Insight into the Patient Quandary

In this article, there are two objectives. First, an update on the trends of confinement related to social issues such as alcohol consumption and sexuality, indicating what role they played in the admission process in KDLA. Secondly, the objective is to highlight the limitations of the information sourced and the interpretation we can presently have on archival data.

Finnane (1981:146) suggests that historically, the contribution of alcohol as a causative factor in admissions to asylums, was exaggerated by contemporaries. Nevertheless, alcohol is the third largest documented cause in the Killarney District Lunatic Asylum (KDLA). Case studies indicate that alcohol was a factor in both male and female admissions. The debate on whether alcohol caused insanity or whether it was just the delirium of intoxicating liquors, was already established in Ireland in the early 1900s (Finnane, 1981:147). Certainly, throughout Ireland, there was a trend of repeated admission of individuals where alcohol was classed as the underlying cause. To substantiate this, the Killarney patient casebook referred to two different cases; one, who I will call Mary, was admitted repeatedly to the asylum. When under the influence of alcohol, she would be repeatedly violent and abusive towards her son. The other was also a female, who I will call Hannah, had a dispute with her husband when under the influence of alcohol and threatened to hurt him. She had no history of previous threatening behavior. Each female spends months confined in the asylum. Mary returned numerous times, always with alcohol related violence as a driving factor. Mary would spend a few months on average in the asylum and would then be released. In fact, in 1900, when offences were still logged in the admission book, it was noted that alcohol was frequently listed as an underlying cause. There was also the case of the young grocery assistant who was admitted on assault on a female servant and had alcohol cited as a contributory factor.

In 1901, the young were the main admission group to asylums with only one in seven patients over 60. Moreover, in contrast with England, single individuals were more likely to be committed than married (Finnane 1981:132). Finnane claims that lunatic asylums dominated any other form of social support such as the Workhouses which by the early 1900s, had fundamentally developed into a geriatric institute for the public poor (130). Within this population group, males under forty were the most common group to be admitted to the KDLA. Within that group, masturbation, was one of the most common underlying causes cited especially in 1915 and 1925 (Figure 1). Moral management initiated from the nineteenth century had a strong influence on what was perceived as a cause of insanity. Patients were remedied using the moral management approach rather than one based on medical principles. Moral management was theoretically founded on kindness and understanding and it encouraged recreation, religious observance, work and a good quality diet as aids to recovery. Under the umbrella of moral management, masturbation was regarded as an abnormal sexual habit that encouraged insanity. Two in five admission cases in 1925 were cited as having masturbation as a contributory cause and it was usually the fourth most common causative listing after hereditary, previous attacks and alcohol. Additionally, though the religious order did not gain authority to run the asylums, unlike other institutes in the Irish Free State, their religious perspective on society was powerful and they preached of the immortality of masturbation. This was a further factor in masturbation being logged as a causative factor for insanity. In one case, referred to in chapter 2, the male patient cursed his brother for introducing him to the habit and felt that it caused spirits and the devil to occupy his body. Predominately, the patients were young males, some with no other clear signs of insanity.

Figure 1


Interestingly some of the medical staff in Irish asylums questioned the diagnosis of insanity and especially the accuracy of the information. Brendan Kelly (2016) refers to the works of Dr Edward O’Neill, medical superintendent of Limerick District Lunatic Asylum in 1903. O Neill published a paper called Increase of Lunacy and Special Reasons Applicable to Ireland where he suggested that Ireland was struggling with accurate data collection and claimed that,

‘obtaining satisfactory information as to the causes of the increase, owing (1) to the meagre and unsatisfactory returns afforded by Asylum Records, and (2) the insufficient description derivable from the admission forms’.

O Neill argues that the criterion for data collection in Irish lunatic asylums was not reflecting the real causes of the rising admissions of patients into asylums and that the famine had affected the natural resources and stamina of the poor in Ireland, resulting in an increase in the pauper lunatic resulting from the ‘inevitable result of mental and physical degeneration’. He named diet, hereditary factors and especially masturbation, in the post famine generations as the main contributors to the insanity levels among the poor. Though O Neill was a strong supporter of the moral management of patients, it could be argued that he found the Irish asylum records did not accurately reflect the situation of that era, leaving a gap of knowledge on why insanity diagnosis were rising so rapidly in Ireland. He possibly felt that immoral factors contributing to insanity were under represented.

It wasn’t only males and masturbation that was a focus of insanity diagnosis. Females and their reproductive cycle were frequently cited as an underlying cause. Lactation, menstrual troubles, climacteric (menopause), childbirth (especially frequent childbirth) and puerperal mania or puerperal melancholia were cited as underlying causes or the actual diagnosis. Popular medical literature of the 1800s and early 1900s often cited reproductive ailments or functions as an underlying cause of insanity (Figure 2). Conditions such as puerperal insanity were a frequent diagnosis noted in early 1900s admissions to the KDLA. According to Marland (2004), puerperal insanity is a mild and curable condition aligned to childbirth and was used by medical professionals to justify the inherent weakness of females and vulnerability to insanity. There may well be an element of control over the poorer women who suffered with physical, emotional or mental dysfunction related to their reproductive system. These women or young girls, often ended up in the asylum for a length of  time, sometimes long after symptoms had declined.

Figure 2

Both males and females were subject to prolonged stays in the KDLA. Going on the admission statistics for 1920, the average stay in KDLA was 5.2 years while Cox noted that most patients spent one year or less in the Carlow district asylum (2012: 141). Cox has shown that not only were most patients released from asylums, periods of confinement were not especially protracted (Cox 132). Finnane suggest that this was also true in Ireland where most patients were discharged. This indicates that KDLA may have had some other factors encouraging their longer length of stay. Possibly familial, social, emigration, bureaucratic factors and of course, the practice method of the medical staff may have had influence over the longer confinement. Most of these factors would not be unique to County Kerry, so a future comparison of these variables may shed some light on why patients appeared to stay longer in the KDLA or if indeed, as Dr O Neill, from Limerick asylum suggested, there were omissions or inaccuracies in the records collected.

Expanding on Dr Edward O’Neill claim on inaccurate data in 1903 correlates with some of the findings from this research. The archives are, indeed, a primary source of data and do give an exceptional insight into the socio-demographics, however there are aspects that are difficult to quantify. In 1900, most patients admitted were in fair health, by 1930, the majority were in good health. Poor health didn’t vary much over the years. While this should be explanatory, discrepancies are observed when the case books are researched. For example, in the case of the young grocery assistant boy. He was recorded in the admission books as having fair health, however, on investigation of his case book notes, he is described as undernourished and small for his height. Clearly, our present-day evaluation of what considered as fair health may not correlate with health standard over a hundred years ago or with an environment where food security was normal for the general population.

General socio-economic stresses and the potential epigenetic changes for generations after a famine are also likely played a role in increasing demands for asylum admissions. Grimsley-Smith, (2012) argues that post-famine admissions to lunatic asylums were a biological event and that severe nutritional deprivation has long-lasting biological and psychological consequences that predisposes individuals to mental health problems as well as shaping how societies and some of the social features develop. Walsh (2015) states that the severe nutritional deprivation between 1845 and 1850 may have caused epigenetic change which consequently could have predisposed survivors of the Great Famine to mental and physical health problems. It is unclear, however, what proportion of admissions to the Killarney asylums was truly suffering from mental disorder and what quantity presented with other complications (e.g. intellectual disability, social deprivation, malnourishment). Certainly, the emergence of the ‘dangerous lunacy’ measures in the 1830s appears to have accelerated admissions well into the 1900s. Nationally and internationally, it was noted that underlying health problems such as thyroid, general paralysis of the insane (syphilis), phthisis (Tuberculosis-TB), pernicious anaemia and undernourishment were contributing factors to admission to mental asylums. In 1914, medical attendant of Killarney asylum noted that many females had suffered ill-health prior to admission and in the case book exploration, influenza had been recorded as an excitation and/or a cause of some forms of insanity. Moreover, the farm produced diet of the KDLA was often of better quality, variety and nourishment in comparison to the diet of the County Kerry poor. Some cases noted a significant improvement after rest and nourishment. However, TB or phthisis was common in Irish asylums and KDLA was not exempt.

Indeed, Dwyer (2002), reported that there was an average of six deaths per month during 1910. A wide range of diagnosis were contributed including acute melancholia exhaustion, pulmonary tuberculosis, acute mania exhaustion, chronic mania, organic brain disease, acute mania, brain atrophy, senile decay and lung congestion of the lungs. Medical diagnostic terminology is not consistent to the symptoms described by different medical doctors in the casebooks. There was a lack of coherence or consistency in the use of some contemporary medical terminology. Melancholia and Mania are two different conditions. One is an excitatory form of insanity, subject to restlessness and unstable mood; the other, melancholia correlates with modern day depression. In some cases, both terms are used interchangeable. Whilst this may be an accurate description of the patient’s symptoms and could be argued that it correlates with present day bipolar, Dr O Neill belief that the records were inconsistent and inaccurate at turn of the century are also a concern. There is also a recognised health vulnerability for individuals with mental illness with statistics demonstrating a correlation with reduced life span and mental health (Ward 2010). This may also have been a factor in the early 1900s, as well as the acknowledgment that life span in that era was significantly lower than present day. Therefore it is possible that there was a recorder bias in writing up the admission and case notes; diagnosis and symptom listing may follow this bias and general health vulnerabilities and reduced life span of the early 1900s may not have been recognised as contributory factors of poor mental health.

Another limitation was the rare recording of suicide in the KDLA admission books (and therefore not registered with the Inspector of Lunacy annual reports). When cross referencing case book medical histories with the admission books, it was found that cases of suicide such as the patients attempted to cut their own throat or drown  themselves, would be written up in the case books but not in the admission books. Case No 7 in article on case histories is an example of this. Another patient was admitted because they were found with a razor attempting to kill themselves and continued to stay in the asylum until the desire was gone. Though this patients case notes clearly records the suicide attempt and desire, there was no record of suicide in the admission book, only a simple diagnosis of melancholia. In fact, the case book sample representation had numerous accounts of suicidal behaviour. Because of the danger associated with attempted suicide, the national policy was to protect and prevent rather than cure. Both suicide and insanity were often seen as by-products of modernity, poverty and the stresses of a modernising society. It was still an offence in the early 1900s and it may have been a policy to disguise the suicide attempt under the label of an insanity diagnosis rather than go before a judicial court. Attempted suicide, and the risk of suicide, were vital criteria in the determination and classification of insanity and the decision of families, communities, workhouse officials and local medical practitioners to seek admission to the asylum (Wright & Shepard 2002). Violence, abusive behaviour perpetrated by and on the mentally ill in addition to suicidal behaviour formed the back drop to most asylum certification (Wright: 94).

Overall, patient case notes and the admission book store a wealth of information. It requires some investigation and delving deeper to get a clearer picture of what the records mean. It is important to understand what society and the medical professions perspective of insanity was in the era. It also requires some acknowledgement of potential bias and why the bias exist.  A comparison with today’s perspective on mental illness and the contributory causes would be a valued comparison and insight. While masturbation would not be regarded as a contributory cause of mental illness in Ireland today, there are perspectives that align female reproductive dysfunction with mental illness (e.g. increased risk of depression with polycystic ovary syndrome). Additionally, alcoholism is still cited as a significant contributory, causative and sign of mental illness in Ireland. As is, suicide, attempted suicide and self-harm, which like the records of the early 1900s, may still be under-reported. As much as we have moved away from descriptive terms for insanity, we have still found similarities with the mental health of patients today and in an era past.

For further discussion on some of the themes, check out A Few Short Words on Jail, Asylum and Psychiatric Care

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