Approaches to mental health

Report of the Commission on the Relief of the Sick and Destitute Poor, including the Insane Poor, 1927

Laid before the Houses of the Oireachtas on 11 October 1927

Detail from the report

This report, published by the Commission on Relief of the Sick and Destitute Poor appointed on the 19th March 1925, was issued in 1927 with the object of devising permanent legislation and to inquire into the existing provision in public institutions for the care and treatment of mentally ill persons among others, including unmarried mothers and their children, and to advise as to whether more efficient methods can be introduced especially as regards the care and training of mentally ill children with due regard being had to the expense involved.

It was written, at the behest of the government of the day, by a committee of men, and one woman, an independent Senator called Jenny Wyse-Power. There was a monsignor on the committee, and a reverend, and several TDs and senators.

Part II documents the history in Ireland of public provision for patients in state care in the early 1800's - "The earliest public provision for the insane took the form of erecting cells in the houses of industry or workhouses. In 1728 cells were erected in the Dublin House of Industry. Later, in the eighteenth century, a small amount of accommodation was provided for the insane in the houses of industry established in several counties under the Act of 1772. Towards the middle of the eighteenth century, there was bequeathed the greater part of Jonathan Swift's estate for the purpose, an asylum for the insane, namely, St. Patrick’s Hospital, which still exists."

It also includes accounts of existing public provisions made for the insane and chronicles the Lunacy Acts, a parliamentary grant for an asylum in Dublin, and a general account of the developement of mental hospitals, including the formation of the District Asylums in 1817.
The report not only reflected the attitudes of the time, but set the tone for future policy.

From the Documents Laid Collection, DL068542

Defects in the Moral Treatment of Insanity in the Public Lunatic Asylums of Ireland, with Suggestions for their Remedy and some Observations on the English Asylums, 1862

Detail from the report

"Immured in a wretched and comfortless prison-house, and left to linger out a lifetime of misery, without any rational attempt at treatment, without employment, without a glimpse of happiness or a hope of liberation, he [inmate] was terrified or starved into submission, lashed, laughed at, despised, forgotten."

This is one of the many pamphlets from the recently catalogued Dublin Castle Tract Collection that scrutinises the state of care for patients in Ireland in the 19th century. It includes extracts from the newly appointed Royal Commission charged with reporting on the condition of the patients in these institutions, as well as into the state of the law respecting 'lunatics'. The extracts are taken from answers provided by the M.D.s of the more prominent asylums existing across Ireland at this time.

"One of the most striking faults which the Irish Asylums present, in common with the greater number of English ones, is the prison aspect which they bear, in spite of a good deal of attempt at architectural effect, and considerable expenditure in external ornamentation. Indeed, almost everything connected with their construction goes to prove that the leading idea of those who designed them must have been that a lunatic should be treated very much after the fashion of a criminal."

The pamphlet also gives us an insight into the stark reality of asylum life faced by many Irish people on admittance to the various types of institutions throughout the country. The main concern of the author, John A. Blake, is not the physical state of the inmates in these asylums in England and Ireland, but that the monotony and desolation of mind endured by 'Lunatic Asylums' should be relieved by occupation and amusement as this has had proven positive effects on curability.

"As regards County Asylums, there is now a great disposition in the officers to set every patient to work as soon as admitted – sometimes very improperly, and when, perhaps, work has made the poor creature mad. A man just admitted is perhaps sent off to the shoemaker’s before his case can have been considered before a physician; and a poor melancholy woman, or a frightened, agitated girl is set to work immediately with a needle and thread, to pursue, as if in a mere workhouse, the same sedentary occupation which has already destroyed her health."

From the Dublin Castle Tract Collection, DCT151004

Observations and Suggestions on the Management of the Maryborough District Lunatic Asylum 1833

Proposed admission form submitted to the consideration of the governors to be adopted for the Maryborough District Lunatic Asylum for the King's and Queen's counties, and the counties of Westmeath and Longford after review of inadequate admissions procedures.

This pamphlet is one of a number of examples in our collection of observations and proposed remedies by medical practitioners given at the time. The author, Mr. John Jacob, M.D. hoped to combat what he perceived as a "serious and growing evil in Ireland". He laments over the power of the managers and matrons of Irish institutions, many of which, he believes, know nothing of medicine or moral treatment and yet are put in charge of such establishments, while the physician has limited influence in the direction of District Asylums.

"The physical causes of deranged intellect were not submitted to the analytical scrutiny adopted in other diseases, and the patient was either left altogether to his fate, or submitted to the chance exhibition of remedies, perhaps as much calculated to injure as to improve him."

One aspect of the authors observations on asylum life in Maryborough was the lack of records on individual patients in the institution. Due to overcrowding in many district asylums, the records of patients were inadequately kept, meaning patients that had been dead for a few years were still registered as being alive and vice versa, as was the case at the Richmond Asylum. However, in Maryborough, the author states that he found it considerably difficult to investigate some cases as there were "imperfect accounts of their previous history". To improve this disadvantage, he proposed a system of admission into the asylum, including an entry form to be signed by the magistrate and parish minister and another form to be signed by the friends/relatives of the admitted. He also proposes that certain questions be asked of the patient; some of which included:

• State the patients age, religion, occupation, whether married or single. If a female, whether she has borne children, their number, and the period of the birth of the last.
• Does the disease appear to have been connected with pregnancy, the puerperal state or lactation.
• What has been the condition of the patient’s health previous to insanity becoming manifest, was anything particular observed as regarded appetite, sleep, condition of the bowels, &c.
• Was the patient naturally either eccentric or of weak mind.
• What are the most prominent features in the present condition of the patients mind, is he the raving promiscuous character, cheerful or melancholy, or is it confined to one particular subject or train of ideas, if so, state particularly what that may be, or what illusions particularly predominate, or whether there be proneness to any particular vice.

The pamphlet also gives us an insight into the type of diet and the daily schedule that the author has proposed be adopted for the better management of every public establishment.

From the Dublin Castle Tract Collection, DCT013008

The Lunacy Law: its Defects; and a Scheme of Reform 1885

Detail from the report

This short pamphlet, reprinted for Mr. William R. Huggard, M.A., M.D. from the British Medical Journal, Jan. 17th, 1885, identifies the problems associated with the legislation on the care of 'lunatics' in the late 19th century and predominantly describes various and often unsatisfactory methods dealt at this time in certifying insanity.

"Not one of all the persons engaged in certifying insanity is required to have any acquaintance, practical or theoretical, with insanity."  It also includes some very interesting observations on the property of persons deemed insane. "When a person is certified insane, his property is left without legal guardian; and, except when the property is very small, the process of appointing a legal custodian is so costly, as well as so slow, that probably a little friendly plunder and mismanagement would damage the estate less."

It mentions the four different kinds of patients admitted at this time known as:

• Private patient (paid for by himself or by his friends),
• Pauper patient (maintained wholly or in part out of the parish rates),
• Chancery patient (that is, found lunatic by inquisition),
• Criminal Lunatic.

He concludes that, although the general consensus was that the law should be addressed with regard to the care of people with mental health difficulties at this time, there will always be opposition to some aspect of the law and therefore, no plans were in place to change it.

From the Dublin Castle Tract Collection, DCT151008

Remarks on the Present State of the Lunatic Asylums in Ireland, and on the Number and Condition of the Insane Paupers in that Kingdom 1808

Detail from the report

In the early 19th century, the author having spent ten months in ascertaining the (then) present state of the pauper and criminal 'lunatics' in Ireland, published a report in the hopes that a member of the House of Commons in Ireland would step forward on their behalf to "accomplish what Mr. Charles W. Williams Wynn has already done in behalf of the criminal and pauper lunatics in England and Wales."

The pamphlet goes into detail about the state of 'lunatic' asylums in all provinces of Ireland and the conditions of the patients, including detailed letters of figures and descriptions etc,  sent to Ireland for the improvement and betterment of these hospitals, as was progressing in England and Wales at this time.

Before the establishment of the District Asylums in Ireland, the 'lunatics' who "become dangerous were sent occasionally to the House of Industry in Dublin. These institutions were supported by Grand Jury Presentments, and were not only the Asylum of the pauper lunatics, but the prison of the vilest outcasts of the country." Money for this purpose was generally raised by voluntary subscription in the town or parish where such poor 'lunatic' resided. "When we come to consider the very great distance which some of them have to travel, and the very precarious provision which exists for their being sent at all, we cannot be surprised at their being suffered to remain with their friends, chained in some out-of-the-way place, as Mr. Edgworth observes, “without any attempt being made to secure them."

The author refuses to mention the misery that he has witnessed in visiting the Asylums in England. Instead, he uses a quote from Sir George Onesepherous Paul: "That there is hardly a parish of any considerable extent in which there may not be found some unfortunate human creature who, if his ill treatment has made him phrenetic, is chained in the cellar or garret of a work-house, fastened to the leg of a table, tied to a post in an out-house, or perhaps shut up in an uninhabited ruin; or, if his lunacy be inoffensive, left to ramble, half naked, half starved, through the streets and high-ways, teased by the scoff and jest of all that is vulgar, ignorant, or unfeeling."

The author makes no apology for the following accounts which show the extent of neglect as a result from inadequate houses and funding and indeed lack of humanity. He also states that it is a sad fact to reflect on the many cases of merely temporary delirium, which have been converted into incurable madness, by the unhappy sufferer having been looked up in these cells.

Description of the County and City House of Industry at Cork and the conditions of the patients:

"The first objects which presented themselves were the vilest prostitutes of the city, and incorrigible young offenders: the former amounted to eighty-two, each of whom had a chain and log fastened upon one leg; they were wretchedly clad, being allowed no prison dress… In another part of the building, I saw the idiots and insane, amounting to one hundred and eight; the former were very few; the latter appeared to have every proper attention paid to them: formerly used to run about the streets unattended."

There are many more descriptions of scenes that the author has witnessed in asylums in Ireland in this pamphlet that certainly "strike the mind with horror"

From the Dublin Castle Tract Collection, DCT073007

Report Upon the Existing System of Public Medical Relief in Ireland 1836

Detail from the report

"By means of these [larger] lunatic asylums, Ireland affords opportunity for investigating the nature of insanity, not surpassed in any part of Europe, and this ample field, though hitherto comparatively un-productive, will, under proper management, yield the most valuable fruits."

In an effort to improve the quality and the management of many district asylums throughout Ireland, the author visited seven institutions in Belfast, Londonderry, Armagh, Ballinaloe, Limerick, Maryborough and Carlow and published this pamphlet in the hope that his observations and suggestions might improve what he witnessed in each.

Because these asylums were generally intended for the pauper poor, certain securities, such as sufficient registration of full medical history was extremely scarce. The author has drawn up a recommended table to be completed and updated annually with a statement of the treatment and result. This appeared to be the case in every county asylum in England, under the joint care and responsibility of the physician and chief resident officer (who must be a medical man) and would "afford data from which new and improved modes of practice may be safely deduced."

The Acts expressly stated that all of Ireland’s 'lunatics' were to be admitted to these hospitals, yet, there were frequent reports stating that certain asylums, such as Belfast and Limerick, were intended for ‘curable’ cases only. Discretion, however, was vested in the Lord Lieutenant by section 5, 1 & 2 Geo. IV. C. 33.

According to many in the medical profession at this time, these asylums are merely in existence to house the 'lunatics' rather than actually treating them or attempting to understand their mental conditions.

"As a consequence of this, not a year passes without some notorious case of insanity being brought before the public in a manner reflecting little credit on the conflicting medical authorities, whilst instances of injudicious or improper confinement of patients are not unfrequent. To the same negligence of the whole subject it must be attributed that we have so few aids to a knowledge of the condition of the brain in the various forms of insanity, that the pathology of insanity is so uncertain and incomplete, and the treatment so generally empirical. Our larger lunatic institutions have contributed little or nothing to our knowledge. When the public establishments are, as under proper regulations they might be, schools of instruction, we shall learn how much our practice in these distressing disorders may be improved".

From the Dublin Castle Tract Collection, DCT013005

Lunacy Inquiry Commission (Ireland) 1879, Review of Report and Evidence

Detail from the report

When Mr. Gladstone introduced the Irish Church Bill in 1869, he referred to the notorious deficiency under which Ireland laboured with regard to the proper maintenance of a large portion of the insane. Long before that time, however, the attention of Government had frequently been directed to the incompleteness of our asylum accommodation, and at the wretched condition of the insane at large. Various commissions had examined into the matter and reported upon it, but their labours were followed by no legislation, and led to no results.

Reports of older commissions, sometimes referred to by the recent commissioners for purposes of comparison, and sometimes quoted to lend emphasis to conclusions at which the latter had arrived by independent investigation. Many of the pamphlets from the Dublin Castle Tract Collection detail some of these independent investigations by a number of mental health practitioners, at the time, by calling for legislation for the better treatment of the patients in Ireland through highlighting certain cases of treatment of these patients before and after the Lunatic Asylums Acts. Many also compare them with the management of 'Lunatic' Asylums in England and Wales.

This pamphlet details an account of a case of neglect of a young man who was forced into confinement in his own home from the report of a tourist to Ireland.  The author took it upon himself to visit more of these sad cases in different parts of the country and some of those cases are recounted in this pamphlet. This particular young man was later removed to a district asylum.

The number of patients in the Irish district asylums at the end of the year 1877: 8,183 (vide 27th Report of Inspectors). Probably curable: 1,991. Probably incurable: 6, 272. Of the probably incurable, 1,360 may be removed to the auxiliary asylums connected with workhouses. This may be due to the fact that Irish asylums were conducted on a far cheaper scale than the English.

It also includes statistics per hospital in the country on housing ‘curables’ and ‘incurables’ which is a prominent area of discussion and debate in the many pamphlets dealing with the issue of 19th century mental health services in the Dublin Castle Tract Collection.

From the Dublin Castle Tract Collection, DCT151007