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Care and Control

Joseph Harbison

The History and Heritage of St James’s Hospital, Dublin, by Davis and Mary Coakley, Four Courts Press, 528 pp, €36, ISBN: 978-1846826078

Among media reports of homelessness and health service crises, it is interesting to reflect on how the destitute and sick poor were cared for before the modern era. The newly published history of Dublin’s St James’s Hospital is more than an exploration of the development of Ireland’s largest hospital; it is also a case study in how the city and country has dealt with the issues of poverty and homelessness over the last three centuries.

The first public hospital in the city was opened on Thomas Street in the 1180s, soon after the Norman invasion. The hospital of St John the Baptist without the Newgate was built in a strategic location at the junction of the Slí Mór and the road down to the “Atha Cliath”, the main ford across the river. A pre-Norman burial ground and church, St Molua’s, may have been present before the hospital’s construction. The site is now occupied predominantly by the large John’s Lane Church, designed by Edward Pugin. The hospital and church were both Augustinian foundations and the hospital functioned as much as a hospice for the sick poor of Dublin, providing care and sustenance to those who had not the resources to receive it in their own home. It is likely that some surgical procedures were performed there but in a time before easily available medications or diagnostic investigations there was little that could be offered to patients beyond nursing, nutrition and prayer. The hospital reached its peak in the early fourteenth century but then slowly deteriorated in function and infrastructure until it was closed in 1538 during the dissolution of the monasteries by Henry VIII.

The institution appeared to be kept open as a private charity and poor house for another one hundred and sixty years, by which time the western boundary of the city had moved from the New Gate to the St James’s Gate, about a kilometre further down the road. Maintaining a poor house within the city limits was considered undesirable to the city’s aldermen and the central government in Dublin castle as it was thought to make it too easy for the residents to enter the centre of the city to beg and thus a new poor house was built beyond St James’s Gate, at Mount Brown, opening in 1708.

It is at this point that the Coakleys’ fascinating and extremely well-written account of the evolution of the institution from poor house to teaching hospital begins. It is of interest to anyone cognisant of the means employed in recent years to counter homelessness and begging in Dublin to read of the attempts of the civic authorities in the eighteenth century to address the same issues. Published in the same month as the government proposes to licence and limit the number of rickshaws in the city, the book describes how the poor house was funded by the creation of a new tax on unlicensed hackney carriages. It also gives and account of the migration flows from the countryside to Dublin, then the fifth largest city in Europe. These new Dubliners found there was little opportunity or housing for them on arrival. The choice of the Mount Brown site was deliberate, beyond St James’s Gate, which was in the seventeenth century an administrative obstruction or checkpoint, lying outside and apart from the walls of the city.

From the outset there was a punitive element to the creation of the poor house and a bridewell or prison was incorporated into its plan. The institution was also required “to detain and keep in the service” of the corporation children between the ages of five and sixteen years, who were to be apprenticed out to “any honest persons, being Protestants”, mendicity being perceived as a problem that should be tackled with what would later be called social engineering. There seems to have been a contradiction between the reformative and punitive functions of the institution, which was in fact constructed with the help of charitable donations, not least by the formidable Mary, Duchess of Ormond.

Although, initially built for only “able bodied” beggars and vagrants it soon became clear, as is well recognised today, that in many cases the reason for homelessness and destitution was underlying psychiatric illness and facilities for dealing with “the insane” were soon incorporated into the poor house. It is probably these individuals who represent the first “patients” of the institution. Homeless children represented nearly half of the workhouse inmates and it was the problem of dealing with these and with abandoned infants and children under five years that led to the eventual change of function in 1730 to “The Foundlings Hospital and Workhouse”, a year after the publication of Dean Swift’s satirical A Modest Proposal, suggesting that the Irish should be encouraged to sell as food for the more prosperous the children they were unable to support.

In a brief aside to the historical narrative, the Coakleys describe the case of one destitute child, saved from the Dublin Workhouse by a sympathetic couple and who possibly became the inspiration for Emily Brontë’s Heathcliff. The book feature a number of these anecdotes and vignettes which help to break up and counterpoint what is an always sympathetic but nevertheless harrowing description of poverty and deprivation.

Perhaps the most troubling account is of that of the Foundlings Hospital, an institution again established with laudable intent but which for much of its history objectively failed in its objectives to protect and nurture the children under its care. In the chequered and often dismal history of the institutional care of children in Ireland reflected in the scandals of the industrial schools and Tuam Mother and Baby Home it is remarkable that we have largely forgotten the Dublin Foundlings Hospital, arguably the first and largest example of the systematic neglect of babies and children.

The hospital was established in an era which saw the foundation of many similar institutions internationally, starting with the Ospedale degli Innocenti in Florence. Between 1750 and 1760 nearly half of the 7,800 children admitted to the hospital died. The causes of such morbidity were varied. The children admitted were often ill and malnourished on presentation but the care in the hospital did not improve their outlook. In an era before any understanding of nutrition, young inmates were fed a diet consisting mainly of ‑ frequently adulterated ‑ bread and milk. The physical conditions and crowding promoted the spread of epidemic disease and the disciplinary environment was exceedingly harsh. Boys could be publicly whipped and girls caned for “offences” as minor as wetting their beds.

In 1772 the workhouse function of the hospital was removed and a number of benefactors and philanthropists, most notably Lady Arabella Denny, strove to improve the conditions for the children. However, social, political and environmental factors meant that whatever small improvements they could deliver were overcome by circumstances. Eighteenth century Ireland suffered several severe famines, resulting in increased internal emigration to the cities. Increasing poverty and perhaps a greater number of women forced into prostitution to support themselves led to an increase in abandoned infants and children. The hospital became responsible for abandoned children from across the country and many of these either died en route or were even murdered by the carriers paid to transport them to Dublin. The increase in demand was not met by an increase in governmental funding. Consequently, mortality among children admitted rose to more than 61 per cent. Mortality among infants admitted to the hospital infirmary, many of whom were suspected of having congenital syphilis or other infectious disease, was more than 99 per cent. Indeed, in the absence of adequate wet nurses prepared to feed these abandoned babies the hospital authorities had little option but to administer laudanum to them to relieve their suffering before they died. The Foundlings Hospital was subject to two governmental inquiries because of the appalling conditions and prognoses of its inmates. The Coakleys give an account of the interactions and conflicts between chief secretary Sir John Blaquiere and the civic authorities in trying to improve conditions in the hospital. Certainly, Blaquiere appears as a hero of the piece, with no less a figure than Henry Grattan faulted for supporting the typically negligent and absentee governors, many of whom were within his social circle.

Conditions in the workhouse improved in the first decades of the nineteenth century, and certainly the impression presented by the authors is that this improvement, as much as anything, contributed to the demise of the institution. An increased survival of inmates resulted in increased operational costs. This, and a change in public policy in respect to institutionalising children, led to the winding up of the Foundlings Hospital in 1831. Although the hospital itself was closed there were still children resident in 1839, when the buildings were transferred to the Poor Law Commissioners for use as a Union workhouse for Dublin. The institution was called a Union in that it provided the facility required to care for the destitute poor, most notably a workhouse, required by the poor law for a large number of parishes who contributed to its upkeep. The South Dublin Union eventually became the second largest in the United Kingdom of that time.

The description of the workhouse, its development and operation, is the subject of much of the middle section of the book. It starts with a concise and informative discussion of the poor laws and the social and political circumstances that resulted in the creation of the workhouses and this material is important to contextualise the rest of the book for the non-expert reader. The section on the workhouse during the famine of the 1840s is remarkable and original from a couple of perspectives. There has of course been a huge amount written on the Great Famine with the Atlas of the Great Irish Famine edited by John Crowley, William Smyth and Mike Murphy providing a recent and encyclopaedic description. Much of the emphasis of previous descriptions has understandably been on rural and particularly western areas, which were most devastatingly affected. This work reflects how the Famine impacted on Dublin, and on the workhouse as a microcosm of these effects.  From Charles Dickens on there have been literary descriptions of the operation of and conditions experienced within workhouses. The Coakleys’ work does not shy away from this perspective either; the conditions inside are graphically described, but the perspective of the workhouse governors and staff is also represented. This is particularly the case in the description of the Famine and of the epidemics of cholera and typhus that followed it. One gets the impression of an administrative staff and management trying to cope with catastrophes they were neither expecting or had the resources to manage. While the system may have been brutal and cruel, the authors give the impression of a board of governors given the primary responsibility of dealing with the crisis of displaced, sick, starving homeless people and trying their best to provide for them. One gets no impression or reflection of a figure such as Dickens’s Mr Bumble in the staff of the Union; although the regime was obviously severe it was organisationally rather than individually cruel. Perhaps one of the most interesting and inadvertently humorous parts is the description of the lengths to which some inmates went to be transported to Australia or the West Indies, a more attractive proposition than staying in the workhouse.

It is telling that during the nineteenth century, while Dublin was the second city of the empire, it also had the worst slums in that empire and also in Europe. Diseases such as cholera, typhus, typhoid, and smallpox that tended to be epidemic in other areas were endemic in Dublin. The descriptions in the book of the 1849 cholera epidemics, with the sick and dying lying in the gutters outside the Union as there was no more room to care for them, are particularly vivid.

The description of life within the workhouse, and in particular of its organisation and how the governors adjusted to changes in circumstance, is interesting. The role of the institution evolved in the sixty years following the Famine, as did the attitude of the population to those requiring its services. There was also clearly an evolution in the beliefs and politics of the workhouse governors, starting out as conservative pillars of the establishment and progressing by the turn of the century to having a more Irish nationalist sentiment. The social function of the workhouse, in an era before social welfare, to provide food and accommodation in return for work to the indigent population changed little over the half-century; its role as a provider of healthcare increased greatly, so it became in essence “a vast hospital’. In an era when poverty greatly increased the chance of illness, and illness frequently resulted in destitution, the Union rapidly became the primary institution providing healthcare to the poor of Dublin. The point where the disparate roles of the Union in providing social support and healthcare were formally separated did not occur until after independence, with the creation of St Kevin’s Hospital as distinct from the Union in the 1920s.

The role of the Union as a large Dublin civic institution during the early years of the twentieth century is considered. This is most notable in a section devoted to the events of Easter week 1916. The South Dublin Union was one of the places occupied by the Irish Volunteers during the rising. The events of the rising have been very well-described over the last few years because of the commemoration of the centenary. The authors dedicate a chapter to a very fair and objective description of the conflict between the army and the Irish Volunteers fourth battalion. The Coakleys point out that, particularly at the beginning of the conflict, the British soldiers trying to reoccupy the Union were largely Irish and from Irish regiments. The episode also raises the perhaps uncomfortable question as to whether the occupation of hospital buildings in a military endeavour is justifiable.

The work also briefly describes the development of the voluntary hospitals in Dublin from the early eighteenth century. The Coakleys are medical historians of repute and this description is necessary to add context to the developing role of the workhouse. The voluntary hospitals, although established to provide care to all, received little or no governmental support and became increasingly dependent on patients who could pay, leaving the poor to access care wherever else they could; and this for many meant entering the workhouse. The relationship between the voluntary hospitals and St Kevin’s is an important theme throughout the remainder of the book. It is clear that at the end of the nineteenth century and into the first decades of the twentieth, these hospitals and the associated medical establishment did not really see the Union as a “proper” hospital, even though it was providing an increasingly large proportion of the emergency and chronic medical care to the population of Dublin. The evolution of care and eventual involvement of trained nurses and nursing sisters, rather than predominantly inmate attendants eventually consolidated the change from workhouse to hospital.

Despite the clear role and function that St Kevin’s had in meeting an otherwise unmet need for healthcare for the poorer people of Dublin it was decades before it was recognised by the medical establishment. Opposition to the very concept of and dispute of the need for a municipal hospital restricted its development. Denial that such an institution could be used to train medical students also reflected the pervading view of St Kevin’s as something less than a respectable hospital. The view of the population was little better. The hospital was still called “St Kevin’s, the Union” by many and there was still a stigma associated with being admitted to “the Old Spike” until the abolition of its remaining workhouse functions in the 1950s. However, this complex and tough evolution created a culture and ethos within the hospital that still exists to today. We care for all, without question and regardless of class, wealth or other factors.

The uncomfortable relations between the voluntary hospitals and St Kevin’s lasted until the early 1970s when, for financial and practical reasons related to the size of the various Federated Dublin Hospitals, they were mainly incorporated onto the Mount Brown site. The name of the hospital was changed to St James’s; the choice being predominantly that of Erskine Childers, the then minister for health. The matter is not expressly mentioned in the book, but one cannot help but wonder if the change of name was also a means of placating the management and clinicians of the hospitals being incorporated over being absorbed by “the workhouse hospital”.

The book finishes with a description of how the hospital has developed from the 1970s into a large university teaching hospital of international calibre, training clinicians of many types, predominantly in association with Trinity College Dublin but also other Irish and international colleges. There is always a challenge in writing a history of a modern institution and the Coakleys have resolved this by providing brief descriptions of various important developments in the hospital with a background narrative of its growth, culminating with the start of construction of the new National Children’s Hospital on the site last year. The book ends with a chronology of important events, appointments and retirements over the last forty years. As a declaration of possible conflict of interest, I must confess to receiving myself a ‑ deservedly brief ‑ mention towards the end of the book.

The History and Heritage of St James's Hospital, Dublin is a fascinating read for anyone with an interest in the history of Dublin, of Irish society or healthcare. In writing this review I am conscious of the number of times I have used the term “institution”. St James’s and its antecedents were all institutions, but the term has changed from denoting an almost sinister instrument of mean charity and reform in its foundling hospital and workhouse days to referring to the modern, respected, and perhaps even loved, hospital that it is today. This is not a stale account of a dusty institution but an absorbing read of how the entity that was created at the end of the seventeenth century has changed and evolved, reflecting the events and society that surrounded it. It is filled with characters beyond the inmates, patients, administrators and clinicians that walked its corridors, dormitories and wards. The list of authors who have touched or been touched by the events described in the book is indicative of the richness of its history; Jonathan Swift, Emily Brontë, James Clarence Mangan, George Bernard Shaw, Patrick Kavanagh and Thomas Kinsella all play their part. The book is comprehensively referenced and illustrated, many of these illustrations from private collections that have not recently or previously been published. One of these, the eighteenth century seal of the workhouse presents the motto “The diligent hand maketh rich”. The History and Heritage of St James's Hospital, Dublin is a diligent work of many years by the authors and, in addition to being a exemplary work of history is rich in detail, interest and anecdote. Reading through it would be an excellent use of a few hours.

1/1/2019

Joseph Harbison teaches at Trinity College and is a consultant stroke physician at St James's Hospital

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