«Mental Health Law in Ireland, 1821 to 1902: Building the Asylums Brendan D Kelly MD MA MSc MRCPI MRCPsych Consultant Psychiatrist and Senior Lecturer ...»
Mental Health Law in Ireland, 1821 to
1902: Building the Asylums
Brendan D Kelly MD MA MSc MRCPI MRCPsych
Consultant Psychiatrist and Senior Lecturer in Psychiatry, Department of Adult
Psychiatry, University College Dublin, Mater Misericordiae University Hospital
Correspondence to: Brendan D Kelly, email@example.com
The nineteenth century was a time of intensive legislative reform in relation to the management of
mental illness in many countries, including the United Kingdom. Among the important initiatives taken in Ireland at this time, arguably the most enduring resulted in the establishment of an extensive system of public asylums which, in turn, heralded substantial changes to the conceptualisation and experience of mental illness in Ireland (Finnane 1981; Robins, 1986;
Reynolds, 1992; Walsh & Daly, 2004). This paper (a) summarises the central legislative and administrative changes in Irish mental health services between 1821 and 1902, and (b) relates these reforms to prevailing therapeutic paradigms.
Legislative Provisions Prior to 1821 There was scant specific legislative provision for the mentally ill in Ireland in the seventeenth and eighteenth centuries and while various pieces of legislation in the 1700s established a network of workhouses and houses of industry for the destitute poor, many individuals with mental illness spent significant periods in workhouses which were inadequate and inappropriate for their needs (Robins, 1986; Kelly, 2004) as there was no dedicated asylum accommodation. In 1944, an
anonymous psychiatrist, writing in The Bell, an Irish literary periodical, noted that:
“In 1728 cells were erected in the Dublin House of Industry, and later similar provisions were made in houses of industry throughout the country. These, however, could not be classified as institutions. The term ‘cells’ is sufficiently informative.” (Psychiatrist, 1944) Ireland had no tradition of private asylums unlike England where significant numbers of individuals with mental illness were housed either in private asylums or admitted as private patients to large public asylums, such as Bethlem (Shorter, 1997). Without such dedicated public or private provision, the mentally ill in Ireland tended to lives of vagrancy, homelessness and destitution (Robins, 1986). When St Patrick’s Hospital, Dublin opened in 1757, following a bequest by the author Jonathan Swift (Malcolm, 1989), things changed a little. By 1817, St Patrick’s Hospital had 150 inpatients, including 96 “paupers” (Finnane, 1981). This development was welcome but isolated, and there was a serious lack of provision for the mentally ill both in Dublin and throughout Ireland for most of the 1700s.
The first systematic change occurred in 1787, when the Prisons Act empowered Grand Juries to establish lunatic wards in houses of industry and dictated that such wards were to be inspected by the inspector-general of prisons. The response to the 1787 legislation was modest, however, and by 1804 lunatic wards had only been established in Dublin, Cork, Waterford and Limerick (Finnane, 1981). In Cork, however, a pioneering psychiatrist, Dr William Saunders Hallaran, founded the Cork Lunatic Asylum in 1791 which was an important step in establishing dedicated services for the mentally ill in this region (Williamson, 1970). This period also saw a steady expansion in private care with the opening of a private asylum in Cork in 1799 and further private facilities in Bloomfield, Donnybrook (1810), Farnham House, Finglas (1814) and Hampstead House (1826) (Williamson, 1970). Generally, however, there was still a paucity of accommodation and treatment facilities for the mentally ill, especially the destitute mentally ill which put substantial pressure on what was available, especially the houses of industry. This concern was highlighted by Dr Hallaran in Cork, in his 1810 textbook, An Enquiry into the Causes producing the Extraordinary Addition to the Number of Insane together with Extended Observations on the Cure of Insanity with hints as to the Better Management of Public Asylums for Insane Persons (Hallaran, 1810). Following a discussion of treatment modalities in early
nineteenth century psychiatry (Kelly, 2007a), Dr Hallaran commented:
“It has been for some few years back a subject of deep regret, as well as of speculative research, with several humane and intelligent persons of this vicinity, who have had frequent occasions to remark the progressive increase of insane persons, as returned at each Assizes to the Grand Juries, and claiming support from the public purse. To me it has been at times a source of extreme difficulty to contrive the means of accommodation for this hurried weight of human calamity!” (Hallaran, 1810) This “hurried weight of human calamity” continued to pose substantial problems for legislators and social service providers throughout the remainder of the nineteenth century. Public and government concern were fuelled in large part by a widespread belief that rates of mental illness were increasing rapidly in the population, placing further stress on facilities that were already over-stretched and inappropriate (Tuke, 1894; Smith, 1990; Torrey & Miller, 2001; Prior, 2003;
Kelly, 2004). The formal response to this situation was underpinned by an extraordinary period of legislative activity, commencing with the Lunatic Asylums (Ireland) Act of 1821.
Building the Asylums Between 1820 and 1898 there was intensive legislative activity: the need for extensive and systematic reform had been highlighted in 1804 by a Select Committee of the House of Commons which recommended the establishment of four provincial asylums dedicated to the treatment of the mentally ill so as to minimise the numbers residing in prisons and houses of industry (O’Neill, 2005). There was a time of substantial reform in England (Jones, 1955) but progress was slow in Ireland. The Richmond Asylum in Grangegorman, Dublin eventually opened its doors in 1815. It had a Board of Governors with powers “for the regulation, direction and management of themselves and of the said asylum and of all the patients therein and of all and every physician, surgeons, apothecaries, housekeepers, nursetenders, and other attendants, officers and servants of what nature and description soever of or belonging to the same” (Reynolds, 1992). The Board was answerable to the Lord Lieutenant (the chief administrator of British government in Ireland), the Duke of Richmond, after whom the asylum was named (Kelly, 2007b). Patients were admitted to the asylum on the basis of a certificate of insanity which had to be signed by a medical practitioner, clergyman or magistrate (O’Neill, 2005).
The prevailing therapeutic paradigm was that of “moral management”, an approach which had emerged as an alternative to traditional “medical” treatments such as blood-letting, the use of “circulating chairs”, etc (Hallaran, 1810). Jean-Étienne Esquirol (1772–1840), an influential French psychiatrist, defined “moral treatment” as “the application of the faculty of intelligence and of emotions in the treatment of mental illness” (Esquirol, 1805). The “moral” approach emphasised the importance of the doctor-patient relationship and employed the principles of reward and punishment, reason and emotion, in order to reduce symptoms (Carlson & Dain, 1960). It was followed in Ireland in the early decades of the nineteenth century (Williamson, 1992; Reuber, 1996) and practised with enthusiasm when the new Richmond Asylum opened in 1815.
The Richmond Asylum was quickly overcrowded and it was soon apparent that systematic reform at national level was needed. Following considerable discussion in parliament (Williamson, 1970), a bill to establish such a system of asylums was presented by William Vesey Fitzgerald and passed on July 11 1817. This legislation, amended in 1820, 1821, 1825 and 1826, set in motion the creation of Ireland’s extensive system of district asylums, many of which remained in use for over 150 years.
It was the Lunatic Asylums (Ireland) Act 1821 that empowered the Lord Lieutenant (chief administrator of British government in Ireland) to direct the erection of asylums throughout Ireland which were funded by both central government (nationally) and grand juries (locally).
The establishment and planning of asylums were to be directed centrally by “Commissioners for General Control and Correspondence” but local responsibility for directing asylum activity resided with boards of governors for each asylum (Robins, 1986).
In 1825, the first asylum was established in Armagh followed by a further seven asylums in Limerick, Belfast, Derry, Carlow, Portlaoise, Clonmel and Waterford, at a total cost of £245,000 (Williamson, 1970) and completed within ten years. The asylums reflected the therapeutic paradigms practised throughout the 1800s; for example, as the emphasis on isolation and classification in the early part of the century yielded to the moral management approach (Williamson, 1992), asylums assumed a “panoptic” or radial design that was deemed consistent with the principles underlying moral management (Reuber, 1996).
As asylum-building continued, so the numbers of individuals resident in asylums increased significantly: by 1851 there were 3,234 individuals resident in Irish asylums. By 1891 there were 11,265 (Inspectors of Lunatics, 1893). The Lunacy (Ireland) Act 1821 had directed that applications for admission needed to be accompanied by a medical certificate of insanity and a statement from next-of kin confirming poverty; applications were then considered by the physician and manager of the asylum, and presented to the Board for acceptance (O’Neill, 2005).
The 1821 legislation also directed that individuals who were insane at the time of a crime or at the time of indictment could be acquitted in court but detained in indefinite custody at a psychiatric institution “at the pleasure” of the Lord Lieutenant. In 1850 the Central Mental Hospital was opened in Dundrum, Dublin under provisions of the Central Criminal Lunatic Asylum (Ireland) Act (1845, 1846) to provide “a central asylum for insane persons charged with offences in Ireland” and detained indefinitely under this legislation (Smith, 1990).
The Case of Mr A, Detained “at the Lord Lieutenant’s Pleasure” Mr A was a 37-year old man admitted to the Central Mental Hospital in the late 1860s having been convicted of the murder of a fellow patient in a large district asylum. Found to be “insane on arraignment” he was sentenced to be detained in the Central Mental Hospital “at the Lord Lieutenant’s pleasure” (i.e. indefinitely). On admission, Mr A’s level of education was recorded as “nil” (i.e. he could neither read nor write) and he had “no occupation”. Admission notes at the Central Mental Hospital describe Mr A as “intemperate” and his “mental state on admission” was one of “recurrent mania with dementia”.
Medical notes record that Mr A “denies his crime [and] states that he is unjustly detained here”. He showed symptoms of “chronic mania and dementia” and was “constantly talking to himself and imaginary people”. It is important to note that, in the nineteenth century, the meaning of the term “dementia” differed from its contemporary meaning; in the nineteenth century, “dementia” denoted any severe mental illness with delusions and hallucinations (e.g.
schizophrenia), whereas currently the term refers to certain chronic brain syndromes chiefly seen in later life (e.g. Alzheimer’s disease). These changes in the uses of psychiatric terminology over time make it difficult to interpret clinical diagnoses from the nineteenth century and provide accurate contemporary equivalents of psychiatric disorders recorded at that time.
In accordance with the principles of moral management, Mr A was put to work as a “division cleaner” and while he was “quiet and well conducted as a rule” he was also “excitable at times”.
Some 27 years after admission, Mr A was still a “very quiet and well behaved patient” and a “useful and obliging worker”. He was, however, “in a weakly state of health [and] slightly depressed”. Mr A’s heart was “weak” and late one evening, some 33 years after admission, the asylum doctor found Mr A “in great pain, in a state of almost complete prostration, his heart weak and fluttering”. Mr A recovered from this episode but remained “very weakly”. Some months later he again “suddenly became collapsed, had an attack of vomiting” and “sank fast”. Mr A died later that night and an inquest confirmed he “died from heart disease”. Aged 70 years at his death, Mr A had spent 33 years in the Central Mental Hospital.
The case of Mr A sheds some light on both the criminal justice system and forensic psychiatric services in nineteenth-century Ireland. Like Mr A many patients were detained for decades at the Central Mental Hospital at this time (Gibbons, Mulryan & O’Connor, 1997; Mulryan, Gibbons & O’Connor, 2002). His death at the asylum was not unusual; all Irish asylums experienced significant mortality rates during the nineteenth century, mainly due to illnesses such as syphilis, dysentery, heart disease, epilepsy and tuberculosis (Kelly, 2007b). The emphasis placed on Mr A’s performance as a “division cleaner” was typical of the times and reflects the importance that “moral management” accorded to gainful occupation as a key component of treatment (Robins, 1986).
Other Legislative Initiatives in Ireland Throughout the 1800s There was further legislative activity in Ireland as the nineteenth century progressed. The Criminal Lunatics (Ireland) Act 1838, for example, provided a separate form of admission to district asylums for individuals who were considered to be dangerous; such individuals could be detained indefinitely by two justices of the peace, who had the option of using medical evidence to inform their decision. The involvement of the judicial authorities in this way was by no means unique to Ireland: similar laws were introduced at around this time in Canada (Wright, Moran & Gouglas, 2003), Australia (Coleburn, 2003), Switzerland (Gasser & Heller, 2003) and France, with the 1838 French law establishing “official committal” as the normal means of committal for individuals who were deemed to represent a danger to public safety or order (Prestwich, 2003).