these concerns, many of which were equally relevant to most other asylums of the day, there is still plentiful evidence that the ‘benevolent intentions of the founder’ of St Patrick’s were being observed in important ways in the early 1800s, although the latter part of the century was to bring more significant problems for the hospital, relating to patient care, financial challenges and structural dilapidation of the building.83
In many respects, the story of St Patrick’s from the mid-1700s to the late 1800s was typical of the trajectory of early asylum care in Ireland, commencing with noble intentions, followed by enthusiasm, and then difficulty sustaining the enthusiasm and standards so clearly required for care of the mentally ill. St Patrick’s was, however, a private, charitable establishment as opposed to a government run institution. The network of public asylums that developed alongside St Patrick’s during the 1800s merits consideration from this perspective too and its inception, was, in significant part, attributable to the work of one especially dominant figure in Irish asylum medicine, Dr William Saunders Hallaran (1765–1825).
Dr William Saunders Hallaran:
Treating the Mentally Ill
The most prominent and prolific Irish asylum doctor of the late eighteenth and early nineteenth centuries,84 William Saunders Hallaran was born in 1765 and studied medicine at Edinburgh. He spent much of his working life as Senior Physician to the South Infirmary and Physician to the House of Industry and Lunatic Asylum of Cork. Hallaran established the Cork Lunatic Asylum during the late 1780s and early 1790s,85 and Citadella, a private asylum in Douglas, County Cork, in 1799 (‘Bull’s Asylum’).86 Throughout his career, Hallaran was not only an industrious, progressive administrator, clinician and teacher, but also a tireless advocate for a more systematic approach to mental disorder and its treatment.
In 1810, Hallaran published the first Irish textbook of psychiatry, titled An Enquiry into the Causes producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with Hints as to the Better Management of Public Asylums for Insane Persons.87 This book outlined many of the central themes that defined his approach to the mentally ill, including explicit recognition of the roles of physical or bodily factors as causes of mental disorder in certain cases; deep concern about the apparent increase in mental disorder in nineteenth-century Ireland; and systematic, scientific engagement with the causes, courses and outcomes.
The recognition of physical or bodily factors (such as infections) rather than just psychological or ‘moral’ factors in causing mental disorder was an especially key theme:88
A principal object of this essay is to point out what heretofore seems to have escaped the observation of authors on the subject, namely, the practical distinction between that species of insanity which can evidently be referred to mental causes, and may therefore be denominated mental insanity, and that species of nervous excitement, which, though partaking of like effects, so far as the sensorium [i.e. mind] may be engaged, still might appear to owe its origin merely to organic [i.e. physical or bodily] injury, either idiopathically [i.e. by unknown mechanisms] affecting the brain itself, or arising from a specific action of the liver, lungs or mesentery [i.e. inside the abdomen]; inducing an inflammatory disposition in either, and thereby exciting in certain habits those peculiar aberrations, which commonly denote an unsound mind. That this distinction is material in the treatment of insane persons, cannot well be denied, any more than that the due observance of the causes connected with the origin of this malady, is the first step towards establishing a basis upon which a hope of recovery may be founded.89
This was consistent with preexisting theories linking mental disorder with, for example, disorders of the spleen – a theory outlined with particular enthusiasm by Sir Richard Blackmore of the Royal College of Physicians in London in 1726.90 Almost a century later, Hallaran’s distinction between causes ‘of the mind’ and physical or bodily causes of mental disorder held clear importance when planning treatment:
In the mode of cure, however, I would argue the necessity of the most cautious attention to this important distinction, lest as I have often known to be the case, that the malady of the mind which is for the most part to be treated on moral principles, should be subjected to the operation of agents altogether more foreign to the purpose; and that the other of the body, arising from direct injury to one or more of the vital organs, may escape the advantages of approved remedies … this discrimination has been found to be of the highest importance where a curative indication was to be looked for, nor need there be much difficulty in forming a prognosis, where either from candid report, or from careful examination, the precise nature of the excitement shall be ascertained.91
In his incisive, often witty, textbook, Hallaran paid particular attention to the role of the liver in causing mental disorder, recommending that ‘the actual state of the liver in almost every case of mental derangement should be a primary consideration; even though the sensorium should be largely engaged’.92 Hallaran finished the opening discussion of his 1810 text by reemphasising both the distinction and the links between the ‘sensorium’ and the body:
Here we have sufficient evidence of the existence of insanity on the principle of mere organic [i.e. physical or bodily] lesion; holding a connection as it would appear, with the entire glandular system. Hence we may be led to suppose than an imperfect or a specific action in certain portions of this important department tends to lay the foundation of that affection, which I would under such circumstances, denominate the ‘mania corporea’ of Cullen; including at the same time within this species, the different varieties of the complaint as described by authors, depending upon the various causes, whether mechanical or otherwise, as affecting the sensorium, and the other important organs of the animal economy.93
‘Cullen’ was Dr William Cullen (1710–1790), a prominent Scottish physician who had substantial influence on an entire generation of prominent asylum doctors including Hallaran, John Ferriar, Benjamin Rush and Thomas Trotter, author of A View of the Nervous Temperament.94 Cullen was the first asylum doctor to use the term ‘neurosis’ which, in contrast with later usage, he used to denote a range of psychiatric disorders that occurred in the absence of pyrexia (i.e. in the absence of raised body temperature).95 Consistent with Cullen’s approach, Hallaran’s distinction between organic (physical) and non-organic (psychological and moral) factors in causing mental disorder was to consolidate the foundation for much subsequent work on determining causes of insanity throughout the nineteenth and twentieth centuries.
Syphilis, for example, was cited as a major cause of admission to psychiatric institutions throughout nineteenth-century Europe,96 despite the fact that accurate diagnosis was not possible prior to the work of August Paul von Wassermann (1866–1925), the German bacteriologist who developed a complement fixation test for syphilis in 1906.97 Nevertheless, Hallaran undertook to gather the first systematic data on the causes of psychiatric admissions in Ireland, and identified, as best he could, that venereal disease accounted for a lower proportion of admissions in Ireland than elsewhere.98
Towards the end of the nineteenth century, several decades after Hallaran’s textbook appeared, the classification of mental disorders underwent further revision as Emil Kraepelin (1856–1926), a German psychiatrist, divided all mental disorders into 13 groups, including two groups of ‘functional psychosis’ (i.e. mental disorders involving a loss of contact with reality but without demonstrable organic or physical cause).99 These two groups were: affective psychosis (in which loss of contact with reality was accompanied by disturbance of mood) and non-affective psychosis (in which it was not).
Kraepelin’s classification, like Hallaran’s approach, recognised the key role of organic or physical factors in producing certain cases of mental disorder, but went a step further by dividing ‘functional psychosis’ into these two separate groups. This classification duly led to the emergence of ‘manic depression’ (bipolar disorder, sometimes involving psychosis with prominent mood disturbance) and ‘dementia preacox’
