draw considerable attention to the importance of diet in the asylum and highlighted the need for good physical healthcare for patients.284
Tuberculosis, too, presented significant challenges to physical health in nineteenth and early twentieth-century Ireland, both inside and outside the asylums. By 1904, tuberculosis accounted for almost 16 per cent of all deaths in the Irish general population.285 Staff and patients in asylums were at particular risk and in 1901 tuberculosis accounted for 25 per cent of deaths in Irish asylums, with an average age of death of between 37 and 39 years.286 This problem was by no means exclusive to the Irish asylums: tuberculosis was also the leading cause of death in South Carolina Lunatic Asylum at the turn of the century.287 In Ireland, progress with tuberculosis was slow, but the start of the twentieth century saw renewed public health initiatives,288 dedicated legislative measures, such as the Tuberculosis Prevention (Ireland) Act of 1908,289 and changes in sociopolitical circumstances that helped alleviate matters somewhat.290
Even so, death rates in Irish asylums still presented a substantial cause for concern throughout this period. In 1893, the Inspector of Lunatics reported a national death rate of 8.3 per cent in the asylums; this figure was derived by dividing the number of deaths in Irish district asylums in 1892 (995 deaths) by the daily average number of asylum residents; on 1 January 1893, that number stood at 12,133.291 Of those who died in district asylums, 198 (19.9 per cent) underwent post-mortem examinations which were, in the Inspector’s opinion, ‘of so much importance for the protection of the insane and for the furtherance of the scientific study of insanity’.292
Death rates varied between asylums, with, for example, the Richmond in Dublin reporting a death rate (12.5 per cent) higher than the national average (8.3 per cent), possibly related to particular problems with overcrowding and infective illnesses at the Richmond.293 Comparable rates were, however, reported in other jurisdictions, with a 14 per cent death rate in South Carolina Lunatic Asylum between 1890 and 1915.294 Similarly, one third of men and 21 per cent of women admitted to the Toronto Asylum between 1851 and 1891 died there.295 At the Central Criminal Lunatic Asylum in Dublin, 42 per cent of individuals committed following a court finding of mental disorder between 1850 and 1995 died there,296 and 27 per cent of women committed following infanticide or child murder between 1850 and 2000 died there.297
Walsh and Daly studied admissions to Sligo District Lunatic Asylum between 2 February 1892 and 6 May 1901, during which period there were 454 admissions with sufficient details for analysis.298 Of these, 75 per cent were male, 64 per cent single and 86 per cent Roman Catholic. Among those for whom family history was recorded, some 87 per cent had a family history of mental disorder. The most common recorded causes were heredity, alcohol, and domestic issues or financial worries. The most common diagnoses were mania (40 per cent) and melancholia (28 per cent). The most frequent recorded causes of death were tuberculosis and phthisis (probably pulmonary tuberculosis; 23 per cent), exhaustion (16 per cent) and dementia (9 per cent).
Serious challenges with physical health continued into the 1900s, with the influenza epidemic of 1918299 hitting the asylums especially hard: a fifth of all patients in Belfast asylum died of it, and one patient in every seven in the asylums in Kilkenny, Castlebar, Maryborough and Armagh fell victim.300 Against this rather bleak background, there were, nonetheless, continued efforts to ameliorate the problems in the asylums, with Norman at the Richmond, for example, doggedly (if unsuccessfully) promoting ‘boarding out’ in the late 1800s and early 1900s.301 In addition, outpatient clinics were promoted in the early 1900s and the Society of St Vincent de Paul was later approached to set up an after care committee.302
Notwithstanding these efforts, conditions in Irish asylums remained very difficult throughout the late 1800s and early 1900s, owing to toxic combinations of mental disorder, physical illness, overcrowding, suicide, and violence – the latter involving both patients and staff, and often resulting in physical or chemical restraint.303 In the early 1900s, a night nurse in Castlebar was violent towards a patient with a poker and was found guilty of burning the patient, resulting in a sentence of 18 months hard labour.304
From the outset, medical conflicts were common in the asylums, especially between visiting physicians and resident medical superintendents: in 1862, the latter was accorded superiority305 and in 1892 the post of visiting physician was abolished in new rules drafted by the Inspectors of Lunatics (then including Dr E.M. Courtenay); this was a defining moment in the emergence of the profession of psychiatry in Ireland.306 The new specialists, increasingly trained in the asylums themselves,307 were immediately confronted with complex tangles of psychiatric, medical, social and legal challenges in many individual cases, with no immediate solutions to hand, apart from further institutional care. These challenges are well illustrated by some interesting cases of folie à plusieurs, a rare but fascinating psychiatric syndrome, drawn from the archives of the Central Criminal Lunatic Asylum in the 1890s.
Case Studies: Folie à Plusieurs
Folie à deux is a rare psychiatric syndrome in which two individuals share symptoms of mental disorder, most commonly paranoid delusions. While there were several clinical descriptions of the syndrome throughout the seventeenth and eighteenth centuries,308 the term folie à deux was coined in the 1870s309 and translated as ‘communicated insanity’ by William Wetherspoon Ireland, a Scottish polymath, in the 1880s.310
The term folie à plusieurs refers to cases of ‘communicated insanity’ in which symptoms are shared by three or more individuals. There tends to be one ‘primary’ patient, whose symptoms are ‘transmitted’ to ‘secondary’ patients. The majority of cases of induced psychotic disorder occur within families and involve, most commonly, mother and child, wife and husband, or woman and sibling.311 Treatment involves identifying the primary patient312 and treating their mental illness and physical disorder (if present); the secondary patient may not require specific treatment following separation from the primary patient. The concept of Capgras à plusieurs (a shared delusional belief that a person has been replaced by a double) has been invoked in relation to the celebrated case of Bridget Cleary, burned to death in 1895.313
From the outset, there were reports of forensic or criminal complications of ‘communicated insanity’,314 including theft, violence,315 attempted murder316 and murder.317 One Irish case from the late 1800s involved two brothers admitted to the Central Criminal Lunatic Asylum on the same day in 1896. Both were single farmers who lived on a family farm. They were charged with the murder of another brother and detained in the Central Criminal Lunatic Asylum ‘at the Lord Lieutenant’s pleasure’ (i.e. indefinitely).318 Patrick, the elder, was 36 years of age and admission notes described him as ‘industrious, honest … timid and nervous’. At the time of admission, Patrick had ‘two brothers and a sister in an asylum’ because ‘all the family became insane at the same time’. Patrick himself was ‘timorous and sleepless, watching an insane brother for about 12 days’. He was diagnosed with ‘acute delusional mania, convalescent’. The cause was ‘hereditary’.
While physical examination on admission to the Central Criminal Lunatic Asylum was normal, the Prison Surgeon’s Report from four months earlier (when the brothers were in prison awaiting trial), noted that they were ‘wild and haggard-looking’. Patrick’s temperature was 100º Fahrenheit (38º Celsius) with a pulse rate of 116 beats per minute (i.e. raised). At night time, the brothers’ conditions worsened: Patrick became ‘wildly delirious, believed there were devils in his cell, sprinkling bed and cell with water, praying constantly, pupils dilated, voice hoarse, spitting frequently … hallucinations of sight and hearing, refused food, slept none that night, were placed in muffs …’
Over the following days, Patrick began to recover, although ‘he remained in a state of the most extreme collapse for some weeks, tongue white and furred, complained of headache and giddiness. Prisoner was kept quiet in hospital and given plenty of milk beef tea and two bottles of stout daily’. Apparently, ‘delirium occurred at night in the different police barracks where [the brothers] were confined previous to committal to prison’.
When
