Custody, Care and Criminality E-Book

Brendan Kelly

• Herausgeber: THP Ireland
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 516

Veröffentlichungsjahr: 2014

Beschreibung

In this fundamentally important work, Professor Brendan Kelly explores the background to Irish psychiatry in the nineteenth and early twentieth centuries, charting its progress and development. Using detailed case studies from the original records, the author examines some of the more unusual treatments explored and the history behind them. What emerges is a collection of piercing, untold stories of crime and illness, drama and tragedy. They are filled with a sense of the powerlessness of those detained and the dedicated – and sometimes misguided – enthusiasm of those trying to help. This book sheds important light on the foundations for the treatment of mental illness in Ireland.

Leseprobe

This book is dedicated to my parents, sisters and niece

Contents

Title Page

Dedication

Foreword by Professor Harry Kennedy

Acknowledgements

Introduction

1 Mental Health Care in Nineteenth-Century Ireland

2 Creating the Asylums and the Insanity Defence

3 Women in the Central Criminal Lunatic Asylum, Dublin, 1868–1948

4 Clinical Aspects of Criminal Insanity in Nineteenth- and Twentieth-Century Ireland

5 Reformation and Renewal: Into the Twentieth Century

Notes

Bibliography

Copyright

Foreword

It is a pleasure to welcome the reader to this treasure trove of material assembled and analysed by Professor Brendan Kelly from primary sources in Irish hospital archives. Professor Kelly has gone beyond the nineteenth century, delving back into the 1700s and forwards into the twentieth century. Professor Kelly has drawn together the archives of the Irish asylums, case notes and committee minutes, to allow the reader to understand how this extraordinary mass confinement grew and declined. This is an important book for anyone interested in the real history of asylums, the management of mental health services and the care of the severely mentally ill and incapacitated. Those preparing syllabuses at undergraduate or postgraduate level will find this book valuable as a starting point for seminars on care, culture and compassion in mental health services, on mental health law and human rights.

What can the non-historian learn from this review? Professor Kelly raises a number of questions that are familiar, and some that are not.

WERE THE CALCULATIONS WRONG?

Was there a real increase in the number of new cases of severe mental illness in Ireland between the beginning of the eighteenth and end of the nineteenth centuries? Professor Kelly identifies distinguished writers such as Tuke (1894) and Conolly Norman, the forerunners of modern psychiatric epidemiology, who carefully calculated the increasing number of persons detained on the grounds of (legal) insanity in Ireland and concluded that there was a real increase in such disorders in Ireland over the course of the eighteenth and nineteenth centuries. They can be forgiven for confusing legal categories with clinical reality. The means of making such calculations were still being developed. National census data had been compiled from about 1821 onwards and Durkheim in France began calculating population-based suicide rates and the related confounding factors only from the 1890s. Hacking has reviewed the emergence of our modern understanding of probability and risk at about that time.1

THE FAMINE 1845–1852

Did the asylums increase in size so dramatically in Ireland because of the famine? They also increased in England, though not to the same extent. Was the growth of asylum care due to urbanisation and the loss of family cohesion and supports? Not in Ballinasloe or the other west of Ireland asylums.2 Was it due to emigration, leaving the mentally incapacitated behind? This at least is a possible explanation for some of the growth in the numbers dependent on asylums, but as Professor Kelly shows in this excellent book, there are many other factors that may be relevant also.

How would a modern epidemiologist think about the famine and its consequences? The famine in Ireland might have created a dispossessed generation of physically impaired and mentally traumatised survivors.

Biological factors may have contributed to a real increase in severe mental illness. Starvation in utero would produce a generation reaching adulthood in the decades after the famine with impaired intellectual function and vulnerabilities to schizophrenia and other mental illnesses. Pelvic disproportion due to childhood malnutrition might have caused a second generation burdened with birth injury presenting four or five decades after the famine. Even in modern times, birth injury has been described as part of the diathesis for schizophrenia.3 However, these are only speculations.

CULTURE AND WELFARE

It would be no surprise that the famine and the evictions around the same time should lead to transgenerational welfare dependence. In Ireland two factors may have limited this – the ease of emigration for those who were capable, and the lack of any welfare system on which the incapable could depend, other than the work houses and asylums. This was acknowledged in what may have been a satirical sketch by John Millington Synge who recounts a conversation with a woman in Wicklow, sometime around the end of the nineteenth century –

In Wicklow, as in the rest of Ireland, the union, though it is a home of refuge for the tramps and tinkers, is looked on with supreme horror by the peasants. The madhouse, which they know better, is less dreaded …

‘My brother Michael has come back to his own place after being seven years in the Richmond Asylum; but what can you ask of him, and he with a long family of his own? And, indeed, it’s a wonder he ever came back when it was a fine time he had in the asylum.’

She saw my movement of surprise and went on:

‘There was a son of my own, as fine a lad as you’d see in the county – though I’m his mother that says it, and you’d never think it to look at me. Well, he was a keeper in a kind of private asylum, I think they call it, and when Michael was taken bad, he went to see him, and didn’t he know the keepers that were in charge of him, and they promised to take the best of care of him, and, indeed, he was always a quiet man that would give no trouble. After the first three years he was free in the place, and he walking about like a gentleman, doing any light work he’d find agreeable. Then my son went to see him a second time, and ‘You’ll never see Michael again,’ says he when he comes back, ‘for he’s too well off where he is.’ And, indeed, it was well for him, but now he’s come home.4

RURAL DEPOPULATION, URBAN DRIFT

The subdivision of small holdings by the law of inheritance up to the time of the famine and the evictions that followed it forced the numerous offspring of Irish families to leave the land. Elsewhere in Europe a drift from rural areas to cities was actively facilitated by urban growth and the need for labour in industrial centres. Since there was no industrialisation and little urban growth in Ireland, the young and fit went to industrial centres abroad. Those not fit for emigration gravitated towards the workhouses and asylums. In industrialised countries such as England the urbanised poor had subsistence work and access to a market in rented or social accommodation of a decent standard – they did not have the same expectation of inheritance, of property rights and of a living. The urban disabled could share in what was available without threatening any right of succession, where none was expected. Emigration, for the Irish brought up on a small holding, was a liberation. In Ireland, the only market in rented accommodation was the crowded tenements of Dublin.5 Paradoxically, family cohesion may have been easier in urban centres abroad than in rural Ireland.

CYCLES OF ASYLUM REFORM AND REGRESSION

The asylums described by Professor Kelly appear to veer cyclically from enlightened and humane ‘moral’ regimes to custodial and impoverished, and were often inherently lacking in relational care. Asylums were at times designed as places of utopian idealism.6 The early asylum doctors regarded the design and management of their hospitals as a scientific project,7,8 as science was understood in their day. The careful description of the roles and duties of all those working in an asylum accords with modern interests in the distinction between care and custody.9 Relational care is that therapeutic alliance between clinicians and patients that is now recognised as central to recovery. It is the antithesis of custodial control. Why are asylums characterised by cycles of idealism and enlightenment, followed by custodial repression, followed by further cycles of reform and regression? Professor Kelly records the ‘moral’ humanitarian hospital regime of Dr William Saunders Hallaran in the early years of the nineteenth century in Cork, where he was medical superintendent from 1789 to 1825, as was prevalent also in England, the USA and elsewhere. This was followed by unrestrained growth and regressive, custodial care in the aftermath of the famine. By the 1930s the Inspector’s reports on conditions in the Cork asylum described oppressive, unhygienic and impoverished facilities and custodial practices. Dr Robert MacCarthy10 was medical superintendent at Our Ladies Hospital, Cork from 1961 where he had to reform the ‘existing regime of institutional care … abolishing padded cells and straitjackets … injected a dose of humanity into what was a harsh environment inherited from Victorian times.’

In Dublin, reform took hold again around the turn of the nineteenth and twentieth centuries with Conolly Norman in Dublin (medical superintendent of the Richmond Asylum Grangegorman 1886–1908), followed by Dunne’s reforms (1937–1966) at the same hospital after a further period of regression during the Second World War or ‘emergency’. To these reformers could be added Blake in Carlow.11 Yet by the late 1970s when I first visited Grangegorman as a medical student it was in such a state of decay that closure seemed the only possible course. Closure eventually occurred – in 2013.

Clearly Hallaran’s work in Cork had not taken hold, any more than the work of Conolly Norman or Dunne had in Grangegorman. The prolonged recession of the 1970s and ’80s led to further set-backs. Why did the asylums grow, and even more to the point, why did they regress from the idealistic havens of moral therapy and humanitarian care, to custodial and neglected places in what appear to have been regular cycles? Simple economic strictures, cycles of public expenditure and austerity, are probably the most obvious explanation.

Table 1 in chapter 2 shows the very low ratio of doctors to patients across all asylums in 1906, and the ratio of ward-based staff was likely to be as low in modern terms. The asylums therefore had to rely on security procedures and physical structures – walls, locked doors and the like, to maintain a safe environment for the patients and for the staff. This has been the downfall of hospital care in all eras. When well-resourced, it is easy to provide a caring and therapeutic service. In times of austerity it is easy to cut staff numbers while increasing bed numbers – doing more for less – though the quality of what is done falls to the point of toxicity. It is a recurrent feature of the history of asylums that in every generation the culture of custody re-emerged and smothered the culture of care. Lack of resources and lack of public esteem will inevitably lead to this regression.

The failure to distinguish between three types of performance monitoring for psychiatric hospitals may have permitted this cycle of regression and regeneration. First, inspectors charged with the enforcement of absolute compliance with legal rules (and the power to punish non-compliance) have not been in a position to encourage quality initiatives and standards. This second type of performance monitoring to improve quality and minimise risk requires cycles of audit and improvement programmes that always require trust and openness, not the fear of censure. Third, the commissioners of public mental health services generally seek cost efficiency over clinical effectiveness, and will generally prefer customer satisfaction over clinical effectiveness.

POLICY DEVELOPMENT, LEGAL REFORM AND UNINTENDED CONSEQUENCES

Ireland after independence did not continue the pattern of frequent parliamentary reports and Royal Commissions that continuously drove the steady evolution of policy in the UK. Professor Kelly documents the many such reports that modernised Irish mental health legislation up to the first years of the twentieth century. Taking the UK as one example, mental health policy continued to progress before and after the Second World War. On the subject of forensic psychiatry alone the London Parliament published the Emery Report (1961)12 on high secure hospitals, the Glancy Report (1974) and the Butler Report (1975)13 on the need for local and regional secure hospitals to fill the gap left between the old asylums and the new open units in district general hospitals. The Reid Report (1995)14 set out the rights of detained patients to high-quality services. All of these led to real change in policy, legislation and service provision.15 Similar developments in modern forensic psychiatric services could be traced in the Netherlands and other modern European states, in Canada and Australia. These were seen as a necessary counterbalance to the rapid development of community care in the interests of a comprehensive mental health service in order to include those too disturbed or challenging for community treatment. In Ireland, the prison population grew as the asylums shrank16 and the mentally ill gravitated towards prisons, as happened throughout the developed world, though to a much greater extent17 because the counterbalances implemented elsewhere in the 1980s and 1990s did not happen in Ireland.

Yet there were government reports and policy papers in the new state too. Professor Kelly summarises a 1927 Report of the Commission on the Relief of the Sick and Destitute Poor including the Insane Poor18 that recommended the repeal of the many scattered pieces of legislation inherited from the former regime, to be replaced with a single amending and consolidating Act. A 1933 Committee of Investigation added weight to this. The result was the adoption of recommendations from a 1903 Conference of Irish Asylums Committee and the eventual Mental Treatment Act of 1945, which failed to do anything about the various pieces of legislation regarding insanity or transfers from prisons to hospitals and failed to properly establish the status of ‘voluntary’ patients. The 1945 Act established an Inspector of Mental Hospitals, but the annual reports of the inspector were not published for several years up to 1987. There followed a Commission of Inquiry on Mental Illness (1966)19 and an embarrassing sequence of delays (Green Paper on Mental Health 1992, White Paper: A New Mental Health Act 1995) and false starts that came to nothing (Mental Treatment Act 1961, Health (Mental Services) Act 1981 and Disability Act 2005), and policy documents (Planning for the Future 198420 and Vision for Change 200621) that have made very slow progress. The introduction of new legislation, the Mental Health Act of 2001 and the Criminal Law (Insanity) Act of 2006 has produced real change, but more is required.

While policy led law reform elsewhere, in Ireland law reform often appeared disconnected from or even drove policy and practice, though often because of unintended consequences. The Criminal Lunatics (Ireland) Act of 1838 gave the power to justices of the peace to detain ‘dangerous lunatics’ without any medical certification. This probably drove much of the growth of the asylums from that date until the Mental Treatment Act of 1945 restored medical control over diagnosis and admission.22 Contrary to modern expectations, this restoration of medical control was associated with a decline in hospitalisation.17 Yet the Criminal Law (Insanity) Act 2006 attempted to re-introduce judicial detention without medical certification for those unfit to stand trial. This was only partially reformed in 2010, and only because it was so obviously contrary to the case law of the European Court of Human Rights.23

MENTAL HEALTH POLICY IN NATIONAL AND INTERNATIONAL CONTEXT

Dr Dermot Walsh, who was a major influence on the policy makers of the Commission of Inquiry on Mental Illness in 1966, Planning for the Future in 1984 and Vision for Change in 2006, drew attention in 1989 to the misuse of mental health services as local employment schemes.24 This situation persists. Rural services, with less psychiatric morbidity, have disproportionate resources, while the ‘new’ urban centres are under-provided and rely disproportionately on the prisons and forensic hospital beds.25 This political use of one public service to achieve the ends of an unrelated policy, usually regionalism, can be seen as part of a broader pattern in Irish policy and public services, with rejected attempts at regional development policies26 and inefficient decentralisation of public services.27

Ireland was not only slow to modernise mental health services. The British Government published and quickly acted on the Wolfenden Report on Homosexual Offences (1957) as did most other western democracies while in Ireland, only action in the courts and eventually the European Court of Human Rights (1988)28 produced change in Irish legislation (in 1993).29 In a more general sense, the governance of the new republic after independence was often inward-looking, reluctant to embrace change and slow to adapt to modernity.30

In mental health legislation and service development, it could be argued that it was the European Convention on Human Rights, the European Court of Human Rights31 and its enforcement agency, the Council of Europe Committee for the Prevention of Torture and Inhumane or Degrading Treatment or Punishment (The Committee for the Prevention of Torture)32 that has driven the passage of the Mental Health Act 2001, the Criminal Law (Insanity) Act 2006 and 2010, and the still awaited Mental Capacity and Assisted Decision Making Bill. The Criminal Law (Insanity) Acts still fall far short of the reform and consolidation recommended in the 1927 Report,33 or the 1959 Mental Health Act for England and Wales. The European Union’s increasing interest in medical services including mental health34 may eventually become a further impetus for common standards across the European Union, a development that could not come soon enough if further cycles of reform, stagnation and regression are to be avoided.

THE END OF HISTORY?

Many of the most enlightened reformers of mental health services in recent decades have come to the view that hospital care for any but the shortest periods of time leads inevitably to custodial and harmful care. The only long-term, certain way of preventing the cyclical deterioration of hospital services would be to close all such hospitals. But there is no denying the natural history of severe mental illnesses and other mental incapacities. Those who, because of their illnesses or developmental disorders, are prone to harming others or themselves will need the professional protection of others and protection for the sake of others including their own families and communities. Such persons continue to accumulate in the prisons35 and although much can be done with modern enhanced prison mental health services,36,37 these should be seen only as reactions, not as effective solutions. Prison custody for the severely mentally ill is not an intended consequence or a part of modern community mental health policy. Detention and compulsory treatment under mental health legislation, continuing now at the Central Mental Hospital in Dundrum for over 160 years, can be seen from an ideological point of view as paternalistic, discriminatory and more objectively, vulnerable to regression. But safe, therapeutic and humane hospital care followed by structured community care will always be needed for the most severely disturbed and challenging who are mentally incapacitated and mentally disabled, often for prolonged periods. A well-organised, secure hospital must be well-resourced38 to remain oriented towards care and recovery. It would be better for the future to recognise the pressures that occur during economic recessions and avoid the pit-falls of a return to custodial care by providing fewer, more intensively staffed hospital and community places rather than more but impoverished places.

Harry Kennedy BSc, MB BCh BAO, MD, FRCPI, FRCPsych Consultant Forensic Psychiatrist and Executive Clinical Director, National Forensic Mental Health Service, Central Mental Hospital, Dundrum, Dublin and Clinical Professor of Forensic Psychiatry, Trinity College Dublin.

Acknowledgements

Much of the research that informs this book was performed in the archives of the Central Mental Hospital (previously Central Criminal Lunatic Asylum), Dundrum, Dublin, Ireland. I am deeply grateful for the support of Professor Harry Kennedy of the National Forensic Psychiatry Service throughout this project. I also greatly appreciate his foreword to this book.

This book is primarily based on sixteen published, peer-reviewed research papers on psychiatric history. These papers, along with a 15,000-word critical appraisal, constituted my PhD in history (by means of published works) at the University of Northampton, England in 2011. I am very grateful for the supervision of Dr Cathy Smith (First Supervisor) and Professor Jon Stobart (Director of Studies) at the School of Social Sciences (History) in the University of Northampton. Their encouragement and supervision were crucial factors in completing my PhD and contextualising my archival and historical research work.

I also wish to acknowledge the educational influences of my colleagues in clinical and academic psychiatry, the doctors, nurses, social workers, occupational therapists, psychologists, lecturers, administrators and students with whom I work. I am very grateful for the assistance and support of Dr Larkin Feeney, Dr John Bruzzi and Mr Gerry Devine of the (HSE). In addition, I have benefitted enormously from my contact with mental health service-users and their families, carers, advocates and legal advisors.

I am very grateful to Professor Sharlene Walbaum, her family, colleagues and students at Quinnipiac University, Connecticut. Shar’s wisdom, enthusiasm and hospitality have added greatly to my historical work.

I greatly appreciate the teaching and guidance of my teachers at Scoil Chaitríona (Renmore, Galway) and St Joseph’s Patrician College, Galway, especially Mr Ciaran Doyle (my history teacher, now principal) who conveyed a genuine enthusiasm for history to me. I also owe a debt of gratitude to my teachers and supervisors at the School of Medicine in the National University of Ireland, Galway.

Most of all, I appreciate deeply the support of my wife (Regina), children (Eoin and Isabel), parents (Mary and Desmond), sisters (Sinéad and Niamh) and niece (Aoife) throughout all of my academic and publishing endeavours.

PUBLICATION ACKNOWLEDGEMENTS AND PERMISSIONS

All reasonable efforts have been made to contact the copyright holders for text used in this book. If any omissions are brought to my attention, appropriate acknowledgement will be included in any future editions of this work.

Quotations from ‘Modern Psycho-therapy and out Asylums’ by E. Boyd Barrett (Studies 1924: 8: 29-43) are reproduced by kind permission of the editor of Studies: An Irish Quarterly Review.

Quotations from the Official Report of Dáil Éireann and Official Report of Seanad Éireann are Copyright Houses of Oireachtas.

Quotations from The Irish Times are used by kind permission of The Irish Times. Quotations from the Journal of Mental Science are used by kind permission of the Royal College of Psychiatrists.

Introduction material was drawn from:

Kelly, B.D., ‘Poverty, Crime and Mental Illness: Female Forensic Psychiatric Committal in Ireland, 1910-1948’, Social History of Medicine (2008; 21 (2): 311–28), used with kind permission of Oxford University Press who publish Social History of Medicine on behalf of The Society for the Social History of Medicine

Kelly, B.D., ‘Criminal Insanity in Nineteenth-Century Ireland, Europe and the United States: Cases, Contexts and Controversies’, International Journal of Law and Psychiatry,(2009; 32: 362–8), used with kind permission of Elsevier. www.sciencedirect.com/science/article/pii/S0160252709001046

Kelly, B.D., ‘Intellectual Disability, Mental Illness and Offending Behaviour: Forensic Cases from Early Twentieth-Century Ireland’, Irish Journal of Medical Science (2010; 179: 409–16), used with kind permission from Springer Science+Business Media: Irish Journal of Medical Science, Intellectual disability, mental illness and offending behaviour: forensic cases from early twentieth-century Ireland, Volume 79, Year of publication: 2010, Pages: 409–16, Author: Brendan D. Kelly

Material for Chapter 1 was drawn from:

Kelly, B.D., ‘Dr William Saunders Hallaran and Psychiatric Practice in Nineteenth-Century Ireland’, Irish Journal of Medical Science (2008; 177: 79–84), used with kind permission from Springer Science+Business Media: Irish Journal of Medical Science, Dr William Saunders Hallaran and Psychiatric Practice in Nineteenth-Century Ireland, Volume: 177, Year of publication: 2008, Pages: 79–84, Author: Brendan D. Kelly

Kelly, B.D., ‘Mental Illness in Nineteenth Century Ireland: A Qualitative Study of Workhouse Records’, Irish Journal of Medical Science (2004; 173: 53–5), used with kind permission from Springer Science+Business Media: Irish Journal of Medical Science, Mental Illness in Nineteenth Century Ireland: A Qualitative Study of Workhouse Records, Volume 173, Year of publication: 2004, Pages 53–5, Author: Brendan D. Kelly

Material for Chapter 2 was drawn from:

Kelly, B.D., ‘Mental Health Law in Ireland, 1821–1902: Building the Asylums’, Medico-Legal Journal (2008; 76: 19–25), used with kind permission of SAGE Publications Ltd. http://mlj.sagepub.com/content/76/1/19.full.pdf+html

Kelly, B.D., ‘Mental Health Law in Ireland, 1821–1902: Dealing with the “Increase of Insanity in Ireland”’, Medico-Legal Journal (2008; 76: 26–33), used with kind permission of SAGE Publications Ltd. http://mlj.sagepub.com/content/76/1/26.full.pdf+html

Kelly, B.D., ‘One Hundred Years Ago: The Richmond Asylum, Dublin in 1907’, Irish Journal of Psychological Medicine (2008; 24: 108–14), used with kind permission of MedMedia Group and with the agreement of Cambridge University Press, current publisher of the Irish Journal of Psychological Medicine on behalf of the College of Psychiatrists of Ireland.

Kelly, B.D., ‘Criminal Insanity in Nineteenth-Century Ireland, Europe and the United States: Cases, Contexts and Controversies’, International Journal of Law and Psychiatry (2009; 32: 362–8) used with kind permission of Elsevier. www.sciencedirect.com/science/article/pii/S0160252709001046

Material for Chapter 3 was drawn from:

Kelly, B.D., ‘Clinical and Social Characteristics of Women Committed to Inpatient Forensic Psychiatric Care in Ireland, 1868–1908’, Journal of Forensic Psychiatry and Psychology (2008; 19: 261–73), reprinted by permission of the publisher, Taylor & Francis Ltd, http://www.tandf.co.uk/journals/

Kelly, B.D., ‘Poverty, Crime and Mental Illness: Female Forensic Psychiatric Committal in Ireland, 1910–1948’, Social History of Medicine (2008; 21(2): 311–28), used with kind permission of Oxford University Press who publish Social History of Medicine on behalf of The Society for the Social History of Medicine

Kelly, B.D., ‘Murder, Mercury, Mental Illness: Infanticide in Nineteenth Century Ireland’, Irish Journal of Medical Science (2007; 176: 149–52), used with kind permission from Springer Science+Business Media: Irish Journal of Medical Science, Murder, Mercury, Mental Illness: Infanticide in Nineteenth Century Ireland, Volume: 176, Year of publication: 2007, Pages: 149–52, Author: Brendan D. Kelly

Material for Chapter 4 was drawn from:

Kelly, B.D., ‘Folie à Plusieurs: Forensic Cases from Nineteenth-Century Ireland’, History of Psychiatry (2009; 20: 47–60), used with kind permission of SAGE Publications Ltd. http://hpy.sagepub.com/content/20/1/47.abstract. I am also very grateful for the suggestions of Professor GE Berrios of the Department of Psychiatry, University of Cambridge, United Kingdom in relation to this paper. Quotations are reproduced by kind permission of the Royal College of Psychiatrists

Kelly, B.D., ‘Learning Disability and Forensic Mental Healthcare in Nineteenth-Century Ireland’, Irish Journal of Psychological Medicine (2008; 25: 116–8), used with kind permission of MedMedia Group and with the agreement of Cambridge University Press, current publisher of the Irish Journal of Psychological Medicine, on behalf of the College of Psychiatrists of Ireland

Kelly, B.D., ‘Intellectual Disability, Mental Illness and Offending Behaviour: Forensic Cases from Early Twentieth-Century Ireland’, Irish Journal of Medical Science (2010; 179: 409–16), used with kind permission from Springer Science+Business Media: Irish Journal of Medical Science, Intellectual disability, mental illness and offending behaviour: forensic cases from early twentieth-century Ireland, Volume 79, Year of publication 2010, Pages: 409–16, Author: Brendan D. Kelly

Kelly, B.D., ‘Syphilis, Psychiatry and Offending Behaviour: Clinical Cases from Nineteenth-Century Ireland’, Irish Journal of Medical Science (2009; 178: 73–7), used with kind permission from Springer Science+Business Media: Irish Journal of Medical Science, Syphilis, Psychiatry and Offending Behaviour: Clinical Cases from Nineteenth-Century Ireland, Volume: 178, Year of publication: 2009, Pages: 73–7

Material for Chapter 5 was drawn from:

Kelly, B.D., ‘The Mental Treatment Act 1945 in Ireland: An Historical Enquiry’, History of Psychiatry (2008; 19: 47–67), used with kind permission of SAGE Publications Ltd. http://hpy.sagepub.com/content/19/1/47.abstract

Kelly, B.D., ‘Physical Sciences and Psychological Medicine: The Legacy of Prof John Dunne’, Irish Journal of Psychological Medicine (2005; 22: 67–72), used with kind permission of MedMedia Group and with the agreement of Cambridge University Press, current publisher of the Irish Journal of Psychological Medicine, on behalf of the College of Psychiatrists of Ireland. Professor John Dunne’s Presidential Address was delivered to annual meeting of the Royal Medico-Psychological Association (RMPA), the forerunner of the Royal College of Psychiatrists, on 13 July 1955 and was reprinted in the Journal of Mental Science in the following year (Dunne, J., ‘The Contribution of the Physical Sciences to Psychological Medicine’, Journal of Mental Science (1956; 102: 209–20)). Quotations from that paper are reprinted with the kind permission of the Royal College of Psychiatrists, and with the consent of Dr David Dunne. The author is grateful for the co-operation of the Royal College of Psychiatrists and Dr David Dunne.

Kelly, B.D., ‘Mental Health Law in Ireland, 1945 to 2001: Reformation and Renewal’, Medico-Legal Journal (2008; 76: 65–72), used with kind permission of SAGE Publications Ltd. http://mlj.sagepub.com/content/76/2/65.full.pdf+html

Introduction

In the early 1890s, Henry, a 77-year-old farmer, was charged with murder, declared insane, and detained ‘at the Lord Lieutenant’s pleasure’ (i.e. indefinitely) in the Central Criminal Lunatic Asylum in Dundrum, Dublin, Ireland’s only inpatient forensic psychiatry hospital, designed for individuals with mental disorder who engaged in offending behaviour.1

On admission, Henry was diagnosed with ‘chronic mania’ and described as ‘intemperate’ (as opposed to ‘sober’). The medical officer noted that Henry ‘vomits frequently after his meals’ and had ‘some chronic intestinal trouble but I am unable to discover the exact nature thereof’.

Seven years after admission, ‘this impulsive old man’ was ‘delicate and losing strength’ , ‘very weakly’ and ‘confined to bed’. He was diagnosed with ‘pleurisy of the left side’ (i.e. chest pain) and prescribed ‘whiskey, 4 ounces’, but ‘got rapidly worse’. A couple of days later, Henry died of a chest infection, at the age of 84 years, having spent over fifty years in various psychiatric institutions, including the Central Criminal Lunatic Asylum.

Some years later, in the early 1900s, Patricia, a 45-year-old woman from the south of Ireland was charged with the murder of a child. Owing to her mental state, she was, like Henry, detained indefinitely at the Central Criminal Lunatic Asylum.2

Admission notes record that Patricia ‘formerly lived with her brother who is a farmer … She threw his child aged nine months into a pond and drowned it’. There was, however, little evidence that Patricia was suffering from mental disorder on admission and considerable evidence that her chief problem was intellectual disability. Clinical notes recorded that Patricia ‘lacks intelligence and has evidently been weak-minded from birth. She is practically devoid of reason, speaks with difficulty and is incapable of conversing intelligently’. Seven months later, Patricia had ‘given no trouble since admission’ but ‘seems oblivious to everything’. After five years in the Central Criminal Lunatic Asylum, Patricia was ‘incapable of coherent conversation or concentrated effort’.

Occasionally, Patricia became more disturbed for periods of time. Medical notes recorded that ‘she hammers on the door and shutters of her cell, whistles and in general creates as much noise as she can. Her reason for this tirade is that she is dead and wishes to get out of her coffin … She requires large doses of paraldehyde [a medication for epilepsy, sedative or ‘hypnotic’] … ordinary hypnotics are useless …’ Despite these disturbances, Patricia continued ‘to work daily in the laundry and is in good bodily health’.

Some twenty-five years after admission to the Central Criminal Lunatic Asylum, Patricia was still firmly behind the asylum walls, now suffering from epilepsy, bronchitis and influenza, as well as her ongoing features of intellectual disability and episodic mental disorder. Her future at that point was not bright: once an individual had been detained in an Irish asylum for more than five years, she or he was virtually certain to die there.3

This book is about people like Henry and Patricia, whose histories have been forgotten or misunderstood, and whose fates were determined by the vast, complicated asylum system that developed in Ireland over the nineteenth and early twentieth centuries. This was a time of dramatic change in Irish mental health services, with a rapid increase in asylum populations and multiple changes in legislation, including Ireland’s unique criminal insanity legislation of the mid-1800s. In this book, I am concerned with the fate of the mentally ill and intellectually disabled during this period, with a particular focus on women charged with crimes, declared insane, and committed to the Central Criminal Lunatic Asylum, a remarkable institution which was later renamed the Central Mental Hospital and remains part of Ireland’s forensic psychiatric services today.4

Forensic psychiatric services provide mental health care to individuals with mental disorder who engage in offending behaviour.5 In most societies, both mental disorder and offending behaviour are associated with socio-economic status; mental ill-health is more common in lower socio-economic groups and individuals in lower socio-economic groups are more likely to be incarcerated for offending behaviour.6 In addition, individuals with mental disorder are more likely to be taken into custody following an offence, compared to individuals without mental disorder.7 As a result, rates of mental disorder in prison today are remarkably high: almost 4 per cent of prisoners have a psychotic mental disorder, while over 10 per cent have major depression.8 Some of these individuals are today transferred from prison to modernised forensic psychiatric facilities, such as the Central Mental Hospital, for specialist care, with the result that admission profiles to forensic facilities also show a strong socio-economic gradient. In Ireland, the majority of forensic psychiatric admissions are from deprived inner-city areas with limited provision of social and health-care resources.9

These phenomena are not new. Incarceration has been a constant feature of the experience of mental disorder over many centuries and individuals with enduring disorders have consistently experienced social prejudice, downward ‘social drift’ and systematic exclusion from the social, political and economic lives of societies in which they have lived.10 The roots of these problems are complex and likely relate to myriad factors, including the effects of mental disorder itself, specific social, political and economic circumstances, and the legal context in which prosecution, committal and incarceration occur.

In order to tell the complicated stories of people like Henry and Patricia as fully and accurately as possible, I explore their medical case histories from the archives of the Central Criminal Lunatic Asylum in a number of ways throughout this book. First, I outline the general historical background to the network of institutions in which these stories unfolded, through analysis of workhouse records, asylum committee minutes, inspectors’ reports, mental health legislation, nineteenth-century textbooks and other published materials. Secondly, as both an historian and practicing psychiatrist, I integrate the material from these historical sources with careful clinical consideration of individual case records from the archives of the Central Criminal Lunatic Asylum, dating from the late 1800s to the early 1900s. In this way, historical analysis is combined with ‘the clinical gaze’ to integrate clinical dimension of patients’ experiences with their institutional and legislative experiences of Ireland’s courts and asylum system.11

The heart of this book lies in these case histories which explore the stories of women who killed their children, individuals who developed shared mental disorders (e.g. an entire family that developed a belief that one child was a changeling and together killed that child), individuals with intellectual disability (charged with crimes they poorly understood), individuals with syphilis (rightly or wrongly diagnosed), and many other vividly drawn cases of mental disorder, physical illness, social deprivation and crime.

For the most part, these are piercing stories of poverty, illness, crime and tragedy. However, these histories also demonstrate much that is positive, especially in the efforts of certain doctors to reform Ireland’s system of institutional care and develop more humane treatments for the mentally ill and intellectually disabled. The history of this period is also much more complex than a cursory examination at first suggests, especially as the case histories presented in this book commonly demonstrate real physical and mental health need among those detained. While the asylums commonly failed to meet these needs in a comprehensive or humane way, the alternatives for these individuals included committal to workhouses or prison, or lives of vagrancy and early death. As a result, these are complicated, nuanced histories which need to be explored in context in order to determine their true lessons for reformers today.

Chapter 1 is concerned with ‘Mental Health Care in Nineteenth-Century Ireland’. This chapter outlines the background to mental health care in early nineteenth-century Ireland, when many individuals with mental disorder or intellectual disability were either homeless or placed in workhouses or one of the few asylums that existed at that time. While there may have been few asylums, however, there was already great enthusiasm for new treatments for ‘lunacy’ within those asylums and Chapter 1 explores some of the treatments used in a particular Cork asylum, including bleeding, purging, a broad range of medications (e.g. digitalis, opium, camphor, mercury), ‘moral treatment’ and the infamous ‘Dr Cox’s Circulating Swing’. Chapter 1 also examines the fate of the large number of individuals with physical or mental disorders who entered the Irish workhouse system during the nineteenth century. This exploration is based on examination of original workhouse records and minutes from the Ballinrobe Poor Law Union, County Mayo which was located in an area especially badly affected by the Great Irish Famine (1845–52).

Against this background, Chapter 2, titled ‘Creating the Asylums and the Insanity Defence’, examines the emergence of Ireland’s cavernous asylum system, an extraordinary creation which grew at an unprecedented rate throughout the 1800s: in 1851 there were 3,234 individuals in Irish asylums and by 1891 this had more than tripled, to 11,265.12 While there were similar problems with high committal rates in other countries, including Britain, France, and the United States, Ireland’s admission rates were especially high at their peak, and especially slow to decline.13 Chapter 2 examines the legal underpinnings of this system, the widespread belief that insanity was increasing uniquely quickly in Ireland, and the kind of asylums that emerged from these concerns in the nineteenth and early twentieth centuries. This chapter also examines the emergence of the idea of criminal insanity in Ireland, Europe and the United States, with particular emphasis on the insanity defence, using case histories from the archives of the Central Criminal Lunatic Asylum to demonstrate specific clinical and legal issues in the Irish context.

Chapter 3 focuses on one specific group within Ireland’s asylum system: ‘Women in the Central Criminal Lunatic Asylum, Dublin’ between 1868 and 1948. Most of the women admitted to the hospital during this period had been charged with crimes, deemed insane by the courts, and sent to the Central Criminal Lunatic Asylum for indefinite periods of custody and care. Chapter 3 uses original archival case records to examine the clinical and social characteristics of these women, and presents histories of mental disorder, social deprivation and infanticide (the killing of infants). In these discussions, I place particular emphasis on the clinical dimensions of these cases, unearthing and decoding, as best as possible at this remove, signs and symptoms of mental disorder in these women.

Chapter 4 examines, in greater depth, specific ‘Clinical Aspects of Criminal Insanity in Eighteenth and Nineteenth-Century Ireland’ and presents further case histories of men and women committed to the Central Criminal Lunatic Asylum in the late 1800s and early 1900s, examining both clinical and social aspects of their cases. This chapter includes cases of syphilis, intellectual disability and folie à plusieurs, an unusual disorder in which one or more delusions (fixed, false beliefs, not amenable to reason) are shared by several individuals, often within a close-knit group or family. Forensic complications of these physical and mental conditions are explored in the broader context of the clinical and social challenges these individuals and families faced.

Chapter 5 is titled ‘Reformation and Renewal: Into the Twentieth Century’ and concludes the book by examining the process of reform of Ireland’s mental health laws and institutions in the early to mid-twentieth century. This movement found its clearest expression in the Mental Treatment Act 1945 which coincided with new enthusiasm for increasingly scientific approaches to treatment. This chapter completes the story by drawing conclusions for reformers of today, based on the case histories explored throughout the book.

A NOTE ON TERMINOLOGY

In order to maintain confidentiality, patients’ names in the case histories drawn from the archives of the Central Criminal Lunatic Asylum have all been changed so as to render them unidentifiable. In all other respects, original language and terminology from the nineteenth-century records have been maintained. This represents an attempt to optimise fidelity to historical sources and does not represent an endorsement of the broader use of such terminology in contemporary settings.

1

Mental Health Care in Nineteenth-Century Ireland

INTRODUCTION

The nineteenth century was a time of significant change in mental health care in Ireland. At the start of the century, the majority of individuals with mental disorder or intellectual disability were either living with their families, homeless or placed in workhouses or one of the few asylums that existed at that time.1

While there may have been few asylums, there was already substantial enthusiasm for new treatments for ‘lunacy’ within those asylums. The first part of this chapter explores some of the treatments used in a particular Cork asylum in the early 1800s, including bleeding, purging, ‘moral treatment’, a broad range of medications (e.g. digitalis, opium, camphor and mercury) and the infamous ‘Dr Cox’s Circulating Swing’.2

Asylum care was, however, the exception rather than the rule at the start of the 1800s, and the second part of this chapter examines the fate of the much greater number of individuals with physical or mental disorders who entered the Irish workhouse system during the nineteenth century. This exploration is based on examination of original workhouse records and minutes from the Ballinrobe Poor Law Union, County Mayo, which was located in an area especially badly affected by the Great Famine (1845–1852).3

The therapeutic enthusiasm within the asylums (as demonstrated in the Cork asylum) and the difficult conditions facing the physically and mentally ill outside the asylums (as demonstrated in the Ballinrobe Workhouse) formed the background to the great asylum-building era of the 1800s, which is examined in the next chapter.

DR WILLIAM SAUNDERS HALLARAN AND PSYCHIATRIC PRACTICE IN THE EARLY 1800s

In Ireland, there was scant provision for individuals with mental disorders throughout the seventeenth and eighteenth centuries.4 In 1817, the House of Commons (of Great Britain, then including Ireland) established a committee to investigate the plight of the mentally ill in Ireland. The committee reported a disturbing picture:

When a strong man or woman gets the complaint [mental disorder], the only way they have to manage is by making a hole in the floor of the cabin, not high enough for the person to stand up in, with a crib over it to prevent his getting up. This hole is about five feet deep, and they give this wretched being his food there, and there he generally dies.5

The situation in nineteenth-century Ireland was not unique, as the majority of individuals with mental disorder in Ireland, England and many other countries lived lives of vagrancy, destitution, illness and early death.6 Toward the end of the 1700s there were, however, signs of reform, most notably in Paris where Dr Phillipe Pinel (1745–1862) pioneered less custodial approaches to asylum care,7 and York where William Tuke (1732–1822), an English Quaker businessman, founded the York Retreat in 1796, based on policies of care and gentleness, combined with benevolent medical supervision.8

These reforms were accompanied by a clear commitment to the ‘moral management’ paradigm of treatment.9 This approach was based on the idea that ‘insanity’ found its roots in disorders of the emotions and thoughts, and that traditional medical treatment and physical restraints might not always be appropriate. The principles of moral management included the idea that the doctor should speak with the patient in a rational fashion, and the patient should have a healthy diet, exercise frequently and, where possible, engage in gainful occupation.

Jean-Étienne Dominique Esquirol (1772–1840), a French psychiatrist, described moral treatment as ‘the application of the faculty of intelligence and of emotions in the treatment of mental alienation’.10 This approach represented a significant break from the past which had emphasised custodial care rather than engagement with the patient as an individual. Today, such an approach would likely be described as ‘milieu therapy’ involving the establishment of therapeutic communities and a group-based approach to recovery.11

MENTAL HEALTH REFORM IN IRELAND

In Ireland, the leading proponent of these kinds of reforms was Dr William Saunders Hallaran, the most prominent and prolific Irish psychiatrist of the nineteenth century.12 Born in 1765, Hallaran studied medicine at Edinburgh and spent much of his working life as Senior Physician to the South Infirmary and Physician to the House of Industry and Lunatic Asylum of Cork. Throughout his career, Hallaran was not only an industrious and progressive clinician and teacher, but also a tireless advocate for a more scientific and systematic approach to mental disorder and its treatment.

In 1810, Hallaran published the first Irish textbook of psychiatry, impressively titled An Enquiry into the Causes Producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with Hints as to the Better Management of Public Asylums for Insane Persons.13 This book outlined many of the central themes that defined Hallaran’s approach to the treatment of mental disorder, including:

• Recognition of physical or bodily factors (e.g. syphilis) as important causes of mental disorder

• Deep concern about the apparent increase in mental disorder in nineteenth-century Ireland, a concern which Hallaran shared with many others at that time

• Engagement with the causes, courses and outcomes of mental disorder in a more systematic fashion than was customary

• Careful reconsideration of traditional treatments, such as blood-letting, vomiting and purgatives, which were widely used during this period

• Detailed exploration of novel treatment modalities, such as ‘Dr Cox’s Circulating Swing’

• Careful re-evaluation of traditional medicinal remedies, such as digitalis (foxglove), opium, camphor and mercury

• Critical re-consideration of other contemporary, non-medicinal, physical treatments for insanity, such as shower baths, diet and exercise

• The role of physical factors in causing mental disorder

In the opening section of his 1810 textbook, Hallaran clearly outlined the importance of physical or bodily factors (such as infections) in causing mental disorder in many people:

A principal object of this essay is to point out what heretofore seems to have escaped the observation of authors on the subject, namely, the practical distinction between that species of insanity which can evidently be referred to mental causes, and may therefore be denominated mental insanity, and that species of nervous excitement, which, though partaking of like effects, so far as the sensorium may be engaged, still might appear to owe its origin merely to organic [i.e. physical or bodily] injury, either idiopathically [i.e. inexplicably] affecting the brain itself, or arising from a specific action of the liver, lungs or mesentry; inducing an inflammatory disposition in either, and thereby exciting in certain habits those peculiar aberrations, which commonly denote an unsound mind. That this distinction is material in the treatment of insane persons, cannot well be denied, any more than that the due observance of the causes connected with the origin of this malady, is the first step towards establishing a basis upon which a hope of recovery may be founded.14

This distinction between causes ‘of the mind’ and physical or bodily causes of mental disorder was clearly important when planning treatment:

In the mode of cure, however, I would argue the necessity of the most cautious attention to this important distinction, lest as I have often known to be the case, that the malady of the mind which is for the most part to be treated on moral principles, should be subjected to the operation of agents altogether more foreign to the purpose; and that the other of the body, arising from direct injury to one or more of the vital organs, may escape the advantages of approved remedies … this discrimination has been found to be of the highest importance where a curative indication was to be looked for, nor need there be much difficulty in forming a prognosis, where either from candid report, or from careful examination, the precise nature of the excitement shall be ascertained.

Hallaran paid particular attention to his belief in the role of the liver in causing mental disorder, recommending that ‘the actual state of the liver in almost every case of mental derangement should be a primary consideration; even though the sensorium should be largely engaged’. Hallaran concluded his textbook’s opening discussion by re-emphasising both the distinction and the links between the ‘sensorium’ (or mind) and the body:

Here we have sufficient evidence of the existence of insanity on the principle of mere organic [i.e. physical or bodily] lesion; holding a connection as it would appear, with the entire glandular system. Hence we may be led to suppose than an imperfect or a specific action in certain portions of this important department tends to lay the foundation of that affection, which I would under such circumstances, denominate the ‘mania corporea’ of Cullen; including at the same time within this species, the different varieties of the complaint as described by authors, depending upon the various causes, whether mechanical or otherwise, as affecting the sensorium, and the other important organs of the animal economy.

This opening discussion clearly outlines one of Hallaran’s greatest contributions to psychiatric thinking: a clear recognition of the importance of physical or bodily factors in causing certain cases of mental disorder.15 As he concluded this discussion, Hallaran made reference to Dr William Cullen (1710–1790), a prominent Edinburgh physician who had a substantial influence on a generation of leading asylum-doctors including Hallaran, John Ferriar, Benjamin Rush and Thomas Trotter, author of A View of the Nervous Temperament.16 Cullen was the first to use the term ‘neurosis’ to describe various mental disorders that occurred in the absence of any physical or bodily illness. Consistent with this, Hallaran’s distinction between mental factors and physical or bodily factors in causing mental disorder laid the foundation for much subsequent progress in determining the causes of insanity throughout the nineteenth and twentieth centuries.

Syphilis, for example, was a major cause of admission to psychiatric institutions throughout nineteenth-century Europe, with syphilitic ‘general paralysis’ accounting for over 30 per cent of voluntary admissions of men to Sainte Anne asylum in Paris between 1876 and 1914 (Chapter 3).17 ‘Syphilis-related disorders’ would later be one of the three main focuses of the Würzburger Schlüssel classification of psychological disorders in Germany.18 Hallaran gathered the first systematic data on the apparent causes of psychiatric admissions in Ireland and also found that a significant proportion of psychiatric disorders in Cork were attributable to venereal disease, including syphilis.19 Combined with observations from Paris and elsewhere, these findings further supported the emphasis that Hallaran laid on the relevance of physical or bodily factors (such as syphilis) in causing many cases of mental disorder.

‘THE EXTRAORDINARY INCREASE OF INSANITY IN IRELAND’

The next topic to concern Hallaran in his 1810 textbook was the ‘cause of the extraordinary increase of insanity in Ireland’:

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!

Characteristically, Hallaran believed that the reasons for this apparent increase in insanity related to both ‘corporeal’ (physical or bodily) and ‘mental excitement’ (in the mind):

To account therefore correctly for this unlooked for pressure of a public and private calamity, it appears to be indispensably requisite to take into account the high degree of corporeal as well as of mental excitement, which may be supposed a consequence of continued warfare in the general sense … In some it was evident that terror merely had its sole influence, producing in most instances an incurable melancholia. In others where disappointed ambition had been prevalent, the patients were of an opposite cast, and were in general cheerful, gay and fanciful; but extremely treacherous and vindictive.

In addition to the effects of social unrest and conflict in increasing rates of illness, Hallaran was also concerned about ‘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.

Once 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.’ 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’. At population level, 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.

Hallaran also identified ‘terror from religious enthusiasm’ as a cause for 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.

Hallaran was by no means alone in his efforts to explain the apparent rise in mental disorder in Ireland. This issue was a recurring concern for psychiatrists, policy-makers and governments in Ireland throughout the nineteenth and twentieth centuries. Even in the early 1700s there was a clear recognition that the needs of increasing numbers of mentally ill individuals were not being met by existing provisions in workhouses, prisons or hospitals.20

Concern about this problem grew steadily throughout the 1700s and 1800s, despite efforts to increase provision for the mentally ill through the opening of St Patrick’s Hospital, Dublin in 175721 and various developments and initiatives at workhouses, such as that in Cork, aimed at assisting the mentally ill.22 Despite these measures, Dr D. Hack Tuke,23 toward the end of the nineteenth century, warned that the number of ‘certified lunatics’ in Irish workhouses was still increasing rapidly, which was particularly worrying given the poor care available to the mentally ill in these settings.24 Similarly, the Irish Inspectors of Lunatics were increasingly concerned about overcrowding in general asylums25 and by this time there was compelling evidence of similar overcrowding in the Central Criminal Lunatic Asylum in Dundrum, Dublin, too.26

Hallaran’s 1810 textbook, combined with evidence of apparently increasing rates of insanity, played a critical role in prompting the authorities to instigate the building of the Richmond Asylum in Dublin, Ireland’s largest asylum, which opened in 1814.27 Later known as Grangegorman Mental Hospital and St Brendan’s Hospital, this institution was quickly filled with individuals transferred from workhouses, and came under sustained pressure to take admissions well beyond its original capacity.28 These events prompted the building of further asylums at multiple locations including Dublin, Derry, Belfast, Limerick, Armagh, Killarney, Kilkenny, Omagh, Mullingar and Sligo.29 All of these developments were informed, in no small part, by the observations of Hallaran in his 1810 textbook and his personal efforts to ensure adequate provision of care and accommodation for the mentally ill, within the conceptual and therapeutic frameworks of the times.

CAUSES, COURSES AND OUTCOMES OF MENTAL DISORDER DURING THE 1800s

In terms of the causes of mental disorder, Hallaran recognised not only the effects of socio-political context and excessive alcohol consumption, but also the role of inherited predisposition:

The lamentable and undeniable proofs of the existence of this complaint by inheritance, cannot be considered by the serious and intelligent, without feelings of the strongest emotion … I can at this instant produce several young persons of from six to fourteen years old, who are now insane, and who have been reported to me as being mischievous since their infancy, and who since then, have continued to evince strong evidence of insanity. In the generality of those, I have been able to trace the cause by inheritance even to two generations, and almost invariably taking its course in the male and female line, without deviation from its original inclination.

Hallaran also noted that the mentally ill tended to die relatively young:

It does not often happen that insane persons will arrive at what may be termed old age. I have seen some who have arrived at the sixtieth year, but those were for the most part such as had enjoyed long intervals between each paroxysm, or who had only continued in a state of relative quiescence from the commencement.

In terms of recovery, Hallaran noted that:

The appearances which chiefly denote a prospect of recovery, are not at all times easily to be defined: though they are in themselves, evident proofs of the approaching event. It has been universally allowed in those cases, where the violence of the symptoms has been most remarkable, that the expectation of a favourable issue may be the more confidently entertained.

Hallaran further wrote:

The interval between any two paroxysms is in duration regulated by the continuance of that which had preceded, and that as the complaint assumes a more benign aspect, the length of the paroxysm, as well as the interval, will increase in mutual proportion: till at length, by taking advantage of the opportunity, the disease ceases to attract observation. [Moreover] as the paroxysms begin to assume a more protracted form, the intervals will be less distinct, though of longer duration, and as the disease advances, they will run into the continued form, with occasional remissions only.

Hallaran felt the period toward the end of recovery from an acute illness was a time that presented particular risks:

Insane persons at this period will require the strictest watching … Under such circumstances, and having attained a thorough knowledge of the state that had so recently overwhelmed them, they are ever disposed to become alarmed for the supposed consequences: they will frequently assume a sullen silence, bordering on despondency, suspicious to a great degree, of every measure, however obviously intended for their advantage. This, as it may be termed, the secondary state of the complaint, has been too often neglected … Too much attention cannot be paid at this important period.

Almost two centuries of clinical observation have confirmed the importance of this observation. The ‘sullen silence, bordering on despondency’ described by Hallaran is consistent with today’s diagnosis of ‘post-schizophrenic depression’, characterised by persistent low mood, loss of enjoyment and disturbances of appetite, energy and sleep, following an episode of schizophrenia.30