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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 and hallucinations are rarely random in their content and are commonly, demonstrably shaped by context. This is surely equally true when they are sourced from archival case notes.

      Finnane, for example, recounts the case of a young woman in the Richmond Asylum in the early 1890s, who was brought up as an orphan in the workhouse but then went to prison and was later admitted to the asylum.84 According to the asylum case book, she was frightened when she believed she saw three nuns on a ladder beating their own foreheads with stones, and when distressed she believed herself to be dead. Might not this young woman have had good reason to fear nuns, or at least view them as difficult to understand and somewhat strange? And, following a difficult childhood, imprisonment and, now, incarceration in an asylum, was she entirely incorrect to consider herself, in a certain sense, ‘dead’?

      At the Central Criminal Lunatic Asylum in 1892, a 34-year-old servant from Dublin was admitted after being charged with the murder of her 8-month-old child. Her previous five children had all died young.85 The asylum’s case book records that, ‘on the morning of the crime, she took the child in her arms and left the house. She wandered off some distance from home, did not know where she was or what she was doing. She imagined that she was followed by a large crowd of soldiers and people’. A distressed young mother in late nineteenth-century Ireland, mourning the loss of her five children, feels persecuted and alone? True, there were no soldiers following her that morning, but surely there is still a very compelling truth in her delusions of persecution? Her feelings of being lost? Her hopelessness?

      The ultimate truth about what this or other patients thought about their committal and treatment may lie hidden somewhere in these evolving delusions and hallucinations, or in the patients’ own stories (wherever they may be), or even in the physical objects and personal effects that patients left behind when they died or finally left Ireland’s asylums behind them.86 Some of these objects and possessions are explored with particular power and poignancy in ‘Personal Effects: A History of Possession’ by Irish artist Alan Counihan, focusing on patients’ personal effects found in the attic of a disused hospital building at Grangegorman Mental Hospital in Dublin (later St Brendan’s).87 A profound sense of tragedy is palpable in many of these found objects and images, as is a sense of loss and, more often than one might expect, a real sense of survival, hope and life.

      For the historian, the methodological challenges inherent in hearing patients’ voices from the asylums of the past are all opportunities, complicated to navigate but by no means impervious to exploration, and certainly not impossible to understand. As a result, while the voices of patients from the 1800s and early 1900s might presently remain largely unknown, they are certainly not unknowable. Maybe we just need to listen harder and, perhaps, listen better. This book sets out to do so, insofar as possible, with particular focus on case histories and various other accounts and analyses of patients’ experiences inside and outside the asylums.

      The Title, Approach and

      Structure of this Book

      This book is titled ‘Hearing Voices: The History of Psychiatry in Ireland’. There are three reasons for this choice of title. First, ‘hearing voices’ (auditory hallucination) is one of the classic symptoms traditionally associated with mental disorder, so it inevitably features in any history of psychiatry. Second, as I’ve just discussed, this book is an attempt to hear voices that have not often been heard: not only the voices of patients in the asylums, but also those of clinical staff88 who lived their lives behind asylum walls, in circumstances that differed significantly, although by no means completely, from those of their patients.

      Third, evolving attitudes towards the experience of ‘hearing voices’ reflect important, iconic changes in psychiatry in recent decades, which I am very keen to highlight.

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