the countryside, and the addictive qualities of tea were also noted by Dr William Graham of Armagh and Dr E.E. Moore of Letterkenny, who believed that heredity was the predisposing cause of insanity in 70 per cent of admissions.149 Tea was, however, also implicated.
Ireland and Great Britain were by no means alone in experiencing these problems with increased rates of committal. There were similar trends apparent in other countries, including France, England and the US,150 but Ireland’s rates were especially high at their peak, and especially slow to decline.151 Doctors and commentators elsewhere considered proposed contributory factors similar to those considered by Hallaran, Drapes, Tuke and Norman in Ireland, and many, like F.B. Sanborn, previous Inspector with the Massachusetts State Board of Health, Lunacy and Charity, concluded that there was a real increase in incident cases of insanity in their areas too, even after various other factors were taken into consideration.152
The extent of alarm produced by this apparent trend in Ireland is evident in the broad range of solutions proposed (ranging from increased institutional provision to sterilisation), and the publication, in 1894, of the Special Report from the Inspectors of Lunatics to the Chief Secretary: Alleged Increasing Prevalence of Insanity in Ireland.153 Even relatively enlightened figures, such as Drapes, were sufficiently alarmed that their generally humane approach was regrettably affected by the prevailing sense of panic about the key unresolved question that dominated, and still dominates, the history of Irish psychiatry: was there really an increase in mental disorder in nineteenth-century Ireland?154
Why did the Asylums Grow so Large?
In considering whether or not there was a true increase in the incidence of mental disorder in nineteenth-century Ireland, it is useful first to examine other, relatively clearer reasons why the Irish asylums grew so large in the 1800s and early 1900s.155 Was this development really due to increased rates of mental disorder or were these other factors more relevant?
Taking a bird’s eye view, it appears highly likely that a variety of related and mutually reinforcing circumstances contributed to the growth of the Irish asylums, including (1) increased societal recognition of, and diminished tolerance for, the problems presented by mental disorder; (2) mutually reinforcing patterns of asylum building and psychiatric committal, underpinned by continual, almost obsessional legislative change;156 (3) changes in diagnostic and clinical practices (including the search for professional prestige among clinical staff); and (4) possible epidemiological change, owing to sociodemographic changes in Irish society and/or unidentified biological factors leading to altered patterns (although not increased incidence) of mental disorder.157
In the first instance, the end of the eighteenth century saw substantial changes in societal attitudes to mental disorder throughout Europe. The growing humanitarian approach of the early-nineteenth-century greatly increased efforts to provide care to persons with mental disorder, resulting in an apparent increase in incidence owing to increased diagnosis,158 as suggested by Tuke in 1894.159 This change in attitude was evident not just in Ireland but throughout Great Britain and Europe, and led to considerable systematic governmental reform in many countries, including Great Britain.160 In Ireland, the 1804 Select Committee of the House of Commons recommended the establishment of four provincial asylums dedicated to the treatment of the mentally ill161 and in 1814 one such establishment, the Richmond Asylum, finally opened in Dublin.162 While it is difficult to quantify the precise role of changes in professional and public attitudes in these developments, it is inevitable that, at the very least, they contributed to increased recognition and diagnosis of mental disorder and, in turn, increased rates of presentation to the newly established asylums.
The latter part of the nineteenth century was also a time of industrialisation, resulting in significant reconfigurations at family, community and societal levels in many European countries, albeit somewhat limited in Ireland. Nonetheless, structural community changes associated with this era of history increased the visibility of individuals with mental disorder in Irish communities, resulting in increased presentations to asylums and an apparent (although not actual) increase in rates of mental disorder for this reason.163
This is consistent with Tuke’s observation that Norman, at the Richmond Asylum, emphasised the centrality of social attitudes, such as decreased prejudice against asylums and reduced tolerance for mental disorder in communities, in increasing presentations.164 These changes in social attitudes, community structures and patterns of presentation, as well as changes in diagnostic practices, represented significant modifications in the interpretation and experience of mental disorder at both individual and societal levels, contributing to increased presentations to asylums. Various complexities relating to land, marriage, family relations, inheritances and emigration were also likely relevant in different ways in specific cases.165
The second key factor that contributed to increased rates of presentation was the elaborate process of legislative reform and asylum building that commenced in the early 1800s and gathered extraordinary pace as the nineteenth century progressed. The Lunatic Asylums (Ireland) Act 1821 authorised the establishment of a network of district asylums throughout the country and within fifteen years there were large public asylums established in Armagh, Limerick, Belfast, Derry, Carlow, Portlaoise, Clonmel and Waterford.166 The reports of the Inspectors of Lunatics for this period demonstrate that these asylums were rapidly filled to capacity soon after opening.167 As Finnane demonstrates in his brilliant, path-finding book, Insanity and the Insane in Post-Famine Ireland, this process was much more centralised in Ireland compared to England,168 resulting in greater institutionalisation.169
In any case, there can be little doubt that the sudden availability of hundreds of asylum beds led to increased rates of presentation by mentally ill individuals who had previously lived with families, lodged in workhouses, languished in prisons, or been homeless. The Great Irish Famine also played a role in increasing social need and pressure for accommodation and food (as well as potentially affecting future mental health needs). It remains unclear, however, precisely what proportion of asylum admissions was truly suffering from mental disorder, what proportion was admitted for other reasons (e.g. intellectual disability or social problems), and what proportion was admitted owing to misuse of the ‘dangerous lunatic’ procedures which offered several practical advantages to families seeking to have family members committed (e.g. the asylum could not refuse to admit a ‘dangerous lunatic’).170
It is clear, however, that the rapid overcrowding of asylums was related not only to increased rates of presentation, but also prolonged length of stay and accumulation by non-discharge. Between the years 1850 and 1890, the excess of admissions over discharges was approximately 200 annually; i.e. there were, potentially, 200 new long stay patients created in district asylums each year,171 which further increased occupancy and pressure on beds.
Changes in diagnostic and clinical practices are the third factor that contributed to increased rates of psychiatric hospitalisation in the 1800s, in addition to increased recognition of the problems presented by mental disorder and mutually reinforcing patterns of asylum building and psychiatric committal, underpinned by a constant churn of legislative activity (Chapter 2).
Diagnostic practices are constantly changing in psychiatry with the result that there are significant difficulties establishing the contemporary equivalents of diagnoses made in the nineteenth century, especially when retrospective diagnostic endeavours are based on inconsistent, incomplete medical records.172 There were likely at least four nineteenth-century terms that correlated with diagnoses that are now known as ‘functional psychoses’ (i.e. schizophrenia and bipolar affective disorder): mania, melancholia, monomania and dementia.173 The confusion and conflation of these terms in the literature adds greatly to the difficulties of interpreting statistics from the 1800s and early 1900s. Some of these diagnostic challenges, along with the difficulties separating mental disorder from socioeconomic concerns, are demonstrated by the case of Mary, outlined here based on her original case records from the Central Criminal Lunatic Asylum, Dublin.174
Mary
