Monday, 4 November 2019

A Prescription for Change: Training a Doctor in Nineteenth and Twentieth-Century Ireland


In this blog post, Natalie Baldwin, a graduate of UCD's MA in History of Welfare & Medicine in Society, explores the realities of training as a medical professional, past and present.


Today, when we think of a medical doctor, it is easy to imagine an intelligent, respected, hard-working and well paid members of society who enjoys a high social status. It is therefore tempting to assume this has always been the case, that a career in medicine has always been both socially and financially rewarding. It may be surprising, then, to learn of the ups and downs medical students and their families have faced since the nineteenth century. 

A Case of History Repeating Itself  


The Fitzgerald family kept a small but considerable archive of artefacts and documents relating to members of the family reaching back to the 1840s. When these were donated to the Royal College of Physicians of Ireland Archives, they presented an incredibly exciting opportunity for an inherently curious person like myself to get stuck in. As I began to work through this archive, what struck me most about the Fitzgerald family was that so many of its members entered into a career in medicine. What seemed to start with Alexis and his brother James in the 1850s resulted in a medical dynasty that still survives today. Two members of the family stood out especially. Dr James Fitzgerald was born in or around 1838 in Tipperary. He moved to Dublin in the 1850s to study medicine, a move that was perhaps in part motivated by the fact that his older brother Alexis did the same thing a few years earlier. Two generations later, his grand-nephew Gerald entered UCD, the reincarnation of the Catholic University of Ireland which James had attended, to study medicine. Like his great-uncle James, he was following a path set by his older brothers and by now, his father, as medicine had firmly taken root as the Fitzgerald family business. James and Gerald went on to leave Ireland once they graduated. For James, it was to join the Navy while Gerald was offered the chance to further his education and career by leaving for England and Scotland. Sadly, these were not the only striking similarities between the pair as both died prematurely back home in Ireland in their thirties.

Thinking about James as representative of a doctor’s education and career in the nineteenth century and Gerald as representative of the twentieth century, we will take a look at how the education, career, and social standing of a doctor in Ireland changed or perhaps, stayed the same.

Status Update

'A poor apothecary in a cart being drawn by his servant are 
overtaken by a wealthy couple in a horse-drawn carriage 
with a seat at the back for their servant'. 
Credit: ​WellcomeCollection​. ​CC BY

The decade or so preceding James’s entry into medicine saw many attempts to professionalise the sector. In trying to move medicine away from being considered a trade to a profession, this naturally had a knock on effect towards the social standing of the doctor. Generally, and particularly before the middle of the nineteenth century, medicine had a tripartite structure and like most structures, was hierarchical in nature. At the top there was the physician, followed by the surgeon with the apothecarist sitting on the bottom rung of the ladder. The three enjoyed differing levels of social status. Alongside the orthodox or ​regular practitioners, were the unorthodox practitioners or "quacks". These included druggists, bonesetters or any member of the medical community that occupied the fringes of society. The medical marketplace was already overcrowded, especially in England, and having to compete for patients alongside unqualified "quacks" naturally created some anxiety for the trained practitioner. 


The Medical Act, 1858 attempted to alleviate some of these concerns. The Act tried to regulate the education and training of doctors and required all practicing members to sign the registry of the General Medical Council (GMC). While it differentiated between regular and irregular practitioners by only allowing fully trained and qualified ones to sign the register, the Act failed to prevent "quacks" from actually practicing. Members of the public were still unlikely to be able to discern between the two. The Act went some way towards professionalising medicine by trying to control entry and setting a standard of training. This meant that registered practitioners could distance themselves from tradespeople by charging for a service rather than a commodity. However, the Act was considered a failure for many orthodox members of the community as it still meant they had to jostle their way through a saturated market rife with "quacks".1

So what did all this mean for James and Gerald? Well for James, he started his studies just a few years before the 1858 Act came into effect. In fact, he graduated the following year. For students studying at this time, the terms of the Act specified that they would not be penalised and their training and education would be valid. Gerald did not begin his studies until 1930 but even so, the Medical Act of 1858 could have caused some worries of their own for him, even almost seventy years later. Unlike his great-uncle, Gerald began his medical career in post-independence Ireland. However, like his great-uncle’s experience, medical education was still under the influence of Britain and the control of the GMC. The Medical Act of 1858 threw up its own obstacles for the medical profession in the newly established Free State. For starters there was talk of setting up a separate medical register for the newly partitioned island. This created unease amongst the community with many highlighting the fact that Irish doctors relied on work in Britain and therefore needed to remain eligible to sign the general medical register upon graduation. Universities would suffer too if the numbers of medical students dropped as they relied heavily on their fees to keep the university as a whole afloat. Luckily for Gerald and those who studied in the few years before him, the issue was resolved in 1927 with the Medical Practitioners Act where it was agreed that Irish doctors could still sign the general medical register.

The Price of Education 


Despite the fact that medicine was clearly an economically precarious and overcrowded business, in nineteenth and twentieth-century Ireland, many students, or indeed their parents, were motivated to study medicine by the promise of social mobility and the chance to earn a place among the ranks of the middle classes.2

'A foppish medical student smoking a cigarette, 
tankard  is on top of his medical books;  
denoting cavalier attitude (1854)'. 
Credit: WellcomeCollection​. ​CC BY

Encouraging your child to attend a medical school was not without its financial sacrifices though. Factoring in the cost of lodgings, lectures, grinds, clothing expenses, reading materials and general maintenance costs, it is estimated that sending a student to Cecilia Street where James received his education, cost about £400-500.3 Bursaries were available for less well-off students attending Cecilia Street who wanted to study medicine but amounted to only £40 a year for up to two year’s study. In most cases, the cost of funding a medical student’s education fell to the parents. Nothing in James Fitzgerald’s personal notes indicated he was working to fund his studies so most likely he was put through university by his parents. James’s older brother Alexis was also a doctor and graduated four years before he did. Considering a doctor during the late nineteenth century would go on to earn about £90 to £120 a year, it seems less likely that parents were driven by the financial incentive of having a doctor in the family. We should also remember that the sacrifices began well before sending a student to university as in the second half of the nineteenth century receiving just a second level education placed you in the minority.4 For James’s grand-nephew Gerald, the financial costs of a medical degree had increased further. Gerald graduated from UCD in 1936. In the years before the outbreak of World War Two, the cost of obtaining a medical education was said to be approximately £1500.5

The financial situation may not have improved for James even after he qualified and secured a position as assistant surgeon in the Royal Navy. For starters, navy surgeons had to acquire their own kit of surgical tools. This seems unreasonable enough but when you consider that an assistant surgeon like James was paid only about £2-£3 per month,6 the economic incentive for becoming a doctor seems less and less appealing.

Upwardly Mobile


If the potential financial rewards were not especially inspiring, it would seem more convincing that the motivation for parents to encourage their children into a career in medicine was driven by the sense of respectability garnered through having a doctor in the family. Kelly likens this to the social standing Catholic families in the late nineteenth and early twentieth century attained from having a priest in the family.7 James and Alexis’s parents must surely have enjoyed a significant sense of respectability as not only did they have two doctors in the family, but a priest as well in their third son Fr Michael.

There may have been other factors though in motivating James’s and Gerald’s entry into the world of medicine. Kelly writes about how medical education in Ireland tied in with notions of manhood and its transformative power of turning boys into men. She also speaks of how its competitive nature further emphasised the traditionally masculine nature of the medical student.8 As James’s older brother Alexis studied medicine too, it is possible to imagine that this competitive manliness tied in with sibling rivalry and he simply wanted to copy his older brother’s example.

The Family Business


By the time Gerald decided to begin his journey towards being a doctor though, things had changed quite a bit for the Fitzgerald family. While the two generations prior had seen his great-uncles James and Alexis carve a path into medicine, Gerald was born into quite a different landscape. Gerald’s father Alexis was doctor and medical officer at Waterford District Asylum at the time of Gerald’s birth in 1913. Many students entered into medicine because it was the profession of their father. Over 11% of students who graduated from the Queen’s Colleges in 1872-1917 had a family background in medicine.9 However, it wasn’t just Gerald’s father that could have influenced his decision. Not only were his father’s two uncles doctors, but his own uncle James as well as his two older brothers Oliver and Patrick. So while James and Alexis in the mid-nineteenth century may have been driven by a desire for middle-class respectability, Gerald may likely have felt that medicine was the family profession. 

The Spectre of Emigration 


Leaving Ireland upon graduating medical school was a fate that befell both James and Gerald. Ireland saw high levels of emigration generally throughout the late nineteenth and early twentieth century. This was particularly acute though within the medical profession.10 With so many doctors emigrating to England from the medical schools in both Ireland and Scotland, these years ushered in a period of underemployment among doctors. Add an abundance of qualified doctors to the fact that there still remained some competition from the unregulated practitioners, and there was now increased pressure to find suitable and fulfilling positions for the medical graduate.11

Out at Sea


'Naval officers and men on a ship, dressed in the 
uniform of nine labelled ranks of the Royal Navy'.
Credit: Wellcome Collection. CC BY  
James graduated in 1859. In a cohort of medical students studied by Jones from the period 1860-1960, the number working outside of Ireland ten years after graduation was found to be 41%. James was therefore not unusual in his path following graduation as the same cohort studied showed that for those not practicing in Ireland after graduation, the majority either set up their own practice in England or, like James, served in the military or within the British Empire.12 It may seem unusual for a Catholic like James to have joined the Royal Navy but in fact, he was one of a growing number of men from Ireland who joined from the 1840s onwards. For them, life in the Navy particularly as a medic, offered an escape from Ireland and a chance to further their career in a way that staying at home couldn’t allow.13 So while it would seem that he may not have been well rewarded financially, perhaps the adventure was enough to keep him there for seven full years considering many assistant surgeons left after serving only three years.14 Although, considering his sick list seemed to mainly record him treating case after case of venereal disease and coughs and colds, life in the Navy undoubtedly wasn’t one non-stop adventure.

The Export Market


Ireland enjoyed a good reputation in the post-independence era for its medical schools but like students of James’s era, emigration was still prevalent for graduates owing somewhat to economic hardship in the post-war period.15 The hundred year period from 1860 to 1960, which included Gerald’s years of study, saw more students go through Irish medical schools than there were positions for at the other end. Essentially, the emigration of medical graduates was considered par for the course. It may therefore seem strange that universities in Ireland continued to oversubscribe students for their medical schools knowing full well that they would be exporting many but the universities, particularly the Catholic University, relied heavily on the contribution medical students’ fees made towards the running of the entire institution.16 Gerald moved to London in 1938, two years after he graduated from UCD. He had been awarded a travelling scholarship by the Mater Hospital to study neurology. He stayed in London for some time before eventually moving to Edinburgh to further his career again, this time to study psychiatry. He did not return to Ireland until about 1945 when he took up a post in the Mater Hospital.17 Like James, leaving Ireland had certainly afforded Gerald greater opportunities to develop as a doctor, gain independence, and broaden his skills.

The More Things Change…


What of today then? We could easily assume that a doctor in the twenty-first century has it much easier than James or even Gerald did. But perhaps things actually are not so different. While a doctor’s social status may have improved since James’s time, recent studies have shown that members of the medical profession report feeling under-respected. With increased competition from other healthcare practitioners echoing the struggle of the previous generations, and less and less professional autonomy, many doctors feel they do not enjoy the same level of status as the profession once did or as perhaps they expected to experience.18 There are regular reports in the news highlighting the fact that Ireland continues to produce doctors for export with many leaving for the UK, Australia and the US. Staff shortages are common place in Irish hospitals along with overcrowding from patients. Salaries for consultancy positions have not recovered to the levels they were before the economic recession.19 

So if today’s doctor is overworked, underpaid, and under-respected, who would want to join such a profession? Well apparently, quite a lot of people. Places to study medicine in Irish universities are still some of the most competitive, typically requiring some of the highest CAO points. The introduction of the Health Professions Admissions Test (HPAT) some years ago attempted to ensure that well rounded candidates were offered places rather than just those that achieved the highest academic scores. School leavers and even mature students are clearly not deterred despite the various challenges – new and old – that beset the medical profession. Like James and Gerald, many could be following an already established family path into the profession. It is likely that for many, having to leave Ireland upon graduating is seen as an exciting opportunity rather than enforced emigration. Rather than being seen as a badge of social standing, there is also the possibility that an offer to study medicine is viewed as a mark of intellectual status. It is well known how hard a secondary school student must work to earn enough Leaving Certificate points to be offered a place. To actually complete the five to six years of medical training is definitely a remarkable achievement. For some, perhaps medicine is just in the blood; a path they were destined to follow, neither a trade nor a profession but simply a vocation.

Natalie Baldwin


Natalie Baldwin completed her MA on History of Welfare & Medicine in Society at the UCD Centre for the History of Medicine in Ireland in 2018/2019.

Acknowledgements


Research completed in collaboration with Harriet Wheelock, Keeper of Collections, Royal College of Physicians of Ireland Archive Collections.




1. Anne Digby, ​Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911 (Cambridge, 2002), pp 28, 31, 36-37.
2. Laura Kelly, ​Irish Medical Education and Student Culture, c. 1850-1950 (Liverpool, 2017), pp 200-203, 71, 73.
3. F.O.C. Meenan, ​Cecilia Street: The Catholic University School of Medicine 1855-1931 (Dublin, 1987), p. 24.
4. Kelly, ​Irish Medical Education, p. 74.
5. ‘​The Cost of Medical Education’, British Medical Journal, 6 September 1947, p. 392.
6. Jonathan Charles Goddard, ‘The Navy Surgeon’s Chest: Surgical Instruments of the Royal Navy during the Napoleonic War’, ​Journal of the Royal Society of Medicine, 97 (2004), pp 191-197.
7. Kelly, ​Irish Medical Education, p. 84.
8. Laura Kelly, ‘Irish Medical Student Culture and the Performance of Masculinity, c. 1850-1930’, ​History of Education, 46, no. 1 (2017) pp 39-57.
9. Kelly, ​Irish Medical Education, p. 73.
10. Greta Jones, ‘“Strike Out Boldly for the Prizes that are Available to You”: Medical Emigration from Ireland 1860-1905’, ​Medical History, 54 (2010), pp 55-74.
11. Digby, ​Making a Medical Living, p. 140.
12. Jones, “Strike out Boldly,’’ pp 56, 59.
13. S. Karly Kehoe, ‘Accessing Empire: Irish Surgeons and the Royal Navy, 1840-1880’, ​Social History of Medicine ​ 26, no. 2 (2012), pp 204-224, 207.
14. ‘Army and Navy Medical Service’, ​British Medical Journal 1, no. 275 (1866), p. 366.
15. Kelly, ​Irish Medical Education, p. 201.
16. Jones, ‘Strike out Boldly’, p. 68.
17. Edward A. Martin, ​A Historical, Biographical and Anecdotal Account of the Neurological Sciences in Ireland from the earliest days to 1975 (Dublin, 2012), pp 40-1.
18. Lipworth et al. Doctors on Status and respect: A Qualitative Study, ​Bioethical Inquiry, ​10 (2013) pp 205-206.
19. ​Irish Times, 26 Dec 2017; Irish Times, 26 Sept 2018.

Monday, 2 September 2019

Who’s to Blame?: Inquests into Convict Deaths in Mountjoy, c.1868-1900

In this blog post, Annika Liger, a graduate of UCD's MA in History of Welfare & Medicine in Society, reveals anxieties around the medical care of prisoners in the late nineteenth century by examining newspaper coverage of inquests into convict deaths in Mountjoy prison.

“Death of a Convict in Mountjoy Prison”, Evening Telegraph
(1 October 1895). Newspaper image © The British Library Board
All rights reserved. With thanks to the British Newspaper Archive.
Following a convict’s death, nationalist journalist Alexander Sullivan wrote to the city coroner saying, ‘you cannot be unaware that Mountjoy prison lies under public suspicion as to the medical treatment of prisoners’.1 This ‘suspicion’ surrounding Mountjoy greatly influenced the inquests into convict deaths in the late 1800s. These hearings, which were widely covered in newspaper reports, reflected the public’s interest in Mountjoy and the circumstances surrounding prisoner deaths. While many of the hearings resulted in a simple death by natural causes verdict, the courses of the inquests reveal deep reservations concerning Mountjoy’s medical care. When the juries decided that someone was to blame for a prisoner’s death, it then prompted the question of who was more at fault—the prison medical officer (PMO) or the prison system?  


Inquests


In late 1800s Ireland, when someone died an investigation into their death was carried out at the coroner’s discretion. Generally, inquests only happened in cases of suspicious or unusual deaths, and the last attending medical practitioner, or any other local medical professional, was consulted. The medical community in general took these inquests quite seriously, and the ‘Principal Laws’ that governed United Kingdom medical professionals included a section on proper inquest conduct. These rules emphasized that medical officials giving evidence should be honest and accurate as their testimony was usually very influential.2

For general medical practitioners, these inquests could be stressful affairs. Depending on the outcome, the inquest could either enhance their professional reputation or destroy it. The same held true for PMOs, who had the added weight of also being responsible for protecting the prison’s reputation.3 Prior to 1877, prisoner death inquests were only called if the coroner felt one was necessary. In 1877, with the passing of the General Prison (Ireland) Act, inquests became mandatory in the event of a prisoner’s death. As a result, the number of inquests increased and PMOs ended up in front of a jury more frequently defending themselves and the prison. 


The PMOs


For information on prisoner death inquests, I mainly looked at Irish newspaper articles concerning the Dublin convict prison Mountjoy and two PMOs that worked there in the late 1800s: Dr James William Young and Dr Patrick O’Keefe. Young served at Mountjoy as a PMO from 1867-83. O’Keefe succeeded Young as head PMO at Mountjoy and served there from 1883-c.1907. Both Young and O’Keefe were highly educated individuals with multiple medical degrees who made careers out of working for the Irish prison system as medical officers.4 As PMOs, Young and O’Keefe were in charge of the general health of prisoners. They assigned diets, determined whether or not prisoners were suited for punishment or labor, and treated inmates’ specific aliments, among other duties.

Newspaper reports of the coroner’s inquests reveal that while Young and O’Keefe faced scrutiny in these hearings, Mountjoy itself received the majority of the blame in prisoner deaths. Coroner’s inquests in the late 1800s largely ended up being arenas where juries, coroners, and even the PMOs themselves, questioned and critiqued the Irish penal system’s care of prisoners in Mountjoy. 



Death by Natural Causes


In a few cases where Young and O’Keefe testified, the jury found no reason to blame either of the PMOs or the prison. They simply concluded that the prisoner had died of natural causes, as was the case when prisoner Patrick Naughton died in 1886.5 Likewise, when in 1893, Thomas Pembroke fell ill and died in prison, after testimony from multiple doctors, including O’Keefe, the jury decided that Pembroke was treated adequately and no one was at fault for his death.6

In other cases, ultimately both the prison and PMOs were cleared of blame, but during the trial there were debates over the various parties’ culpability. This is perhaps due to the general sense of skepticism when it came to Mountjoy that Sullivan mentioned in his letter at the beginning of this post. We can see evidence that others shared Sullivan’s concern over Mountjoy through the kinds of questions juries asked of the defendants, which often demanded that the PMOs explain in detail the care provided to the deceased. Some of the newspapers also reported that the juries were critical of the PMOs going into the inquests. After the death of a prisoner in 1868, for example, the jury was reportedly suspicious of Young from the outset. However, in this case they ultimately decided that he was not to blame.7

The testimonies that Young, O’Keefe, and other prison officials provided also suggest they were well aware of the public’s suspicion surrounding Mountjoy and tried to assuage any such fears. In 1883, during the inquest into Michael Watters’ death, Young, O’Keefe, and Kelly, another medical practitioner, all agreed that ‘death was not attributable to punishment or any form of ill-treatment’, thus contesting the notion that the prison’s disciplinary methods could be responsible for Watters’ death.8 In an 1886 case, the jury found that James Davies’ died of natural causes after a very laudatory testimony from the city coroner concerning the treatment of prisoners in Mountjoy. The coroner was adamant that Davies did not die as a result of neglect, saying that once a prisoner became ill ‘all his crimes appeared to be forgotten by the prison officials, who did everything for his comfort … they always have the best medical treatment’.9 Given the suspicion surrounding Mountjoy at the time, this praise was quite possibly an active attempt to combat the concern over inadequate prisoner care.

PMO Blamed for Convict Death


Unfortunately for the PMOs and Mountjoy, juries did not always decide that death was simply due to natural causes. When the juries found someone at fault, it placed the PMOs and the prison in a very critical spotlight and left juries, commissioners, and journalists debating which party was more to blame  the PMO or the prison. In particular, Young faced two noteworthy inquests, one in 1868 over Matthew Lynagh and the other in 1870, concerning Johanna Hayes. Both of these cases were suspicious enough to prompt inquests in a time before inquests were mandatory. Additionally, both cases were widely covered in newspapers across Ireland.

During Lynagh’s inquest, Young explained that he was treating Lynagh, but thought he was improving. As a result, Young initially declined to send Lynagh to the prison hospital. Ultimately, the jury blamed Young for Lynagh’s death, arguing that Lynagh should have been sent to the hospital much sooner. They also specifically called out Young, saying he ‘might be more attentive to extern patients’.10

Or Was the Prison Really at Fault?


While the jury in the Lynagh case firmly held that Young was to blame, the nationalist newspaper The Nation and the official Commissioners’ Report presented slightly different takes on Lynagh’s death. Both addressed the jury’s critique of Young, but argued that Lynagh’s death was not actually Young’s fault. One month after the inquest, the Commissioners released their report exonerating Young. They recognised the jury’s verdict, but said that Lynagh’s death was inevitable and ‘that the man was not neglected during his illness by Dr Young or the other officers of the prison’.11 Notably, while defending Young, they also declined to assign any blame to the prison system.

In 1871, The Nation published a scathing review of Mountjoy prison and mentioned the Lynagh case from 1868. The writer primarily saw Young as an agentless cog in a machine, thereby absolving him of blame. They claimed that the Lynagh inquest ‘resulted in a verdict censuring the Medical Officer; a clear injustice towards him, inasmuch as he probably did his duty as far as he could [sic] under the altered systems’.12 The article continued and reiterated this point suggesting that some vague prison bureaucracy prevented Young from providing more treatment to Lynagh. Unlike the Commissioner’s report which absolved Young but did not blame the prison system, The Nation blatantly held the prison at fault for Lynagh’s death.

Conclusions like this that pardoned the PMO while simultaneously condemning the prison system were not uncommon. In an 1895 inquest over Christopher Connor’s death the coroner told the jury that ‘the evidence showed that no blame attached to Dr. O’Keefe or the governor ... they did all that the rules permitted for the man ... the rules as the nursing of sick persons in [Mountjoy] were simply abominable’.13 The jury agreed with the coroner and their verdict called out the prison’s nursing system while also clearly stating that O’Keefe was not at all responsible for Connor’s death.

The Complicated Case of Johanna Hayes


In 1870, Young was dragged back into the spotlight with the death of Johanna Hayes in Mountjoy Female prison. During the hearing, Young reportedly testified that after entering the prison Hayes’ health began declining, and he recommended that she be released from prison with respect to her failing health. However, this recommendation was not heeded, and Hayes remained in prison where she died. In contrast to the Lynagh case, here the jury lauded Young for his attempts to aid Hayes and get her released. Interestingly, the jury did not directly blame the prison system, despite the penal system’s denial of Hayes’ release on medical grounds. The jury did note, however, that Hayes died as a result of her being in prison.14 This conclusion suggests the jury found the prison partly to blame, but not wholly at fault as it had not actively contributed to Hayes’ death.

While this trial ended relatively well for Young and the prison, not everyone agreed with the jury’s take on the events. Like the jury, Sullivan, the aforementioned nationalist journalist, did not blame Young, although he was skeptical of him. Rather, Sullivan railed against the Irish penal system in a letter to the city coroner, which was eventually published in the newspaper The Warder. In this letter, Sullivan addressed his preference for Young’s predecessor, Dr Macdonnell, and basically called Young a government lackey. He also commented on the testimonies presented in the Hayes trial. In particular, Sullivan disliked the reliance on Young’s deposition, saying the jury held ‘a suspiciously laudatory protestation’ of Young, and that it was ‘very likely all true; but methought the jury did protest too much’.15

Sullivan’s issue with the jury’s praise was further illuminated during a libel trial that resulted from the publication of this letter. During that libel trial, Mr Butt, speaking for defendant Sullivan, argued that the jury’s praise was for the benefit of Young and the prison system:

Then came the [Hayes] inquest, when Dr. Younge [sic] whitewashed off the black cloud of censure passed on him at the first inquest [Lynagh’s case in 1868] … was it very strange if Mr. Sullivan should say this was an attempt to prop up a new system, in which Dr. Younge [sic] was to be praised for his exertions?16 

While Sullivan did take some shots at Young with his suggestions that he was a government stooge, he ultimately did not think Young was to blame, even if the jury’s praise in the Hayes inquest was suspicious. Instead, Sullivan complained about the penal system and how it affected prisoner health. While not directly stating that Mountjoy was responsible for prisoner deaths, Sullivan certainly found the inquests, and their non-critical outcomes, to be dubious, thinly-veiled attempts to protect the prison’s reputation following convict deaths.

In House Complaints


Critiques of the prison system were not unusual in inquests, and as we have already seen there was an established suspicion surrounding prisoner deaths and the prison system’s level of blame. Prison outsiders, such as juries, coroners, and journalists like Sullivan, used these inquests to question the prison system. Likewise, prison insiders also utilized inquests to critique the prison, and Young and O’Keefe occasionally provided testimonies that called out the prison’s operation and treatment of prisoners.

O’Keefe, albeit somewhat begrudgingly, spoke out against the prison system in his testimony during the 1895 inquest into Christopher Connor’s death. The jury began the inquest highly suspicious of the prison, with O’Keefe, the prison governor, and the penal system all being called into question. One of the coroner’s and jury’s main problems was that Connor’s family and friends had not been alerted to his illness, a matter one juror reportedly called ‘monstrous’.17 O’Keefe explained that no one was contacted because he did not believe that Connor’s condition was as serious as it ended up being. He also emphasized that the governor notified families, not the PMO, so he was not technically to blame for the lack of contact.

The other issue highlighted in the newspaper coverage was the implementation, or lack thereof, of night nursing in Mountjoy. The coroner implied that Connor would have been better cared for had there been a better nursing system in place. When the coroner asked O’Keefe for his take on the system of night nursing, O’Keefe initially refused to give an opinion. After the coroner pressed, O’Keefe relented replying ‘Well, I think it might be improved’.18

Following the death of a convict in 1878, Young testified that he had done what he could for the patient in the prison cells, but chose not to send the prisoner to the hospital. This decision was vastly unpopular with the jury who heavily questioned Young’s decision. Young claimed that the convict was not sent to the hospital because of ‘the small hospital accommodation and heat of the weather … the accommodation [in hospital] was insufficient’.19 Using the public forum of the inquest, Young aired his complaint about the prison hospital and argued its inadequacy directly contributed to the convict’s death.

While both Young and O’Keefe clearly critiqued Mountjoy and the ways in which the prison was run, these criticisms were not perhaps without ulterior motive. Going into these inquests, the juries were already suspicious of Young and O’Keefe and the care they provided. As a result, it is possible that O’Keefe and Young highlighted the poor night nursing and hospital accommodations respectively as a way to transfer the blame from them to the prison at large. In both of these cases as well, neither O’Keefe nor Young were found at fault for the prisoner’s death.

Conclusions


Coroner’s inquests into prisoner deaths were weighty affairs for the PMOs and Irish prison system. While in most cases the juries and coroners agreed that death was by natural causes, there was still an underlying suspicion concerning the prison officials and the prison. When the inquests found that the convicts’ deaths were preventable, it resulted in a debate over which party, the PMO or the prison, bore the brunt of the blame. In the end, while the juries were skeptical of the PMOs, it was the prison that was blamed most often for deaths in Mountjoy in the late 1800s. 

Annika Liger


Annika Liger completed her MA on History of Welfare & Medicine in Society at the UCD Centre for the History of Medicine in Ireland in 2018/2019.

Acknowledgements


Research completed in collaboration with Harriet Wheelock, Keeper of Collections, Royal College of Physicians of Ireland Archive Collections.




1. “Assize intelligence” The Warder 1 April 1871.
2. “Duty of medical men as witnesses”, United Kingdom Register 1889, pp. 18-9. Royal College of Physicians Ireland (RCPI) Archives.
3. Michael J Clark, “General practice and coroners’ practice: Medico-legal work and the Irish medical profession, c. 1830-c.1890” in Cultures of Care in Irish Medical History 1750-1970 eds. Catherine Cox and Maria Luddy (New York, 2010), p. 40, 50.
4. Biographical information was gathered from papers, medical registers, and the Kirkpatrick Index all held in the RCPI archive.
5. “The death of a convict” The Daily Express 18 September 1886
6. “Death of a convict”, Evening Herald 9 January 1893
7. “Mountjoy prison”, Nenagh Guardian 21 March 1868
8. “Death of a convict” The Daily Express 25 October 1883
9. “Death of a convict” The Daily Express 11 March 1886
10. “Coroner’s inquest on the body of a convict” Saunders’s Newsletter 15 February 1868
11. Report of the Commissioners appointed by Lord Lieutenant to inquire into circumstances concerning death of convict M. Lynagh in Mountjoy Prison, H.C. 1867-1868.  p. 4
12. “Secrets of the prison-house” The Nation 15 April 1871
13. “Death of a convict in Mountjoy prison: Extraordinary condition of things: Strong condemnation by the coroner and jury” Evening Telegraph 1 October 1895.
14. “Inquest at Mountjoy prison” Irish Times12 January 1870
15. “Assize intelligence” The Warder 1 April 1871
16. “Assize intelligence” The Warder 1 April 1871
17. “Death of a convict in Mountjoy prison: Extraordinary condition of things: Strong condemnation by the coroner and jury” Evening Telegraph 1 October 1895.
18. Ibid
19. “The sudden death in a convict prison” The Northern Whig 27 July 1878



Saturday, 15 June 2019

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.




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.


Monday, 3 June 2019

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 36th Amendment. The 36th 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 8th 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).