Irish Medical Responses to Problem Drinking from Institutionalisation to Public Health: Part I

In the first of this two-part series, Dr Alice Mauger, Wellcome Trust Postdoctoral Research Fellow at the Centre for the History of Medicine in Ireland, UCD, looks at the changing approaches of medical practitioners and psychiatrists to problem drinking in Ireland at the turn of the twentieth century.

After over 1,000 days of debate, in October 2018, the Irish government passed the Public Health (Alcohol) Bill. The Act will introduce minimum unit pricing as well as rigorous regulations surrounding advertising, sponsorship, sale and supply. Under this legislation, Ireland may become the first country in the world to attach stark health warnings to alcohol products. Billed as the first time the Irish state has legislated for alcohol as a public health issue, the Act is intended to significantly alter the culture of drinking in Ireland. While unsurprisingly the subject of extensive lobbying from the drinks industry and other stakeholders, the measures have gained overwhelming support from the Irish medical profession. The Bill’s tortuous passage is therefore a reminder of Ireland’s ambivalent and complex relationship with alcohol. This relationship is deeply embedded in Irish politics, culture and society and has a very long historical lineage. 

A ‘Disease Concept’ of Inebriety

Ephraim M. Cosgrave (1853-1928). Courtesy of the
Royal College of Physician of Ireland Heritage Centre

Like their European and American colleagues, by the 1890s many Irish doctors were describing the inability to resist alcohol as a disease. But the belief shared by many that the ‘drunkard’ was to blame for their condition, and therefore deserved punishment, was resilient. 

Perhaps the most ardent Irish medical commentator on alcohol in this period was Ephraim MacDowel Cosgrave, a physician at several Dublin hospitals who would later become president of the Royal College of Physicians (RCPI). For Cosgrave, the creation of institutions specially designed for the ‘control of inebriates’ would be the answer to Ireland’s ‘drink question’.¹  

Cosgrave was not alone in promoting this approach. Inebriate homes are said to have originated in the United States in the first half of the nineteenth century and by 1870 had begun to appear in Britain. Cosgrave’s stance mirrored British developments, where under the guidance of leading inebriety expert, Dr Norman Shanks Kerr, medical practitioners were canvassing for the system’s expansion. Yet, in Ireland, many doctors continued to recommend alternatives ranging from committal of drunkards to lunatic asylums to their detention at home by physical force.²  

Despite the almost draconian nature of these suggestions, such attitudes did not apparently extend to alcohol itself. Reacting to proposals to further restrict pub opening hours at weekends, in 1895 a contributor to the Dublin Journal of Medical Science declared:

We object to the grandmotherly legislation and coercion. The liberty of the subject is sufficiently restricted already, and the patience with which millions of law-respecting citizens tolerate the curtailment of their personal liberty, lest a weak brother should offend, is a marvellous testimony to our inborn respect for law. Restrictions and pledges cannot create an Utopia.³ 

Such claims diverged significantly from the now commonly accepted ‘disease view’ of inebriety, which saw alcohol as an inherently addictive substance, which put anyone who drank at serious risk of losing control over their habit. In Ireland, at least some doctors were openly contesting further restrictions, a fact which lends further weight to traditional portrayals of more permissive popular attitudes towards drunkenness in Ireland. 

Institutions for Inebriates

Painting by patient in St Patrick’s Hospital, Dublin (1905).
Source: E/137 Case Book, Males, St. Patrick’s, p.32.

Calls for inebriate reformatories in Ireland were eventually met in 1898. The Inebriates Act of that year was the first to extend to Ireland and allowed for the committal to state-funded reformatories of anyone who was tried and convicted of drunkenness at least four times in one year. But what medical reformers had been campaigning for – that is the compulsory power to detain non-criminal inebriates – never became law. In Ireland, this Act led to the creation of four specialist institutions. Of these four, only the Lodge Retreat in Belfast accepted non-criminal inmates and these were limited to relatively wealthy (fee-paying) Protestant women with no compulsory power for their detention. The remaining three institutions could only be accessed by those committed through the courts. Perhaps unsurprisingly then, this inebriate system was short-lived, catered for only a small proportion of Ireland’s ‘habitual drunkards’ and by 1920, all but the Lodge Retreat in Belfast had closed.

Instead, lunatic asylums became the principal treatment centres for problem drinkers. By 1900, 1 in 10 people admitted to Irish asylums were sent there due to ‘intemperance in drink’. This trend gained increasing attention among psychiatrists, not least because of mounting uncertainty as to whether excessive drinking could actually cause mental illness. Some asylum doctors recognised intemperance as a manifestation of an existing mental disorder, others cited adulterated alcohol as a cause and still more believed that the habitual drunkard produced offspring liable to insanity. This latter claim was to be expected, given that alcohol and degeneration were now strongly linked in discussions of the alleged increase of insanity both in Ireland and overseas.

Given the influx of these cases, the Irish psychiatric community were soon called upon to respond. In 1904, delegates at a conference of the British Medico-Psychological Association in Dublin were confronted with evidence of the ‘disastrous effects everywhere observed’ of drink. Reporting on this event in the association’s official journal, the writer proclaimed:

It may cause some searching of conscience to ask whether our profession as a whole, and particularly our speciality, have up to the present taken a sufficient leading part in the holy war against alcohol. It is high time for our Irish colleagues to make themselves heard upon this subject, when in at least one asylum, one third of the male admissions are attributed chiefly to this cause.⁴ 

This battle cry reverberated with the temperance rhetoric of the day, a movement which boasted strong support from some Irish asylum doctors. Meanwhile, members of the wider medical community showed signs of absorbing, and even propagating, the Nationalist-toned temperance claim that sobriety held the key to Irish independence. In 1904 a reviewer for the Dublin Journal of Medical Science decreed:

One of the heaviest blows which a patriotic Ireland could possibly inflict on its neighbouring British rulers would be given by taking the pledge all round – old and young – and keeping it! Why, we often say to ourselves, do not patriotic politicians utilise this fact?⁵ 

In spite of calls to engage in the ‘holy war against alcohol’, Irish psychiatrists made little comment in the ensuing decades. Soon after, discussion of the links between alcoholism and degeneration became seriously compromised by new scientific studies which found no evidence that alcoholism in a parent gave rise to mental defects in their children.

As will be discussed in the next instalment of this series, after the First World War, there was a shift in focus towards alcohol and later, problem drinkers, with the eventual acceptance of a new ‘disease view’. 

Alice Mauger

Dr Alice Mauger

Dr Alice Mauger is a Postdoctoral Research Fellow at the UCD Centre for the History of Medicine in Ireland in the School of History, University College Dublin. Her research project 'Alcohol Medicine and Irish Society, c. 1890-1970' is funded by the Wellcome Trust. The project explores the evolution of medicine's role in framing and treating alcoholism in Ireland. It aims to make a significant contribution to the medical humanities, exploring historical sources to better understand and contextualise Irish society's relationship with alcohol. Alice was awarded a PhD by UCD in 2014 for her thesis which examined public, voluntary and private asylum care in nineteenth-century Ireland. Prior to this she completed the MA programme on the Social and Cultural History of Medicine at the UCD Centre for the History of Medicine in Ireland, UCD. Both her MA and PhD were funded by the Wellcome Trust. 

Alice has published on the history of psychiatry in Ireland including a full-length monograph: The Cost of Insanity in Nineteenth-Century Ireland: Public, Voluntary and Private Asylum Care (Palgrave Macmillan: 2017), which is available via open access and in hardcopy.

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1 Ephraim MacDowel Cosgrave, ‘The Control of Inebriates’, Dublin Journal of Medical Science, Vol. XCIII (Jan-Jun 1892), pp.178-85.^↩

2 ‘Section of State Medicine’, Dublin Journal of Medical Science, Vol. XCIII (Jan-Jun 1892), pp.327-328.^↩

3 ‘Review of Norman Kerr, Inebriety: its Etiology, Pathology, Treatment, and Jurisprudence, 3rd edition’, Dublin Journal of Medical Science, Vol. XCIX (Jan-Jun 1895), p.50.^↩

4 ‘Intemperance’, Journal of Mental Science, 50, no. 208 (Jan 1904), pp.117-118, p.117.^↩

5 ‘The Medical Temperance Review’, Dublin Journal of Medical Science, Vol CXVIII (Jul-Dec 1904), p.140.^↩

Abortion and Symphysiotomy in Ireland

In this month's blog post Dr Lynsey Black, Lecturer in Criminology, Department of Law, Maynooth University, considers the legal and historical context of abortion and symphysiotomy in Ireland.

Law and Gender in Modern Ireland

Lynsey Black and Peter Dunne (eds.),
Law and Gender in Modern Ireland: Critique
 and Reform (Hart Publishing, 2019

We are currently in the midst of a ‘Decade of Centenaries’ in Ireland. For anyone working broadly in the field of gender, it is also clear that we have lived through a decade of reckoning. As editors of the recently published Law and Gender inModern Ireland: Critique and Reform (Hart, 2019), one of the key challenges has been to present the current legal regime in its historical context. As the book started to take shape, it became clear that the intersection of medicine, gender and the law was an essential part of this story. Within the collection, chapters by James Gallen (Dublin City University) and Máiréad Enright (University of Birmingham), which deal with symphysiotomy and abortion respectively, have provided insight into the role that gender ideologies played in medical practice in post-independence Ireland. Their chapters outline the prevailing historical context in which these medical procedures became emblematic of Catholic conservative Ireland, and the contemporary redress and reform which have attempted to resolve these wrongs.

Catholic society

The march of the Archbishops - Bishops etc.,
outside Pro Cathedral, Congress 1932, Dublin City.
Eason Collection, National Library of Ireland.

Law and policy on abortion and symphysiotomy took shape in the decades after independence, years in which the Catholic Church emerged as an imposing character. In this era of nation-building, Catholic social teaching informed the views of many in government, while members of the Catholic hierarchy offered policy contributions on matters integral to the creation of a Catholic society. Such input disproportionately affected the lives of women and girls, as morality, sexuality, and maternity became focal points for concern. These concerns were fundamental to the histories of both abortion and symphysiotomy. Measures enacted conspired to circumscribe women’s role to a narrow template of womanhood that revolved around the idea of woman as ‘child-bearer’.

Symphysiotomy

As Gallen notes, crucial to the project of nation-building was the valorisation of the family based on marriage, and the corresponding demonisation of women who became pregnant outside marriage. Gallen’s exposition of gendered historical abuse underlines the primacy of marital fertility in this abuse. Such ideologies had tangible consequences, in the preference for symphysiotomy over Caesarean sections to preserve female fertility. Symphysiotomy was often preferred as an alternative to Caesarean sections, considered a risk to potential future pregnancies. Symphysiotomy was a surgical procedure, requiring the partial cutting of fibres joining the pubic bone to the pelvis. Gallen outlines figures from the 2012 State-commissioned Walsh Report, which estimated that 1,500 women had undergone the procedure unknowingly from the 1940s to the 1960s. Its revived use in these decades ‘arose from a confluence of legal and religious gendered restrictions on women’s bodily autonomy’ (page 265). The procedure itself exposed women to the risk of health problems, and in many cases was carried out where it was entirely unnecessary, and against the standards of best practice.

Abortion

The primacy of fertility further influenced the intersection between medicine and the law with regard to the status of abortion, culminating in the insertion into the Constitution of Article 40.3.3in 1983, which created a near-total prohibition on abortion. Through the decades of Ireland’s independence, the legal position on abortion had created the context of unwanted pregnancy and forced birth. As with symphysiotomy, the case of abortion is illustrative of a wider historical failure in Irish law and society to prioritise women’s agency. As Gallen writes in relation to consent for medical procedures, there have often been priorities more highly valued by the Irish state than women’s consent and agency, namely, the preservation of women as child-bearers. Similarly, Enright notes that the Catholic template of motherhood had been one of self-sacrifice, and for decades ‘Irish abortion law has emphasised the protection of prenatal life in ways which efface women’s personhood’ (Enright, page 58).

Historical abuse

Gallen and Enright also elucidate the painstaking efforts to have historical abuse acknowledged and redressed, and to ameliorate and transform the ongoing harm caused by Ireland’s restrictive laws on abortion.

Survivors of symphsiotomy

In the case of symphysiotomy, on foot of the 2012 Walsh Report, in 2014 the Surgical Symphysiotomy Ex Gratia PaymentScheme was established, administered by Judge Maureen Harding Clark. Gallen highlights the efforts of the various groups that brought historical gendered abuse into the political foreground. Organisations such as Survivors of Symphysiotomy compiled victim-survivor testimony, often carrying out their own research where no such efforts were forthcoming from successive Irish governments.

Repeal of the 8th Amendment

A mural outside the Bernard Shaw pub in Portobello Dublin
depicting Savita Halappanavar and calling for a yes vote
in Ireland's referendum to remove the 8th Amendment.
Photo by Zcbeaton, Creative Commons Licence.

Enright too overviews the legal twists and turns which, in May 2018, finally led to the removal of Article 40.3.3 from the Constitution, replaced with the 36^th Amendment. The 36^th Amendment removes the constitutional ban on abortion and replaces it with a statement of the government’s capacity to pass legislation on abortion. As Enright notes, the legislation proposed in the wake of the May referendum has caused a dramatic change to constitutional law on pregnancy in Ireland. Like the recognition grudgingly given to victim-survivors of symphysiotomy, Enright discusses the necessary and transformative effect of activism in the reform of abortion law, overviewing the grass-roots campaign to remove the 8^th Amendment. Crucially, State recognition builds slowly from public awareness, and public disquiet.

Continuing concerns

As the authors note, gains made in this area are hard-won, and achieved against official obfuscation and denials of harm or responsibility. Crucially, any gains achieved cannot be taken-for-granted. In his chapter, Gallen emphasises how the State was, and remains, resistant to many of the arguments made by victim-survivors. Gallen outlines how the redress schemes falls short of international best practice in many regards, and is highly critical of the judgemental tone of many of its reports. Similarly, as the debate on the Regulation of Termination of Bill makes its way through the Oireachtas, the danger that the hopes of real reform could be stifled are very evident. Crucially, the intersections between legal and medical regimes remain a point of vulnerability felt particularly by women. Indeed, as recent developments regarding CervicalCheck have shown, the dangers of gendered medical mistreatment continue to be a real concern in Ireland. Although Law and Gender in Modern Ireland outlines many of the positive reforms in recent years, it does so with a note of caution.

Lynsey Black

Dr Lynsey Black

Dr Lynsey Black is a Lecturer in Criminology, Department of Law, Maynooth University. Lynsey researches in the areas of gender and punishment, the death penalty, and historical criminology. She completed her PhD in the School of Law at Trinity College Dublin in 2016. Her doctoral work examined the cases of women sentenced to death in independent Ireland. From 2016 to 2018, Lynsey was an Irish Research Council Government of Ireland Postdoctoral Fellow at the Sutherland School of Law, University College Dublin.

Her IRC-funded project took a comparative approach to capital punishment in Ireland and Scotland from 1864 to 1914. Recent collaborations include a public engagement and knowledge exchange project undertaken with Dr Lizzie Seal (University of Sussex) and Dr Florence Seemungal (University of the West Indies/University of Oxford) along with the United Nations Development Programme in Barbados. This ongoing collaboration is focused on reform of the death penalty regimes in Barbados, and Trinidad and Tobago.

Lynsey has published recently in Law and History Review and the Social History of Medicine, and is editor of the collection, Law and Gender in Modern Ireland: Critique and Reform (Hart Publishing, 2019).