factors.184 Torrey and Miller argue that there has been an epidemic of mental disorder over the past three centuries and that while this has gone largely unnoticed owing to its gradual onset, it represents an important but neglected force in world history.
It remains exceedingly difficult to determine, with any degree of accuracy, how much of the pressure on asylums in nineteenth-century Ireland was due to true epidemiological change and how much was due to other factors, such as changes in diagnostic practices and societal circumstances.185 The matter is further complicated by the fact that certain societal circumstances (e.g. conflict, famine) tend to produce a true increase in rates of certain mental disorders, and not just an apparent increase due to increased rates of presentation. Broadly, however, I agree with Brennan that institutionalisation during this period was primarily driven by social factors rather than a biomedical increase in insanity.186
All told, it is my conclusion that the growth of the Irish asylums in the 1800s and 1900s was attributable to a combination of increased societal recognition of mental disorder (owing to changes in society rather than changes in the nature or occurrence of mental disorder); continual legislative change, asylum building and psychiatric committal throughout the 1800s (with each of these three processes reinforcing the other two); evolving changes in diagnostic and clinical practices (underpinned by asylum doctors’ search for professional status and respectability); and – possibly most importantly – sociodemographic changes, especially increased survival, leading to altered patterns and prevalence of mental disorder (although not a proven rise in core rates of occurrence).
While some of these matters will likely continue to be the subject of debate, it is beyond dispute that the perception of an increase in insanity, and rising rates of presentation to asylums, had a decisive influence on mental health policy and legislation in Ireland in the 1800s and early 1900s. This perception was strongly linked with the remarkable asylum building programme of the 1800s and the steady increase in asylum populations over the course of the nineteenth and early twentieth-centuries. The asylums in Carlow and Kilkenny demonstrate many of the key trends during this period, especially in terms of diagnostic practices, ranging from the mundane and repetitive to the quixotic and unexpected.
Psychiatric Diagnoses in the Nineteenth Century:
Mania, Melancholia and ‘Insane Ears’
The asylum in Carlow (later St Dympna’s Hospital) opened in 1832 to care for the mentally ill of Carlow, Kildare, Kilkenny and Wexford.187 A review of the diagnoses in its clinical archives offers a valuable window into diagnostic practices and some of the clinical outcomes in the late 1800s.
The Register of Patients admitted between 1848 and 1896 (‘Admission Book’) demonstrates a wide range of diagnoses in use during this period, along with suggestions about the ‘supposed cause of insanity’ in each case.188 Among men, common diagnoses included ‘mania’, ‘melancholia’189 (with or without delusions), ‘paranoia’, ‘epilepsy’, ‘post-febrile’ illness (i.e. mental illness following a fever), ‘idiot’, ‘imbecile’, ‘homicidal and suicidal’, and ‘dementia’ (diagnosed in young people, this was likely similar to ‘mania’). ‘Senile mania’, ‘senile melancholia’ and ‘senile dementia’ were reported in the elderly, and ‘mania a potú’ also featured, referring to ‘mania’ owing to ‘intemperance’ or ‘alcohol’.
‘Mania’ itself could be ‘acute’, ‘chronic’ or ‘religious’. The term ‘monomania’ was used when a single pathological feature (e.g. delusion) was the central feature of the disorder. The ‘supposed causes’ of ‘mania’ in men ranged from ‘poverty and drinking excess of porter’ to ‘sunstroke’, from ‘mental annoyance’ to ‘heredity’, from ‘unknown’ to ‘can’t say’. More specific causes included psychological traumas (‘loss of money’, ‘matrimonial disappointment’, ‘death of wife’), physical traumas (‘a beating received’, ‘fell from a horse’) and hypothesised disorders of the brain (‘effusion of blood on brain’, ‘affection of the brain’, ‘disease of brain, fits’, ‘probably an attack of meningitis when a child’).
One man was admitted with ‘acute mania’ owing to ‘shock on his brother being sent to asylum’, his brother having been admitted two months earlier with ‘mania’ due to ‘religious excitement’. Another man was admitted in the mid-1890s with a four day history of ‘mania’, the ‘supposed cause’ of which was his ‘wife’s insanity’, his wife having been admitted with ‘mania’.
The range of diagnoses recorded in women was similarly broad and included ‘mania’, ‘melancholia’ (with or without delusions), ‘delusional insanity’, ‘dementia’, ‘paranoia’, ‘senile mania’, ‘senile melancholia’ and ‘monomania’. ‘Mania’ in women could be ‘recurrent’, ‘acute,’ ‘chronic’, ‘partial’, ‘suicidal’, ‘religious’ or ‘puerperal’ (i.e. occurring during or immediately following childbirth). Causes of mania in women included ‘heredity’, ‘drink’, ‘intemperance’, ‘domestic troubles’, ‘adverse circumstances’, ‘mental anxiety and worry’, ‘grief’, ‘loss of employment’, ‘desire to leave workhouse’, ‘injury to spine’, ‘childbirth’ and ‘religious excitement’.
Causes of melancholia among women included ‘fright’, ‘mental anxiety’, ‘sudden death of a friend’, ‘sudden death of husband’, and ‘domestic troubles’. Other entries for women under ‘diagnosis’ included ‘insanity doubtful’ or simply a blank space; in one such case, an additional note was added to the page, presumably in order to explain the admission: ‘statements against character’.
The cases linked with childbirth are especially involving. One woman in her 30s, the ‘wife of a carpenter’, was admitted in the mid-1890s with a one month history of ‘puerperal melancholia’ which was ascribed to ‘heredity and puerperium’ (i.e. occurring in the first six weeks after giving birth). Noted to be anaemic on admission (pale, likely owing to blood loss), this woman spent just over six months in the asylum before she ‘was removed at request of husband’. She was described as ‘relieved’ (as opposed to ‘recovered’) on the day of discharge and was readmitted just a week later, with a recurrence of ‘puerperal melancholia’, now simply ascribed to ‘heredity’. Related diagnoses in other women included ‘recurrent mania’ ‘following pregnancy’; ‘puerperal mania’ after ‘childbirth’; ‘dementia’ ‘in childbirth’ or ‘following parturition’; and ‘mania’ owing to ‘amenorrhoea’ or ‘loss of child’.
Other causes of ‘insanity’ among women included ‘poverty and hardship’ (linked with ‘senile melancholia’); ‘sunstroke’, ‘worry and hardship’ (‘paranoia’); ‘fright’ (‘melancholia with delusions’); ‘pecuniary disappointment’ (‘monomania’); ‘cerebral changes’ (‘religious mania’); ‘sunstroke’ and ‘loss of situation’ (‘dementia’); and ‘heredity’, linked with ‘delusional insanity’, ‘senile mania’ and ‘dementia’ (also associated with ‘paralysis agitans’ or Parkinson’s disease).
Readmission was not uncommon. A school teacher in her early 60s was admitted in the mid-1890s with a ‘relapse’ of ‘monomania’, having had a previous episode four years earlier. She was discharged ‘recovered’ after a year but readmitted after a further year, this time with ‘recurrent melancholia’ due to ‘heredity’. On this occasion, she spent five months in the asylum before being discharged, ‘recovered’. At around the same time, a ‘labourer’ in his 50s was admitted with a one week history of ‘mania’, having ‘inflicted a wound on his throat’. Just over two years later, he was ‘allowed out on approval as “relieved”, at the request of his friends’, but readmitted just six days later.
Another ‘labourer’ and ‘ex-soldier’ in his early 20s experienced
