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History of Mental Health Services in Ireland

A Nation once again.  

Dr Dermot Walsh        


    PLEASE NOTE :  the terms used in this article reflect the language of the day and denote the historical context                                           

 

The recent establishment of a truly national body representing Irish psychiatrists and entitled the  College of Psychiatrists in Ireland, replacing the British- based Irish Division of the Royal College, which in recent years had adopted, confusingly and inappropriately the title Irish College of Psychiatry, is of such  importance as to deserve a historical review of our association with the British College and attempts to create an indigenous body.                                                        

 


In the nineteenth century following the passing of the Act of Union in 1800 Ireland formed an integral part of the United Kingdom of Great Britain and Ireland although with its separate administration based in Dublin Castle. 


It was therefore natural that professional organisations in medicine should align themselves with those of the Kingdom as a whole. Indeed the Royal College of Physicians in Ireland had been formed as far back as 1654.      


St Patrick's Hospital Dublin, Founded by Dean Swift                                                       

 


As far as psychiatry was concerned, although there had been sporadic asylum provision prior to 1800 it was not until the early years of the century that the beginnings of a network of asylums in the constituent parts of the Kingdom, including Ireland, came into being. 


By 1840 there were eight public  and  a number of private asylums in Ireland.                                                                                                                        

 







District Lunatic Asylum Castlebar,Co Mayo

in the 1890's


Asylum doctors began to replace lay managers in what has been called the “medicalisation” of asylums. Notwithstanding, asylum doctors began to feel isolated and alone (they were at first often the only doctors in the asylums) and resentful of the subsidiary role thrust on them by the visiting physicians to the asylums.                                                                                                                

 

It was from this vulnerable beginning in 1841 that Dr. Samuel Hitch, Resident Physician of the Gloucester Asylum, circulated all visiting physicians and resident medical superintendents, 88 in total, of 26 asylums ,of which 11 were in Ireland, with a view to holding annual meetings for consideration of  common interests and purposes. Forty four replied favourably and a preparatory meeting was held in that year in the Gloucester Asylum. This meeting resolved that an Association be formed and the inaugural meeting of the Association of Medical Officers of Asylums and Hospitals for the Insane was held later in 1841. It is not know whether there was Irish representation.


The second meeting of the Association was held at the Lancaster Asylum in 1842 to facilitate the attendance of members from Scotland and Ireland. Once again it is unclear how many, if any, Irish attended. However at the Association’s third meeting there were only eight attendees, one of whom was Dr. Robert Stewart of Belfast, who at the fourth meeting in 1844 acted as secretary in the absence of Dr. Hitch and, who at the fifth meeting in 1847, was elected honorary secretary for Ireland. In 1846 an Office of Lunacy was created in Dublin Castle and with it the posts of Inspectors of Lunatics in Ireland and these officials were also ex-officio governors of district asylums.  The first Inspector was Dr. Francis White joined by  Dr. John Nugent, formerly travelling physician to Daniel O’Connell, in the Inspectorate -  one Protestant, the other Catholic for the sake of political correctness.






The AsylumCarlow 

Handtint photo from 1890's




At first the Association was headed by chairmen and it was not until 1854 that the first president was elected. By 1855 the Association was publishing the Asylum Journal of Mental Science, which superseded the Asylum Journal established in 1853, and was later to become the Journal of Mental Science in 1858 and the British Journal of Psychiatry in 1963.  In 1865 under the chairmanship of Dr. Wood, and at the suggestion of Henry Maudsley, the Association changed its name to the Medico-psychological Association by which time there were 12 Irish members.                                                                                    

 

From the very beginning the Journal showed a lively interest in Irish affairs. It published a detailed account of the Report of a Commission Inquiring into the Erection of District Lunatic Asylums in Ireland in 1855. All three Commissioners were English! They proceeded from the principle that “lunatic asylums are hospitals for the recovery of curable patients and houses for the reception of incurable lunatics and not prisons for the safe custody of dangerous madmen”. They found an excess of embellishment at  the asylums at Cork and Sligo, that the driving rains had penetrated the walls in six asylums and that the walls were reeking with wet in Cork and Killarney ( a defect never fully remedied in the latter). They concerned themselves with heating, lighting and the conditions of privies. The same issue of the Journal commented that only a small number of public asylums of Ireland published an annual report.

 

In its issue of January 1859 the Journal gave pride of place to the  critical Report of the Lunacy Commissioners into the State of Irish Asylums and the riposte to these  severe criticisms by one of the Inspectors, Dr. Nugent, to the Chief Secretary, the Viscount Lord Naas. It is of interest that the long-running issue of the need for posts of visiting physicians to asylums (appointed to take care of the physical illnesses of patients) was dealt with by the Commissioners in favour of their abolition, despite the opposition of Dr. Dominic Corrigan president of the College of Physicians. The Commissioners, who were English, were highly critical of many aspects of Irish asylum care and administration. To Dr. Nugent’s robust response the Journal had this to say, lacking geographical exactitude, ” of course no one likes to be found fault with, even in a conciliating manner; and Paddy himself could not persuade his friend to relish a broken head because his shellagh (sic) was made of rose-wood. But the shellagh of the Commissioners is a black-thorn with the thorns on it: and at Killarney they certainly omitted to salute that blessed stone which sheds the influence of honied speech on Irishmen”.

 

Despite these English witticisms the Irish connection was strengthened in 1861 when Joseph Lalor of the Richmond became the 7th  and first Irish president. Only 21 members attended this meeting which was held in Dublin.  Much of the business oif the meeting resolved around the matter of the role of the visiting physicians which was held to demean that of the resident physician who, after all was the expert in dealing with mental illness. After the meeting a deputation met with the Chief Secretary, Sir Robert Peel, and brought the matter to his attention.                                                                                                                            

 

As a result the  April 1862 issue of  the Journal welcomed the Revised Rules of the Irish Government for the better Control of District Lunatic Asylums in Ireland. In particular it welcomed the affirmation of the role of the Resident Medical Superintend putting at rest “such disreputable freaks as occurred from time to time in the Maryborough Asylum.”, This refers to a bitter dispute between the resident physician (Dr Burton) and the visiting physician ( Dr Jacob), in that institution, which led to the “Maryborough Investigation” being fully reported in the Journal. By 1862 there were 200 members of the Association of whom 26 were Irish.








District Asylum Maryboro (now Portlaoise)

                                                                                                                        

                                                           

In April 1869 the Irish Secretary, Dr. Stewart died. In 1835 he had been appointed as resident physician to the Belfast District Asylum and was in effect the first Irish medical superintendent. He was regarded as the Father of the Irish Asylum service according to his obituary notice in the Journal.” From the outset he was a warm supporter of the Medico-psychological Association and its first branch secretary for Ireland. He was an early adherent of the non-restraint system of treatment and a frequent contributor to the Journal and other medical periodicals”.                                                                                                                                                                     

 

In 1875 Dr James Duncan became the 2nd Irish president of the Association and delivered the Presidential address in the College of Physicians in Dublin. He had succeeded his late father as superintendent/proprietor of Farnham House, a private asylum in Finglas. During the course of his address Duncan, referred to the College of  Physicians “ it deserves to be put on record that the Irish College has not made the cultivation of this branch (lunacy) a bar to the attainment of its highest offices. Two of my predecessors in the presidential chair, Drs. Mollan and Banks were physicians to the Richmond District Asylum”. Having stated that those who treated the mentally ill were emerging from the stigma hitherto attaching to them he went on to assert the importance of recognising lunacy as deserving a scientific approach and, echoing English criticism regretted that “ the Irish contingent of this Association has done so little for the practical advancement of the science. So far as psychological literature is concerned we are all unhappily charged with the reproach of silence”. As we shall see this was about to change. He pointed out that only four of the 22 Irish asylums had a second resident medical officer.  For the rest he was content to raise the long running issue of pensions and the destructive influences of modern life on mental health and its causative role in lunacy.                                                                                                                        

 

In 1885 Dr. J.A. Eames, superintendent at Cork was elected President and delivered his presidential address at Queen’s College, Cork (later UCC). Some of his address was apologetic for the state of Irish asylums but with pride he pointed out that  “ While we are behind you in many matters we must take  credit in one important particular, namely having a course of instruction in mental diseases made compulsory in the curriculum of the Royal University of Ireland and students be obliged to pass an examination in the same before obtaining the degree of MD”. His lecture was largely taken up with the history of lectures on mental disease which in Ireland dated back to 1845. He then went on to announce the bequest of the late Dr Henry Hutchinson Stewart of a scholarship to the annual value of 50 pounds tenable for three years for proficiency in the knowledge of mental diseases.                                                                                                                                                                                            

 

In 1886 the Journal announced the death of Dr. Eames and ran an obituary on Dr Joseph Lalor praising, inter alia, his bringing a system of education into the Richmond asylum. Thus within a short period of time two former Irish presidents of the Association had passed away. Lalor had retired in 1886 and died some months later aged 76     

                                                                                                                                        

 BY now the Irish division was holding regular meetings usually in the College of Physicians followed by dinner in the Shelbourne Hotel but sometimes at an asylum on the invitation of the superintendent. However the number present was usually small and representative of the more senior members.  At the January 1886 meeting there were but seven recorded as being present.  In 1887 William Thornley Stoker, visiting surgeon to Swift’s Hospital, was elected a member of the Association. At the Irish branch meeting at Physicians in 1889 there were 13 members in attendance, when a number of papers were presented.

                  






Jonathan Swift, Dean of St Patrick's Cathedral, Dublin, 

Author of Gulliver's Travels

Founder of St Patrick's Hospital in Dublin






Sir George O’Farrell, Inspector of Lunatics in Ireland was elected the only Irish honorary member of the Association in 1891. In 1893 Connolly Norman advocated that the rules be changed to allow women to become members of the Association and he proposed as the first female member Dr. Eleanora Fleury who was working with him in the Richmond. Despite some resistance the rules were amended and Dr. Fleury was elected a member in 1894. This same year saw Connolly Norman present his presidential address at the College of Physicians, Dublin. The death of former President J.F. Duncan who had also been vice- president of the College of Physicians was recorded in 1895.                                                              

 

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                By 1899 Connolly Norman had become one of three editors of the Association’s official organ, the Journal of Medical Science. Sir John Nugent, the acerbic Inspector from 1847 to 1890, died in the St George’s Club Hanover Square, London on 26 January 1899 at the age of 94. He left 34,000 pounds. Described as a good hater he had been a foundation pupil of Clongowes and of the Reform Club.  The January 1901 issue listed 48 Irish members and in the April issue members extended a warm welcome to Edward the Seventh and commiserated on the death of their late Queen and Empress, Victoria.

 

The annual meeting of the Association was held in Cork at the Queen’s College, Cork later that year (1901) under the presidency of Dr. O.T. Woods of the Cork Asylum, with the annual dinner taking place at the Imperial Hotel  at a cost of one guinea per ticket on July 25th.The Royal Cork Yacht Club opened its doors to members. Oscar Woods delivered his presidential address at this, the 60th Annual meeting of the Association                                                                                      

 

The Journal in 1905 gave copious attention to the auxiliary asylum to Cork at Youghal and of the Sligo Asylum, It was amused at the goings-on at Monaghan where a motion was  put to the Board that a medical opinion be arranged to determine whether Dr. Taylor was capable of carrying out his duties as RMS in view of the present state of his eyesight. The writer commented on the manner in which the proceedings were carried out “in lively original and truly Hibernian character which the mere Saxon never can understand”. Early 1908 say the death of Connolly Norman who was also vice president of the College of Physicians and who wa remembered by a portrait in Physicians and a mural in St. Patrick’s Cathedral.                                                                        





Monaghan Lunatic Asylum Fire Brigade

Early 1900's.                                                                           

 




Also reported in 1907 was the retirement of Sir George O’Farrell, Inspector of Lunatic Asylums. The summer meeting of the Irish Division received a letter from Mr. Winston Churchill conveying the thanks of His Majesty the King and Queen Alexandra for the resolution passed at the last meeting ( I have been unable to trace what the resolution concerned).

 

Then in 1911 came W.R. Dawson’s celebrated Presidential address on “Relation between the geographic distribution of Insanity and certain social and other conditions in Ireland.” Dawson was by now Inspector of Lunatic Asylums in Ireland. The meeting took place in the College of Physicians and a farewell dinner was held in the Shelbourne Hotel.  Nineteen fifteen also saw the Journal publish the “ Asylum roll of honour” containing the names of assistant medical officers who had joined the Royal Army Medical Corps (RAMC) of whom seven were from Irish asylums.  The journal regularly published the name and asylums of successful Irish candidates in the nursing certificate examinations.

 










Portrane Auxiliary Asylum opened in North Co Dublin 
in 1903 as an Auxiliary Hospital to St Brendan's which 
had become chronically overcrowded.









Many asylums were designated “ War Hospitals” for the reception and treatment of soldiers with psychiatric illness; their superintendents  were ex-officio created lieutenant colonels of the RAMC. Among them was the Richmond and its RMS, Dr O’C Donelan. W.R. Dawson, now Major Dawson, was presenting to the Division on his experience of shell shock and associated problems in soldiers. At the April 1917 meeting a resolution was passed  to appoint a committee“ to consider the position of asylum officers in regards pension under a possible home rule government”                                                                           

 

The first item in the April 1920 issue of the Journal was a black- lined obituary with a full page photograph running to six pages by W.R Dawson of Thomas Drapes who had died on October 5th 1919, having retired from Enniscorthy on May 15 of that year and having attended the annual meeting of the Association at York in July. Knowledgeable in European languages he was elected co-editor of the Journal of Mental Science in 1912, later to become editor. The next meeting of the Irish division were concerned with what element of government would cater for the asylum system in the new State and what the effect on superannuation might be and in 1920 the division addressed a memorandum to the Chief Secretary on the topic.                                                                                                                  

 

In October 1924 at the 83rd annual meeting in Belfast, Dr. Nolan of Downpatrick delivered his presidential address “ Some considerations on the Present-day knowledge of Psychiatry and its application to those under care in Public institutions for the Insane”. In 1925 W.R. Dawson, OBE, Lt. Col and now Chief Officer of Home Affairs Northern Ireland had published a paper on the “The Work of the Belfast War Hospital”                                                     

 

IN 1931 Dr.Leeper of St. Patrick’s delivered the 90th Presidential address to the Association in Dublin and this was published in the Journal as an original article, on July 8th entitled “Some reflections on the progress of psychiatry”. Included in his text was “ Of Freudian doctrine I have read much but evermore came out from that same door from wherein I went. Much seems to me utterly fantastic and repulsive to a sane and disciplined mind …….”.

 

In July 1935 there was an obituary on by Dawson on Thomas Considine who had joined him in the Inspectorate in 1911. Nineteen forty two saw the obituary of Leeper and 1945 that of Nolan who died 27 December 1944, having entered psychiatry in 1888.In 1951 Finnigen of Mullingar, a former chair and secretary of the Irish division was laid to rest to rest among his demised patients in the Mullingar patient’s cemetery;  he was aged 99.                                                                             

 

Finally in 1956 The Journal gave lead place to the 114TH presidential address in Dublin by John Dunne on “The contribution of the physical sciences to psychological medicine”. This concluded 26 county involvement at the highest level of the RMPA. However Dr William McCartan of the Nortern Ireland Ministery of Health and Local Government served as President 1961-62.                                                                               

 








Notice on the Regulations for the Bathing of Patients

signed by Dr John Dunne 

Resident Medical Superintendent

Grangegorman Mental Hospital  






                                                                            

The relationship of the Irish to the British Association in the 19th century was certainly very close, “loyal”  and sustaining when the number of Irish asylum doctors was small. What the English thought of their Irish colleagues is unclear despite some occasional jocular references in the Journal. On this issue the US psychiatrist Fuller Torrey had this to say  “ Irish psychiatrists were members of the British Medico-psychological Association but were looked down upon by many of their English colleagues. The annual summary of Irish mental hospitals published in the Journal of Mental Science was routinely disdainful and on those occasions when the Irish statistics appeared favourable, the English editors still faulted them. For example, in 1878, the Irish asylums recorded a very low number of suicides for the year. The editors of the Journal of Menial Science responded that “ this number is far too good to be satisfactory for it implies too little liberty given to the patients” The “right” suicide rate was apparently the English rate, more than that or fewer than that could be equally criticised”1. And indeed the editor and author of the first definitive textbook on mental disease in these islands, the Scot T.S. Clouston referred to the Irish peasantry as “primitive”.

 

In a sense the latter decades of the 19th century had been the golden age of Irish psychiatry in an era where much was empirical and science was starting to feel its way with influences from continental Europe beginning to permeate asylum thought and practise. Irish psychiatrists, whatever the English thought of their poorly funded asylums, were making more than their pro rata contribution to the Journal of Mental Science and more local publications such as the Dublin Journal of Medical Science and the Medical Press and Circular. The senior figures from this era had made scientific curiosity and enquiry part of their daily equipment. Significant papers to the Journal such as Lalor on Education and Training in Treatment,  Connolly Norman’s three part series on Hallucinations, on Cocainism, and on Lunacy Legislation complaining that under the Dangerous Lunatics Legislation lunatics were conveyed to the asylum by two policemen armed with rifles. The next issue of the Journal had a note by Petit of Sligo pointing out that, following Norman’s letter, the Inspector General of Constabulary in Ireland had issued a circular to the effect that “ In future all escorts with lunatics are to carry truncheons only”, Nolan of Downpatrick on Katatonia and Folie a Deux, his colleague Cotter, on 31 cases of Maniacal –depressive insanity treated in the Down asylum, Finnigen of Mullingar on Dress-fitting for Female Inmates of Asylums, Graham of Belfast on Psychotherapy in Mental Disorders, Drapes of Enniscorthy on Psychiatric Terminology and Classification and on the Treatment of Pthisis in Asylums. Drapes was also contributing on the Manic-depressive Insanity of Kraepelin and questioning whether there “ was such a disease as he postulates”. There were several other less well-known Irish contributors as well.  

                                                                                                             

From 1948 onwards the issue of a College of Psychiatry was prominent and a committee was formed to examine and report. There were no Irish members of this committee. A long and tortuous path followed which involved consideration of the new College becoming a faculty within the College of Physicians, a free standing College or an updated RMPA. Eventually the Privy Council acceded to the request to form a Royal College and it became a reality in 1971. There was little or no input from Ireland, not surprisingly as the legislative and other considerations establishing the College had no force in Ireland.

 

As far as postgraduate education in Ireland was concerned the attainment of a Diploma in Psychological Medicine (DPM) was sufficient evidence of professional qualification and expertise to obtain a permanent position up to that of Superintendent in the Irish psychiatric service. DPMs were instigated in the 1950s and were awarded by UCD, TCD and RCSI. In some cases there were formal lectures, in others not. With the formation of the Royal College and the introduction of the Membership examination the DPM become of minor importance and trainees aimed at the membership or exceptionally a Physicians’ membership in psychiatry.. However existing members of the RMPA became grandfather MRCPsychs. In 1971 the College assumed the right to inspect and approve training posts and set up a Joint Committee on Higher Psychiatric Training which incorporated a representative from the Republic of Ireland. The Irish Division, together with nine other divisions of the College took part in this accreditation exercise so that members from other divisions visited Irish services for accreditation purposes and Irish members went to other divisions appraising training programmes. These began in 1977. With the establishment of the Post- graduate Medical and Dental Board, the Irish Psychiatric Training Committee (IPTC) was established and controlled both basic and higher training. Effectively it was an implementation body for the training programmes of the Royal College and played little or no role in their design.                                                                 

 

By the late 1950s stasis in Irish mental health services had reached such a point that it was necessary to establish a Commission of Enquiry on Mental illness in an attempt to move matters forward. This, despite the continuing adherence of some Irish psychiatrists, in name anyway, to the Irish division which held meetings from time to time. However the link with Britain had by now become very tenuous. The Irish division had no location of its own, presumably seldom availed of the distant headquarters in Belgrave Square (acquired in 1973) and as far as corresponding with its own members was concerned was obliged to forward letters to London for dispatch back to Ireland.

                                        

In those days other medical specialities in Ireland were establishing their own national identities, the obstetricians had set up their Institute, anaesthetists were acquiring their own location and these and others were creating their own Faculties within Physicians, setting up their examinations and accreditation procedures while psychiatrists were still sending subscriptions to London. However there those psychiatrists who had begun to think that an independent nation with its own legislative and administrative frameworks needed representation tailored to its own requirements and environment. One of the signs of this sentiment for the colloquial was the establishment of an Irish Journal of Psychiatry in 1990. A few years later, in 1993, Irish consultant psychiatrists were circularised as to their views on the establishment of an Irish representative body. The response was sufficiently encouraging to result in a series of meetings extending from 1993 to 1995 at which the issue was thoroughly debated. While there was considerable support for the establishment of an indigenous body among many members of the group, conservative views prevailed and no progress was made at that time. It was considered by some that the Irish division had become a constricted and dependent body and had exrerienced little sucess in progressing  the interests of Irish psychiatry in the round, Notwithstanding, inertia prevailed fuelled by speculation that had raised significant anxieties among trainees that joining an Irish body might limit their training and employment prospects in the UK. In the face of a perceived threat to their hegemony, or for other reasons, the Royal College established an office in Dublin for the Irish Division. This now styled itself the Irish College of Psychiatry without any legislative foundation  to do so.

 


The result of this approach was to delay for over a decade the establishment of material assets for the second largest group of consultants in Irish medicine. However the impetus of 1993 was not entirely extinguished and in the early 2000s attempts led by Dr. Justin Brophy and a small group of like-minded consultants established the Irish Psychiatric Association as a national professional body. The final twist in the quest for autonomy, ironically, did not, in this author’s assessment, come from within. In 2003 the control of medical education in Britain passed from the Royal Colleges, including that of psychiatry, to a new, more broadly-based body, the Postgraduate Medical Education and Training Board. 


In these changed circumstances the British College informed the IPTC that it would no longer inspect and accredit training in Ireland. This perhaps, more than anything, propelled Irish psychiatry towards autonomy with the necessity of taking responsibility for our own training, accreditation and examinations, a task that is now being progressed by the IPTC which hitherto had solely implemented the British scheme.                                                                                                                   



Dr Justin Brophy

First President of the College of Psychiatrists in Ireland

 

At the same time meetings between the  Irish College and the IPA began, ultimately resulting in the formation of a College of Psychiatrists in Ireland with effect from the first of January 2009 and with the incorporation of the IPTC as a central element. The structures of the new body have been constitutionally established and Dr. Brophy himself elected as the first president. The College has acquired temporary accommodation and secretariat but appears to have rejected aligning it self with the Irish College of Physicians despite the long association of its predecessor in the 19th century and the evident professional and practical advantages of such an alliance. The Department of Health and Children has generously donated a substantial sum on a one-off basis to help the College establish itself. Its day to day activities and training and education will be supported by subscriptions and fees.                                                                                                                        

 

Thus after a century and a half we have an indigenous body and the responsibility of managing our own affairs within our own legislative and administrative frameworks. Irish psychiatrists owe a debt of gratitude to the Royal College and its predecessor for the support and guidance they have accorded their Irish counterparts over this time, particularly in education and training and in the employment of Irish trainees in UK centres of excellence – an arrangement that will still be available to our graduates should they wish to avail of it. It might, of course be alleged that the British connection in later years delayed our independence and self-reliance and that it might have been better for us had they encouraged us in that direction earlier. Finally it will be for later historians to ponder whether the withdrawal of the Royal College from our educational and accreditation scene was the essential catalyst for the establishment of the College of Psychiatrists in Ireland and whether, had this not happened, it would still be in abeyance. To date its creation has met with general acceptance by Irish psychiatrists who acknowledge the necessity and inevitability of the change but who must also invest a large personal stake in its future.

 Reference                                                                               

 

1.  Fuller Torrey, E. and Miller, J. (2007). The Invisible Plague. The rise of mental illness from 1750 to the present. Rutgers University Press. New Brunswick, New Jersey and London.  


See Also Historical Collection at St Brendan's Hospital Dublin                                                                                                  

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