Hearing Voices - Brendan Kelly

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writing in the context of Enniscorthy Lunatic Asylum between 1916 and 1925, McCarthy notes that admissions of women were commonly related to menstruation, childbirth or miscarriage, and that single women often ended up drifting into the asylum in a lost, purposeless and generally unwanted state.346 In all, 56 per cent of women admitted to Enniscorthy between 1916 and 1925 were single and, like others so committed, they often struggled with impossible combinations of family misfortune, strict behavioural codes and expectations, economic uncertainty and social powerlessness.

      Indeed, Parry argues that, from a gender perspective, the asylums ‘replicated the social structure of wider society’:

      The administration of the system was predominately in the hands of men. Each asylum had a Board of Governors, made up of prominent men from the surrounding county. Rarely, if indeed ever, did a woman feature on these Boards – the prevailing ideology of femininity held women to be mentally and physically unsuited to public life, and hence to holding public posts. Except for the position of Matron, all top staff positions (Medical Superintendent, Clerk, Storekeeper) were all held by men. In the early days of moral management, when asylums were run by a Moral Governor, women had a certain amount of power in the asylum system in that the Governor’s wife usually superintended over the female wards. However, lay managers of asylums were gradually replaced by doctors as the century progressed, and simultaneously the role of matron declined in status. Medical superintendents believed they held their posts based on specific expertise, and hence could not justify their wives, in the absence of any expertise, holding any sort of managerial position in the asylum system.347

      The fate of women in Irish asylums and the ways in which gender affected the development of the asylum system are fascinating themes that merit greater consideration.348 Particular attention could usefully be paid to specific, albeit difficult to research aspects of these themes such as the fate of babies born in the asylums349 and the experiences of children admitted to them.350 These are stories that need to be told.

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      PSYCHIATRY AND SOCIETY IN THE 1800S

      Every Physician holding or accepting of an appointment [in a District Lunatic Asylum in Ireland], is requested to bear in mind that the object of the Government is not simply to have the bodily ailments of the Patients attended to, but to assist their recovery by moral or medical means, and to advance Medical Science in cases of Lunacy through the great range of experience which the Public Asylums afford.

      Lord Lieutenant and Council of Ireland, General

      Rules for the Government of All the District Lunatic

      Asylums of Ireland, Made, Framed and Established

      by the Lord Lieutenant and Council of Ireland (1843)1

      The avowedly humanitarian approach to the mentally ill adopted by Hallaran in Cork in the late eighteenth century,2 consistent with Pinel in France3 and Tuke in England,4 was much needed in nineteenth-century Ireland owing not only to under provision for the mentally ill, but also the Great Irish Famine (1845–52). The Famine was one of the most devastating natural disasters in the history of modern Europe: between 1841 and 1851, the population of Ireland fell by approximately 20 per cent.5 Over a million Irish people died as a result of the Famine and one million more emigrated in its immediate aftermath. Given the Famine’s seismic impact on nineteenth-century Ireland, its effects on psychiatry are considered next.

      The Great Irish Famine (1845–52):

      ‘Weak Minded from the Start’

      Interestingly, the Great Irish Famine is generally under-represented in the historiography of mental disorder in Ireland. This is likely attributable, at least in part, to the broader literature’s strong focus on the building of asylums which occurred around the same time. There is, however, little doubt that the Famine increased reliance on various forms of social support among the Irish population in general,6 including those with mental disorder,7 as was duly noted by asylum doctors at the time.8 But did the Famine itself actually increase the rates of occurrence of mental disorder?

      Evidence from other countries suggests that this is certainly possible: certain cohorts of people, who were in gestation during the Dutch Winter Hunger of 1944 and born shortly afterwards, were found to have twice the risk of schizophrenia in later life compared to those not exposed to famine conditions during pre-birth development.9 This is likely attributable to the effects of hunger and stress on the developing brain prior to birth, leading to altered patterns of brain development in childhood and adolescence and increased risk of schizophrenia in young adulthood.10 Did something similar occur in Ireland during the Famine?

      Walsh used data derived chiefly from the Annual Reports of the Irish Inspectors of Lunacy on the District, Criminal and Private Lunatic Asylums, adjusting nineteenth-century diagnostic labels to elucidate, as best as feasible, if the Famine increased rates of schizophrenia in Ireland.11 He found that while there was indeed an increase of 86 per cent in first admission rates for apparent schizophrenia between 1860 and 1875 (when those in gestation during the Famine reached the high risk age for developing schizophrenia), admissions with other diagnoses (chiefly ‘melancholia’) also increased, and similar increases were evident in other jurisdictions over the same period. These results are, therefore, inconclusive.

      The absence of any dramatic trend in Walsh’s work is consistent with the views of Torrey and Miller, who suggest that the effect of the Famine on committal rates was minimal, as admissions simply continued to rise steadily during this period anyway.12 Given the devastation wrought by the Famine and the fact that the asylum system had been firmly established by the late 1830s,13 the continued rise in admissions is unsurprising: in times of unprecedented difficulty and distress the asylum offered, at the very least, food and shelter for those in need. In 1844 there were 2,136 ‘mentally ill’ persons resident in public asylums on the island of Ireland and by 1855 this had risen to 3,522.14 This trend, however, continued long after the Famine: by 1900, the number had reached 16,404.

      Given these generally increasing admission rates over the course of the 1800s, is there any other way of looking at existing data so as to elucidate further any possible links between the Famine and admission patterns? First, it is useful to note that, although no part of Ireland fully escaped the effects of the Famine, not all counties were affected equally. Counties in the west of Ireland, such as Galway, Mayo and Roscommon, were particularly badly hit: the death rate in County Mayo between 1846 and 1851 was approximately 60 per 1,000, while the death rate in Kildare and Wexford was under 5 per 1,000.15 Western counties had a particular reliance on potato crops, so when the crops failed from 1845 to 1849, western subsistence farmers and their families were especially vulnerable.

      Grimsley-Smith, in a fascinating analysis of admission rates over the decades following the Famine, notes a significant and sustained increase in admissions of 20- to-30-year-olds between 1857 and 1868 in Connaught (the area worst affected by the Famine) but not in Ulster, Leinster and Munster.16 She also points to the 1914 report of the Inspectors of Lunatics who examined statistics from this period and concluded, subject to certain caveats, that there seemed to be ‘an exceptional number of insane and idiots derived from the population born during the decade 1841-51’:

      It seems probable that children born and partially reared amidst the horrors of the famine and the epidemics of disease that followed it were so handicapped in their nervous equipment as to be weak minded from the start or to fall victims to mental disease later.17

      This supports the idea that, in the areas worst affected, the Famine altered early human development in such a fashion as to increase risk of mental disorder later on, in young adulthood. There are, of course, many challenges associated with reaching such a conclusion, not least of which are the potentially confounding effects of concurrent changes in committal practices, rates of co-occurring physical illnesses, patterns of migration, changes in population structure, declining rates of marriage, and various other demographic factors. There are, in addition, great challenges associated with interpreting diagnostic categories from the past and translating them into contemporary diagnostic categories, even on an approximate basis.18

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