child in the mid-1890s. She was ‘acquitted on the grounds of insanity’ and detained at the Central Criminal Lunatic Asylum ‘at Her Majesty’s Pleasure’ (i.e. indefinitely). Mary’s admission diagnosis was ‘chronic melancholia’, attributed to ‘heredity’; admission notes record that she had a sister in a district asylum.
Medical records note that Mary’s ‘expression of face, attitude and gestures are characteristic of melancholia; she is emotional at times. [She] does not exhibit any delusion’. Her notes also, however, record that ‘she takes an interest in her surroundings and associates with the other patients; readily enters conversation. Appetite good, sleeps well, clean and tidy in dress and person. [She] is bad tempered and inclined to sulk if corrected. [She] does needlework and house cleaning’.
Subsequent entries confirm that Mary was ‘well-behaved, quiet and respectable’, and ‘an excellent worker’. Much of this is not consistent with the diagnosis of ‘chronic melancholia’. Notes from almost two years after her admission specify that Mary ‘will cry when meditating on her misfortunes’; this reaction appears understandable, given Mary’s situation, following the loss of her child and her indefinite detention at the hospital.
Clinical notes from six years after Mary’s admission record that ‘this patient is perfectly sane and is most anxious for her discharge but there is some difficulty as her husband is in a workhouse and she has no friends sufficiently well off to provide for her’. Two years later, however, Mary, then described as ‘perfectly harmless’, was ‘discharged … in care of her daughter’. In this case, the diagnosis of ‘chronic melancholia’ appears, by today’s diagnostic criteria, largely unsupported by the clinical details recorded in the sparse notes documenting Mary’s stay in the Central Criminal Lunatic Asylum.
Despite these difficulties with the interpretation of clinical records, some general conclusions can still be drawn about changes in diagnostic practices throughout the nineteenth century. There is, for example, strong evidence of a diagnostic shift from intellectual disability (‘idiots’) towards mental disorder (‘lunatics’) during the latter part of the 1800s. In 1893, the Inspectors of Lunatics presented findings from the General Report of the Census Commissioners demonstrating a fall in the number of ‘idiots’ (from 7,033 in 1861 to 6,243 in 1891) and a rise in the number of ‘lunatics’ (from 7,065 in 1861 to 14,945 in 1891).175 There are many possible reasons for these changes, the most significant of which is the sudden availability of hundreds of asylum beds for individuals with mental disorder, which may have prompted a reclassification of certain intellectually disabled individuals as ‘lunatics’ in order to secure easier access to long term asylum accommodation.
Another contributor to the rising inpatient numbers was the search for professional prestige among asylum doctors, who were very keen to enhance their status, income and control over asylums.176 The 1874 General Rules and Regulations for the Management of District Lunatic Asylums in Ireland articulated a direct link between patient numbers and pay:
The annual sums and allowances to be paid and made to the several Resident Medical Superintendents, whose salaries and allowances have not been equivalently fixed by order of the Lord Lieutenant in Council, and to all persons hereafter to be appointed as such Resident Medical Superintendents, shall be as follows: -
When the accommodation for patients in the Institution shall be under 250, the salary of the Resident Medical Superintendent shall be at the rate of £340 per annum.
When the accommodation for patients shall be 250 and under 350, such salary shall be at the rate of £400 per annum.
When the accommodation for patients shall be 350 and under 500, such salary shall be at the rate of £450 per annum.
When the accommodation for patients shall be 500 and under 600, such salary shall be at the rate of £500 per annum.
When the accommodation for patients shall be 600 and under 800, such salary shall be at the rate of £550 per annum.
It shall, however, be lawful for the Lord Lieutenant in Council to increase the salary of any Resident Medical Superintendent who may have served eight years in any Asylum to the satisfaction of the Board of Governors, upon the recommendation of such Board and of the Inspectors; such increase not exceeding in any case £100 per annum.
And the allowances to be made to all such Resident Medical Superintendents shall be apartments, fuel, light, washing, vegetables, bread, and milk.177
Any RMS appointed after that date (23 February 1874) was not ‘allowed any furniture for the apartments occupied by them, save and except the following fixtures: chimney pieces, grates, presses, fixed shelves, locks, bells, gas fittings and gasaliers, blinds. Carpets or matting may, with the sanction of the Board of Governors or of the Inspectors, be allowed in corridors or on stairs in the Resident Medical Superintendent’s apartments, if such corridors or stairs are used by officers, patients, or attendants.’
These arrangements were revised on the ‘28th day of April, 1885’, when the ‘Lords Justices-General and General Governors of Ireland, by and with the advice of the Privy Council of Ireland’ declared that the RMS’s basic salary was to be determined by the institution in which he [sic] worked, as follows: Richmond and Cork: £600; Ballinasloe, Belfast, Limerick and Omagh: £500; Castlebar, Clonmel, Downpatrick, Kilkenny and Killarney: £450; Letterkenny, Maryborough, Monaghan, Mullingar and Sligo: £450; Armagh, Carlow, Ennis, Enniscorthy, Londonderry and Waterford: £400. Various other payments and allowances were also mandated, including a £100 ‘increase in salary’ after serving ‘eight years to the satisfaction of the Board of Governors’.178 While it is difficult to determine the precise magnitude of the effect of these arrangements on asylum admission rates, they clearly linked higher pay with asylum size, presumably with predictable consequences.
Possible epidemiological change is the fourth factor that contributed to increased rates of psychiatric hospitalisation, in addition to (1) increased societal recognition of the problems presented by mental disorder; (2) mutually reinforcing patterns of asylum building and psychiatric committal, underpinned by continual legislative change; and (3) changes in diagnostic practices and the emergence of a distinct profession of psychiatry hungry for recognition and respectability.179
The possibility of true epidemiological change in the incidence of mental disorder in nineteenth century Ireland is, however, difficult to resolve definitively, owing to the absence of reliable data about both the incidence of mental disorder and the precise population of Ireland. Even at the time, it was recognised that epidemiological analysis was significantly hampered by the absence of reliable data about the population in general, a point made with particular clarity by Dr Richard Powell, in a paper read to the Royal College of Physicians in London in 1810.180 If the baseline population is not accurately known, how can a possible increase in rates of insanity be identified?
Notwithstanding these statistical challenges, it remains reasonable to conclude that certain demographic factors and changes in population structure might have played a role in producing, at the very least, an apparent increase in the rate of mental disorder in nineteenth-century Ireland. There were, for example, substantial increases in life expectancy around 1800 and these increased the survival of individuals prone to develop schizophrenia.181 This increased the prevalence of mental disorder (i.e. number of cases extant at any given moment) and, therefore, burden of care, but not necessarily the incidence (i.e. number of new cases per year). This was one of the factors emphasised by the Inspectors of Lunatics in their 1906 Special Report on the Alleged Increase of Insanity, along with fewer discharges and deaths than in English asylums, greater accessibility to asylums, less sick patients being admitted, transfers from workhouses, reduced stigma and the alleged return of emigrants who had become insane182 (which undoubtedly occurred).183 In addition, increased preoccupation with quality of life, rather than mere survival, may have further increased rates of presentation to asylums,
