Disease and the early days of asylum

By 1874, it was recorded in the Minutebooks that ‘fever’ had broken out in the asylum on three occasions and there were no isolation facilities although the Resident Medical Superintendent Dr John Charles Robertson (RMS Monaghan Asylum, 1869–1885) had pressed for them. In December of that year, the RMS noted that one female patient and one nurse had contracted scarlet fever in the preceding month. The patient died and the nurse was sent to the County Fever Hospital. Twenty years later, the Inspectors of Lunatics, in their annual report for 1894, called the attention of the Governors of the asylum to the danger ‘which would accrue in so large an institution in the event of an outbreak of any epidemic’. They added that there were ‘serious warnings’ of a ‘visitation of cholera’ during the coming summer. They suggested the erection of one or two wooden huts, capable of accommodating about a dozen patients so as to isolate the infected cases in the event of cholera or other similar disease making an appearance in the asylum. Four years passed and, on 18 May 1898, the local newspaper The Northern Standard discussed the cost of erecting cholera sheds and purchasing ‘a disinfectant apparatus’. When sheds were eventually built, they were soon filled with patients: however these patients were victims of overcrowding not disease. The provision of proper isolation facilities was still unresolved in the mid 20th century. Overcrowding and the need for sleeping quarters trumped all other issues. In September 1899, the Minutebooks recorded the effect of overcrowding on staff as well as patients. The two assistant medical officers had to sleep in the old county infirmary while the hall porter had to sleep in the ‘body of the house’. There was no ‘proper surgery’ nor room for one and there was no office ‘of any sort’ for the Resident Medical Superintendent. It was common practice in Irish district asylums, such as Monaghan, for attendants to sleep in rooms adjoining and communicating with patient dormitories so that they were readily available in case of emergencies. This increased the possibility of diseases spreading from patients to staff.

The experience of staff succumbing to fevers and mysterious maladies in the 19th century was not confined to Monaghan. For instance, in an extraordinary episode in Grangegorman, in Dublin, staff as well as patients may have suffered from beriberi, a disease then thought to be contagious although now known to be dietary in origin (Reynolds, Reference Reynolds1992). Although historian Margaret Crawford is not convinced by the diagnosis of beriberi, there is no doubt that staff and patients succumbed to this mysterious malady (Crawford, Reference Crawford2012). Meanwhile, in her study of asylums in the south east of Ireland from 1820 to 1900, Catherine Cox found, that in Carlow Lunatic Asylum, staff were infected with cholera, fevers and tuberculosis and some died from these infections (Cox, Reference Cox2012).

In 1900, the report of the Inspectors of Lunatics noted that it was easy to understand why some diseases, such as tuberculosis, which were prevalent in the general population also infected the asylums. There were other diseases, such as typhoid, which was associated with unsanitary conditions in the buildings themselves. The advent of the 20th century did not bring any improvement with respect to overcrowding. As Brendan Kelly has noted, ‘in the early 1900s, Ireland’s asylums were still large, unsanitary, overcrowded and highly stigmatising places’ (Kelly, Reference Kelly2014a , 118; 2015b). Monaghan Asylum’s patient population continued to grow while space remained at a premium. Unsurprisingly, outbreaks of infectious diseases continued to plague both patients and staff at Monaghan Asylum/Mental Hospital in the first half of the 20th century.

Spanish influenza 1918–1919

The vulnerability of Monaghan and other asylum patients to epidemics that commenced outside the walls was demonstrated in late 1918 and early 1919. The First World War was followed by a pandemic of Spanish influenza with the virus responsible, on a global scale, for more deaths than the whole of the First World War (Beiner et al. Reference Beiner, Marsh and Milne2009; Foley, Reference Foley2011).

The Spanish flu hit Ireland in 1918. It was terrifying in its virulent symptoms with projectile nose bleeding, the coughing up of blood and the skin turning a blue-black colour. The patients gave off a strange and puzzling stench. As well as producing symptoms that were reminiscent of the plague, the Spanish flu displayed a preference for young adults. In Ireland, historian Ida Milne has estimated that more than 20 000 people died and as many as 600 000 people were infected (Milne, Reference Milne2011). Doctors and nurses were overworked and exhausted. The cause of the disease was not known, adding to a sense of helplessness and despair among the professionals.

In 1917, the death rate (calculated using average daily patient occupancy) in Irish district asylums was 10.5%, a considerable increase on the previous highest quinquennial average rate of 8.1% from 1893 to 1917. The Inspectors of Lunatics, in their annual report for 1917, attributed the increase to the ‘long continued spell of cold and inclement weather accompanied by an outbreak of influenza’. However, only 51 of the 2191 deaths were attributed directly to influenza. In 1918, the death rate rose to 11.1% with the same causative factors cited by the inspectors and 234 deaths attributed directly to influenza.

In Monaghan Asylum, a female patient died of influenza in September 1918 - this seemed to be an isolated case. But, the asylum was not to escape. On 14 November 1918, the RMS Dr Thomas Conlon reported to the Board of Governors that there was a ‘severe outbreak’ of influenza in the institution among both patients and staff with about 130 patients and 30 of the staff ‘laid up’. The outbreak of influenza which began in the last week of October retained its grip on the asylum until the second week in December. There were about 250 cases in all, with 200 among the patients and 50 among the staff. The disease was much more severe in the main building, especially on the female side. In his report contained in the Minutebooks, the RMS noted that ‘a large number of the patients attacked were very bad subjects for a disease of such virulent nature, the percentage of deaths was considerable’.

Some of the patients who were admitted during this time had already contracted influenza before their admission and many were in a ‘very weak state’ when they first entered the asylum. ‘In fact, one man was in a dying condition’, according to the RMS. It is unsurprising that patients were admitted with the condition as Monaghan County was relatively badly affected by influenza: it was ranked eighth in a league table showing influenza death rates per county in the report of the Registrar General for Ireland, 1918, with 3.19 deaths per 1000 population. In all, there were 25 deaths among Monaghan Asylum patients during the six or seven weeks of the epidemic with two of the nurses dying also. Dr Conlon paid tribute to the staff who contracted the disease and who worked very hard nursing the patients. He was ‘convinced’ that but for this, the percentage of mortality would have been much higher.

A second wave of the flu hit the asylum in March 1919. This time, the outbreak was described by the RMS as slight with seven cases among the patients and four among the attendants. Unfortunately, one of the attendants, a young man who had only entered the service of the institution, contracted pneumonia and died. By April, there were a few cases of flu lingering on the female side but the ‘attack was of a mild nature’ and the patients recovered well.

Monaghan asylum was not alone in suffering the effects of the Spanish flu however the Inspectors’ report for 1918 demonstrates the variability of the attacks. They recorded ‘severe’ outbreaks in Antrim, Youghal Auxilliary, Downpatrick and Waterford with a ‘very severe’ outbreak in Monaghan. In Kilkenny and Maryborough, influenza was prevalent throughout the year. In Letterkenny, although there were ‘many’ cases of influenza, the death rate fell for 1918. There was no mention of influenza in Mullingar or Killarney while Cork had ‘some’ cases. In Monaghan, the death rate for patients in 1918 rose to 13% from 7% the previous year, almost 2% above the average death rate for district asylums that year. There were 25 patient deaths from influenza (daily average 877 patients) in Monaghan Asylum compared to a recorded total of 234 deaths from influenza in Irish district asylums (daily average 20 178 patients). Matters took a turn for the better in 1919, as Spanish influenza burned itself out; the average death rate in district asylums declined to 9.3% with influenza accounting for 92 deaths.

The Inspectors do not include information on staff experience of influenza in the various asylums. In the case of Monaghan, it would seem from the information recorded in the Minutebooks that, proportionately, staff were affected more by the Spanish flu than the patients. The Monaghan experience is unlikely to be singular: it is probable that staff in other asylums also contracted influenza. Dr Conlon’s worries about the vulnerability of the patient population, were, to some extent at least, misplaced in the case of Spanish flu. In Ireland, the virus seemed to affect young healthy adults rather the more usual vulnerable elderly and ill populations which succumbed to seasonal influenza (Milne, Reference Milne2013). This would explain the increased vulnerability of staff in the face of the virus.

Typhoid

In January 1872, nine female patients in Monaghan Asylum had diarrhoea while one had typhoid. Dr Robertson attributed this to the sewers not being properly ventilated for ‘when the wind blows strongly from the southward, a strong and decided smell of sewer gas is perceptible’. Typhoid, enteric fever and general fevers associated with sewerage issues are frequently mentioned in the annual Inspectors’ reports on Irish asylums. For instance, in 1872, five deaths from fever associated with a defect in the sewerage system were recorded in Maryborough Asylum. Once the defect was remedied, the deaths ceased. However, the course of these fevers were not always so clear-cut and, with accreting patient populations, most asylums would have had patients who were carriers of typhoid. Staff could also have served as reservoirs of the disease.

A decade later, in December 1883, RMS Dr Robertson, reported that three female patients had symptoms that were ‘almost conclusive’ that typhoid fever was present in the asylum. ‘Overcrowded divisions mean that we are precluded from isolating these cases. The anxiety of the staff is very great’, he wrote in his monthly report. Then, matters took a turn for the worse as laundry maid Catherine Murphy went home feeling ill and Dr Robertson was informed that she had typhoid fever and was seriously ill. He inspected the drains but they seemed to be in good order with no smell of sewage. A special Board meeting was convened to discuss the need to enlarge the asylum. By the end of January 1884, the Minutebooks recorded that six female patients had contracted typhoid and one died.

Five years later, there were seven cases of typhoid fever, with two of the cases in attendants and five among the patients, and the RMS Dr Taylor was of the same opinion as his predecessor Dr Conolly Norman in attributing the outbreak to overcrowding. In February, attendant Philip Ward, who had been ‘faithful in the discharge of his duties’ during his 3 years’ service, died from typhoid. He was one of three cases of the disease that month. New buildings were just coming on stream and some of them began to be used for sleeping purposes but overcrowding was not eliminated. At the end of 1890, there was continued overcrowding on the female side of the house and some of the dayrooms were being used as dormitories – several cases of typhoid fever broke out. Typhoid remained a difficulty in other asylums: for instance, in 1892, eight patients, two nurses and a male attendant contracted typhoid in Letterkenny Asylum. This outbreak was attributed by the Inspectors of Lunatics to an inadequate water supply. In 1900, the Inspectors of Lunatics focused on zymotic diseases and included the following information on staff in district asylums: a ‘number of female staff’ with typhoid in Armagh, 10 staff with enteric fever in Ballinsloe, four staff with typhoid in Clonmel, two fatal cases of typhoid in female staff in Omagh and two staff in Sligo.

Cases of typhoid continued to occur among staff at the Monaghan asylum during the period from 1900 to 1930. In some instances, a full recovery was made; in others, death was the result. For instance, in January 1905, a nurse Brigid McMahon contracted the disease but made a good recovery. That same year, a nurse in Armagh Asylum also contracted the disease. In January 1913, a female patient was not so lucky: she appeared to be doing well but, sadly, ‘when over the most dangerous period of the illness died from heart failure consequent on the fever’. Two months later, a nurse died of typhoid. In 1916, when typhoid once again appeared among the female patients, water samples were tested and the town water was found to be fine but the well water at the asylum was unsatisfactory. This well water was only used when the asylum supply from the town was cut off.

In February 1917, an attendant John Ellis who contracted typhoid the preceding October was still unfit for work. In April 1918, an attendant John Ward died from enteric fever (the terms were used interchangeably in the Minute books). In October 1930, the RMS reported that the Head Nurse, who had contracted typhoid earlier in the year remained in a weak condition. In March 1931, the Joint Management Committee asked her to resign as she was physically unable to continue. In 1932, a nurse who had contracted typhoid died on 26 September. Another nurse had also contracted the disease but was recovering. The RMS Dr Conlon reported: ‘In connection with these cases I had water from our well tested by a bacteriologist and the report was satisfactory. I also had a consultation with the County Medical Officer of Health (CMOH) as regards to cases but we were unable to trace the cause’. In 1938, Dr Coyne worked with the CMOH to try and locate the source of the recurrent infections – of two recent cases, one had ended in death. It was decided to vaccinate against typhoid. By 19 April 1939, all patients had been given anti-typhoid inoculation and inoculations had been commenced in the nursing staff.

This seemed to be reasonably successful: it was noted in September 1951 that since the introduction of preventive inoculation against typhoid some years ago, this disease once endemic in the institution, has not occurred, despite the fact that there are still some ‘carriers’ among the patients. It has been estimated that between 3% and 5% of all cases of typhoid fever became chronic carriers of the disease (Flynn, Reference Flynn1957). Re-inoculation of all patients and staff had been carried out. The close proximity of patients and staff, the fact that they ate the same food, drank the same water and lived in overcrowded conditions, made staff as well as patients vulnerable to the often deadly typhoid.

The use of inoculation during the 1930s, following an outbreak, was not confined to Monaghan Mental Hospital. For instance, the report of the Inspectors of Mental Hospitals, 1937, noted that six typhoid carrier had been located in Mullingar Mental Hospital. Isolation was not possible with the overcrowding in the institution, but all staff and patients were inoculated. In 1940, there were 10 deaths in district asylums attributed to typhoid and paratyphoid.

Tuberculosis: staff and cattle

The Irish tuberculosis epidemic peaked in 1904 (Jones Reference Jones2001). The death rate then went into a slow decline with spikes occurring during both World Wars (Counihan & Dillon, Reference Counihan and Dillon1943/1944; Deeny, Reference Deeny1961/1962). Tuberculosis was a serious problem in Irish district asylums at the end of the 19th and the beginning of the 20th century (Kelly, Reference Kelly2012, Reference Kelly2014a , Reference Kelly2014b ). In 1892, according to the Inspector of Lunatics report, the most common cause of death among deaths in Irish asylums was consumption (tuberculosis). While tuberculosis was contagious and the overcrowding in Monaghan asylum predisposed for cross infection from tubercular patients to staff, it seemed that there was another possible source of tuberculosis on the grounds of Monaghan asylum. In March 1941, the Minutebooks record that a veterinary surgeon tuberculin tested the dairy herd and eight out of 14 cows tested positive. There were one or two doubtful reactions and retesting was carried out. He did not test the three heifers near calving. The Joint Management Committee noted that if they were to keep a tubercle free herd than all the cows that reacted would have to be got rid of and the byre disinfected. They decided to get rid of the bull and the tubercular cows were to be disposed of by a thinning out at an early date. The byre was to be disinfected in summer months. Dr William Coyne, the RMS, protested very strongly that neither patients nor staff should be supplied with milk from tuberculous cows. The Minutes of March 1941 record that he also pointed out the very high rate of tuberculosis in the institution. In April, the Inspectors suggested that a pasteurising plant was required and the RMS was authorised to price one.

In May 1945, the long-awaited new hospital on Monaghan Mental Hospital campus was completed. However, it was almost immediately given to Monaghan County Council to be used as a tuberculosis sanitorium. Ironically, the mental hospital still did not have its own isolation facilities.

In the late 1950s, Ireland’s tuberculosis epidemic came to an effective end. Diagnosis had improved. Effective antimicrobial treatments and preventive vaccines were made available and socio-economic conditions were improving. All of these interventions helped stem the tide of the disease (Jones, Reference Jones2001). While tuberculosis is not mentioned in respect of staff other than during the incident of the tubercular cattle, it is likely that staff were infected by patients (Mac Lellan, Reference Mac Lellan2013). It would, however, have been difficult, during Ireland’s long tuberculosis epidemic, to disentangle occupational disease from disease acquired elsewhere.

Serious assaults on staff

At times, asylums could become chaotic, with violence endangering both patients and staff. Violence was unpredictable: some patients were known to be violent while others, who had been calm since admission or for long periods, might suddenly exhibit violent behaviours. The monotonous routine of life in dreary institutions chafed both patients and staff (Conolly, Reference Conolly1904). Overcrowding, long hours, insufficient resources and poor staff to patient ratios, made it difficult to retain the caring curative atmosphere that rhetoric decreed. Indeed, Mark Finnane has suggested that life in the asylum was ‘centered on the continual struggle to wrest some order out of the chaos which surrounded doctors and attendants’ (Finnane, Reference Finnane1981). When assaults were mentioned in the Reports of the Inspectors of Lunatics with respect to asylums and mental hospitals, they usually concerned patients being assaulted by other patients or by staff. However, patients also attacked staff. Finnane notes incidences where patients suddenly attacked staff in the Richmond, Derry and Maryborough. Fists, a knife and a flagging stone were employed as weapons. In 1875, the Ennis Superintendent made an unsuccessful attempt to have two inmates prosecuted and sent to the central criminal asylum at Dundrum but it was deemed that the district asylums were supposed to contain violence. In this context, Finnane opines that attendants and medical staff had to accept the ‘relative immunity’ of patients from the ‘norms of the world outside’.

Joseph Reynolds opines, with respect to Grangegorman Ireland’s largest asylum, that it was ‘hardly true to say that staff walked in fear of the patients, although such statements were made from time to time, particularly when nurses and attendants were seeking to better their pay or working conditions’ (Reynolds, Reference Reynolds1992). He adds that the ‘very occasional serious attack’ on a member of staff by a patient lent credence to such statements. The emphasis on attendants is not surprising: Finnane correctly points out that the attendants were in close daily contact with the inmates to a ‘degree approached by few asylum doctors’ (Finnane, Reference Finnane1981). Nonetheless, in Monaghan, occasional serious attacks on staff were not confined to nurses and attendants but also included members of the medical staff. In January 1885, the first Resident Medical Superintendent of the asylum Dr Robertson tendered his resignation due to ill health. The Board of Governors praised Dr Robertson highly and remarked on his skilful management and administration along with the ‘remarkable economy’ he had practiced without impairing the asylum’s efficiency. He had worked in Monaghan for 16 and a half years. The minutes of January 1885 record that the Board of Management recommended that 7 years’ service be added to Dr Robertson’s pension entitlement in view of his excellent service (bringing it to £268 six shillings and eight pence per annum) and also ‘having received a serious and we believe permanent injury in the discharge of his duty’.

In 1909, 2 years after Dr Donaldson was promoted from assistant medical officer in Monaghan District Asylum to Resident Medical Superintendent, he sustained ‘serious (spinal) injuries’ from an assault by a female patient but returned to work (Irish Times, British Medical Journal, 1910). Continued problems from the spinal injury necessitated his retirement after 25 years’ service in the institution and he was granted superannuation from 1 April 1910.

In 1917, another nurse, Mary Anne Cahill, retired after 27 years’ service and was also compensated for an injury. The Joint Management Committee added 7 years’ service to her pension ‘in consequence of her long service, the onerous nature of her duties as charge nurse in the refractory and reception ward and owing to the fact of her having received two injuries in the discharge of her duty which are certified by the RMS’. Male attendants, too, received serious injuries. In October 1918, attendant John Connolly had 10 years added to his superannuation entitlements in consequence of his having received a kick from a patient while discharging his duties. Connolly had two operations in a Belfast hospital but still certified unfit for work by the RMS Thomas P. Conlon. Connolly left the asylum having completed 20 years’ service. In 1927, another long-serving staff member, Matron Miss Teresa Shaw had to resign after 28 years’ service to the asylum. She had 3 years added to her pension because of ‘her health breaking down as the result of an accident sustained in the discharge of her duty’.

It would seem from this catalogue of injuries, gleaned from a yearly sampling of Minutebooks, that staff, at all levels, were at some risk from patients. While overcrowding probably played a part, attacks by staff on patients were not confined to overcrowded public asylums. Elizabeth Malcolm notes that in Swift’s Hospital, Dublin, in 1862, the master Dr Francis Robinson applied for sick leave following injury by a patient while in 1883, the then master Dr William Rice had to take a month off from work to recover from a knee injury inflicted on him by a patient. Attacks by patients on staff seem to have been fairly common in the years 1850 to 1899 (Malcolm, Reference Malcolm1989). Constant vigilance on the part of staff must have taken its toll in terms of stress.

Staff and mental illness

The difficulties experienced by staff as well as patients living in a large institution were elaborated upon by Dr Conolly Norman in 1904 in the Journal of Mental Science. He stated that the natural unit of society was the family and that existence in large institutions, which are not, and cannot, be modelled on family life, is an unnatural one. ‘Such existence is uninteresting, monotonous, and irksome. Its tendency is to drive the mind in upon itself, to produce unhealthy brooding and dreaming, and to deprive the individual of the ordinary interests that belong to his fellow-creatures’ (Norman, 1904). Dr Norman went on to point out that these effects were not only felt by the patients but were also felt among the staff. Among these ‘petty jealousies, suspicions, and all kinds of rancorous ill-feelings are apt to arise’, and are ‘surely fostered by the peculiar conditions of institution life’. Elizabeth Malcolm notes that the stress of the job took its toll on nurses who had to be treated for ‘nervous’ and ‘hysterical’ disorders, and in 1898 a nurse, who had worked in Swift’s hospital for 25 years, became insane (Malcolm, Reference Malcolm1989). Catherine Cox, also notes in the context of Carlow Lunatic Asylum, that some employees became mentally ill, and when their families could not be found, they were subsequently admitted as patients (Cox, Reference Cox2012). While sampling the Minutebooks in Monaghan did not reveal any cases of staff becoming mentally ill, it is likely that there were some cases.