Sir,—In her ‘Local Archives’ article in HI 30.3, May/June 2022, on St Joseph’s Hospital/Limerick District Lunatic Asylum, Jacqui Hayes refers briefly to the death of a patient ‘after being submerged in a bath’. I enclose a detailed account of the event and its outcome following a special enquiry, which may be of interest to your readers.
In January 1872 a patient named James Danford was being shaved by attendant John Connell when he struck the attendant with a razor strop, cutting his ear. The attendant reported the matter to Dr Fitzgerald, the resident medical superintendent, who ordered ‘a slight plunge bath’. It was well known that the patient had a horror of water and a fear of drowning. Despite this the patient was given a bath, prior to which his feet were bound, as were his hands behind his back. He asked not to be put into the bath and was kicking and resisting. The attendant had a hold of him by a strap attached to his feet and when his head was under water he vomited and soon after died.
Dr Fitzgerald told an inquiry that he had ordered the bath as a remedial measure; when asked whether it was a punishment bath, he replied that it was a semi-sanitary punishment bath. The patient was buried surreptitiously in Mount St Lawrence Cemetery adjacent to the asylum, with no record of his burial. He was a member of the Church of Ireland but was buried without the knowledge of the Protestant chaplain, who had not been informed of his death. It transpired that the asylum had a private entrance to the cemetery, which was used to transport the bodies of patients who were not claimed by their relatives.
The attendant Connell was charged with manslaughter and spent several months in Limerick Jail. He was acquitted, as no inquest had taken place and it was eight months after the event that the matter came to light. The attendant subsequently requested the balance of his wages of eleven shillings and eight pence for the time he spent in jail and requested his pension, which was refused.
The under-secretary of state then wrote to Dr Fitzgerald, requesting details of the type of bath ordered and whether he was present when it was given. Dr Fitzgerald replied that he had ordered ‘a slight plunge bath’ and that the patient was in the bath some two minutes and then taken out and died immediately. The asylum report book read that Dr Fitzgerald had seen the patient in the morning in a ‘morbid state and that he died from exhaustion and was declining for some time’. This report was subsequently changed and replaced by a statement that ‘James Danford died suddenly yesterday’. The under-secretary wrote again to Dr Fitzgerald, informing him that the lord lieutenant had ‘grave doubts as to his fitness entrusted with the important duties of his present office’.
Dr Fitzgerald replied, referring to his excellent character and history of kindness to the patients. He expected that the plunge bath would be carried out in ‘the usual kind and beneficial manner’. He further contested, bizarrely, that the patient died from ‘violent and acute mania’. He also defended his decision as being for the purpose of ‘maintaining a wholesome discipline on the patients’. Paradoxically, Dr Fitzgerald also reported that the ‘Turkish Baths in the Asylum had an excellent effect’, raising the question of why this had not been ordered.
When asked why no post-mortem had been carried out, he explained that he ‘had a very great dislike of them due to the bad effects they had on patients’. He admitted finally that he was guilty of ‘an error of judgment’ in not informing the inspector of the death, but at the time he was suffering from ‘an acute and painful attack which Dr Gelston (the visiting Physician) will endorse and as a result of which my judgment may have been warped’. The under-secretary replied that His Excellency found his explanation ‘not at all satisfactory’ and advised him to apply ‘at the earliest possible moment for superannuation’. He resigned on 25 March 1873 and requested a ‘liberal consideration of my retirement allowance bearing in view in the winter of my life I am as it were obliged to begin the world again’; he was granted a full pension. His resignation was recorded in the 23rd report of lunatic asylums in Ireland (1874), where he is described as ‘a gentleman of remarkable benevolence during his long period of his service and much liked by his patients’.
The private entrance from the asylum to the graveyard was then closed and all funerals of patients not claimed by their relatives had to enter the graveyard from the public road. As a result, ‘the proper and decent burial of lunatics could take place’, as ordered by the lord lieutenant in April 1874. Thereafter no clandestine and anonymous burials could take place and, if not in life, at least in death some measure of dignity would be granted to all unclaimed deceased patients.—Yours etc.,
DR PETER KERWIN
Clinical Director (Emeritus)
St Joseph’s Hospital
Limerick