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EARLY-TWENTIETH-CENTURY PSYCHIATRY

Good lunacy laws should make it possible to obtain care and treatment in asylums with ease, but they should make unnecessary detention difficult.

Committee on Lunacy

Administration (Ireland), Second Report

of the Committee Appointed by the

Lord Lieutenant of Ireland on Lunacy

Administration (Ireland) (1891)1

The early twentieth century was a time of extraordinary change in Ireland with the advents of the Easter Rising (1916), War of Independence (1919–21) and Civil War (1922–3), and establishment of the Irish Free State (Saorstát Éireann; 1922–37). This was also a time of considerable change in Irish psychiatry, as determined efforts were made to move from the asylum based system of the 1800s to a better, more humane model of service provision for the mentally ill.

The problems presented by the mentally ill were clearly acute: by 1900, the 11 pre-existing district asylums had increased to 22, housing a total of 16,404 patients.2 There were, in addition, 709 patients in 12 private asylums and 4 charitable hospitals; 162 patients in the Central Criminal Lunatic Asylum; 89 patients looked after as single patients in private residences; and some 3,805 patients in workhouses. That came to a total of 21,169 patients in these locations in 1900; the number outside these settings was unknown.

Nine years earlier, in 1891, the issue of patient numbers was considered (yet again) by the Committee on Lunacy Administration (Ireland), which comprised Sir Arthur Mitchell (Lunacy Commissioner for Scotland), R.W.A. Holmes (Treasury Remembrancer for Ireland) and Dr F.X.F. MacCabe (medical inspector with the Local Government Board).3 The Committee noted that many factors, other than mental disorder itself, contributed to rates of certification, especially among the poor:

It has been said that ‘human power cannot multiply the lunatics of a country,’ but this opinion is here treated as entirely erroneous, if by lunatics are meant those persons whom the State registers and treats as such; and it must be erroneous, unless the views here expressed are wrong. In point of fact, the lunacy of a country is far from being a fixed amount, which can neither be increased nor diminished. There is no uniform standard of mental soundness or unsoundness which is accepted by all medical men when considering whether a certificate of insanity shall or shall not be granted, nor indeed by any one medical man in all circumstances. The ease or difficulty of getting certificates of insanity may depend, and does often depend, on the object in view, or the results which will follow certification. Circumstances apart altogether from the mental condition necessarily influence the granting of these certificates – the source, for instance, from which any expenditure consequent on the granting of the certificates is to be obtained, cannot fail to have an influence.

If all this is true of lunacy generally, it is of necessity still truer of pauper lunacy, because, in addition to the lunacy, there is then the pauperism, about the determination of which it is clear there may be uncertainty. A lunatic, for example, will become a pauper lunatic in one locality who will almost certainly remain a private lunatic in another. A rich parish will admit a lunatic as a pauper, whom a poor parish would refuse to admit, and of course, a poor parish will admit him, if the consequent expenditure by the parish is to be small more readily than it will if the consequent expenditure is to be considerable.4

One of the key variables in this context was the parlous state of Ireland’s lunacy legislation. By the end of the 1800s mental health law had become impossibly complex, frequently contradictory and ultimately impenetrable. In 1886, a definitive tome on the topic was published, impressively titled The Law and Practice of Lunacy in Ireland as Administered by the Lord Chancellor under the Sign Manual Together with a Compendium of the Law Relating to Establishments for the Care of the Insane.5 Written by George Whitley Abraham, Barrister-at-Law and Registrar in Lunacy, the book ran to a total of 752 densely written, convoluted pages, and the indefatigable author did not even live to see his masterwork published: he died when it was with the printer. Nonetheless, Abraham’s impressive book presented useful, if lengthy, accounts of topics ranging from the ‘general policy of laws concerning the insane’ to ‘management of the lunatic’s estate’, from ‘civil contracts’ to ‘varieties of incapacity attaching upon lunacy’, and included a ‘compendium of the law relating to establishments for the care of the insane’. Ultimately, however, there was no hiding the fact that the legal position of the mentally ill was a desperate mess, albeit an exhaustively documented one.

The matter was stated even more directly in 1891 by the Committee on Lunacy Administration (Ireland) which concluded, with admirable brevity, that ‘fresh Lunacy legislation for Ireland is beyond question necessary’:

In regard to many matters it is extremely difficult, if not impossible, to know what is, or is not, statutory. For this reason alone, the codification or consolidation of the Statutes relating to Lunacy appears to us to have become necessary. But, apart from this, the provisions of the Statutes are in many respects of an undesirable character. They do not sufficiently guarantee the proper treatment of the insane, nor do they adequately safeguard the public against unnecessary detention in Asylums.6

In terms of service provision, the Committee suggested ‘that it be considered whether some of the empty Workhouses could not be acquired and converted into’ provincial asylums:

If this were done, the buildings would cease altogether to be Workhouses, and would be as unconnected with the Poor Law Authorities as District Asylums. In this way increased Asylum accommodation might be cheaply obtained in those cases in which extensive structural changes would not be necessary for the conversion of the Workhouse accommodation into Asylum accommodation, and in which the acquisition of additional land would not be needed. Sometimes the necessary structural changes are very extensive and costly […]. But there may be other unoccupied Workhouses which could be altered at small cost so as to afford suitable accommodation for incurable and easily-managed Lunatics, and our suggestion is that the possibility of utilising some of the disused Workhouses in this way should be carefully considered.7

The Committee suggested ‘the creation of a General Board of Lunacy for Ireland’8 and various changes to administration9 and admission procedures.10 It also supported the idea of lunatics ‘boarding out’ of workhouses, in private homes:

It would not be difficult, in our opinion, by co-operation between the Lunacy Inspectors and the Local Government Board, to make such rules and arrangements as would afford a reasonable security that the money given for the relief of lunatics so boarded out of Workhouses, whether with relatives or with strangers, was spent for their benefit. If this reasonable security were obtained in such a way as to enable the Inspectors of Lunatics to certify that they believed the boarded-out pauper lunatics to be properly cared for, it seems to us only right that there should be participation on their account in the Grant from Imperial Sources towards the maintenance of the insane poor.11

Sadly, the Committee’s relatively enlightened and compassionate stances on many matters were generally not reflected in policy changes,12 although the early years of the 1900s did see continued discussion about possible reform along these and other lines. Issues relating to overcrowding inevitably dominated the Conference of the Irish Asylums Committee at the Richmond Asylum in 1903;13 the Richmond itself organised a special enquiry ‘into the question of provision for workhouse lunatics’ and a diagnostic ‘segregation’ of all asylum patients in 1907;14 and, in 1927, the Irish Free State published its seminal Report of the Commission on the Relief of the Sick and Destitute Poor, Including the Insane Poor.15

The 1927 Report noted that the Commission, appointed in 1925, was instructed ‘to inquire into the existing provision in public institutions for the care and treatment of mentally defective persons and to advise as to whether more efficient methods can be introduced especially as regards the care and training of mentally defective children, due regard being had to the expense involved’.16 The Commission interpreted the term ‘mentally defective’ to ‘include mentally disordered as well as mentally deficient persons’.

The Commission provided a mercifully brisk, useful summary of legislation underpinning the asylum system from the 1700s up to the early 1900s, with particular emphasis on changes occurring around the turn of the century:

The system of administration which we have outlined underwent radical alteration when the Local Government Act, 1898, came into operation. From 1821 to 1899 the asylums were in the general control of the Lord Lieutenant. The administration was divided amongst three bodies whom he appointed, namely, the Board of Control, the Boards of Governors and the Inspectors of Lunatics. The Board of Control was entrusted with the provision of accommodation, the local Boards of Governors managed the asylums in accordance with prescribed uniform rules called the Privy Council Rules, and the Inspectors had not only the duty of visiting the asylums and inquiring into their condition, but had administrative functions, such as the framing of estimates, the approval of pensions, the regulation of dietary scales, the fixing of hours of meals and of rising and retiring, and also certain duties in connection with the audit of accounts.

Under the Act of 1898 a new administrative system was set up and it became the duty of the County Councils created by the Act to provide sufficient accommodation for the lunatic poor, and manage the asylum for the county. The Board of Control was abolished and the powers of the Lord Lieutenant and the Inspectors as to the appointment and removal of officers and the regulation of expenditure were transferred to the Councils. The County Council’s powers were to be exercised through a Committee appointed by them, one-fourth of which might be composed of persons not members of the Council […].

The Committees of Management were given power to make regulations respecting the government and management of the asylums; the admission, detention and discharge of patients; and the conditions as to payment and accommodation for private patients. The Privy Council Rules were to continue in operation until these regulations were made and approved. All the Committees of Management except those for the asylums at Carlow, Castlebar, and Mullingar [had by 1927] made regulations under the Act.17

The Commission also noted that the Local Government Act 1898 made provision for the establishment of ‘auxiliary asylums for chronic and harmless lunatics’,18 and that the Lunacy Act 1901 introduced various additional reforms:

The Lunacy Act of 1901 provided for the conditional discharge of criminal lunatics and extended to Ireland certain provisions of the English Lunacy Act of 1890 designed to protect lunatics from ill-treatment. It provided for the expenses connected with the maintenance of criminal lunatics in district asylums being defrayed out of government funds. The central asylum at Dundum could not accommodate all persons classed as criminal lunatics, and it had become the practice to send persons who had committed only trivial offences, or were serving short sentences, to the district asylums, reserving the Central Asylum largely for those who had committed serious offences. The Act of 1901 gave the same power of recovering the cost of maintenance of dangerous lunatics as existed in the case of ordinary patients, and it also permitted Committees of Management to unite for the purposes of promoting pathological research.19

Against this background, the early twentieth century was, clearly, a time of considerable discussion and, to a certain extent at least, change in mental health services owing not only to the reforming Acts of 1898 and 1901, but also to growing unrest about the state of Irish asylums and the fate of the destitute mentally ill. Before considering asylum reforms of the early 1900s any further, however, it is worth exploring briefly what is known about the fate of the mentally ill outside the asylums in the early years of the new century.

Outside the Walls: The Mentally Ill

Outside the Asylums (1901)

The historiography of Irish psychiatry demonstrates a strong focus on the history of institutions, echoing the emphasis government traditionally placed on institutional provision as a key element in resolving the social problems presented by people with apparent mental disorder or intellectual disability.

Throughout the nineteenth century, these developments were largely shaped by a strong belief that rates of mental disorder were increasing rapidly, especially toward the end of the 1800s.20 As explored in Chapter 3, the subsequent expansion of the Irish asylum system was a complex sociomedical phenomenon,21 as was the admission of increasing numbers of the mentally ill to the Irish workhouse system.22

Notwithstanding these developments, there was still a large number of people with mental disorder who were not in asylums, workhouses or other institutions in Ireland at the start of the twentieth century. One study, based on Ireland’s 1901 national census,23 found that there were 482 persons described as ‘lunatics’ and not resident in psychiatric hospitals, workhouses or other institutions in Ireland on census night (31 March) in 1901, yielding a point prevalence of 11 per 100,000 population (i.e. approximately one in every 10,000 persons outside an institution was recorded in the census as a ‘lunatic’).24

TABLE 1Geographical distribution of persons described as ‘lunatics’ and not resident in psychiatric hospitals, workhouses or other institutions in Ireland on census night (31 March) in 1901.
Province	County	Population	Number of ‘lunatics’ outside institutions	Number of ‘lunatics’ outside institutions per 100,000 population
Connaught	Galway	192,845	31	16
Leitrim	69,460	12	17
Mayo	198,098	33	17
Roscommon	100,563	23	23
Sligo	80,555	13	16
Connaught Total	641,521	112	18
Munster	Clare	112,309	21	19
Cork	402,388	48	12
Kerry	165,940	34	21
Limerick	147,154	9	6
Tipperary	155,517	11	7
Waterford	87,205	12	14
Munster Total	1,070,513	135	13
Leinster	Carlow	37,228	7	19
Dublin	439,915	21	5
Kildare	61,312	4	7
Kilkenny	75,447	8	11
Laois	57,171	8	14
Longford	46,720	8	17
Louth	65,107	1	2
Meath	70,304	10	14
Offaly	60,341	9	15
Westmeath	61,998	3	5
Wexford	104,028	8	8
Wicklow	59,906	11	18
Leinster Total	1,256,989	98	8
Ulster	Antrim	457,983	20	4
Armagh	124,803	12	10
Cavan	97,437	7	7
Donegal	173,121	26	15
Down	290,061	14	5
Fermanagh	65,015	17	26
Derry	144,823	15	10
Monaghan	74,425	8	11
Tyrone	150,687	18	12
Ulster Total	1,578,355	137	9
Ireland Total		4,547,378	482	11

This overall prevalence seems quite low, presumably as a result of specific aspects of census methodology.25 The very lowest prevalence of ‘lunatics’ outside of institutions (8 per 100,000 population) was recorded in Leinster (possibly owing to enhanced provision of workhouses and asylums); the highest was in Connaught (18 per 100,000 population). A majority of these ‘lunatics’ were female (60 per cent) with an average age of 46 years. Two thirds were single (i.e. never married), while one third of females were married, compared to 14 per cent of males. The most common relationship to the ‘head of household’ (as recorded in the census) was child (33 per cent) although some were boarders or lodgers. Majorities were Roman Catholic (82 per cent) and could ‘read and write’ (65 per cent). Among those for whom the ability to speak Irish was recorded, 74 per cent spoke both Irish and English.

These results, although interesting, need to be interpreted with an awareness of various limitations of the census methodology, not least of which is the (likely) inconsistent use of the terms ‘imbecile’, ‘idiot’ and ‘lunatic’, despite definitions being provided. A ‘lunatic’, for example, was ‘a mentally ill person with periods of lucidity’. This definition is similar, although not identical, to the definition of a person of ‘unsound mind’ in the Fourth Census of Canada in 1901, which stated that ‘it is not necessary that the degree of infirmity should be absolute or total, but that it should be so sufficiently marked in any one of the classes as to have reached the stage of incapacity’.26 The Irish definition is quite similar, at least to the extent that it defines lunacy as involving a lesser degree of impairment than ‘imbecile’ or ‘idiot’.

It is difficult, if not impossible, to clarify just how conscientiously these definitions were used by various enumerators in 1901. It seems likely that, at the very least, the terms ‘imbecile’ and ‘idiot’ were used interchangeably. The Mental Deficiency Act of 1913 later defined an ‘imbecile’ as an individual unable to take care of himself or herself, and an ‘idiot’ as a person unable to protect himself or herself from common dangers.27 The 1901 census, however, preceded the Mental Deficiency Act of 1913 by more than a decade, and the 1913 Act was not, in any case, applied in Ireland. As a result, the terms ‘imbecile’ and ‘idiot’ were likely used interchangeably in the 1901 census. In this context, it also appears likely that the low prevalence of ‘lunatics’ in the census is explained, at least in part, by the way in which the definition of ‘lunatic’ was used.

Notwithstanding these complexities, it is interesting that a majority (60 per cent) of ‘lunatics’ outside the institutions in 1901 were female and the average age of females (47 years) was higher than that of males (44 years). By way of comparison, there were, on 1 January 1901, 21,169 mentally ill people in Irish institutions, of whom 48 per cent were female.28 This difference in gender distribution inside and outside the institutions might reflect an increased likelihood for women, possibly especially slightly older women, to remain in the home, despite showing signs of mental disorder. This is consistent with the fact that women generally tended to be admitted to asylums at a later stage in their illness than men, and were more likely to be discharged.29

From the 1901 census, the most common relationship outside the institutions between a ‘lunatic’ and the ‘head of household’ was child (33 per cent), suggesting that children with mental disorder may have remained in the home in order to be cared for by their families, or, alternatively, in order to care for their parents, attend to household tasks or work on farms.

It is interesting that certain counties with large asylums (e.g. Kerry) had a relatively high prevalence of ‘lunatics’ outside the asylums and workhouses. This might reflect the fact that many Irish asylums demonstrated significant rates of both admission and discharge,30 possibly resulting in relatively larger numbers of persons with diagnosed mental disorder living in counties with asylums. Local geography was also important, as people living near asylums were more likely to be admitted than those living far distances away, at least in the 1800s.31

On the other hand, the prevalence in Dublin was relatively low, despite the presence of a number of asylums, suggesting that this explanation was not universal, or that other factors were at play, especially in Dublin. It is also notable that some of the ‘lunatics’ outside the institutions who were ‘boarders’ were unrelated to the ‘head of household’ suggesting the possibility that these households may have represented early or informal de facto ‘boarding out’ initiatives, as championed tirelessly by Norman at the Richmond.32

While no ‘occupation’ was provided for 38 per cent of ‘lunatics’ in the 1901 census, farming was the most common occupation recorded (41 per cent).33 Also consistent with the broader population, majorities were Roman Catholic (82 per cent); could ‘read and write’ (65 per cent); and, among those for whom ability to speak Irish was recorded, 74 per cent spoke both Irish and English. This, too, is consistent with broader trends in Ireland, as illiteracy had fallen rapidly in preceding decades from 53 per cent in 1841 to 18 per cent in 1891.34

In these important respects (occupation, religion, literacy), ‘lunatics’ living outside the Irish institutions in 1901 bore significant similarities to the broader population, although it remained the case that the lives they led differed significantly from the lives of those who were not labelled as ‘lunatics’. This situation was largely attributable to the twin processes of continual legislative change and inexorable expansion of institutions for the mentally ill during the late nineteenth and early twentieth centuries. These matters were of enormous concern to asylum doctors in the early 1900s and predictably dominated the Conference of the Irish Asylum Committees in 1903.

Conference of the Irish Asylum Committees (1903):

Degeneration, Politics and Tea

Issues relating to overcrowding were strongly to the fore of the agenda at the Conference of the Irish Asylums Committee convened at the Richmond Asylum in 1903.35 By that time, it was felt that the increase in admissions was related in large part to ‘heredity’ rather than poverty, adversity, religion or mental anxiety – a conclusion which contrasted in certain respects with that of Hallaran a century earlier, who had emphasised physical illness, alcohol, political disturbance and ‘terror from religious enthusiasm’ as causes of mental disorder.36 This was not a universally agreed position, however, with some commentators, such as Dr M.J. Nolan, then RMS in Downpatrick (having previously worked in Dublin and Limerick), citing ‘stress’ as a key contributor, and appealing passionately that the needs of the mentally ill should not be ignored.37

With palpable alarm, the 1903 conference noted that there were 22,139 ‘registered lunatics’ in Ireland and this number was increasing.38 Dr Edward D. O’Neill, medical superintendent of Limerick District Lunatic Asylum, read a paper titled Increase of Lunacy and Special Reasons Applicable to Ireland and noted, at the outset, the difficulties with accurate data collection: