however, found that it was noticeably difficult to reconstruct the living conditions of the patients there.55 There was a wealth of information regarding details of the building, the provision of food and so forth, but, from a clinical and historical perspective, the patients themselves proved remarkably elusive.56
This elusiveness may reflect a lack of governmental interest in individual patients and an exuberance of interest in psychiatric hospitals as institutions. Dr William J. Coyne, chief psychiatrist and resident governor at the CMH in Dundrum, who resided at the hospital from 1949 to 1965, was, every year, in the words of his grandson, Dr Maurice Guéret, ‘hauled before politicians on the public accounts committee to explain matters like failures of the carrot crop on the hospital farm, low prices from sales of hospital sheep, victualling rations for staff and the late delivery of spring seeds. Never once was he asked a single question about his patients’.57
As a result of these factors, the historiography of psychiatry in Ireland, as elsewhere, focuses largely on the histories of institutions and legislation, and the patients themselves remain ephemeral, elusive and largely unknown. Despite their vast numbers, patients’ voices are astonishingly distant and frequently inaudible to today’s historians. How can this be remedied?
Searching for Patients’ Voices
Recent decades have seen some progress towards seeking out the patients’ voices in the history of Irish psychiatry, commonly through analysis of official clinical records in certain establishments, including St Brigid’s Hospital, Ballinasloe,58 the Central Criminal Lunatic Asylum,59 St Brendan’s Hospital,60 and Enniscorthy Lunatic Asylum, County Wexford,61 among others. These are, however, analyses of official medical records, with all of their associated narrative and interpretative ambiguities.
One of the key merits of historical research based on clinical records is that such records are uniquely useful for identifying shifts in clinical practice over time and conveying the complexity of hospital life.62 Compared to approaches framed by institutional or legislative perspectives, which are so common in the historiography of Irish psychiatry, approaches based on clinical notes move somewhat towards Porter’s conceptualisation of ‘medical history from below’,63 although they still rely on official records written by medical superintendents and others, rather than direct patient accounts, such as patients’ own correspondence or memoirs.64 Official medical records can be manipulated, consciously and unconsciously, by the individuals writing the records, to demonstrate, for example, that staff always behaved in a fashion appropriate to the doctor-patient relationship (even if they did not).65 But such accounts do, at least, seek to tell that patient’s story at the individual level, as it was experienced.
Given these methodological issues, it is apparent that constructing an ‘authentic’ account of patient experience is a complex, challenging and possibly impossible task.66 Be that as it may, the case record still reflects both the patient’s behaviour and the interpretation of such behaviour by hospital authorities and, as such, presents a unique and crucial account of the patient’s experience – an account which generally played an important role in determining how the patient was treated in and by the institution. Archival case records are used to present patient histories throughout this book (e.g. the cases of three brothers committed to the Central Criminal Lunatic Asylum in the 1890s in Chapter 2, and that of Mary in Chapter 3).
Other limitations with approaches based on archival case notes include unclearness about how systematic medical notetaking was in the nineteenth century; potentially inconsistent use of medical terms; and inclusion of clinical descriptions which may be challenging or impossible to interpret today.67 These issues, however, present both challenges and opportunities. In relation to individuals with apparent intellectual disability, for example, an enquirer with experience of both historical and clinical work can at least attempt to move beyond the diagnostic labels used loosely throughout historical case records and focus on more objective descriptions of clinical symptoms (many of which are readily recognisable today), in order to provide a clinical analysis of the extent to which such patients in nineteenth- and early twentieth-century Ireland were truly intellectually disabled by today’s standards.68
Therefore, while extreme caution must be exercised when associating archival clinical descriptions with contemporary diagnoses (‘presentism’),69 this approach can nonetheless prove fruitful if archival accounts of patients’ experiences can meet the careful ‘clinical gaze’,70 with an emphasis on descriptive pathology rather than loosely applied diagnoses, and a focus on the clinical rather than institutional or legislative dimensions of patients’ histories. The case study of Michael in Chapter 4 presents an example of this approach from the 1890s.
Patients’ Symptoms, Letters
and Belongings
Even with careful interpretation and analysis, however, official clinical records are still at least one step removed from the voices and thoughts of patients themselves. In order to move closer to the patient’s voice, recent international attention has focused on other materials such as patients’ letters, journals and first-person accounts of incarceration and treatment.71 Beveridge, for example, studied letters written by patients admitted to the Royal Edinburgh Asylum and found evidence of commonality between symptoms in the letters and symptoms commonly seen in clinical practice today.72 Similarly, Smith studied letters from families and some patients at Gloucester Asylum between 1827 and 1843.73 While some admissions and discharges were undoubtedly problematic, there was also evidence of dialogue between asylum staff, families and patients, and by no means were all interactions conflictual, with certain patients very grateful for their care. There have also been studies of correspondence related to the York Retreat in England74 and the colonial asylums of New Zealand and Australia.75
Not all discharged patients described positive experiences, of course, and patient accounts of treatment in England and the US during the 1800s and 1900s were often highly critical.76 In Ireland, the past few decades have seen interesting initiatives seeking out patients’ voices in different ways, including through the reminiscences that accompanied the closure of St Senan’s Hospital in Enniscorthy.77 Other patient voices from recent decades were presented by Prior78 and McClelland,79 with the latter providing a fascinating account of Speedwell magazine, and its ‘insider view’ of Holywell Psychiatric Hospital, Antrim, from 1959 to 1973. Another mental hospital magazine, The Corridor Echo, of St Mary’s Hospital, Castlebar, provides further insights from 1966 onwards.80
Notwithstanding these records, accounts and publications, however, there remains a real paucity of detailed patients’ accounts of psychiatric admission and treatment in Ireland in the 1800s and early 1900s. Despite the general dearth of such literature in Ireland, this book includes, where possible, patients’ voices, with particular consideration of patient accounts of treatment in Irish psychiatric hospitals, such as those provided by the Reverend Clarence Duffy (1944)81 and Hanna Greally (1971)82 (Chapter 6).
In the absence of a plentiful supply of such accounts, however, it is worth speculating if there are other routes to the patient’s voice from past decades and centuries that merit exploration. What about delusions or hallucinations, which are often recorded in some detail in archival case notes? Delusions are convictions which are strongly held despite evidence to the contrary and hallucinations are perceptions without appropriate external stimuli (e.g. hearing voices).83 Can such phenomena be gainfully understood or decoded by the historian or clinician today, up to two centuries after they were recorded?
In other words, even though delusions and hallucinations are, in most conventional senses, ‘false’, might they also reflect truths, possibly unspeakable truths, in disguised or metaphorical form? Certainly, in contemporary clinical practice, both delusions
