a fall in the number of ‘idiots’ (from 7,033 in 1861 to 6,243 in 1891) and a rise in the number of ‘lunatics’ (from 7,065 in 1861 to 14,945 in 1891).175 There are many possible reasons for these changes, the most significant of which is the sudden availability of hundreds of asylum beds for individuals with mental disorder, which may have prompted a reclassification of certain intellectually disabled individuals as ‘lunatics’ in order to secure easier access to long term asylum accommodation.

Another contributor to the rising inpatient numbers was the search for professional prestige among asylum doctors, who were very keen to enhance their status, income and control over asylums.176 The 1874 General Rules and Regulations for the Management of District Lunatic Asylums in Ireland articulated a direct link between patient numbers and pay:

The annual sums and allowances to be paid and made to the several Resident Medical Superintendents, whose salaries and allowances have not been equivalently fixed by order of the Lord Lieutenant in Council, and to all persons hereafter to be appointed as such Resident Medical Superintendents, shall be as follows: -

When the accommodation for patients in the Institution shall be under 250, the salary of the Resident Medical Superintendent shall be at the rate of £340 per annum.

When the accommodation for patients shall be 250 and under 350, such salary shall be at the rate of £400 per annum.

When the accommodation for patients shall be 350 and under 500, such salary shall be at the rate of £450 per annum.

When the accommodation for patients shall be 500 and under 600, such salary shall be at the rate of £500 per annum.

When the accommodation for patients shall be 600 and under 800, such salary shall be at the rate of £550 per annum.

It shall, however, be lawful for the Lord Lieutenant in Council to increase the salary of any Resident Medical Superintendent who may have served eight years in any Asylum to the satisfaction of the Board of Governors, upon the recommendation of such Board and of the Inspectors; such increase not exceeding in any case £100 per annum.

And the allowances to be made to all such Resident Medical Superintendents shall be apartments, fuel, light, washing, vegetables, bread, and milk.177

Any RMS appointed after that date (23 February 1874) was not ‘allowed any furniture for the apartments occupied by them, save and except the following fixtures: chimney pieces, grates, presses, fixed shelves, locks, bells, gas fittings and gasaliers, blinds. Carpets or matting may, with the sanction of the Board of Governors or of the Inspectors, be allowed in corridors or on stairs in the Resident Medical Superintendent’s apartments, if such corridors or stairs are used by officers, patients, or attendants.’

These arrangements were revised on the ‘28th day of April, 1885’, when the ‘Lords Justices-General and General Governors of Ireland, by and with the advice of the Privy Council of Ireland’ declared that the RMS’s basic salary was to be determined by the institution in which he [sic] worked, as follows: Richmond and Cork: £600; Ballinasloe, Belfast, Limerick and Omagh: £500; Castlebar, Clonmel, Downpatrick, Kilkenny and Killarney: £450; Letterkenny, Maryborough, Monaghan, Mullingar and Sligo: £450; Armagh, Carlow, Ennis, Enniscorthy, Londonderry and Waterford: £400. Various other payments and allowances were also mandated, including a £100 ‘increase in salary’ after serving ‘eight years to the satisfaction of the Board of Governors’.178 While it is difficult to determine the precise magnitude of the effect of these arrangements on asylum admission rates, they clearly linked higher pay with asylum size, presumably with predictable consequences.

Possible epidemiological change is the fourth factor that contributed to increased rates of psychiatric hospitalisation, in addition to (1) increased societal recognition of the problems presented by mental disorder; (2) mutually reinforcing patterns of asylum building and psychiatric committal, underpinned by continual legislative change; and (3) changes in diagnostic practices and the emergence of a distinct profession of psychiatry hungry for recognition and respectability.179

The possibility of true epidemiological change in the incidence of mental disorder in nineteenth century Ireland is, however, difficult to resolve definitively, owing to the absence of reliable data about both the incidence of mental disorder and the precise population of Ireland. Even at the time, it was recognised that epidemiological analysis was significantly hampered by the absence of reliable data about the population in general, a point made with particular clarity by Dr Richard Powell, in a paper read to the Royal College of Physicians in London in 1810.180 If the baseline population is not accurately known, how can a possible increase in rates of insanity be identified?

Notwithstanding these statistical challenges, it remains reasonable to conclude that certain demographic factors and changes in population structure might have played a role in producing, at the very least, an apparent increase in the rate of mental disorder in nineteenth-century Ireland. There were, for example, substantial increases in life expectancy around 1800 and these increased the survival of individuals prone to develop schizophrenia.181 This increased the prevalence of mental disorder (i.e. number of cases extant at any given moment) and, therefore, burden of care, but not necessarily the incidence (i.e. number of new cases per year). This was one of the factors emphasised by the Inspectors of Lunatics in their 1906 Special Report on the Alleged Increase of Insanity, along with fewer discharges and deaths than in English asylums, greater accessibility to asylums, less sick patients being admitted, transfers from workhouses, reduced stigma and the alleged return of emigrants who had become insane182 (which undoubtedly occurred).183 In addition, increased preoccupation with quality of life, rather than mere survival, may have further increased rates of presentation to asylums, thus increasing burden of care without truly increasing incidence.

Torrey and Miller note that many medical directors in the nineteenth century believed that there was a true increase in rates of mental disorder and cast doubt on arguments suggesting this phenomenon were entirely attributable to accumulation of patients in asylums, decreased stigma, incarceration of individuals with alcohol problems, transfers from workhouses, heredity, the return of unwell emigrants, or various other factors.184 Torrey and Miller argue that there has been an epidemic of mental disorder over the past three centuries and that while this has gone largely unnoticed owing to its gradual onset, it represents an important but neglected force in world history.

It remains exceedingly difficult to determine, with any degree of accuracy, how much of the pressure on asylums in nineteenth-century Ireland was due to true epidemiological change and how much was due to other factors, such as changes in diagnostic practices and societal circumstances.185 The matter is further complicated by the fact that certain societal circumstances (e.g. conflict, famine) tend to produce a true increase in rates of certain mental disorders, and not just an apparent increase due to increased rates of presentation. Broadly, however, I agree with Brennan that institutionalisation during this period was primarily driven by social factors rather than a biomedical increase in insanity.186

All told, it is my conclusion that the growth of the Irish asylums in the 1800s and 1900s was attributable to a combination of increased societal recognition of mental disorder (owing to changes in society rather than changes in the nature or occurrence of mental disorder); continual legislative change, asylum building and psychiatric committal throughout the 1800s (with each of these three processes reinforcing the other two); evolving changes in diagnostic and clinical practices (underpinned by asylum doctors’ search for professional status and respectability); and – possibly most importantly – sociodemographic changes, especially increased survival, leading to altered patterns and prevalence of mental disorder (although not a proven rise in core rates of occurrence).

While some of these matters will likely continue to be the subject of debate, it is beyond dispute that the perception of an increase in insanity, and rising rates of presentation to asylums, had a decisive influence on mental health policy and legislation in Ireland in the 1800s and early 1900s. This perception was strongly linked with the remarkable asylum building programme of the 1800s and the steady increase in asylum populations over the course of the nineteenth and early twentieth-centuries. The asylums in Carlow and Kilkenny demonstrate many of the key trends during this period, especially in terms of diagnostic practices, ranging from the mundane and repetitive to the quixotic and unexpected.

Psychiatric Diagnoses in the Nineteenth Century:

Mania, Melancholia and ‘Insane Ears’

The asylum in Carlow (later St Dympna’s Hospital) opened in 1832 to care for the mentally ill of Carlow, Kildare, Kilkenny and Wexford.187 A review of the diagnoses in its clinical archives offers a valuable window into diagnostic practices and some of the clinical outcomes in the late 1800s.

The Register of Patients admitted between 1848 and 1896 (‘Admission Book’) demonstrates a wide range of diagnoses in use during this period, along with suggestions about the ‘supposed cause of insanity’ in each case.188 Among men, common diagnoses included ‘mania’, ‘melancholia’189 (with or without delusions), ‘paranoia’, ‘epilepsy’, ‘post-febrile’ illness (i.e. mental illness following a fever), ‘idiot’, ‘imbecile’, ‘homicidal and suicidal’, and ‘dementia’ (diagnosed in young people, this was likely similar to ‘mania’). ‘Senile mania’, ‘senile melancholia’ and ‘senile dementia’ were reported in the elderly, and ‘mania a potú’ also featured, referring to ‘mania’ owing to ‘intemperance’ or ‘alcohol’.

‘Mania’ itself could be ‘acute’, ‘chronic’ or ‘religious’. The term ‘monomania’ was used when a single pathological feature (e.g. delusion) was the central feature of the disorder. The ‘supposed causes’ of ‘mania’ in men ranged from ‘poverty and drinking excess of porter’ to ‘sunstroke’, from ‘mental annoyance’ to ‘heredity’, from ‘unknown’ to ‘can’t say’. More specific causes included psychological traumas (‘loss of money’, ‘matrimonial disappointment’, ‘death of wife’), physical traumas (‘a beating received’, ‘fell from a horse’) and hypothesised disorders of the brain (‘effusion of blood on brain’, ‘affection of the brain’, ‘disease of brain, fits’, ‘probably an attack of meningitis when a child’).

One man was admitted with ‘acute mania’ owing to ‘shock on his brother being sent to asylum’, his brother having been admitted two months earlier with ‘mania’ due to ‘religious excitement’. Another man was admitted in the mid-1890s with a four day history of ‘mania’, the ‘supposed cause’ of which was his ‘wife’s insanity’, his wife having been admitted with ‘mania’.

The range of diagnoses recorded in women was similarly broad and included ‘mania’, ‘melancholia’ (with or without delusions), ‘delusional insanity’, ‘dementia’, ‘paranoia’, ‘senile mania’, ‘senile melancholia’ and ‘monomania’. ‘Mania’ in women could be ‘recurrent’, ‘acute,’ ‘chronic’, ‘partial’, ‘suicidal’, ‘religious’ or ‘puerperal’ (i.e. occurring during or immediately following childbirth). Causes of mania in women included ‘heredity’, ‘drink’, ‘intemperance’, ‘domestic troubles’, ‘adverse circumstances’, ‘mental anxiety and worry’, ‘grief’, ‘loss of employment’, ‘desire to leave workhouse’, ‘injury to spine’, ‘childbirth’ and ‘religious excitement’.

Causes of melancholia among women included ‘fright’, ‘mental anxiety’, ‘sudden death of a friend’, ‘sudden death of husband’, and ‘domestic troubles’. Other entries for women under ‘diagnosis’ included ‘insanity doubtful’ or simply a blank space; in one such case, an additional note was added to the page, presumably in order to explain the admission: ‘statements against character’.

The cases linked with childbirth are especially involving. One woman in her 30s, the ‘wife of a carpenter’, was admitted in the mid-1890s with a one month history of ‘puerperal melancholia’ which was ascribed to ‘heredity and puerperium’ (i.e. occurring in the first six weeks after giving birth). Noted to be anaemic on admission (pale, likely owing to blood loss), this woman spent just over six months in the asylum before she ‘was removed at request of husband’. She was described as ‘relieved’ (as opposed to ‘recovered’) on the day of discharge and was readmitted just a week later, with a recurrence of ‘puerperal melancholia’, now simply ascribed to ‘heredity’. Related diagnoses in other women included ‘recurrent mania’ ‘following pregnancy’; ‘puerperal mania’ after ‘childbirth’; ‘dementia’ ‘in childbirth’ or ‘following parturition’; and ‘mania’ owing to ‘amenorrhoea’ or ‘loss of child’.

Other causes of ‘insanity’ among women included ‘poverty and hardship’ (linked with ‘senile melancholia’); ‘sunstroke’, ‘worry and hardship’ (‘paranoia’); ‘fright’ (‘melancholia with delusions’); ‘pecuniary disappointment’ (‘monomania’); ‘cerebral changes’ (‘religious mania’); ‘sunstroke’ and ‘loss of situation’ (‘dementia’); and ‘heredity’, linked with ‘delusional insanity’, ‘senile mania’ and ‘dementia’ (also associated with ‘paralysis agitans’ or Parkinson’s disease).

Readmission was not uncommon. A school teacher in her early 60s was admitted in the mid-1890s with a ‘relapse’ of ‘monomania’, having had a previous episode four years earlier. She was discharged ‘recovered’ after a year but readmitted after a further year, this time with ‘recurrent melancholia’ due to ‘heredity’. On this occasion, she spent five months in the asylum before being discharged, ‘recovered’. At around the same time, a ‘labourer’ in his 50s was admitted with a one week history of ‘mania’, having ‘inflicted a wound on his throat’. Just over two years later, he was ‘allowed out on approval as “relieved”, at the request of his friends’, but readmitted just six days later.

Another ‘labourer’ and ‘ex-soldier’ in his early 20s experienced several admissions, initially spending two months in the asylum with ‘melancholia’ due to ‘heredity’. On readmission 10 months later, he was diagnosed with ‘mania a potú’ owing to ‘alcohol’ (rather than melancholia) and spent three months in the asylum. ‘Melancholia’ was linked with a broad range of ‘causes’ among men at this time, including syphilis, ‘heredity’, ‘family troubles’, ‘domestic troubles’, ‘love affairs’, ‘pecuniary loss’, ‘betting on race horses’, ‘religion’, ‘fright’, ‘influenza’, ‘phthisis [tuberculosis] and exhaustion’.

Some patients were presented to the asylum through the criminal justice system. In the early 1890s, one man in his early 20s was ‘transferred from Kilmainham jail’ (Dublin) by the authority of the ‘Lord Lieutenant’, with a one week history of ‘mania’ owing to ‘religious delusions’. He spent almost two years in the Carlow asylum before being discharged, ‘recovered’, ‘by order’ of the Lord Lieutenant. A man in his 40s of no fixed abode was admitted from Kilkenny jail at around the same time, with diagnoses of ‘imbecility and mania’; he died in the asylum five months later. A woman with ‘partial mania’ was admitted from Grangegorman Prison (Dublin) and a man in his 40s transferred from the Central Criminal Lunatic Asylum (Dundrum, Dublin), as his sentence had expired. He had previously been in ‘Kilkenny prison’ and spent three months in the Carlow asylum with ‘melancholia’ due to ‘domestic troubles’.

A woman in her 50s also developed ‘melancholia’ due to ‘domestic trouble’ during this period, but her record is notable because it records that she had ‘left insane ear’. ‘Insane ear’ referred to ‘haematoma auris’, a swelling of the ear lobe owing to effusion of blood. Throughout the 1800s, this was thought to be connected with certain forms of insanity including GPI (late stage syphilis, affecting the brain) and epilepsy (especially when associated with mania).190 ‘Insane ear’ was, however, also linked with the use of physical restraint or coercion,191 and this seems a more likely explanation for its reported frequency in asylums.

Various physical causes were commonly cited as reasons for insanity. In the mid-1890s, a ‘housekeeper’ in her late 50s was admitted for two months with a two week history of ‘epileptic mania’, and was also physically ‘debilitated’. A ‘labourer’s wife’ in her 50s was admitted with ‘melancholia’ attributed to ‘sequelae of influenza’; she too was physically ‘debilitated’. One man’s ‘dementia’ was attributed to ‘injury to head’, another’s ‘paranoia’ was linked with ‘possible injury to cranium’, and another man was ‘homicidal and suicidal’ owing to ‘injury of head’. In the late 1890s, a woman was admitted with ‘acute melancholia with delusions’ owing to ‘domestic troubles’ but was also ‘much emaciated’ from ‘tuberculosis’.

Life circumstances were commonly cited as reasons for admission. A case of ‘senile melancholia’ in a ‘servant’ in his 70s admitted from ‘Carlow Union, Carlow’ was attributed to ‘poverty and hardship’; his ‘bodily condition’ was only ‘fair’ and he died six months later. Another man in his 70s had ‘senile mania’ owing to ‘want and age’. A ‘coachman’ in his 40s developed ‘acute mania’ owing to ‘business troubles and loss of sleep’; he had previously been ‘a patient in Mullingar Asylum on two occasions’ and spent three months in the Carlow asylum. A man in his late 20s was admitted with ‘acute mania’ due to a ‘love affair’, while a farmer in his 30s developed ‘melancholia’ also owing to ‘love affairs’.

Some diagnoses appear somewhat curious. In the mid-1890s a ‘servant’ in her late 20s was admitted with ‘mania’ due to ‘overwork’. Around the same time, a ‘well educated’ man in his early 40s spent three months in the asylum with ‘diagnosis’ of ‘insanity doubtful’. The same description was applied to a woman admitted in her 60s during the same period, although she was also ‘debilitated from old age’.

Perhaps the most moving cases relate to women who lost or missed their children. One woman was admitted with ‘mania’ owing to ‘loss of a child’, while a ‘housekeeper’ in her 40s was ‘fretting for a daughter left the country’, and had ‘palpitation of the heart’. Most affecting, however, was the case of a woman in her 50s who was admitted in the mid-1880s with a three month history of ‘acute mania’ owing to ‘her two sons going to America’. This woman was never discharged: she died in the asylum 10 years later.

In 1848, 16 years after the asylum opened in Carlow, building began for ‘Kilkenny District Lunatic Asylum’ (later St Canice’s Hospital), which was formally opened on 1 September 1852.192 Dr Joseph Lalor was the first Resident Physician and manager. The first patient was a 70-year-old woman who had been committed at the age of 30 owing to a nervous breakdown following childbirth. She and 53 other Kilkenny patients were admitted to the new asylum from ‘Carlow District Hospital for the Insane’. They were joined by 47 patients from ‘Kilkenny Local Lunatic Asylum’ (a small local establishment), 24 from the county Kilkenny Prison, and 10 directly from the district.193

Patient numbers in Kilkenny increased rapidly, to 295 in 1880, 440 in 1902, and peaking at 550 in 1939. By the early 2000s, however, numbers had decreased to approximately 100, in line with national psychiatric deinstitutionalisation. In March 2003 a new purpose built acute psychiatric admission unit opened on the site of Kilkenny General Hospital resulting in significant improvements in care and a sharp contrast with the district asylums of the 1800s and 1900s.194

From an historical perspective, the litany of diagnosis from Carlow in the 1880s and 1890s shows the diversity of cases that presented to the asylums during that period and the inventiveness of some of the diagnoses applied. Similar diagnoses were described in Portlaiose,195 Sligo196 and elsewhere.197 The records of discharges are also interesting, and, even if some discharges were followed by readmission, they still provide evidence of a desire to minimise asylum stays and avoid the institutionalisation that so concerned asylum staff and broader society at this time.

Asylums, Friends and Religious Involvement in

Mental Health Care

One of the outstanding features of the history of psychiatry in Ireland, and the emergence of the asylum system in particular, is the limited role played by the Roman Catholic Church in developing services for the mentally ill.198 While there was some accommodation for the mentally ill in the early Irish monasteries, this was always very limited in scope and the dissolution of the monasteries in the mid-1500s diminished it even further.199 Following this, the Roman Catholic Church remained generally uninvolved in formal mental health care, apart from providing chaplains to the asylums – and even this was not without controversy in, for example, Belfast.200 This was the position up until the late-1800s and mid-1900s when certain organisations (e.g. Daughters of Charity, Brothers of Charity, Brothers of St John of God, Sisters of La Sagesse and Sisters of Jesus and Mary) became central to the provision of services to the intellectually disabled, building on the histories many of these organisations had in this field.201

The late 1800s and early 1900s also saw increased involvement of locally powerful Catholic figures on asylum boards in certain locations, such as Carlow202 and Cork,203 but, notwithstanding these local developments, the Roman Catholic Church never attained, or sought, a dominant, national position in mental health care similar to that it assumed in general healthcare and education.

There were, nonetheless, specific initiatives, chiefly relating to specific religious orders. In 1882, the Brothers of St John of God established a private psychiatric hospital in Stillorgan, County Dublin (Chapter 6).204 St Vincent’s Hospital in Fairview, Dublin is another one of the relatively few examples of a Roman Catholic organisation, the Daughters of Charity of St Vincent de Paul, becoming involved in mental health care in Ireland.205 St Vincent’s was founded in 1857 following the bequest of Francis Magan, a barrister and member of the United Irishmen (an Irish republican organisation) whose fortune had resulted from his informing on the leader of the 1798 rebellion, Lord Edward Fitzgerald (1763–1798).206 When Magan’s sister died, the fortune was used to found a hospital in Fairview for mentally ill Catholic women and men, although only the female side progressed. In 1857 the hospital had seven patients; by 1862 there were 30.207 The first physician was Sir Dominic Corrigan (1802–1880), who was also the first Catholic president of the Royal College of Physicians of Ireland (1859). The French Daughters of Charity of St Vincent de Paul came to Ireland to run St Vincent’s and remained until 1998.

St Vincent’s expanded substantially throughout the 1800s, and underwent further developments in 1932, 1978 and 1993. By 1997, St Vincent’s had 97 inpatients and there were 1,074 admissions and 1,073 discharges (and two deaths) over the previous twelve months.208 There were also 14 patients in St Aloysius Ward, which opened in October 1994 in the Mater Misericordiae University Hospital, one of Dublin’s major general hospitals founded in 1861 by the Sisters of Mercy.209 Both of these developments in mental health care, at St Vincent’s and the Mater, found their backgrounds in the Catholic organisations that operated the establishments.

Overall, however, while certain Catholic organisations became involved in specific initiatives within mental health care (e.g. a Child Guidance Clinic was opened at the Mater in 1962),210 it remains the case that the official Roman Catholic Church is notable by its general absence from the history of the systematic provision of psychiatric services in Ireland. While certain people with psychological problems undoubtedly sought individual guidance from the Church and from priests or other religious, the Church itself did not become systematically involved in formal mental health services. As a result, the Irish asylums were very much State institutions rather than Church ones.

This is intriguing: the Roman Catholic Church was deeply involved in Irish politics, general (i.e. physical) healthcare and education, but did not develop formal, systematic initiatives in mental health care. The reasons for this are complex (and in need of further study) but likely relate, at least in part, to the Church’s attention to other areas (e.g. medical care, schools) rather than mental health care, and the prominent involvement of figures from other religious traditions in early Irish mental health care, most notably Jonathan Swift, an ordained priest in the Established Church of Ireland who bequeathed his entire estate to establish the hospital for ‘idiots and lunaticks’ that later became St Patrick’s Hospital, the first formal asylum in Ireland.211

The Religious Society of Friends (‘Quakers’) was another religious group that developed a strong association with early mental health care, exemplified by the establishment of The Retreat at York in England in the 1790s.212 In Ireland, representatives of the Yearly Meeting of Friends in Ireland, along with some other Friends, met on 29 April 1807 to consider providing accommodation for the mentally ill.213 Three years later they bought Bloomfield in Donnybrook, Dublin, a house formerly occupied by Dr Robert Emmett, State Physician and physician to St Patrick’s Hospital.214 On 16 March 1812, the first patient was admitted to Bloomfield.215 Among the sources of funding were the proceeds from the sales in Ireland of the works of Henry Tuke (1755–1814), eldest son of William of The Retreat. There was also Quaker involvement in other early initiatives in Cork.216

On 15 May 1815, John Eustace (1791–1867) arrived at Bloomfield as lay superintendent and, two months later, received permission to continue medical studies in Trinity.217 Eustace served as physician to the Cork Street Fever Hospital and, in 1825, opened up an Asylum and House of Recovery for Persons Afflicted with Disorders of the Mind at Hampstead in Glasnevin, Dublin.218 Accommodation at Hampstead was relatively luxurious and surrounded by 1,200 acres of land. Treatments focused on therapy in the garden and farm, among other interventions. Eustace departed definitively from Bloomfield in 1831.

Moral treatment continued to the fore at Bloomfield, actively informed by the ongoing development of practices at The Retreat.219 A second wing was built in 1830220 and, between 1863 and 1912, some 537 patients were admitted.221 The 1900s saw various further developments at Bloomfield and by 1997 the accommodation comprised 60 beds, albeit with just eight admissions over the previous year.222 At that point, 49 patients at Bloomfield were voluntary and 11 were Wards of Court. Standards of hygiene, decor and ‘patient care were of a very high order’, according to the Inspector of Mental Hospitals. Medical services were provided by two general practitioners and there were psychiatric consultations by two old age psychiatrists.223

In 2005, Bloomfield moved from Donnybrook to Rathfarnham, Dublin. Ten years later, this 114 bed hospital was offering a range of specialist services including mental health treatment and care for older adults; services for persons with acute, serious and enduring mental health disorders; complex mental health issues associated with neuropsychiatric disorders and dementia; and a memory clinic.

In parallel with the evolution of Bloomfield, Eustace’s Hampstead Hospital developed and expanded throughout the 1800s, based on the idea that care should be offered in a comfortable, family setting. Highfield Hospital was opened for female patients and in 1888 the remarkable Dr Richard Leeper gained his introduction to psychiatry there when he was appointed Resident Physician at Hampstead and Highfield.224 Leeper held this positon for three years before going on to a long and distinguished career, including becoming Medical Superintendent at St Patrick’s Hospital in 1899 (Chapter 5).225 The services at Hampstead and Highfield evolved further throughout the 1900s and by 1997 there were 42 female patients in Highfield (including two Wards of Court) and 41 patients at Hampstead (including two Wards of Court), and, the Inspector noted, the ‘standard of care, hygiene and décor were high’.226

By the early 2000s the Eustace family had been providing mental health care at Hampstead and Highfield for six generations over almost two centuries, becoming such a part of the fabric of Dublin that they were mentioned in James Joyce’s Ulysses in 1922.227 In 2015, ‘Highfield Healthcare’ was providing specialist care to the elderly across four facilities, with a total of 313 beds. An adult acute psychiatry unit had also been developed. Throughout its fascinating history, the organisation maintained a core commitment ‘to providing the highest standard of care and support to all our residents’ in ‘an environment appropriate to their needs, where the priority is to preserve their dignity and promote their independence’.

Overall, in terms of the role of the Roman Catholic Church in Irish mental health care, it is clear that while certain Catholic groups became involved with specific developments (e.g. St Vincent’s in Fairview, the Mater Hospital services, St John of God Hospital and various services for the intellectually disabled), the Roman Catholic Church itself did not develop a systematic, formal or dominating involvement in the field as it did in relation to general hospitals and schools. For many decades, then, the key role of the Roman Catholic Church in Irish mental health care lay chiefly in the provision of chaplains to the state run asylums that emerged in the 1800s and early 1900s.

That is not to say that the Church was entirely without influence: the specific initiatives described above were both substantive and innovative, and priests were often significant figures in shaping and informing care.228 But it is worthy of note that the field of mental health care in Ireland, unlike the fields of general healthcare and education, was not dominated by the Roman Catholic Church and that the asylums were, for the most part, not religious institutions. As a result, there was plenty of room for developments and innovations by others within the asylum system, including other religious traditions, such as the Society of Friends, and individual clinicians, such as the singular Dr Conolly Norman of the Richmond Asylum in Dublin.

Dr Conolly Norman:

Reforming Doctor

Conolly Norman (1853–1908), the leading psychiatrist of his generation, was born on 12 March 1853 at All Saints’ Glebe, Newtown Cunningham, County Donegal. He was the fifth of six sons of Hugh Norman, rector of All Saints Church, and Anne Norman (née Ball). Norman was educated at Trinity College Dublin, the Carmichael School of Medicine (North Brunswick Street) and the Richmond Hospital. He received the licences of the Royal College of Surgeons in Ireland, King and Queen’s College of Physicians in Ireland, and Rotunda Hospital in 1874. He was elected fellow of the Royal College of Surgeons in Ireland in 1878 and member of the King and Queen’s College of Physicians in Ireland in 1879; he became a fellow of the latter in 1890.

Norman was interested in psychiatry from the outset and worked as assistant medical officer at Monaghan District Asylum from 1874 to 1881, before a period at Bethlem Royal Hospital in London, after which he served as medical superintendent at Castlebar (1882–5)229 and Monaghan District Asylums (1885–6).

Throughout his career, Norman was an inveterate innovator and a freethinker. In Monaghan, he experimented with hypnone (phenyl-methyl-acetone) and, in a case series published in the Journal of Mental Science in 1887, concluded that it was a useful sleep inducing agent, especially in cases characterised by excitement.230

In 1886, Norman was appointed as RMS in Richmond District Asylum in Dublin, a notably powerful and prominent position in Irish medicine. The energetic, enthusiastic doctor had a profound effect on the vast institution: restraints were relaxed, buildings renovated, staff numbers increased and a laboratory built, placed under the direction of Dr Daniel Rambaut.231

As the Irish Times later noted, Norman’s appointment had immediate positive effects both in the Richmond and beyond:

When he became Superintendent he immediately started a campaign with a view to improving the condition of the patients, and it is mainly owing to his efforts that the dietary and clothing of the inmates have undergone a vast improvement. The reforms he effected in the management of the institution are almost innumerable. To him must also be attributed the initiation of a campaign against the use of instruments of restraint in asylums. On his advice the ‘straight jacket’ was abolished in the institution, and his influence in this respect penetrated into all the asylums in Ireland and very many institutions in England and Scotland. He established the principle of allowing the patients with violent tendencies to walk in the grounds instead of confining them in irons indoors […]. The nursing and attendant staff also engaged his close attention, and he did much in securing for them better accommodation, better clothing, better pay and shorter hours of duty. Dr Norman’s name will be associated with almost all asylum reforms in this country, and it is impossible to estimate his efforts in this respect. His services have brought about a wonderful change in the treatment of lunatics, and many lives have been brightened by his zealous devotion to their welfare.232

While this effusive praise is well deserved and based in fact, Norman was by no means alone in seeking to reduce the use of restraint in the Irish asylums; Dr John Jacob of Maryborough (Portlaoise), for example, was another pioneer in the removal of restraints, in the 1840s.233 Jacob belonged to a distinguished Quaker family and also operated a private asylum in the area. Jacob’s initiative was strongly consistent with the broader ‘non-restraint’ movement in England in the late 1830s,234 as were Norman’s fruitful efforts at the Richmond in the latter part of the century.

Like other reformers, Norman encountered stern opposition to certain of his efforts, including his attempt to develop a model of ‘boarding out’ similar to those in Scotland235 and Belgium.236 The colony at Gheel in Belgium had been founded in the tradition of St Dymphna, an Irish girl who, in the early seventh century, fled there from her father when he sought to marry her in replacement of his deceased wife.237 She went to Gheel with her priest, but her father followed and killed them both. St Dymphna’s remains at Gheel became a focus of pilgrimage for the mentally ill, and Gheel later evolved into a colony for their care.

In 1904, Norman wrote in the Journal of Mental Science about the need for similar ‘family care of persons of unsound mind in Ireland’, noting that there were many objections to be made against asylum life, not least of which was its separation of patients from the ordinary interests of life.238 Norman was deeply opposed to prolonged institutionalisation239 and there was already long standing evidence that care outside of institutions could be effective in Ireland. One such case (and there were likely many) concerned the 16-year-old Charles Stock, son of Bishop Joseph Stock of Killala, who suffered from likely schizophrenia a full century earlier, between 1806 and 1813, but was treated chiefly at home, under the supervision of Dr William Harvey, physician at Steevens Hospital and a governor of the Richmond Asylum.240 Notwithstanding such cases and the many clear objections to asylum life, Norman’s enlightened suggestions about ‘boarding out’ and ‘family care’ did not find favour with governmental authorities and so did not prosper at that time.

Notwithstanding these setbacks, Norman remained extremely active, enthusiastic and highly productive both in his clinical work and in the broader context of the emerging profession of psychiatry. He was deeply involved with the MPA, becoming a member in 1880, secretary to the Irish division in 1887 (until 1904), and president in 1894. In his presidential address, Norman touched on many of the themes that defined his career and contribution to psychiatry: education in asylums, research in pathology and physiology, asylum management and models of family care.241

More broadly, Norman’s vivid, incisive and plentiful writings covered such themes as aphasia, brain tumours, dementia, medication trials, hallucinations, delusional insanity, beri beri (based on his controversial experiences at the Richmond from 1894 onward),242 diagnostic systems243 and dysentery.244 Norman spoke out strongly about mental health law (bemoaning disproportionate force and incarceration)245 and made robust contributions to Allbutt’s System of Medicine246 and Tuke’s Dictionary of Psychological Medicine.247 In his personal life, Norman maintained strong interests in book collecting, literature, botany, archaeology, architecture, music and languages, and was a keen student of German, French and Italian. His library, presented to the Royal College of Physicians of Ireland following his death, reveals the depth and breadth of his reading across classic and lesser known texts in English, French and German.248

In addition to his participation in the MPA, Norman was a member of the British Medical Association, joint editor of the MPA’s Journal of Mental Science,249 and vice president of the Royal College of Physicians of Ireland,250 among other positions.251 In 1907, he received a richly merited honorary doctorate (MD) from Trinity College, Dublin.

The following year, however, Norman died unexpectedly just outside his home on the North Circular Road, as reported in the Irish Times:

With deep regret we announce the death of Dr Conolly Norman, Resident Medical Superintendent, Richmond Lunatic Asylum, Dublin, which occurred with painful suddenness on Sunday afternoon. About four o’clock in the afternoon Dr Norman left his residence, St Dympna’s, North Circular Road, Dublin for a short walk, but after going a few hundred yards he became ill, and collapsed on the pavement. Mr Neill, Head Attendant at the Asylum, who lived near, was informed, and had Dr Norman conveyed to his home. Sir Thornley Stoker, Dr Finny, and Dr Cullinan were quickly in attendance, but Dr Norman had already died. For some months past he was unwell, suffering from a severe attack of influenza, followed by bronchitis, and moreover, he suffered from a cardiac affection.252 In December last he was obliged to relinquish his duties with a view to recuperating his health. Last week he resumed duty and appeared to have greatly benefited by his rest.253

The Irish Times noted that Norman’s sudden death on 23 February 1908 would ‘be received with sincere regret by every section of the community. His loss is a public one for Dr Norman devoted his life to the care of afflicted humanity, and how nobly he fulfilled his trust is recognised on all sides’.254 Norman was buried in Mount Jerome Cemetery on 26 February 1908255 and fulsome tributes were paid at a special meeting of the Joint Committee of the Richmond District Asylum the following day.256

Norman was a well-known figure, widely respected and duly mentioned in the opening pages of Joyce’s Ulysses.257 A memorial by Joseph M.S. Carré was erected by public subscription in St Patrick’s Cathedral, Dublin and unveiled on 18 October 1910 by the Lord Lieutenant, the Earl of Aberdeen, who spoke highly of Norman’s life and work.258 An after-care programme was established in Norman’s honour and a portrait presented to the Royal College of Physicians, of which he had been vice president.259 The Conolly Norman medal was also initiated, to be presented to the best student in psychiatry at Trinity College Dublin annually.

As the British Medical Journal noted, Norman’s career combined intellectual brilliance with pragmatic devotion to developing new models for better treatment of mental disorder.260 While Norman’s campaign in favour of alternatives to large institutions met with distinctly mixed success at the time, it still paved the way for many future reforms, as did his efforts to provide specialist treatment for the intellectually disabled and persons with alcohol problems. Fittingly, Norman’s own house at Grangegorman was later named ‘St Dymphna’s’ and devoted to the treatment of alcohol problems. Later again, it was renamed ‘Conolly Norman House’ and housed a mental health service; it is now a mental health service management centre.

In terms of his overall contribution, it is clear that Norman continued and deepened the progressive tradition of certain of his predecessors, such as Hallaran in Cork who, a century earlier, had similarly combined intellectual enquiry with energetic innovation and pragmatic efforts to improve care of the mentally ill.261 Norman is, however, remembered not just for his reforms of asylum care and his writings, but also his contributions to the development of psychiatry as a profession. These contributions include, not least, Norman’s strong promotion of the career of Dr Eleonora Fleury and the historic change that her professional progression brought to the emerging discipline of psychiatry in Ireland and Great Britain.

Dr Eleonora Fleury:

Republican Doctor

As the 1800s drew to a close, there were, finally, emerging signs of significant change in the Irish asylums. The increase in inpatient numbers might have shown no signs of abating, but this apparently unstoppable trend was now accompanied by subtle but definite signs of reform. These changes were, in the first instance, most visible within the profession of psychiatry itself, and their complexity is well demonstrated by the life and career of Dr Eleonora Fleury (1867–1960),262 the first female psychiatrist in Ireland or Great Britain.

Eleonora (Norah) Lilian Fleury was born in Manchester in 1867.263 Fleury studied medicine at the London School of Medicine for Women and the Royal Free Hospital. She received first class honours and in 1890 became the first female medical graduate of the Royal University of Ireland.264 In 1893, Fleury was awarded an MD from the Royal University of Ireland and won a gold medal.265 She then went on to work at Homerton Fever Hospital in London, the Richmond Asylum in Grangegorman and its sister asylum in Portrane (later St Ita’s Hospital).266

The Richmond Asylum had opened in 1814 in response to growing evidence of unmet medical and social need amongst the mentally ill.267 As the 1800s progressed, however, the Richmond, like the other asylums, expanded at an alarming rate.268 As a result, official attention shifted from the humane treatment of individual patients to the management of the increasingly complex institutions, which were beset by problems relating to overcrowding, staff shortages, poor funding, and lack of activity for patients.269 Nationally, this led to significant disillusionment with the asylum project itself.270 By the early 1890s, when Fleury arrived to work there, the Richmond Asylum had almost 1,500 patients resident in accommodation designed for 1,100.271

Notwithstanding these problems, as the 1800s drew to a close psychiatry had clearly emerged as a profession within Irish medicine. In Great Britain, this process took a significant step forward in 1841 with the foundation of the Association of Medical Officers of Asylums and Hospitals for the Insane, later known as the Medico-Psychological Association (MPA).272 The purpose of the organisation was to facilitate communication between doctors working in asylums and thus improve patient care. An Irish division was formed in 1872, although Irish members had participated in the organisation long before that,273 and the organisation consistently urged Dublin Castle to appoint medical doctors as managers of asylums.274 The MPA (as it was known from 1865 onward) was central to the emergence of psychiatry as a profession in Ireland and was indelibly linked with the asylums. From its foundation, however, the organisation admitted only men until, in 1893, Fleury’s name was put forward for membership by the ever forward-looking Norman.275

A discussion ensued at the MPA and, in 1894, its rules were duly altered:276 Fleury became the first woman member and, thus, the first female psychiatrist in Ireland or Great Britain. The following year, Fleury’s paper on ‘Agitated Melancholia in Women’ was read at the meeting of the MPA’s Irish Division, held at the College of Physicians, Kildare Street, Dublin. Fleury herself was unavoidably absent but her paper outlined specific cases of ‘agitated melancholia’ in younger and older women. These case histories are remarkable not only for their astute clinical descriptions, but also the extent to which Fleury linked psychiatric problems with social and life events such as examinations, marital difficulties, separations and bereavements.277

Also in 1895, the British Medical Journal announced that Fleury had been appointed to the post of assistant medical officer at the Richmond.278 Fleury’s work at the Richmond involved not only treating patients but also teaching nurses and attendants studying for the newly established certificate of proficiency in mental nursing.279 Interestingly, the Medical Directory for 1905 records both Fleury and Dr Ada English (1875–1944; see Chapter 4) at the Richmond that year, with English there as a clinical assistant, shortly after graduating.280 The lives and careers of Fleury and English were to bear significant similarities to each other in the decades to follow.281

Following the death of Norman in 1908, Fleury was made medical officer in charge of the female house at the Richmond.282 In 1912, when there was a vacancy for a new head of the asylum in Portrane, Fleury was passed over, as the committee felt it would be inadvisable to place a woman in such a position. Fleury later became deputy medical superintendent in Portrane.283

Like English, Fleury’s medical concerns extended to population health and wellbeing, and, like Dr Kathleen Lynn (1874–1955), a contemporary doctor and political activist, Fleury was very concerned about the spread of venereal disease in the early 1900s.284 Also, like English, Fleury was deeply involved in the nationalist movement, often using the Richmond and Portrane asylums to conceal and assist wounded republican fugitives.285 As was the case with English, Fleury’s activism landed her in trouble with the authorities and she was arrested and imprisoned in 1923.286 (This period in Fleury’s life is discussed in greater detail in Chapter 4.) During her imprisonment, Fleury was especially concerned with the medical welfare of republican women prisoners – a concern which persisted following her release – as she highlighted the prisoners’ plight and appealed for better conditions.

Following her release from prison, Fleury returned to work at the asylum in Portrane and continued her medical career. After her retirement, she lived at Upper Rathmines Road in Dublin and, like Lynn, remained exceptionally physically active all her life. Fleury died in 1960 and is, like Norman, buried in Mount Jerome Cemetery in Harold’s Cross, Dublin.287

Over the course of her life, Fleury, like English, combined academic ability with progressive medical practice and persistent republican activism. In these regards, Fleury had much in common not only with English but also with Lynn,288 Dr Dorothy Stopford Price (1890–1954), a republican doctor remembered for her work on tuberculosis,289 and Dr Brigid Lyons Thornton (1898–1987), a politically active public health doctor.290 All combined progressive medical practice with acute social conscience and political activism. They made remarkable contributions at a time when Ireland was undergoing a period of exceptionally rapid political change and when there appeared to be genuine opportunities to effect political, social and medical reform, for the betterment of all.

Emily Winifred Dickson (1866–1944) was another comparable figure who worked in asylums and shared Fleury’s concern with public health, although Dickson worked in the English asylum system and for shorter periods than Fleury. Dickson had graduated with first class honours from the Royal College of Surgeons in Ireland in 1893 and later worked at Rainhill Mental Hospital in northern England.291 Like English, Dickson lectured extensively, was involved in the Irish Women’s National Health Association,292 and was deeply concerned with public health, especially among the socially excluded (e.g. women and children in workhouses).293

While Fleury, English and Dickson focused their medical work on the mentally ill, both Fleury and English, like Lynn, Price and Thornton, were deeply concerned about the medical and social wellbeing of the disadvantaged, and consistently linked this concern with the need for political and social change. The decision of these women to enter medicine in the first instance was likely linked, at least in part, to their personal awareness of health and social problems during their childhoods. Their continued awareness of the social context of medicine was likely deepened by their medical training, growing political awareness, experiences in the practice of their profession, and contacts with other woman practitioners.

To this extent, these women were living embodiments of the views of Rudolf Virchow (1821–1902), the German pathologist and politician, who declared that ‘medicine is a social science, and politics nothing but medicine on a large scale’.294 The lives and contributions of Fleury, Lynn, Price, Thornton and English certainly supported the truth of Virchow’s statement, and their pioneering work demonstrated the power of combining medicine with revolutionary politics at a time of exceptional challenge and opportunity in Irish history.295

Psychiatry and Society in the 1800s:

‘A Distant, Deviant Other’

Throughout the 1800s, the development of psychiatry in Ireland, as elsewhere, was largely shaped by the society in which the discipline evolved and came of age. From this perspective, the Famine was undoubtedly one of the defining events of the century, as people with worsening mental disorder and starvation-related distress sought to enter workhouses and asylums in unprecedented numbers.

The Famine may have also shaped the epidemiology of mental disorder in Ireland for several further generations if, as seems likely, it both increased risk of mental disorder in persons who were in gestation at the time (and born during or shortly after the Famine) and had transgenerational effects on patterns of illness many decades later, possibly through epigenetic change (i.e. changes in the ways genes are expressed, rather than changes in genes themselves).296 This possible impact of the Famine on mental disorder both requires and merits further study, just as the Famine’s possible (although likely quite different) impact on the epidemiology of cardiovascular disease has been similarly raised in recent years.297 These areas merit closer study.298

It is already clear, however, that the presence of large numbers of mentally ill persons in workhouses presented very real problems during the 1800s. The Irish workhouses were chronically overcrowded, deeply unsanitary and grossly unsuited to the needs of the destitute mentally ill or intellectually disabled. Nonetheless, the nineteenth century saw workhouses become de facto elements of the system of ‘care’ for the mentally ill,299 as patients were commonly admitted from workhouses to asylums,300 and discharged from asylums back to workhouses.301

The intellectually disabled, much neglected in most historical studies, were also much neglected during this period, with the result that their fate was often similar to that of the mentally ill: there was minimal dedicated provision for their needs, and they either lived at home, became homeless or were admitted to workhouses or, increasingly, the growing number of asylums for the mentally ill.302 As a result, the experiences of the intellectually disabled were in many cases similar to those of the mentally ill who tended to experience lengthy periods of detention in poorly therapeutic facilities, poor mental and physical health, and a high risk of dying in asylums.303

Certain practitioners, such as RMS Drapes of the Enniscorthy District Asylum, sought to improve matters though relatively enlightened asylum management,304 but these efforts were continually hampered by the seemingly inexorable ‘increase of insanity in Ireland’,305 as the number of ‘mentally ill’ persons in Irish institutions increased from 2,097 in 1829 to an astonishing 17,665 in 1894.306 As Walsh notes, ‘between 1880 and 1900 the number of asylum beds in Ireland doubled and between 1860 and 1900 the numbers of admissions, whether first admissions or not first admissions, increased four-fold’.307 Why?

It is, in summary, clear that a number of different factors contributed to the growth of the Irish asylums, including increased recognition of mental disorder; the search for professional prestige among asylum staff; mutually reinforcing patterns of asylum building and committal, underpinned by continual, restless legislative change; changes in diagnostic practices throughout the 1800s; and possible epidemiological change, although there is insufficient evidence to conclude that there was any true increase in the occurrence of new cases of mental disorder to justify the increase in admissions.308

Ultimately, the Irish asylums were primarily social rather than medical creations, expanding to meet societal and community requirements, rather than demonstrated medical needs. They were, however, constantly accompanied by a certain rhetoric about psychiatric and social care,309 care that was deeply needed (and, often, provided) for many patients; was clearly excessive for others; and was utterly inappropriate for some other unfortunate individuals who were simply fed into the system by a society that saw few alternative, non-institutional options for them. The asylums were, to an extent, necessary at the time, but they were also excessively large, commonly misused and ultimately counterproductive for both the mentally ill and society in general. They were an unmitigated disaster for the profession of psychiatry in Ireland, which was to be haunted and defined by the idea of custodial asylum care for several generations to follow.

Nonetheless, the asylums contributed significantly to the emergence of psychiatry as a profession, a process that took a significant step forward when the annual meeting of the Association of Medical Officers of Asylums of Great Britain and Ireland took place in Dublin on 22 August 1861, with Lalor as president.310 The asylums were also intriguing reflections of a complex, conflicted society, and, in this light, one of the most remarkable features of their history is, as already discussed, the virtual absence of the Roman Catholic Church from the story. Apart from its involvement in specific initiatives, the Church and its associated organisations simply did not concern themselves with systematic or large scale provision of mental health care in nineteenth- or twentieth-century Ireland. This contrasted sharply with the Church’s dominant involvement in general healthcare and education, and means that Ireland’s asylums for the mentally ill were, for the most part, State institutions rather than religious ones.

Against this background, throughout the 1800s there was plenty of room for development and innovation in this field by actors other than the Church, including other religious groups such as the Society of Friends and various individual clinicians, such as Norman of the Richmond, who championed ‘family care of persons of unsound mind’.311 Like many reform-minded doctors, however, Norman found that his enlightened initiative did not find favour with governmental authorities. Many of Norman’s other ideas did, however, bear significant fruit, including his nomination of Fleury for membership of the MPA in 1893.312

Other professional developments during the 1800s included increased emphasis on the treatment of mental disorder in professional medical circles. In June 1844, for example, the College of Physicians was notified that Sir Edward Sugden (1781–1875), later Lord St Leonards, Lord Chancellor of Ireland, had decided to give 10 guineas annually as a prize for the best essay on the treatment of mental disorder,313 having also sought to establish a school for the treatment of mental diseases at St Patrick’s.314 The prize was to be awarded for the following 10 years alternately by the College of Physicians and the College of Surgeons, and it duly stimulated much needed interest in the subject.

Throughout this eventful period in the history of Irish psychiatry, it is unsurprising that the asylums and issues related to mental disorder were a staple feature in the popular press, and subjects of much public discussion.315 O’Neill, in a fascinating study of the ‘portrayal of madness in the Limerick press’ from 1772 to 1845, notes that newspaper accounts of mental disorder and its treatment were influenced by a relatively broad range of factors and not simply a desire to convey information in an impartial and informative fashion:

For newspapers in Limerick, accounts of madness – even accounts with an explicit moral or educational intent – were subsidiary to another consideration, the capacity of the account to attract the reader. Selling newspapers was a business, far more than was mad medicine. Output was driven by an overriding need to gain and sustain readers’ attention and information was a raw product that could be processed into a form to be used to achieve this end. Therefore, stories were re-packaged into forms that were already familiar and were perceived as interesting to the printers and proprietors themselves and to the target audience.316

Other factors were also relevant to coverage of mental disorder in the media, including political concerns, commercial considerations, and a perceived requirement for drama:

The tendency towards sensationalism also worked against the local press discussing changes in the attitude to the insane and their care. Madness was often presented in the newspaper as a way of sensationalising deviant behaviour, all in the interest of generating sales. In reports of suicides, and less frequently of murders, the madness of the perpetrator was used to explain the action or as a mitigating circumstance. Both social class and the location of the incident determined the press attitude. Few details were given regarding local suicides or murders, especially those involving individuals of high social status.317

Ultimately, the position of the mentally ill in nineteenth-century Ireland, both in reality and in the eyes of the press, was rather bleakly defined by institutional care followed by either death in the asylum or a life of social exclusion:

What is certain is that once labelled as mad, an individual was not permitted to maintain any public identity of which the press approved. Therefore, though by the end of the period under discussion insanity was described in the Limerick press as misunderstood, the old stereotypes remained and even after discharge from an asylum the label of lunatic followed individuals into their everyday life and social dealings. Geographic, economic and class issues had clouded opportunities for balanced representations of the mad and madness, and the lunatic was still constructed and portrayed as a distant, deviant other.318