and humanity benefited; and that the benefit would not be limited to Ireland, but that the blessing of a humane and enlightened treatment of the insane would be extended through other countries […].
We cannot doubt that, if proper exertion were made, students in medicine, or graduates who had just completed their course, would seek for appointments as residents in asylums, as the knowledge thus acquired, and the certificates they would obtain of such residence, would be esteemed recommendations in many positions in which they might afterwards be placed. We would recommend that, in the first instance, the experiment of such appointments should be made in the asylums of Dublin (St Patrick’s and the Richmond), of Cork, and of Belfast, in which towns there are large medical schools […].
Such resident pupils might be appointed by the Board of Governors, on the recommendation of the resident physician, and should be subject to his direction. Their duties would consist in keeping notes of the cases admitted, and their treatment, in seeing to the due administration of medicines, baths, & c., and in a general care of the inmates and patients in the intervals of the visits of the resident or visiting physician; in short, in discharging towards the inmates of the asylum such duties as are now performed by resident pupils towards the sick in general hospitals.248
This was an innovative, progressive proposal, aimed at improving standards of care in the longer term, and clearly in line with the commission’s other recommendations for greater medical involvement in the asylums and improved education of staff. Overall, however, the commission’s recommendations were strongly in the direction of an expanded asylum system and permanent institutionalisation for certain patients. Scant attention was paid to the possible merits of other possibilities (e.g. treatment at home),249 as the commission emphatically endorsed the fundamental tenet that ‘it is of the utmost importance that cases of insanity should as speedily as possible be removed to an asylum’.250
Case Studies: Restraint,
Neglect and Cruelty
The 1858 commission’s strong endorsement of asylums as the central element of care for the mentally ill was all the more remarkable in light of the disturbing low standards and gross abuses revealed in their report. This was most evident in relation to the use of restraint, a topic to which the commission devoted particular attention:
We feel it is our duty also to notice the culpable disregard with which the 23rd Rule of the Privy Council has in many instances been treated. This rule requires that ‘The manager is to take charge of the instruments of restraint, and is not, under any pretence, to allow the unauthorized use of them to any person within the establishment; all cases placed under restraint, seclusion, or other deviation from the ordinary treatment, are to be carefully recorded by him in the daily report, with the particular nature of the restraint or deviation resorted to; but in no case shall the shower-bath be used without the authority of the physician’.251 And, by rule 4, he is to enter in the Morning Statement Book ‘the names of those under restraint or seclusion, and the causes thereof’. In some instances, the managers informed us that they were not even aware of the rule, although a printed copy of the Privy Council regulations was furnished to every asylum; in others, that they deemed it a sufficient compliance with the rules to leave the instruments of restraint in charge of the keepers, trusting to their integrity to report the cases in which they were used.252
The commission was especially disturbed by specific examples of restraint in Armagh Asylum, examples which some readers might find disturbing. One ‘patient, on the female side, was strapped down in bed, with body-straps of hard leather, three inches wide, and twisted under the body, with wrist-locks, strapped and locked, and with wrists frayed from want of lining to straps; this patient was seriously ill. There was no record of her being under restraint in the Morning Statement Book, as required by the order of the Privy Council. Another female was in the day room, without shoes or stockings, with strait waistcoat and wrist-locks; she had been two years in the house, and almost continually kept in that state day and night’.253
The most egregious abuse, however, was seen in the case of a male patient in Armagh, whose situation was outlined in detail by the commission and which, again, some readers might find disturbing:
A male patient, in Ward No. 2, was found at our visit, strapped down in bed; in addition, he was confined in a strait waistcoat, with the sleeves knotted behind him; and as he could only lie on his back, from a contrivance we shall presently describe, his sufferings must have been great; his arms were, moreover, confined with wrist-locks of hard leather, and his legs with leg-locks of similar kind; the strapping was so tight that he could not turn on either side; and any change of position was still more effectually prevented by a cylindrical stuffed bolster of ticken,254 of about ten inches thick, which ran round the sides, and top, and bottom of the bed, leaving a narrow hollow in the centre in which the lunatic was retained, as in a box, without power to turn or move. On liberating the patient, and raising him, he was very feeble, unable to stand, with pulse scarcely perceptible, and feet dark red and cold; the man had been under confinement in this state for four days and nights, being merely raised for purposes of cleanliness.255
The commission was deeply affected by this case and all the more alarmed to discover that ‘the manager stated he was aware of the man being in bed, but not of his having all these instruments of restraint upon him. No record of the case of restraint appeared in the Morning Statement Book’. They concluded that ‘neither the manager nor physician had seen or visited this patient while under confinement, or even been aware of his state’. The manager in Armagh was Thomas Jackson, who, some thirty years earlier, had worked to improve conditions in the old Dublin House of Industry; clearly, decades spent working in institutional conditions had greatly limited the effectiveness of his reformist zeal.256
Unsurprisingly, the commission found similar problems elsewhere:
We may here mention that in Omagh Asylum we found a bed in use for refractory patients, thus described by the resident physician: ‘It is a wooden bed in the sides, and there is an iron cover which goes over both rails; it is sufficiently high to allow a patient to turn and twist, but he cannot get up … the bars are from twelve to fourteen inches above the patient’s head’.257
Faced with these damning examples of the use, overuse, misuse and abuse of restraint, the commission felt it was ‘scarcely necessary to say that we recommend that the most strict observance of the rule should be enforced; that all instruments of restraint should be kept solely in the custody of the manager or resident physician; that their unauthorised use shall never be permitted, and that all cases of restraint should be daily visited and recorded’.258
These violations of standards regarding restraint were especially disappointing given the emergence of a strong ‘non-restraint’ movement in the late 1830s, some twenty years prior to the commission’s report. Progress in certain English asylums had been significant, if incomplete: the use of mechanical restraints was abolished at the Lincoln County Asylum in 1838; Northampton Asylum (now St Andrew’s Hospital) was the first institution to advocate non-restraint as a philosophy from the time it opened, in 1838; and non-restraint was introduced in Hanwell Asylum by Dr John Conolly (1794–1866) in the summer of 1839.259 Interestingly, the position was very different in the US, where asylum managers were explicitly hostile towards the English ‘non-restraint’ movement.260 In Ireland, however, the Report from the Select Committee of the House of Lords Appointed to Consider the State of the Lunatic Poor in Ireland noted, in 1843, that, for the most part, the ‘system of management adopted in the District Asylums’ in Ireland involved ‘a humane and gentle system of treatment’, with ‘cases requiring restraint and coercion not exceeding two per cent on the whole’.261
Given the stark contrast between, on the one hand, the non-restraint movement in England in the 1830s and apparently low rates of seclusion in Ireland in 1843, and, on the other, the commission’s damning report of 1858, it is unsurprising that the commission’s findings regarding restraint were highlighted in the
